05-7357. Revised Medical Criteria for Evaluating Neurological Impairments

AGENCY:

Social Security Administration.

ACTION:

Advance notice of proposed rulemaking.

SUMMARY:

We are planning to update and revise the rules we use to evaluate neurological impairments of adults and children who apply for, or receive, disability benefits under title II and Supplemental Security Income (SSI) payments based on disability under title XVI of the Social Security Act (the Act). The rules we plan on revising are sections 11.00 and 111.00 in the Listing of Impairments in appendix 1 to subpart P of part 404 of our regulations (the listings). We invite you to send us comments and suggestions for updating and revising these rules.

After we have considered your comments and suggestions, as well as information about advances in medical knowledge, treatment, and methods of evaluating neurological disorders, and our program experience, we intend to publish for public comment a Notice of Proposed Rulemaking (NPRM) that will propose specific revisions to the rules.

As part of our long-term planning for the disability programs, we are also interested in your ideas for how we may be able to improve our programs for people who have neurological disorders, especially those who would like to work.

DATES:

To be sure your comments are considered, we must receive them by June 13, 2005.

ADDRESSES:

You may give us your comments by: using our Internet site facility (i.e., Social Security Online) at http://policy.ssa.gov/​pnpublic.nsf/​LawsRegs or the Federal eRulemaking Portal at http://www.regulations.gov; e-mail to [e-mail]; telefax to [phone], or letter to the Commissioner of Social Security, P.O. Box 17703, Baltimore, Maryland 21235-7703. You may also deliver them to the Office of Regulations, Social Security Administration, 100 Altmeyer Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, between 8 a.m. and 4:30 p.m. on regular business days. Comments are posted in our Internet site at http://policy.ssa.gov/​pnpublic.nsf/​LawsRegs, or you may inspect them on regular business days by making arrangements with the contact person shown in this preamble.

Electronic Version: The electronic file of this document is available on the date of publication in the Federal Register at http://www.gpoaccess.gov/​fr/​index.html. It is also available on the Internet site for SSA (i.e., Social Security Online) at: http://policy.ssa.gov/​pnpublic.nsf/​LawRegs.

FOR FURTHER INFORMATION CONTACT:

Fran O. Thomas, Social Insurance Specialist, Office of Regulations, Social Security Administration, 100 Altmeyer Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, [phone] or TTY [phone]. For information on eligibility or filing for benefits, call our national toll-free number, 1-800-772-1213 or TTY 1-800-325-0778, or visit our Internet Web site, Social Security Online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION:

What Is the Purpose of This Notice?

We are planning to update and revise the rules that we use to evaluate neurological impairments of adults and children who apply for, or receive, disability benefits under title II and Supplemental Security Income (SSI) payments based on disability under title XVI of the Act. The purpose of this notice is to give you an opportunity to send us comments and suggestions for updating and revising those rules as we begin the rulemaking process. We are also asking for your comments and ideas about how we can improve our disability programs in the future for people with neurological disorders.

Who Should Send Us Comments and Suggestions?

We invite comments and suggestions from anyone who has an interest in the rules we use to evaluate claims for benefits filed by people who have neurological disorders. We are interested in getting comments and suggestions from people who apply for or receive benefits from us, members of the general public, advocates and organizations who advocate for people who have neurological disorders, experts in the evaluation of neurological diseases and injuries, researchers, people who make disability determinations and decisions for us, and any other individuals who may have ideas for us to consider.

Will We Respond To Your Comments From This Notice?

No, we will not respond directly to comments you send us because of this notice. However, after we consider your comments in response to this notice, along with other information such as results of current medical research and our program experience, we will decide how to revise the rules we use to evaluate neurological impairments. When we propose specific revisions to the rules, we will publish an NPRM in the Federal Register. In accordance with the usual rulemaking procedures we follow, you will have a chance to comment on the revisions we propose when we publish the NPRM, and we will summarize and respond to the significant comments on the NPRM in the preamble to any final rules.

Which Rules Are We Considering for Updating and Revision?

We are considering two sections of our listings for updating and revision, sections 11.00 and 111.00. These are the listings for neurological impairments for adults (Part A, 11.00) and children (Part B, 111.00). They include, but are not limited to, such impairments as epilepsy, multiple sclerosis, traumatic brain injury, stroke, cerebral palsy, muscular dystrophy, and myasthenia gravis.

Where Can You Find These Rules on the Internet?

You can find these rules on our Internet site at these locations:

• Sections 11.00 and 111.00 are in the Listing of Impairments in appendix 1 to subpart P of part 404 of our regulations at http://www.ssa.gov/​OP_​Home/​cfr20/​404/​404-ap10.htm.
• You can also look up sections 11.00 and 111.00 of the listings at http://www.ssa.gov/​disability/​professionals/​bluebook/​.
• If you do not have Internet access, you can find the Code of Federal Regulations in some public libraries, Federal depository libraries, and public law libraries.

Why Are We Updating and Revising Our Rules for Evaluating Neurological Impairments?

We last published final rules containing comprehensive revisions to the listings for neurological impairments in the Federal Register on December 6, 1985 (50 FR 50068). Although we also published final rules revising the preface to the neurological body system on August 21, 2000 (65 FR 50746), made technical revisions to the listings that included some changes to the neurological body system listings on April 24, 2002, and moved the listings for malignant brain tumors to our Malignant Neoplastic Diseases body system on November 15, 2004 (69 FR 67018), we have not comprehensively revised the rules since 1985.

The current listings for neurological impairments for adults (11.00) and children (111.00) will no longer be effective on July 1, 2005, unless we extend them or revise and promulgate them again.

What Should You Comment About?

We are interested in any comments and suggestions you have about sections 11.00 and 111.00 of our listings. For example, with regard to our listings, we are interested in knowing if:

• You have concerns about any of the current neurological listings provisions for adults or children; such as whether you think we should change any of our criteria or whether you think a listing is difficult to use or understand.
• You would like to see our neurological listings include something that they do not include now; such as conditions and/or new medical criteria that you believe should be added to the listings.
• You think it would be beneficial to change the current disease-specific listing format to a more inclusive category format such as “Vascular disorders,” “Demyelinating disorders,” and “Movement disorders.”
• You think these listings should continue to include functional criteria that consider all aspects of listed neurological impairments such as motor and sensory deficits, cognitive/behavioral abnormalities, speech/language limitations, and vision/hearing losses.
• You are aware of criteria we should use to define disabling epilepsy at the listing level.

In addition to your comments about our regulations, we are also interested in any ideas you have about how the disability requirements of the Act and our regulations affect people who have neurological disorders, especially those who would like to work, full-time or part-time with supports. Your ideas can address our existing rules and regulations or suggest changes to the law. For example, we know that many people who have neurological disorders might not need benefits from us if they could get treatment before their disease or injury makes them unable to work. Others may be unable to work but may not need to stay out of work indefinitely if they could get treatment or other interventions. Many people with permanent impairments can work if they have a supporting safety net (including title II disability benefits and SSI payments). Work can also be therapeutic for some people. Although the Act and our regulations include some access to health care through Medicare and Medicaid, some provisions for vocational rehabilitation, and a number of work incentives, these provisions are generally for people who already qualify for benefits under our disability programs.

We will consider your ideas as we develop the NPRM we intend to publish for public comment, and, where applicable, as part of our long-term planning for the disability program.

What Other Information Will We Consider?

We will also be considering information from other sources, including the following recent documents, for relevance to our policy for evaluating neurological impairments.

• “Management of Treatment-Resistant Epilepsy.” Evidence Report/Technology Assessment: Number 77. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ Publication No. 03-E028) April, 2004. This report is available at http://www.ncbi.nlm.nih.gov/​books/​bv.fcgi?​rid=​hstat1a.chapter.11665
• “Criteria to Determine Disability Related to Multiple Sclerosis.” Evidence Report/Technology Assessment: Number 100. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ Publication No. 03-E028) May, 2004. This report is available at http://www.ahrq.gov/​clinic/​epcsums/​msdissum.htm#contents

Other Information:

Who Can Get Disability Benefits?

Under title II of the Act, we provide for the payment of disability benefits if you are disabled and belong to one of the following three groups:

• Workers insured under the Act,
• Children of insured workers, and
• Widows, widowers, and surviving divorced spouses (see § 404.336) of insured workers.

Under title XVI of the Act, we provide for Supplemental Security Income (SSI) payments on the basis of disability if you are disabled and have limited income and resources.

How Do We Define Disability?

Under both the title II and title XVI programs, disability must be the result of any medically determinable physical or mental impairment or combination of impairments that is expected to result in death or which has lasted or is expected to last for a continuous period of at least 12 months. Our definitions of disability are shown in the following table:

If you file a claim under . . .	And you are . . .	Disability means you have a medically determinable impairments(s) as described above and that results in . . .
title II	an adult or child	the inability to do any substantial gainful activity (SGA).
title XVI	a person age 18 or older	the inability to do any SGA.
title XVI	a person under age 18	marked and severe functional limitations.

How Do We Decide Whether You Are Disabled?

If you are seeking benefits under title II of the Act, or if you are an adult seeking benefits under title XVI of the Act, we use a five-step “sequential evaluation process” to decide whether you are disabled. We describe this five-step process in our regulations at §§ 404.1520 and 416.920. We follow the five steps in order and stop as soon as we can make a determination or decision. The steps are:

1. Are you working, and is the work you are doing substantial gainful activity? If you are working and the work you are doing is substantial gainful activity, we will find that you are not disabled, regardless of your medical condition or your age, education, and work experience. If you are not, we will go on to step 2.

2. Do you have a “severe” impairment? If you do not have an impairment or combination of impairments that significantly limits your physical or mental ability to do basic work activities, we will find that you are not disabled. If you do, we will go on to step 3.

3. Do you have an impairment(s) that meets or medically equals the severity of an impairment in the listings? If you do, and the impairment(s) meets the duration requirement, we will find that you are disabled. If you do not, we will go on to step 4.

4. Do you have the residual functional capacity to do your past relevant work? If you do, we will find that you are not disabled. If you do not, we w will go on to step 5.

5. Does your impairment(s) prevent you from doing any other work that exists in significant numbers in the national economy, considering your residual functional capacity, age, education, and work experience? If it does, and it meets the duration requirement, we will find that you are disabled. If it does not, we will find that you are not disabled.

We use a different sequential evaluation process for children who apply for payments based on disability under title XVI of the Act. We describe that sequential evaluation process in § 416.924 of our regulations.

If you are already receiving benefits, we also use a different sequential evaluation process when we decide whether your disability continues. See §§ 404.1594, 416.994, and 416.994a of our regulations. All of the sequential evaluation processes, however, include steps at which we consider whether your impairment(s) meets or medically equals one of our listings.

What Are the Listings?

The listings are examples of impairments that we consider severe enough to prevent you as an adult from doing any gainful activity. If you are a child seeking SSI payments based on disability, the listings describe impairments that we consider severe enough to result in marked and severe functional limitations. Although the listings are contained only in appendix 1 to subpart P of part 404 of our regulations, we incorporate them by reference in the SSI program in § 416.925 of our regulations, and apply them to claims under both title II and title XVI of the Act.

How Do We Use the Listings?

The listings are in two parts. There are listings for adults (part A) and for children (part B). If you are a person age 18 or over, we apply the listings in part A when we assess your claim, and we never use the listings in part B.

If you are a person under age 18, we first use the criteria in part B of the listings. If the listings in part B do not apply, and the specific disease process(es) has a similar effect on adults and children, we then use the criteria in part A. (See §§ 404.1525 and 416.925.)

If your impairment(s) does not meet any listing, we will also consider whether it medically equals any listing; that is, whether it is as medically severe. (See §§ 404.1526 and 416.926.)

What If You Do Not Have An Impairment(s) That Meets or Medically Equals a Listing?

We use the listings only to decide that you are disabled or that you are still disabled. We will never deny your claim or decide that you no longer qualify for benefits because your impairment(s) does not meet or medically equal a listing. If you have a severe impairment(s) that does not meet or medically equal any listing, we may still find you disabled based on other rules in the “sequential evaluation process” described above. Likewise, we will not decide that your disability has ended only because your impairment(s) does not meet or medically equal a listing.

List of Subjects

20 CFR Part 404

• Administrative practice and procedure
• Blind
• Disability benefits
• Old-Age
• Survivors and Disability Insurance
• Reporting and recordkeeping requirements
• Social Security

20 CFR Part 416

• Administrative practice and procedure
• Aged
• Blind
• Disability benefits
• Public assistance programs
• Reporting and recordkeeping requirements
• Supplemental Security Income (SSI)

Dated: March 21, 2005.

Jo Anne B. Barnhart,

Commissioner of Social Security.