Listing of Impairments

Listing of Impairments; 404, Subpart P, Appendix 1

Medical Listings 404-ap10

Listing of Impairments

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Appendix 1 to Subpart P

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Code of Federal Regulations

CFR 20 Title Page

Appendix 1 to Subpart P of Part 404—Listing of Impairments

The body system listings in parts A and B of the Listing of Impairments will no longer be
effective on the following dates unless extended by the Commissioner or revised and
promulgated again.
1. Growth Impairment (100.00): July 2, 2007.
2. Musculoskeletal System (1.00 and 101.00): February 19, 2009.
3. Special Senses and Speech (2.00 and 102.00): February 20, 2015.
4. Respiratory System (3.00 and 103.00): July 2, 2007.
5. Cardiovascular System (4.00 and 104.00): January 13, 2011.
6. Digestive System (5.00 and 105.00): July 2, 2007.
7. Genitourinary Impairments (6.00 and 106.00): September 6, 2013.
8. Hematological Disorders (7.00 and 107.00): July 2, 2007.
9. Skin Disorders (8.00 and 108.00): July 9, 2012.
10. Endocrine System (9.00 and 109.00): July 2, 2007.
11. Impairments That Affect Multiple Body Systems (10.00 and 110.00): October 31, 2013
12. Neurological (11.00 and 111.00): July 2, 2007.
13. Mental Disorders (12.00 and 112.00): July 2, 2007.
14. Malignant Neoplastic Diseases (13.00 and 113.00): December 15, 2009.
15. Immune System (14.00 and 114.00): July 2, 2007.
Part A
Criteria applicable to individuals age 18 and over and to children under age 18 where criteria

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are appropriate.
Sec.
1.00 Musculoskeletal System.
2.00 Special Senses and Speech.
3.00 Respiratory System.
4.00 Cardiovascular System.
5.00 Digestive System.
6.00 Genitourinary Impairments.
7.00 Hematological Disorders.
8.00 Skin Disorders.
9.00 Endocrine System.
10.00 Impairments That Affect Multiple Body Systems.
11.00 Neurological.
12.00 Mental Disorders.
13.00 Malignant Neoplastic Diseases.
14.00 Immune System.
1.00 Musculoskeletal System
A. Disorders of the musculoskeletal system may result from hereditary, congenital, or acquired
pathologic processes. Impairments may result from infectious, inflammatory, or degenerative
processes, traumatic or developmental events, or neoplastic, vascular, or toxic/metabolic
diseases.
B. Loss of function.
1. General. Under this section, loss of function may be due to bone or joint deformity or
destruction from any cause; miscellaneous disorders of the spine with or without radiculopathy
or other neurological deficits; amputation; or fractures or soft tissue injuries, including burns,
requiring prolonged periods of immobility or convalescence. For inflammatory arthritides that
may result in loss of function because of inflammatory peripheral joint or axial arthritis or
sequelae, or because of extra-articular features, see 14.00B6. Impairments with neurological
causes are to be evaluated under 11.00ff.

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2. How We Define Loss of Function in These Listings
a. General. Regardless of the cause(s) of a musculoskeletal impairment, functional loss for
purposes of these listings is defined as the inability to ambulate effectively on a sustained
basis for any reason, including pain associated with the underlying musculoskeletal
impairment, or the inability to perform fine and gross movements effectively on a sustained
basis for any reason, including pain associated with the underlying musculoskeletal
impairment. The inability to ambulate effectively or the inability to perform fine and gross
movements effectively must have lasted, or be expected to last, for at least 12 months. For the
purposes of these criteria, consideration of the ability to perform these activities must be from a
physical standpoint alone. When there is an inability to perform these activities due to a mental
impairment, the criteria in 12.00ff are to be used. We will determine whether an individual can
ambulate effectively or can perform fine and gross movements effectively based on the
medical and other evidence in the case record, generally without developing additional
evidence about the individual's ability to perform the specific activities listed as examples in
1.00B2b(2) and 1.00B2c.
b. What We Mean by Inability To Ambulate Effectively
(1) Definition. Inability to ambulate effectively means an extreme limitation of the ability to walk;
i.e., an impairment(s) that interferes very seriously with the individual's ability to independently
initiate, sustain, or complete activities. Ineffective ambulation is defined generally as having
insufficient lower extremity functioning (see 1.00J) to permit independent ambulation without
the use of a hand-held assistive device(s) that limits the functioning of both upper extremities.
(Listing 1.05C is an exception to this general definition because the individual has the use of
only one upper extremity due to amputation of a hand.)
(2) To ambulate effectively, individuals must be capable of sustaining a reasonable walking
pace over a sufficient distance to be able to carry out activities of daily living. They must have
the ability to travel without companion assistance to and from a place of employment or school.
Therefore, examples of ineffective ambulation include, but are not limited to, the inability to
walk without the use of a walker, two crutches or two canes, the inability to walk a block at a
reasonable pace on rough or uneven surfaces, the inability to use standard public
transportation, the inability to carry out routine ambulatory activities, such as shopping and
banking, and the inability to climb a few steps at a reasonable pace with the use of a single
hand rail. The ability to walk independently about one's home without the use of assistive
devices does not, in and of itself, constitute effective ambulation.
c. What we mean by inability to perform fine and gross movements effectively. Inability to
perform fine and gross movements effectively means an extreme loss of function of both upper
extremities; i.e., an impairment(s) that interferes very seriously with the individual's ability to
independently initiate, sustain, or complete activities. To use their upper extremities effectively,
individuals must be capable of sustaining such functions as reaching, pushing, pulling,
grasping, and fingering to be able to carry out activities of daily living. Therefore, examples of
inability to perform fine and gross movements effectively include, but are not limited to, the
inability to prepare a simple meal and feed oneself, the inability to take care of personal
hygiene, the inability to sort and handle papers or files, and the inability to place files in a file
cabinet at or above waist level.
d. Pain or other symptoms. Pain or other symptoms may be an important factor contributing to

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functional loss. In order for pain or other symptoms to be found to affect an individual's ability
to perform basic work activities, medical signs or laboratory findings must show the existence
of a medically determinable impairment(s) that could reasonably be expected to produce the
pain or other symptoms. The musculoskeletal listings that include pain or other symptoms
among their criteria also include criteria for limitations in functioning as a result of the listed
impairment, including limitations caused by pain. It is, therefore, important to evaluate the
intensity and persistence of such pain or other symptoms carefully in order to determine their
impact on the individual's functioning under these listings. See also §§404.1525(f) and
404.1529 of this part, and §§416.925(f) and 416.929 of part 416 of this chapter.
C. Diagnosis and Evaluation
1. General. Diagnosis and evaluation of musculoskeletal impairments should be supported, as
applicable, by detailed descriptions of the joints, including ranges of motion, condition of the
musculature (e.g., weakness, atrophy), sensory or reflex changes, circulatory deficits, and
laboratory findings, including findings on x-ray or other appropriate medically acceptable
imaging. Medically acceptable imaging includes, but is not limited to, x-ray imaging,
computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI), with or
without contrast material, myelography, and radionuclear bone scans. "Appropriate" means
that the technique used is the proper one to support the evaluation and diagnosis of the
impairment.
2. Purchase of certain medically acceptable imaging. While any appropriate medically
acceptable imaging is useful in establishing the diagnosis of musculoskeletal impairments,
some tests, such as CAT scans and MRIs, are quite expensive, and we will not routinely
purchase them. Some, such as myelograms, are invasive and may involve significant risk. We
will not order such tests. However, when the results of any of these tests are part of the
existing evidence in the case record we will consider them together with the other relevant
evidence.
3. Consideration of electrodiagnostic procedures. Electrodiagnostic procedures may be useful
in establishing the clinical diagnosis, but do not constitute alternative criteria to the
requirements of 1.04.
D. The physical examination must include a detailed description of the rheumatological,
orthopedic, neurological, and other findings appropriate to the specific impairment being
evaluated. These physical findings must be determined on the basis of objective observation
during the examination and not simply a report of the individual's allegation; e.g., "He says his
leg is weak, numb." Alternative testing methods should be used to verify the abnormal findings;
e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test. Because
abnormal physical findings may be intermittent, their presence over a period of time must be
established by a record of ongoing management and evaluation. Care must be taken to
ascertain that the reported examination findings are consistent with the individual's daily
activities.
E. Examination of the Spine
1. General. Examination of the spine should include a detailed description of gait, range of
motion of the spine given quantitatively in degrees from the vertical position (zero degrees) or,
for straight-leg raising from the sitting and supine position (zero degrees), any other

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appropriate tension signs, motor and sensory abnormalities, muscle spasm, when present, and
deep tendon reflexes. Observations of the individual during the examination should be
reported; e.g., how he or she gets on and off the examination table. Inability to walk on the
heels or toes, to squat, or to arise from a squatting position, when appropriate, may be
considered evidence of significant motor loss. However, a report of atrophy is not acceptable
as evidence of significant motor loss without circumferential measurements of both thighs and
lower legs, or both upper and lower arms, as appropriate, at a stated point above and below
the knee or elbow given in inches or centimeters. Additionally, a report of atrophy should be
accompanied by measurement of the strength of the muscle(s) in question generally based on
a grading system of 0 to 5, with 0 being complete loss of strength and 5 being maximum
strength. A specific description of atrophy of hand muscles is acceptable without
measurements of atrophy but should include measurements of grip and pinch strength.
2. When neurological abnormalities persist. Neurological abnormalities may not completely
subside after treatment or with the passage of time. Therefore, residual neurological
abnormalities that persist after it has been determined clinically or by direct surgical or other
observation that the ongoing or progressive condition is no longer present will not satisfy the
required findings in 1.04. More serious neurological deficits (paraparesis, paraplegia) are to be
evaluated under the criteria in 11.00ff.
F. Major joints refers to the major peripheral joints, which are the hip, knee, shoulder, elbow,
wrist-hand, and ankle-foot, as opposed to other peripheral joints (e.g., the joints of the hand or
forefoot) or axial joints (i.e., the joints of the spine.) The wrist and hand are considered
together as one major joint, as are the ankle and foot. Since only the ankle joint, which
consists of the juncture of the bones of the lower leg (tibia and fibula) with the hindfoot (tarsal
bones), but not the forefoot, is crucial to weight bearing, the ankle and foot are considered
separately in evaluating weight bearing.
G. Measurements of joint motion are based on the techniques described in the chapter on the
extremities, spine, and pelvis in the current edition of the "Guides to the Evaluation of
Permanent Impairment" published by the American Medical Association.
H. Documentation
1. General. Musculoskeletal impairments frequently improve with time or respond to treatment.
Therefore, a longitudinal clinical record is generally important for the assessment of severity
and expected duration of an impairment unless the claim can be decided favorably on the
basis of the current evidence.
2. Documentation of medically prescribed treatment and response. Many individuals,
especially those who have listing-level impairments, will have received the benefit of medically
prescribed treatment. Whenever evidence of such treatment is available it must be considered.
3. When there is no record of ongoing treatment. Some individuals will not have received
ongoing treatment or have an ongoing relationship with the medical community despite the
existence of a severe impairment(s). In such cases, evaluation will be made on the basis of the
current objective medical evidence and other available evidence, taking into consideration the
individual's medical history, symptoms, and medical source opinions. Even though an
individual who does not receive treatment may not be able to show an impairment that meets
the criteria of one of the musculoskeletal listings, the individual may have an impairment(s)

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equivalent in severity to one of the listed impairments or be disabled based on consideration of
his or her residual functional capacity (RFC) and age, education and work experience.
4. Evaluation when the criteria of a musculoskeletal listing are not met. These listings are only
examples of common musculoskeletal disorders that are severe enough to prevent a person
from engaging in gainful activity. Therefore, in any case in which an individual has a medically
determinable impairment that is not listed, an impairment that does not meet the requirements
of a listing, or a combination of impairments no one of which meets the requirements of a
listing, we will consider medical equivalence. (See §§404.1526 and 416.926.) Individuals who
have an impairment(s) with a level of severity that does not meet or equal the criteria of the
musculoskeletal listings may or may not have the RFC that would enable them to engage in
substantial gainful activity. Evaluation of the impairment(s) of these individuals should proceed
through the final steps of the sequential evaluation process in §§404.1520 and 416.920 (or, as
appropriate, the steps in the medical improvement review standard in §§404.1594 and
416.994).
I. Effects of Treatment
1. General. Treatments for musculoskeletal disorders may have beneficial effects or adverse
side effects. Therefore, medical treatment (including surgical treatment) must be considered in
terms of its effectiveness in ameliorating the signs, symptoms, and laboratory abnormalities of
the disorder, and in terms of any side effects that may further limit the individual.
2. Response to treatment. Response to treatment and adverse consequences of treatment
may vary widely. For example, a pain medication may relieve an individual's pain completely,
partially, or not at all. It may also result in adverse effects, e.g., drowsiness, dizziness, or
disorientation, that compromise the individual's ability to function. Therefore, each case must
be considered on an individual basis, and include consideration of the effects of treatment on
the individual's ability to function.
3. Documentation. A specific description of the drugs or treatment given (including surgery),
dosage, frequency of administration, and a description of the complications or response to
treatment should be obtained. The effects of treatment may be temporary or long-term. As
such, the finding regarding the impact of treatment must be based on a sufficient period of
treatment to permit proper consideration or judgment about future functioning.
J. Orthotic, Prosthetic, or Assistive Devices
1. General. Consistent with clinical practice, individuals with musculoskeletal impairments may
be examined with and without the use of any orthotic, prosthetic, or assistive devices as
explained in this section.
2. Orthotic devices. Examination should be with the orthotic device in place and should include
an evaluation of the individual's maximum ability to function effectively with the orthosis. It is
unnecessary to routinely evaluate the individual's ability to function without the orthosis in
place. If the individual has difficulty with, or is unable to use, the orthotic device, the medical
basis for the difficulty should be documented. In such cases, if the impairment involves a lower
extremity or extremities, the examination should include information on the individual's ability
to ambulate effectively without the device in place unless contraindicated by the medical
judgment of a physician who has treated or examined the individual.

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3. Prosthetic devices. Examination should be with the prosthetic device in place. In
amputations involving a lower extremity or extremities, it is unnecessary to evaluate the
individual's ability to walk without the prosthesis in place. However, the individual's medical
ability to use a prosthesis to ambulate effectively, as defined in 1.00B2b, should be evaluated.
The condition of the stump should be evaluated without the prosthesis in place.
4. Hand-held assistive devices. When an individual with an impairment involving a lower
extremity or extremities uses a hand-held assistive device, such as a cane, crutch or walker,
examination should be with and without the use of the assistive device unless contraindicated
by the medical judgment of a physician who has treated or examined the individual. The
individual's ability to ambulate with and without the device provides information as to whether,
or the extent to which, the individual is able to ambulate without assistance. The medical basis
for the use of any assistive device (e.g., instability, weakness) should be documented. The
requirement to use a hand-held assistive device may also impact on the individual's functional
capacity by virtue of the fact that one or both upper extremities are not available for such
activities as lifting, carrying, pushing, and pulling.
K. Disorders of the spine, listed in 1.04, result in limitations because of distortion of the bony
and ligamentous architecture of the spine and associated impingement on nerve roots
(including the cauda equina) or spinal cord. Such impingement on nerve tissue may result from
a herniated nucleus pulposus, spinal stenosis, arachnoiditis, or other miscellaneous conditions.
Neurological abnormalities resulting from these disorders are to be evaluated by referral to the
neurological listings in 11.00ff, as appropriate. (See also 1.00B and E.)
1. Herniated nucleus pulposus is a disorder frequently associated with the impingement of a
nerve root. Nerve root compression results in a specific neuro-anatomic distribution of
symptoms and signs depending upon the nerve root(s) compromised.
2. Spinal Arachnoiditis
a. General. Spinal arachnoiditis is a condition characterized by adhesive thickening of the
arachnoid which may cause intermittent ill-defined burning pain and sensory dysesthesia, and
may cause neurogenic bladder or bowel incontinence when the cauda equina is involved.
b. Documentation. Although the cause of spinal arachnoiditis is not always clear, it may be
associated with chronic compression or irritation of nerve roots (including the cauda equina) or
the spinal cord. For example, there may be evidence of spinal stenosis, or a history of spinal
trauma or meningitis. Diagnosis must be confirmed at the time of surgery by gross description,
microscopic examination of biopsied tissue, or by findings on appropriate medically acceptable
imaging. Arachnoiditis is sometimes used as a diagnosis when such a diagnosis is
unsupported by clinical or laboratory findings. Therefore, care must be taken to ensure that the
diagnosis is documented as described in 1.04B. Individuals with arachnoiditis, particularly
when it involves the lumbosacral spine, are generally unable to sustain any given position or
posture for more than a short period of time due to pain.
3. Lumbar spinal stenosis is a condition that may occur in association with degenerative
processes, or as a result of a congenital anomaly or trauma, or in association with Paget's
disease of the bone. Pseudoclaudication, which may result from lumbar spinal stenosis, is
manifested as pain and weakness, and may impair ambulation. Symptoms are usually
bilateral, in the low back, buttocks, or thighs, although some individuals may experience only

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leg pain and, in a few cases, the leg pain may be unilateral. The pain generally does not follow
a particular neuro-anatomical distribution, i.e., it is distinctly different from the radicular type of
pain seen with a herniated intervertebral disc, is often of a dull, aching quality, which may be
described as "discomfort" or an "unpleasant sensation," or may be of even greater severity,
usually in the low back and radiating into the buttocks region bilaterally. The pain is provoked
by extension of the spine, as in walking or merely standing, but is reduced by leaning forward.
The distance the individual has to walk before the pain comes on may vary.
Pseudoclaudication differs from peripheral vascular claudication in several ways. Pedal pulses
and Doppler examinations are unaffected by pseudoclaudication. Leg pain resulting from
peripheral vascular claudication involves the calves, and the leg pain in vascular claudication is
ordinarily more severe than any back pain that may also be present. An individual with
vascular claudication will experience pain after walking the same distance time after time, and
the pain will be relieved quickly when walking stops.
4. Other miscellaneous conditions that may cause weakness of the lower extremities, sensory
changes, areflexia, trophic ulceration, bladder or bowel incontinence, and that should be
evaluated under 1.04 include, but are not limited to, osteoarthritis, degenerative disc disease,
facet arthritis, and vertebral fracture. Disorders such as spinal dysrhaphism (e.g., spina bifida),
diastematomyelia, and tethered cord syndrome may also cause such abnormalities. In these
cases, there may be gait difficulty and deformity of the lower extremities based on neurological
abnormalities, and the neurological effects are to be evaluated under the criteria in 11.00ff.
L. Abnormal curvatures of the spine. Abnormal curvatures of the spine (specifically, scoliosis,
kyphosis and kyphoscoliosis) can result in impaired ambulation, but may also adversely affect
functioning in body systems other than the musculoskeletal system. For example, an
individual's ability to breathe may be affected; there may be cardiac difficulties (e.g., impaired
myocardial function); or there may be disfigurement resulting in withdrawal or isolation. When
there is impaired ambulation, evaluation of equivalence may be made by reference to 14.09A.
When the abnormal curvature of the spine results in symptoms related to fixation of the
dorsolumbar or cervical spine, evaluation of equivalence may be made by reference to 14.09B.
When there is respiratory or cardiac involvement or an associated mental disorder, evaluation
may be made under 3.00ff, 4.00ff, or 12.00ff, as appropriate. Other consequences should be
evaluated according to the listing for the affected body system.
M. Under continuing surgical management, as used in 1.07 and 1.08, refers to surgical
procedures and any other associated treatments related to the efforts directed toward the
salvage or restoration of functional use of the affected part. It may include such factors as
post-surgical procedures, surgical complications, infections, or other medical complications,
related illnesses, or related treatments that delay the individual's attainment of maximum
benefit from therapy. When burns are not under continuing surgical management, see 8.00F.
N. After maximum benefit from therapy has been achieved in situations involving fractures of
an upper extremity (1.07), or soft tissue injuries (1.08), i.e., there have been no significant
changes in physical findings or on appropriate medically acceptable imaging for any 6-month
period after the last definitive surgical procedure or other medical intervention, evaluation must
be made on the basis of the demonstrable residuals, if any. A finding that 1.07 or 1.08 is met
must be based on a consideration of the symptoms, signs, and laboratory findings associated
with recent or anticipated surgical procedures and the resulting recuperative periods, including
any related medical complications, such as infections, illnesses, and therapies which impede
or delay the efforts toward restoration of function. Generally, when there has been no surgical

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or medical intervention for 6 months after the last definitive surgical procedure, it can be
concluded that maximum therapeutic benefit has been reached. Evaluation at this point must
be made on the basis of the demonstrable residual limitations, if any, considering the
individual's impairment-related symptoms, signs, and laboratory findings, any residual
symptoms, signs, and laboratory findings associated with such surgeries, complications, and
recuperative periods, and other relevant evidence.
O. Major function of the face and head, for purposes of listing 1.08, relates to impact on any or
all of the activities involving vision, hearing, speech, mastication, and the initiation of the
digestive process.
P. When surgical procedures have been performed, documentation should include a copy of
the operative notes and available pathology reports.
Q. Effects of obesity. Obesity is a medically determinable impairment that is often associated
with disturbance of the musculoskeletal system, and disturbance of this system can be a major
cause of disability in individuals with obesity. The combined effects of obesity with
musculoskeletal impairments can be greater than the effects of each of the impairments
considered separately. Therefore, when determining whether an individual with obesity has a
listing-level impairment or combination of impairments, and when assessing a claim at other
steps of the sequential evaluation process, including when assessing an individual's residual
functional capacity, adjudicators must consider any additional and cumulative effects of
obesity.
1.01 Category of Impairments, Musculoskeletal
1.02 Major dysfunction of a joint(s) (due to any cause): Characterized by gross anatomical
deformity (e.g., subluxation, contracture, bony or fibrous ankylosis, instability) and chronic joint
pain and stiffness with signs of limitation of motion or other abnormal motion of the affected
joint(s), and findings on appropriate medically acceptable imaging of joint space narrowing,
bony destruction, or ankylosis of the affected joint(s). With:
A. Involvement of one major peripheral weight-bearing joint (i.e., hip, knee, or ankle), resulting
in inability to ambulate effectively, as defined in 1.00B2b;
or
B. Involvement of one major peripheral joint in each upper extremity (i.e., shoulder, elbow, or
wrist-hand), resulting in inability to perform fine and gross movements effectively, as defined in
1.00B2c.
1.03 Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint, with
inability to ambulate effectively, as defined in 1.00B2b, and return to effective ambulation did
not occur, or is not expected to occur, within 12 months of onset.
1.04 Disorders of the spine (e.g., herniated nucleus pulposus, spinal arachnoiditis, spinal
stenosis, osteoarthritis, degenerative disc disease, facet arthritis, vertebral fracture), resulting
in compromise of a nerve root (including the cauda equina) or the spinal cord. With:
A. Evidence of nerve root compression characterized by neuro-anatomic distribution of pain,

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limitation of motion of the spine, motor loss (atrophy with associated muscle weakness or
muscle weakness) accompanied by sensory or reflex loss and, if there is involvement of the
lower back, positive straight-leg raising test (sitting and supine);
or
B. Spinal arachnoiditis, confirmed by an operative note or pathology report of tissue biopsy, or
by appropriate medically acceptable imaging, manifested by severe burning or painful
dysesthesia, resulting in the need for changes in position or posture more than once every 2
hours;
or
C. Lumbar spinal stenosis resulting in pseudoclaudication, established by findings on
appropriate medically acceptable imaging, manifested by chronic nonradicular pain and
weakness, and resulting in inability to ambulate effectively, as defined in 1.00B2b.
1.05 Amputation (due to any cause).
A. Both hands; or
or
B. One or both lower extremities at or above the tarsal region, with stump complications
resulting in medical inability to use a prosthetic device to ambulate effectively, as defined in
1.00B2b, which have lasted or are expected to last for at least 12 months;
or
C. One hand and one lower extremity at or above the tarsal region, with inability to ambulate
effectively, as defined in 1.00B2b; OR
D. Hemipelvectomy or hip disarticulation.
1.06 Fracture of the femur, tibia, pelvis, or one or more of the tarsal bones. With:
A. Solid union not evident on appropriate medically acceptable imaging and not clinically solid;
and
B. Inability to ambulate effectively, as defined in 1.00B2b, and return to effective ambulation
did not occur or is not expected to occur within 12 months of onset.
1.07 Fracture of an upper extremity with nonunion of a fracture of the shaft of the humerus,
radius, or ulna, under continuing surgical management, as defined in 1.00M, directed toward
restoration of functional use of the extremity, and such function was not restored or expected
to be restored within 12 months of onset.
1.08 Soft tissue injury (e.g., burns) of an upper or lower extremity, trunk, or face and head,

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under continuing surgical management, as defined in 1.00M, directed toward the salvage or
restoration of major function, and such major function was not restored or expected to be
restored within 12 months of onset. Major function of the face and head is described in 1.00O.
2.00 Special Senses and Speech
A. How do we evaluate visual disorders?
1. What are visual disorders? Visual disorders are abnormalities of the eye, the optic nerve,
the optic tracts, or the brain that may cause a loss of visual acuity or visual fields. A loss of
visual acuity limits your ability to distinguish detail, read, or do fine work. A loss of visual fields
limits your ability to perceive visual stimuli in the peripheral extent of vision.
2. How do we define statutory blindness? Statutory blindness is blindness as defined in
sections 216(i)(1) and 1614(a)(2) of the Social Security Act (the Act). The Act defines
blindness as visual acuity of 20/200 or less in the better eye with the use of a correcting lens.
We use your best-corrected visual acuity for distance in the better eye when we determine if
this definition is met. The Act also provides that an eye that has a visual field limitation such
that the widest diameter of the visual field subtends an angle no greater than 20 degrees is
considered as having visual acuity of 20/200 or less. You have statutory blindness only if your
visual disorder meets the criteria of 2.02 or 2.03A. You do not have statutory blindness if your
visual disorder medically equals the criteria of 2.02 or 2.03A, or if it meets or medically equals
2.03B, 2.03C, or 2.04. If your visual disorder medically equals the criteria of 2.02 or 2.03A, or if
it meets or medically equals 2.03B, 2.03C, or 2.04, we will find that you have a disability if your
visual disorder also meets the duration requirement.
3. What evidence do we need to establish statutory blindness under title XVI? For title XVI, the
only evidence we need to establish statutory blindness is evidence showing that your visual
acuity in your better eye or your visual field in your better eye meets the criteria in 2.00A2,
provided that those measurements are consistent with the other evidence in your case record.
We do not need to document the cause of your blindness. Also, there is no duration
requirement for statutory blindness under title XVI (see §§416.981 and 416.983).
4. What evidence do we need to evaluate visual disorders, including those that result in
statutory blindness under title II?
a. To evaluate your visual disorder, we usually need a report of an eye examination that
includes measurements of the best-corrected visual acuity or the extent of the visual fields, as
appropriate. If there is a loss of visual acuity or visual fields, the cause of the loss must be
documented. A standard eye examination will usually reveal the cause of any visual acuity
loss. An eye examination can also reveal the cause of some types of visual field deficits. If the
eye examination does not reveal the cause of the visual loss, we will request the information
that was used to establish the presence of the visual disorder.
b. A cortical visual disorder is a disturbance of the posterior visual pathways or occipital lobes
of the brain in which the visual system does not interpret what the eyes are seeing. It may
result from such causes as traumatic brain injury, stroke, cardiac arrest, near drowning, a
central nervous system infection such as meningitis or encephalitis, a tumor, or surgery. It can
be temporary or permanent, and the amount of visual loss can vary. It is possible to have a
cortical visual disorder and not have any abnormalities observed in a standard eye

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examination. Therefore, a diagnosis of a cortical visual disorder must be confirmed by
documentation of the cause of the brain lesion. If neuroimaging or visual evoked response
(VER) testing was performed, we will request a copy of the report or other medical evidence
that describes the findings in the report.
c. If your visual disorder does not satisfy the criteria in 2.02, 2.03, or 2.04, we will also request
a description of how your visual disorder impacts your ability to function.
5. How do we measure best-corrected visual acuity?
a. Testing for visual acuity. When we need to measure your best-corrected visual acuity, we
will use visual acuity testing that was carried out using Snellen methodology or any other
testing methodology that is comparable to Snellen methodology.
b. Determining best-corrected visual acuity. (i) Best-corrected visual acuity is the optimal visual
acuity attainable with the use of a corrective lens. In some instances, this assessment may be
performed using a specialized lens; for example, a contact lens. We will use the visual acuity
measurements obtained with a specialized lens only if you have demonstrated the ability to
use the specialized lens on a sustained basis. However, we will not use visual acuity
measurements obtained with telescopic lenses because they significantly reduce the visual
field. If you have an absent response to VER testing in an eye, we can determine that your
best-corrected visual acuity is 20/200 or less in that eye. However, if you have a positive
response to VER testing in an eye, we will not use that result to determine your best-corrected
visual acuity in that eye. Additionally, we will not use the results of pinhole testing or automated
refraction acuity to determine your best-corrected visual acuity.
(ii) We will use the best-corrected visual acuity for distance in your better eye when we
determine whether your loss of visual acuity satisfies the criteria in 2.02. The best-corrected
visual acuity for distance is usually measured by determining what you can see from 20 feet. If
your visual acuity is measured for a distance other than 20 feet, we will convert it to a 20-foot
measurement. For example, if your visual acuity is measured at 10 feet and is reported as
10/40, we will convert this to 20/80.
6. How do we measure visual fields?
a. Testing for visual fields.
(i) We generally need visual field testing when you have a visual disorder that could result in
visual field loss, such as glaucoma, retinitis pigmentosa, or optic neuropathy, or when you
display behaviors that suggest a visual field loss.
(ii) When we need to measure the extent of your visual field loss, we will use visual field
measurements obtained with an automated static threshold perimetry test performed on a
perimeter, like the Humphrey Field Analyzer, that satisfies all of the following requirements:
A. The perimeter must use optical projection to generate the test stimuli.
B. The perimeter must have an internal normative database for automatically comparing your
performance with that of the general population.

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C. The perimeter must have a statistical analysis package that is able to calculate visual field
indices, particularly mean deviation.
D. The perimeter must demonstrate the ability to correctly detect visual field loss and correctly
identify normal visual fields.
E. The perimeter must demonstrate good test-retest reliability.
F. The perimeter must have undergone clinical validation studies by three or more independent
laboratories with results published in peer-reviewed ophthalmic journals.
(iii) The test must use a white size III Goldmann stimulus and a 31.5 apostilb (10 cd/m[2]) white
background. The stimuli locations must be no more than 6 degrees apart horizontally or
vertically. Measurements must be reported on standard charts and include a description of the
size and intensity of the test stimulus.
(iv) To determine statutory blindness based on visual field loss (2.03A), we need a test that
measures the central 24 to 30 degrees of the visual field; that is, the area measuring 24 to 30
degrees from the point of fixation. Acceptable tests include the Humphrey 30-2 or 24-2 tests.
(v) The criterion in 2.03B is based on the use of a test performed on a Humphrey Field
Analyzer that measures the central 30 degrees of the visual field. We can also use comparable
results from other acceptable perimeters, for example, a mean defect of 22 on an acceptable
Octopus test, to determine that the criterion in 2.03B is met. We cannot use tests that do not
measure the central 30 degrees of the visual field, such as the Humphrey 24-2 test, to
determine if your impairment meets or medically equals 2.03B.
(vi) We measure the extent of visual field loss by determining the portion of the visual field in
which you can see a white III4e stimulus. The "III" refers to the standard Goldmann test
stimulus size III, and the "4e" refers to the standard Goldmann intensity filters used to
determine the intensity of the stimulus.
(vii) In automated static threshold perimetry, the intensity of the stimulus varies. The intensity
of the stimulus is expressed in decibels (dB). We need to determine the dB level that
corresponds to a 4e intensity for the particular perimeter being used. We will then use the dB
printout to determine which points would be seen at a 4e intensity level. For example, in
Humphrey Field Analyzers, a 10 dB stimulus is equivalent to a 4e stimulus. A dB level that is
higher than 10 represents a dimmer stimulus, while a dB level that is lower than 10 represents
a brighter stimulus. Therefore, for tests performed on Humphrey Field Analyzers, any point
seen at 10 dB or higher is a point that would be seen with a 4e stimulus.
(viii) We can also use visual field measurements obtained using kinetic perimetry, such as the
Humphrey "SSA Test Kinetic" or Goldmann perimetry, instead of automated static threshold
perimetry. The kinetic test must use a white III4e stimulus projected on a white 31.5 apostilb
(10 cd/m[2]) background. In automated kinetic tests, such as the Humphrey "SSA Test Kinetic,"
testing along a meridian stops when you see the stimulus. Because of this, automated kinetic
testing does not detect limitations in the central visual field. If your visual disorder has
progressed to the point at which it is likely to result in a significant limitation in the central visual
field, such as a scotoma (see 2.00A8c), we will not use automated kinetic perimetry to
evaluate your visual field loss. Instead, we will assess your visual field loss using automated

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static threshold perimetry or manual kinetic perimetry.
(ix) We will not use the results of visual field screening tests, such as confrontation tests,
tangent screen tests, or automated static screening tests, to determine that your impairment
meets or medically equals a listing or to evaluate your residual functional capacity. However,
we can consider normal results from visual field screening tests to determine whether your
visual disorder is severe when these test results are consistent with the other evidence in your
case record. (See §§404.1520(c), 404.1521, 416.920(c), and 416.921.) We will not consider
normal test results to be consistent with the other evidence if either of the following applies:
A. The clinical findings indicate that your visual disorder has progressed to the point that it is
likely to cause visual field loss, or
B. You have a history of an operative procedure for retinal detachment.
b. Use of corrective lenses. You must not wear eyeglasses during the visual field examination
because they limit your field of vision. Contact lenses or perimetric lenses may be used to
correct visual acuity during the visual field examination in order to obtain the most accurate
visual field measurements. For this single purpose, you do not need to demonstrate that you
have the ability to use the contact or perimetric lenses on a sustained basis.
7. How do we calculate visual efficiency?
a. Visual acuity efficiency. We use the percentage shown in Table 1 that corresponds to the
best-corrected visual acuity for distance in your better eye.
b. Visual field efficiency. We use kinetic perimetry to calculate visual field efficiency by adding
the number of degrees seen along the eight principal meridians in your better eye and dividing
by 500. (See Table 2.)
c. Visual efficiency. We calculate the percent of visual efficiency by multiplying the visual acuity
efficiency by the visual field efficiency and converting the decimal to a percentage. For
example, if your visual acuity efficiency is 75 percent and your visual field efficiency is 64
percent, we will multiply 0.75 × 0.64 to determine that your visual efficiency is 0.48, or 48
percent.
8. How do we evaluate specific visual problems?
a. Statutory blindness. Most test charts that use Snellen methodology do not have lines that
measure visual acuity between 20/100 and 20/200. Newer test charts, such as the BaileyLovie or the Early Treatment Diabetic Retinopathy Study (ETDRS), do have lines that measure
visual acuity between 20/100 and 20/200. If your visual acuity is measured with one of these
newer charts, and you cannot read any of the letters on the 20/100 line, we will determine that
you have statutory blindness based on a visual acuity of 20/200 or less. For example, if your
best-corrected visual acuity for distance in the better eye was determined to be 20/160 using
an ETDRS chart, we will find that you have statutory blindness. Regardless of the type of test
chart used, you do not have statutory blindness if you can read at least one letter on the
20/100 line. For example, if your best-corrected visual acuity for distance in the better eye was
determined to be 20/125+1 using an ETDRS chart, we will find that you do not have statutory
blindness as you are able to read one letter on the 20/100 line.

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b. Blepharospasm. This movement disorder is characterized by repetitive, bilateral, involuntary
closure of the eyelids. If you have this disorder, you may have measurable visual acuities and
visual fields that do not satisfy the criteria of 2.02 or 2.03. Blepharospasm generally responds
to therapy. However, if therapy is not effective, we will consider how the involuntary closure of
your eyelids affects your ability to maintain visual functioning over time.
c. Scotoma. A scotoma is a non-seeing area in the visual field surrounded by a seeing area.
When we measure the visual field, we subtract the length of any scotoma, other than the
normal blind spot, from the overall length of any diameter on which it falls.
B. Otolaryngology
1. Hearing impairment. Hearing ability should be evaluated in terms of the person's ability to
hear and distinguish speech.
Loss of hearing can be quantitatively determined by an audiometer which meets the standards
of the American National Standards Institute (ANSI) for air and bone conducted stimuli (i.e.,
ANSI S 3.6-1969 and ANSI S 3.13-1972, or subsequent comparable revisions) and performing
all hearing measurements in an environment which meets the ANSI standard for maximal
permissible background sound (ANSI S 3.1-1977).
Speech discrimination should be determined using a standardized measure of speech
discrimination ability in quiet at a test presentation level sufficient to ascertain maximum
discrimination ability. The speech discrimination measure (test) used, and the level at which
testing was done, must be reported.
Hearing tests should be preceded by an otolaryngologic examination and should be performed
by or under the supervision of an otolaryngologist or audiologist qualified to perform such tests.
In order to establish an independent medical judgment as to the level of impairment in a
claimant alleging deafness, the following examinations should be reported: Otolaryngologic
examination, pure tone air and bone audiometry, speech reception threshold (SRT), and
speech discrimination testing. A copy of reports of medical examination and audiologic
evaluations must be submitted.
Cases of alleged "deaf mutism" should be documented by a hearing evaluation. Records
obtained from a speech and hearing rehabilitation center or a special school for the deaf may
be acceptable, but if these reports are not available, or are found to be inadequate, a current
hearing evaluation should be submitted as outlined in the preceding paragraph.
2. Vertigo associated with disturbances of labyrinthine-vestibular function, including Meniere's
disease. These disturbances of balance are characterized by an hallucination of motion or loss
of position sense and a sensation of dizziness which may be constant or may occur in
paroxysmal attacks. Nausea, vomiting, ataxia, and incapacitation are frequently observed,
particularly during the acute attack. It is important to differentiate the report of rotary vertigo
from that of "dizziness" which is described as lightheadedness, unsteadiness, confusion, or
syncope.
Meniere's disease is characterized by paroxysmal attacks of vertigo, tinnitus, and fluctuating
hearing loss. Remissions are unpredictable and irregular, but may be longlasting; hence, the

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severity of impairment is best determined after prolonged observation and serial
reexaminations.
The diagnosis of a vestibular disorder requires a comprehensive neuro-otolaryngologic
examination with a detailed description of the vertiginous episodes, including notation of
frequency, severity, and duration of the attacks. Pure tone and speech audiometry with the
appropriate special examinations, such as Bekesy audiometry, are necessary. Vestibular
functions is assessed by positional and caloric testing, preferably by electronystagmography.
When polytomograms, contrast radiography, or other special tests have been performed,
copies of the reports of these tests should be obtained in addition to appropriate medically
acceptable imaging reports of the skull and temporal bone. Medically acceptable imaging
includes, but is not limited to, x-ray imaging, computerized axial tomography (CAT scan) or
magnetic resonance imaging (MRI), with or without contrast material, myelography, and
radionuclear bone scans. "Appropriate" means that the technique used is the proper one to
support the evaluation and diagnosis of the impairment.
3. Loss of speech. In evaluating the loss of speech, the ability to produce speech by any
means includes the use of mechanical or electronic devices that improve voice or articulation.
Impairments of speech may also be evaluated under the body system for the underlying
disorder, such as neurological disorders, 11.00ff.
C. How do we evaluate impairments that do not meet one of the special senses and speech
listings?
1. These listings are only examples of common special senses and speech disorders that we
consider severe enough to prevent an individual from doing any gainful activity. If your
impairment(s) does not meet the criteria of any of these listings, we must also consider
whether you have an impairment(s) that satisfies the criteria of a listing in another body
system.
2. If you have a medically determinable impairment(s) that does not meet a listing, we will
determine whether the impairment(s) medically equals a listing. (See §§404.1526 and
416.926.) If you have an impairment(s) that does not meet or medically equal a listing, you
may or may not have the residual functional capacity to engage in substantial gainful activity.
Therefore, we proceed to the fourth, and if necessary, the fifth steps of the sequential
evaluation process in §§404.1520 and 416.920. When we decide whether you continue to be
disabled, we use the rules in §§404.1594, 416.994, or 416.994a, as appropriate.
2.01 Category of Impairments, Special Senses and Speech
2.02 Loss of visual acuity. Remaining vision in the better eye after best correction is 20/200 or
less.
2.03 Contraction of the visual field in the better eye, with:
A. The widest diameter subtending an angle around the point of fixation no greater than 20
degrees;
OR

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B. A mean deviation of -22 or worse, determined by automated static threshold perimetry as
described in 2.00A6a(v);
OR
C. A visual field efficiency of 20 percent or less as determined by kinetic perimetry (see
2.00A7b).
2.04 Loss of visual efficiency. Visual efficiency of the better eye of 20 percent or less after best
correction (see 2.00A7c).
2.07 Disturbance of labyrinthine-vestibular function (including Meniere's disease),
characterized by a history of frequent attacks of balance disturbance, tinnitus, and progressive
loss of hearing. With both A and B:
A. Disturbed function of vestibular labyrinth demonstrated by caloric or other vestibular tests;
and
B. Hearing loss established by audiometry.
2.08 Hearing impairments (hearing not restorable by a hearing aid) manifested by:
A. Average hearing threshold sensitivity for air conduction of 90 decibels or greater and for
bone conduction to corresponding maximal levels, in the better ear, determined by the simple
average of hearing threshold levels at 500, 1000 and 2000 hz. (see 2.00B1); or
B. Speech discrimination scores of 40 percent or less in the better ear;
2.09 Loss of speech due to any cause, with inability to produce by any means speech that can
be heard, understood, or sustained.
Table 1.—Percentage of Visual
Acuity Efficiency Corresponding
to the Best-Corrected Visual
Acuity Measurement for
Distance in the Better Eye
Percent
Snellen
visual
English Metric acuity efficiency
20/16
6/5
100
20/20
6/6
100
20/25
6/7.5
95
20/30
6/9
90
20/40
6/12
85
20/50
6/15
75
20/60
6/18
70
20/70
6/21
65
20/80
6/24
60

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20/100
Table
2.—
Chart
of
Visual
Fields

6/30

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impairment that meets the criteria of these listings. Even if an individual does not show that his
or her impairment meets the criteria of these listings, the individual may have an impairment(s)
equivalent in severity to one of the listed impairments or be disabled because of a limited
residual functional capacity. Unless the claim can be decided favorably on the basis of the
current evidence, a longitudinal record is still important because it will provide information
about such things as the ongoing medical severity of the impairment, the level of the
individual's functioning, and the frequency, severity, and duration of symptoms. Also, the
asthma listing specifically includes a requirement for continuing signs and symptoms despite a
regimen of prescribed treatment.
Impairments caused by chronic disorders of the respiratory system generally produce
irreversible loss of pulmonary function due to ventilatory impairments, gas exchange
abnormalities, or a combination of both. The most common symptoms attributable to these
disorders are dyspnea on exertion, cough, wheezing, sputum production, hemoptysis, and
chest pain. Because these symptoms are common to many other diseases, a thorough
medical history, physical examination, and chest x-ray or other appropriate imaging technique
are required to establish chronic pulmonary disease. Pulmonary function testing is required to
assess the severity of the respiratory impairment once a disease process is established by
appropriate clinical and laboratory findings.
Alterations of pulmonary function can be due to obstructive airway disease (e.g., emphysema,
chronic bronchitis, asthma), restrictive pulmonary disorders with primary loss of lung volume
(e.g., pulmonary resection, thoracoplasty, chest cage deformity as in kyphoscoliosis or
obesity), or infiltrative interstitial disorders (e.g., diffuse pulmonary fibrosis). Gas exchange
abnormalities without significant airway obstruction can be produced by interstitial disorders.
Disorders involving the pulmonary circulation (e.g., primary pulmonary hypertension, recurrent
thromboembolic disease, primary or secondary pulmonary vasculitis) can produce pulmonary
vascular hypertension and, eventually, pulmonary heart disease (cor pulmonale) and right
heart failure. Persistent hypoxemia produced by any chronic pulmonary disorder also can
result in chronic pulmonary hypertension and right heart failure. Chronic infection, caused most
frequently by mycobacterial or mycotic organisms, can produce extensive and progressive
lung destruction resulting in marked loss of pulmonary function. Some disorders, such as
bronchiectasis, cystic fibrosis, and asthma, can be associated with intermittent exacerbations
of such frequency and intensity that they produce a disabling impairment, even when
pulmonary function during periods of relative clinical stability is relatively well-maintained.
Respiratory impairments usually can be evaluated under these listings on the basis of a
complete medical history, physical examination, a chest x-ray or other appropriate imaging
techniques, and spirometric pulmonary function tests. In some situations, most typically with a
diagnosis of diffuse interstitial fibrosis or clinical findings suggesting cor pulmonale, such as
cyanosis or secondary polycythemia, an impairment may be underestimated on the basis of
spirometry alone. More sophisticated pulmonary function testing may then be necessary to
determine if gas exchange abnormalities contribute to the severity of a respiratory impairment.
Additional testing might include measurement of diffusing capacity of the lungs for carbon
monoxide or resting arterial blood gases. Measurement of arterial blood gases during exercise
is required infrequently. In disorders of the pulmonary circulation, right heart catheterization
with angiography and/or direct measurement of pulmonary artery pressure may have been
done to establish a diagnosis and evaluate severity. When performed, the results of the
procedure should be obtained. Cardiac catheterization will not be purchased.

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These listings are examples of common respiratory disorders that are severe enough to
prevent a person from engaging in any gainful activity. When an individual has a medically
determinable impairment that is not listed, an impairment which does not meet a listing, or a
combination of impairments no one of which meets a listing, we will consider whether the
individual's impairment or combination of impairments is medically equivalent in severity to a
listed impairment. Individuals who have an impairment(s) with a level of severity which does
not meet or equal the criteria of the listings may or may not have the residual functional
capacity (RFC) which would enable them to engage in substantial gainful activity. Evaluation of
the impairment(s) of these individuals will proceed through the final steps of the sequential
evaluation process.
B. Mycobacterial, mycotic, and other chronic persistent infections of the lung. These disorders
are evaluated on the basis of the resulting limitations in pulmonary function. Evidence of
chronic infections, such as active mycobacterial diseases or mycoses with positive cultures,
drug resistance, enlarging parenchymal lesions, or cavitation, is not, by itself, a basis for
determining that an individual has a disabling impairment expected to last 12 months. In those
unusual cases of pulmonary infection that persist for a period approaching 12 consecutive
months, the clinical findings, complications, therapeutic considerations, and prognosis must be
carefully assessed to determine whether, despite relatively well-maintained pulmonary
function, the individual nevertheless has an impairment that is expected to last for at least 12
consecutive months and prevent gainful activity.
C. Episodic respiratory disease. When a respiratory impairment is episodic in nature, as can
occur with exacerbations of asthma, cystic fibrosis, bronchiectasis, or chronic asthmatic
bronchitis, the frequency and intensity of episodes that occur despite prescribed treatment are
often the major criteria for determining the level of impairment. Documentation for these
exacerbations should include available hospital, emergency facility and/or physician records
indicating the dates of treatment; clinical and laboratory findings on presentation, such as the
results of spirometry and arterial blood gas studies (ABGS); the treatment administered; the
time period required for treatment; and the clinical response. Attacks of asthma, episodes of
bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum), or respiratory
failure as referred to in paragraph B of 3.03, 3.04, and 3.07, are defined as prolonged
symptomatic episodes lasting one or more days and requiring intensive treatment, such as
intravenous bronchodilator or antibiotic administration or prolonged inhalational bronchodilator
therapy in a hospital, emergency room or equivalent setting. Hospital admissions are defined
as inpatient hospitalizations for longer than 24 hours. The medical evidence must also include
information documenting adherence to a prescribed regimen of treatment as well as a
description of physical signs. For asthma, the medical evidence should include spirometric
results obtained between attacks that document the presence of baseline airflow obstruction.
D. Cystic fibrosis is a disorder that affects either the respiratory or digestive body systems or
both and is responsible for a wide and variable spectrum of clinical manifestations and
complications. Confirmation of the diagnosis is based upon an elevated sweat sodium
concentration or chloride concentration accompanied by one or more of the following: the
presence of chronic obstructive pulmonary disease, insufficiency of exocrine pancreatic
function, meconium ileus, or a positive family history. The quantitative pilocarpine
iontophoresis procedure for collection of sweat content must be utilized. Two methods are
acceptable: the "Procedure for the Quantitative Iontophoretic Sweat Test for Cystic Fibrosis"
published by the Cystic Fibrosis Foundation and contained in, "A Test for Concentration of
Electrolytes in Sweat in Cystic Fibrosis of the Pancreas Utilizing Pilocarpine Iontophoresis,"

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Gibson, I.E., and Cooke, R.E., Pediatrics, Vol. 23: 545, 1959; or the "Wescor Macroduct
System." To establish the diagnosis of cystic fibrosis, the sweat sodium or chloride content
must be analyzed quantitatively using an acceptable laboratory technique. Another diagnostic
test is the "CF gene mutation analysis" for homozygosity of the cystic fibrosis gene. The
pulmonary manifestations of this disorder should be evaluated under 3.04. The nonpulmonary
aspects of cystic fibrosis should be evaluated under the digestive body system (5.00). Because
cystic fibrosis may involve the respiratory and digestive body systems, the combined effects of
the involvement of these body systems must be considered in case adjudication.
E. Documentation of pulmonary function testing. The results of spirometry that are used for
adjudication under paragraphs A and B of 3.02 and paragraph A of 3.04 should be expressed
in liters (L), body temperature and pressure saturated with water vapor (BTPS). The reported
one-second forced expiratory volume (FEV1) and forced vital capacity (FVC) should represent
the largest of at least three satisfactory forced expiratory maneuvers. Two of the satisfactory
spirograms should be reproducible for both pre-bronchodilator tests and, if indicated, postbronchodilator tests. A value is considered reproducible if it does not differ from the largest
value by more than 5 percent or 0.1 L, whichever is greater. The highest values of the FEV1
and FVC, whether from the same or different tracings, should be used to assess the severity of
the respiratory impairment. Peak flow should be achieved early in expiration, and the
spirogram should have a smooth contour with gradually decreasing flow throughout expiration.
The zero time for measurement of the FEV1 and FVC, if not distinct, should be derived by
linear back-extrapolation of peak flow to zero volume. A spirogram is satisfactory for
measurement of the FEV1 if the expiratory volume at the back-extrapolated zero time is less
than 5 percent of the FVC or 0.1 L, whichever is greater. The spirogram is satisfactory for
measurement of the FVC if maximal expiratory effort continues for at least 6 seconds, or if
there is a plateau in the volume-time curve with no detectable change in expired volume (VE)
during the last 2 seconds of maximal expiratory effort.
Spirometry should be repeated after administration of an aerosolized bronchodilator under
supervision of the testing personnel if the pre-bronchodilator FEV1 value is less than 70
percent of the predicted normal value. Pulmonary function studies should not be performed
unless the clinical status is stable (e.g., the individual is not having an asthmatic attack or
suffering from an acute respiratory infection or other chronic illness). Wheezing is common in
asthma, chronic bronchitis, or chronic obstructive pulmonary disease and does not preclude
testing. The effect of the administered bronchodilator in relieving bronchospasm and improving
ventilatory function is assessed by spirometry. If a bronchodilator is not administered, the
reason should be clearly stated in the report. Pulmonary function studies performed to assess
airflow obstruction without testing after bronchodilators cannot be used to assess levels of
impairment in the range that prevents any gainful work activity, unless the use of
bronchodilators is contraindicated. Post-bronchodilator testing should be performed 10 minutes
after bronchodilator administration. The dose and name of the bronchodilator administered
should be specified. The values in paragraphs A and B of 3.02 must only be used as criteria
for the level of ventilatory impairment that exists during the individual's most stable state of
health (i.e., any period in time except during or shortly after an exacerbation).
The appropriately labeled spirometric tracing, showing the claimant's name, date of testing,
distance per second on the abscissa and distance per liter (L) on the ordinate, must be
incorporated into the file. The manufacturer and model number of the device used to measure
and record the spirogram should be stated. The testing device must accurately measure both

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time and volume, the latter to within 1 percent of a 3 L calibrating volume. If the spirogram was
generated by any means other than direct pen linkage to a mechanical displacement-type
spirometer, the testing device must have had a recorded calibration performed previously on
the day of the spirometric measurement.
If the spirometer directly measures flow, and volume is derived by electronic integration, the
linearity of the device must be documented by recording volume calibrations at three different
flow rates of approximately 30 L/min (3 L/6 sec), 60 L/min (3 L/3 sec), and 180 L/min (3 L/sec).
The volume calibrations should agree to within 1 percent of a 3 L calibrating volume. The
proximity of the flow sensor to the individual should be noted, and it should be stated whether
or not a BTPS correction factor was used for the calibration recordings and for the individual's
actual spirograms.
The spirogram must be recorded at a speed of at least 20 mm/sec, and the recording device
must provide a volume excursion of at least 10 mm/L. If reproductions of the original
spirometric tracings are submitted, they must be legible and have a time scale of at least 20
mm/sec and a volume scale of at least 10 mm/L to permit independent measurements.
Calculation of FEV1 from a flow-volume tracing is not acceptable, i.e., the spirogram and
calibrations must be presented in a volume-time format at a speed of at least 20 mm/sec and a
volume excursion of at least 10 mm/L to permit independent evaluation.
A statement should be made in the pulmonary function test report of the individual's ability to
understand directions as well as his or her effort and cooperation in performing the pulmonary
function tests.
The pulmonary function tables in 3.02 and 3.04 are based on measurement of standing height
without shoes. If an individual has marked spinal deformities (e.g., kyphoscoliosis), the
measured span between the fingertips with the upper extremities abducted 90 degrees should
be substituted for height when this measurement is greater than the standing height without
shoes.
F. Documentation of chronic impairment of gas exchange.
1. Diffusing capacity of the lungs for carbon monoxide (DLCO). A diffusing capacity of the
lungs for carbon monoxide study should be purchased in cases in which there is
documentation of chronic pulmonary disease, but the existing evidence, including properly
performed spirometry, is not adequate to establish the level of functional impairment. Before
purchasing DLCO measurements, the medical history, physical examination, reports of chest
x-ray or other appropriate imaging techniques, and spirometric test results must be obtained
and reviewed because favorable decisions can often be made based on available evidence
without the need for DLCO studies. Purchase of a DLCO study may be appropriate when there
is a question of whether an impairment meets or is equivalent in severity to a listing, and the
claim cannot otherwise be favorably decided.
The DLCO should be measured by the single breath technique with the individual relaxed and
seated. At sea level, the inspired gas mixture should contain approximately 0.3 percent carbon
monoxide (CO), 10 percent helium (He), 21 percent oxygen (O2), and the balance nitrogen. At
altitudes above sea level, the inspired O2 concentration may be raised to provide an inspired
O2 tension of approximately 150 mm Hg. Alternatively, the sea level mixture may be employed

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at altitude and the measured DLCO corrected for ambient barometric pressure. Helium may be
replaced by another inert gas at an appropriate concentration. The inspired volume (VI) during
the DLCO maneuver should be at least 90 percent of the previously determined vital capacity
(VC). The inspiratory time for the VI should be less than 2 seconds, and the breath-hold time
should be between 9 and 11 seconds. The washout volume should be between 0.75 and 1.00
L, unless the VC is less than 2 L. In this case, the washout volume may be reduced to 0.50 L;
any such change should be noted in the report. The alveolar sample volume should be
between 0.5 and 1.0 L and be collected in less than 3 seconds. At least 4 minutes should be
allowed for gas washout between repeat studies.
A DLCO should be reported in units of ml CO, standard temperature, pressure, dry
(STPD)/min/mm Hg uncorrected for hemoglobin concentration and be based on a singlebreath alveolar volume determination. Abnormal hemoglobin or hematocrit values, and/or
carboxyhemoglobin levels should be reported along with diffusing capacity.
The DLCO value used for adjudication should represent the mean of at least two acceptable
measurements, as defined above. In addition, two acceptable tests should be within 10
percent of each other or 3 ml CO(STPD)/min/mm Hg, whichever is larger. The percent
difference should be calculated as 100×(test 1-test 2)/average DLCO.
The ability of the individual to follow directions and perform the test properly should be
described in the written report. The report should include tracings of the VI, breath-hold
maneuver, and VE appropriately labeled with the name of the individual and the date of the
test. The time axis should be at least 20 mm/sec and the volume axis at least 10 mm/L. The
percentage concentrations of inspired O2 and inspired and expired CO and He for each of the
maneuvers should be provided. Sufficient data must be provided, including documentation of
the source of the predicted equation, to permit verification that the test was performed
adequately, and that, if necessary, corrections for anemia or carboxyhemoglobin were made
appropriately.
2. Arterial blood gas studies (ABGS). An ABGS performed at rest (while breathing room air,
awake and sitting or standing) or during exercise should be analyzed in a laboratory certified
by a State or Federal agency. If the laboratory is not certified, it must submit evidence of
participation in a national proficiency testing program as well as acceptable quality control at
the time of testing. The report should include the altitude of the facility and the barometric
pressure on the date of analysis.
Purchase of resting ABGS may be appropriate when there is a question of whether an
impairment meets or is equivalent in severity to a listing, and the claim cannot otherwise be
favorably decided. If the results of a DLCO study are greater than 40 percent of predicted
normal but less than 60 percent of predicted normal, purchase of resting ABGS should be
considered. Before purchasing resting ABGS, a program physician, preferably one
experienced in the care of patients with pulmonary disease, must review all clinical and
laboratory data short of this procedure, including spirometry, to determine whether obtaining
the test would present a significant risk to the individual.
3. Exercise testing. Exercise testing with measurement of arterial blood gases during exercise
may be appropriate in cases in which there is documentation of chronic pulmonary disease,
but full development, short of exercise testing, is not adequate to establish if the impairment
meets or is equivalent in severity to a listing, and the claim cannot otherwise be favorably

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decided. In this context, "full development" means that results from spirometry and
measurement of DLCO and resting ABGS have been obtained from treating sources or
through purchase. Exercise arterial blood gas measurements will be required infrequently and
should be purchased only after careful review of the medical history, physical examination,
chest x-ray or other appropriate imaging techniques, spirometry, DLCO, electrocardiogram
(ECG), hematocrit or hemoglobin, and resting blood gas results by a program physician,
preferably one experienced in the care of patients with pulmonary disease, to determine
whether obtaining the test would presents a significant risk to the individual. Oximetry and
capillary blood gas analysis are not acceptable substitutes for the measurement of arterial
blood gases. Arterial blood gas samples obtained after the completion of exercise are not
acceptable for establishing an individual's functional capacity.
Generally, individuals with a DLCO greater than 60 percent of predicted normal would not be
considered for exercise testing with measurement of blood gas studies. The exercise test
facility must be provided with the claimant's clinical records, reports of chest x-ray or other
appropriate imaging techniques, and any spirometry, DLCO, and resting blood gas results
obtained as evidence of record. The testing facility must determine whether exercise testing
present a significant risk to the individual; if it does, the reason for not performing the test must
be reported in writing.
4. Methodology. Individuals considered for exercise testing first should have resting arterial
blood partial pressure of oxygen (PO2), resting arterial blood partial pressure of carbon dioxide
(PCO2) and negative log of hydrogen ion concentration (pH) determinations by the testing
facility. The sample should be obtained in either the sitting or standing position. The individual
should then perform exercise under steady state conditions, preferably on a treadmill,
breathing room air, for a period of 4 to 6 minutes at a speed and grade providing an oxygen
consumption of approximately 17.5 ml/kg/min (5 METs). If a bicycle ergometer is used, an
exercise equivalent of 5 METs (e.g., 450 kpm/min, or 75 watts, for a 176 pound (80 kilogram)
person) should be used. If the individual is able to complete this level of exercise without
achieving listing-level hypoxemia, then he or she should be exercised at higher workloads to
determine exercise capacity. A warm-up period of treadmill walking or cycling may be
performed to acquaint the individual with the exercise procedure. If during the warm-up period
the individual cannot achieve an exercise level of 5 METs, a lower workload may be selected
in keeping with the estimate of exercise capacity. The individual should be monitored by ECG
throughout the exercise and in the immediate post-exercise period. Blood pressure and an
ECG should be recorded during each minute of exercise. During the final 2 minutes of a
specific level of steady state exercise, an arterial blood sample should be drawn and analyzed
for oxygen pressure (or tension) (PO2), carbon dioxide pressure (or tension) (PCO2), and pH.
At the discretion of the testing facility, the sample may be obtained either from an indwelling
arterial catheter or by direct arterial puncture. If possible, in order to evaluate exercise capacity
more accurately, a test site should be selected that has the capability to measure minute
ventilation, O2 consumption, and carbon dioxide (CO2) production. If the claimant fails to
complete 4 to 6 minutes of steady state exercise, the testing laboratory should comment on the
reason and report the actual duration and levels of exercise performed. This comment is
necessary to determine if the individual's test performance was limited by lack of effort or other
impairment (e.g., cardiac, peripheral vascular, musculoskeletal, neurological).
The exercise test report should contain representative ECG strips taken before, during and
after exercise; resting and exercise arterial blood gas values; treadmill speed and grade

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settings, or, if a bicycle ergometer was used, exercise levels expressed in watts or kpm/min;
and the duration of exercise. Body weight also should be recorded. If measured, O2
consumption (STPD), minute ventilation (BTPS), and CO2 production (STPD) also should be
reported. The altitude of the test site, its normal range of blood gas values, and the barometric
pressure on the test date must be noted.
G. Chronic cor pulmonale and pulmonary vascular disease. The establishment of an
impairment attributable to irreversible cor pulmonale secondary to chronic pulmonary
hypertension requires documentation by signs and laboratory findings of right ventricular
overload or failure (e.g., an early diastolic right-sided gallop on auscultation, neck vein
distension, hepatomegaly, peripheral edema, right ventricular outflow tract enlargement on xray or other appropriate imaging techniques, right ventricular hypertrophy on ECG, and
increased pulmonary artery pressure measured by right heart catheterization available from
treating sources). Cardiac catheterization will not be purchased. Because hypoxemia may
accompany heart failure and is also a cause of pulmonary hypertension, and may be
associated with hypoventilation and respiratory acidosis, arterial blood gases may demonstrate
hypoxemia (decreased PO2), CO2 retention (increased PCO2), and acidosis (decreased pH).
Polycythemia with an elevated red blood cell count and hematocrit may be found in the
presence of chronic hypoxemia.
P-pulmonale on the ECG does not establish chronic pulmonary hypertension or chronic cor
pulmonale. Evidence of florid right heart failure need not be present at the time of adjudication
for a listing (e.g., 3.09) to be satisfied, but the medical evidence of record should establish that
cor pulmonale is chronic and irreversible.
H. Sleep-related breathing disorders. Sleep-related breathing disorders (sleep apneas) are
caused by periodic cessation of respiration associated with hypoxemia and frequent arousals
from sleep. Although many individuals with one of these disorders will respond to prescribed
treatment, in some, the disturbed sleep pattern and associated chronic nocturnal hypoxemia
cause daytime sleepiness with chronic pulmonary hypertension and/or disturbances in
cognitive function. Because daytime sleepiness can affect memory, orientation, and
personality, a longitudinal treatment record may be needed to evaluate mental functioning. Not
all individuals with sleep apnea develop a functional impairment that affects work activity.
When any gainful work is precluded, the physiologic basis for the impairment may be chronic
cor pulmonale. Chronic hypoxemia due to episodic apnea may cause pulmonary hypertension
(see 3.00G and 3.09). Daytime somnolence may be associated with disturbance in cognitive
vigilance. Impairment of cognitive function may be evaluated under organic mental disorders
(12.02).
I. Effects of obesity. Obesity is a medically determinable impairment that is often associated
with disturbance of the respiratory system, and disturbance of this system can be a major
cause of disability in individuals with obesity. The combined effects of obesity with respiratory
impairments can be greater than the effects of each of the impairments considered separately.
Therefore, when determining whether an individual with obesity has a listing-level impairment
or combination of impairments, and when assessing a claim at other steps of the sequential
evaluation process, including when assessing an individual's residual functional capacity,
adjudicators must consider any additional and cumulative effects of obesity.
3.01 Category of Impairments, Respiratory System.

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3.02 Chronic pulmonary insufficiency.
A. Chronic obstructive pulmonary disease, due to any cause, with the FEV1 equal to or less
than the values specified in table I corresponding to the person's height without shoes. (In
cases of marked spinal deformity, see 3.00E.);
Table I
FEV1 equal to or less than (L,
Height without shoes
Height without shoes
(centimeters)
(inches)
BTPS)
154 or less
60 or less
1.05
155-160
61-63
1.15
161-165
64-65
1.25
166-170
66-67
1.35
171-175
68-69
1.45
176-180
70-71
1.55
181 or more
72 or more
1.65
Or
B. Chronic restrictive ventilatory disease, due to any cause, with the FVC equal to or less than
the values specified in table II corresponding to the person's height without shoes. (In cases of
marked spinal deformity, see 3.00E.);
Table II
Height without shoes
Height without shoes
FVC equal to or less than (L,
(centimeters)
(inches)
BTPS)
154 or less
60 or less
1.25
155-160
61-63
1.35
161-165
64-65
1.45
166-170
66-67
1.55
171-175
68-69
1.65
176-180
70-71
1.75
181 or more
72 or more
1.85
Or
C. Chronic impairment of gas exchange due to clinically documented pulmonary disease. With:
1. Single breath DLCO (see 3.00F1) less than 10.5 ml/min/mm Hg or less than 40 percent of
the predicted normal value. (Predicted values must either be based on data obtained at the
test site or published values from a laboratory using the same technique as the test site. The
source of the predicted values should be reported. If they are not published, they should be
submitted in the form of a table or nomogram); or
2. Arterial blood gas values of PO2 and simultaneously determined PCO2 measured while at
rest (breathing room air, awake and sitting or standing) in a clinically stable condition on at
least two occasions, three or more weeks apart within a 6-month period, equal to or less than

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the values specified in the applicable table III-A or III-B or III-C:
Table III—A
[Applicable at test sites less than 3,000 feet above sea level]

Arterial PCO2 (mm. Hg) and Arterial PO2 equal to or less than (mm. Hg)
30 or below
31
32
33
34
35
36
37
38
39
40 or above

65
64
63
62
61
60
59
58
57
56
55
Table III—B

[Applicable at test sites 3,000 through 6,000 feet above sea level]

Arterial PCO2 (mm. Hg) and Arterial PO2 equal to or less than (mm. Hg)
30 or below
31
32
33
34
35
36
37
38
39
40 or above

60
59
58
57
56
55
54
53
52
51
50
Table III—C
[Applicable at test sites over 6,000 feet above sea level]

Arterial PCO2 (mm. Hg) and Arterial PO2 or equal to or less than (mm. Hg)
30 or below
31
32
33
34
35
36
37
38

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55
54
53
52
51
50
49
48
47

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39
40 or above

46
45

Or
3. Arterial blood gas values of PO2 and simultaneously determined PCO2 during steady state
exercise breathing room air (level of exercise equivalent to or less than 17.5 ml O2
consumption/kg/min or 5 METs) equal to or less than the values specified in the applicable
table III-A or III-B or III-C in 3.02C2.
3.03 Asthma. With:
A. Chronic asthmatic bronchitis. Evaluate under the criteria for chronic obstructive pulmonary
disease in 3.02A;
Or
B. Attacks (as defined in 3.00C), in spite of prescribed treatment and requiring physician
intervention, occurring at least once every 2 months or at least six times a year. Each inpatient hospitalization for longer than 24 hours for control of asthma counts as two attacks, and
an evaluation period of at least 12 consecutive months must be used to determine the
frequency of attacks.
3.04 Cystic fibrosis. With:
A. An FEV1 equal to or less than the appropriate value specified in table IV corresponding to
the individual's height without shoes. (In cases of marked spinal deformity, see 3.00E.);
Or
B. Episodes of bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum) or
respiratory failure (documented according to 3.00C), requiring physician intervention, occurring
at least once every 2 months or at least six times a year. Each inpatient hospitalization for
longer than 24 hours for treatment counts as two episodes, and an evaluation period of at least
12 consecutive months must be used to determine the frequency of episodes;
Or
C. Persistent pulmonary infection accompanied by superimposed, recurrent, symptomatic
episodes of increased bacterial infection occurring at least once every 6 months and requiring
intravenous or nebulization antimicrobial therapy.
Table IV
[Applicable only for evaluation under 3.04A—cystic fibrosis]

Height without shoes
(centimeters)
154 or less
155-159

Height without shoes
(inches)
60 or less
61-62

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FEV1 equal to or less than (L,
BTPS)
1.45
1.55

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160-164
165-169
170-174
175-179
180 or more

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63-64
65-66
67-68
69-70
71 or more

1.65
1.75
1.85
1.95
2.05

3.05 [Reserved]
3.06 Pneumoconiosis (demonstrated by appropriate imaging techniques). Evaluate under the
appropriate criteria in 3.02.
3.07 Bronchiectasis (demonstrated by appropriate imaging techniques). With:
A. Impairment of pulmonary function due to extensive disease. Evaluate under the appropriate
criteria in 3.02;
Or
B. Episodes of bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum) or
respiratory failure (documented according to 3.00C), requiring physician intervention, occurring
at least once every 2 months or at least six times a year. Each in-patient hospitalization for
longer than 24 hours for treatment counts as two episodes, and an evaluation of at least 12
consecutive months must be used to determine the frequency of episodes.
3.08 Mycobacterial, mycotic, and other chronic persistent infections of the lung (see 3.00B).
Evaluate under the appropriate criteria in 3.02.
3.09 Cor pulmonale secondary to chronic pulmonary vascular hypertension. Clinical evidence
of cor pulmonale (documented according to 3.00G) with:
A. Mean pulmonary artery pressure greater than 40 mm Hg;
Or
B. Arterial hypoxemia. Evaluate under the criteria in 3.02C2.
3.10 Sleep-related breathing disorders. Evaluate under 3.09 (chronic cor pulmonale) or 12.02
(organic mental disorders).
3.11 Lung transplant. Consider under a disability for 12 months following the date of surgery;
thereafter, evaluate the residual impairment.
4.00 Cardiovascular System
A. General
1. What do we mean by a cardiovascular impairment?

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a. We mean any disorder that affects the proper functioning of the heart or the circulatory
system (that is, arteries, veins, capillaries, and the lymphatic drainage). The disorder can be
congenital or acquired.
b. Cardiovascular impairment results from one or more of four consequences of heart disease:
(i) Chronic heart failure or ventricular dysfunction.
(ii) Discomfort or pain due to myocardial ischemia, with or without necrosis of heart muscle.
(iii) Syncope, or near syncope, due to inadequate cerebral perfusion from any cardiac cause,
such as obstruction of flow or disturbance in rhythm or conduction resulting in inadequate
cardiac output.
(iv) Central cyanosis due to right-to-left shunt, reduced oxygen concentration in the arterial
blood, or pulmonary vascular disease.
c. Disorders of the veins or arteries (for example, obstruction, rupture, or aneurysm) may
cause impairments of the lower extremities (peripheral vascular disease), the central nervous
system, the eyes, the kidneys, and other organs. We will evaluate peripheral vascular disease
under 4.11 or 4.12 and impairments of another body system(s) under the listings for that body
system(s).
2. What do we consider in evaluating cardiovascular impairments? The listings in this section
describe cardiovascular impairments based on symptoms, signs, laboratory findings, response
to a regimen of prescribed treatment, and functional limitations.
3. What do the following terms or phrases mean in these listings?
a. Medical consultant is an individual defined in §§404.1616(a) and 416.1016(a). This term
does not include medical sources who provide consultative examinations for us. We use the
abbreviation "MC" throughout this section to designate a medical consultant.
b. Persistent means that the longitudinal clinical record shows that, with few exceptions, the
required finding(s) has been present, or is expected to be present, for a continuous period of at
least 12 months, such that a pattern of continuing severity is established.
c. Recurrent means that the longitudinal clinical record shows that, within a consecutive 12month period, the finding(s) occurs at least three times, with intervening periods of
improvement of sufficient duration that it is clear that separate events are involved.
d. Appropriate medically acceptable imaging means that the technique used is the proper one
to evaluate and diagnose the impairment and is commonly recognized as accurate for
assessing the cited finding.
e. A consecutive 12-month period means a period of 12 consecutive months, all or part of
which must occur within the period we are considering in connection with an application or
continuing disability review.
f. Uncontrolled means the impairment does not adequately respond to standard prescribed

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medical treatment.
B. Documenting Cardiovascular Impairment
1. What basic documentation do we need? We need sufficiently detailed reports of history,
physical examinations, laboratory studies, and any prescribed treatment and response to allow
us to assess the severity and duration of your cardiovascular impairment. A longitudinal clinical
record covering a period of not less than 3 months of observations and treatment is usually
necessary, unless we can make a determination or decision based on the current evidence.
2. Why is a longitudinal clinical record important? We will usually need a longitudinal clinical
record to assess the severity and expected duration of your impairment(s). If you have a
listing-level impairment, you probably will have received medically prescribed treatment.
Whenever there is evidence of such treatment, your longitudinal clinical record should include
a description of the ongoing management and evaluation provided by your treating or other
medical source. It should also include your response to this medical management, as well as
information about the nature and severity of your impairment. The record will provide us with
information on your functional status over an extended period of time and show whether your
ability to function is improving, worsening, or unchanging.
3. What if you have not received ongoing medical treatment?
a. You may not have received ongoing treatment or have an ongoing relationship with the
medical community despite the existence of a severe impairment(s). In this situation, we will
base our evaluation on the current objective medical evidence and the other evidence we
have. If you do not receive treatment, you cannot show an impairment that meets the criteria of
most of these listings. However, we may find you disabled because you have another
impairment(s) that in combination with your cardiovascular impairment medically equals the
severity of a listed impairment or based on consideration of your residual functional capacity
and age, education, and work experience.
b. Unless we can decide your claim favorably on the basis of the current evidence, a
longitudinal record is still important. In rare instances where there is no or insufficient
longitudinal evidence, we may purchase a consultative examination(s) to help us establish the
severity and duration of your impairment.
4. When will we wait before we ask for more evidence?
a. We will wait when we have information showing that your impairment is not yet stable and
the expected change in your impairment might affect our determination or decision. In these
situations, we need to wait to properly evaluate the severity and duration of your impairment
during a stable period. Examples of when we might wait are:
(i) If you have had a recent acute event; for example, a myocardial infarction (heart attack).
(ii) If you have recently had a corrective cardiac procedure; for example, coronary artery
bypass grafting.
(iii) If you have started new drug therapy and your response to this treatment has not yet been
established; for example, beta-blocker therapy for dilated congestive cardiomyopathy.

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b. In these situations, we will obtain more evidence 3 months following the event before we
evaluate your impairment. However, we will not wait if we have enough information to make a
determination or decision based on all of the relevant evidence in your case.
5. Will we purchase any studies? In appropriate situations, we will purchase studies necessary
to substantiate the diagnosis or to document the severity of your impairment, generally after
we have evaluated the medical and other evidence we already have. We will not purchase
studies involving exercise testing if there is significant risk involved or if there is another
medical reason not to perform the test. We will follow sections 4.00C6, 4.00C7, and 4.00C8
when we decide whether to purchase exercise testing.
6. What studies will we not purchase? We will not purchase any studies involving cardiac
catheterization, such as coronary angiography, arteriograms, or electrophysiological studies.
However, if the results of catheterization are part of the existing evidence we have, we will
consider them together with the other relevant evidence. See 4.00C15a.
C. Using Cardiovascular Test Results
1. What is an ECG?
a. ECG stands for electrocardiograph or electrocardiogram. An electrocardiograph is a
machine that records electrical impulses of your heart on a strip of paper called an
electrocardiogram or a tracing. To record the ECG, a technician positions a number of small
contacts (or leads) on your arms, legs, and across your chest to connect them to the ECG
machine. An ECG may be done while you are resting or exercising.
b. The ECG tracing may indicate that you have a heart abnormality. It may indicate that your
heart muscle is not getting as much oxygen as it needs (ischemia), that your heart rhythm is
abnormal (arrhythmia), or that there are other abnormalities of your heart, such as left
ventricular enlargement.
2. How do we evaluate ECG evidence? We consider a number of factors when we evaluate
ECG evidence:
a. An original or legible copy of the 12-lead ECG obtained at rest must be appropriately dated
and labeled, with the standardization inscribed on the tracing. Alteration in standardization of
specific leads (such as to accommodate large QRS amplitudes) must be identified on those
leads.
(i) Detailed descriptions or computer-averaged signals without original or legible copies of the
ECG as described in listing 4.00C2a are not acceptable.
(ii) The effects of drugs or electrolyte abnormalities must be considered as possible noncardiac
causes of ECG abnormalities of ventricular repolarization; that is, those involving the ST
segment and T wave. If available, the predrug (especially digitalis glycosides) ECG should be
submitted.
b. ECGs obtained in conjunction with treadmill, bicycle, or arm exercise tests should meet the
following specifications:

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(i) ECG reports must include the original calibrated ECG tracings or a legible copy.
(ii) A 12-lead baseline ECG must be recorded in the upright position before exercise.
(iii) A 12-lead ECG should be recorded at the end of each minute of exercise.
(iv) If ECG documentation of the effects of hyperventilation is obtained, the exercise test
should be deferred for at least 10 minutes because metabolic changes of hyperventilation may
alter the physiologic and ECG-recorded response to exercise.
(v) Post-exercise ECGs should be recorded using a generally accepted protocol consistent
with the prevailing state of medical knowledge and clinical practice.
(vi) All resting, exercise, and recovery ECG strips must have the standardization inscribed on
the tracing. The ECG strips should be labeled to indicate the date, the times recorded and the
relationship to the stage of the exercise protocol. The speed and grade (treadmill test) or work
rate (bicycle or arm ergometric test) should be recorded. The highest level of exercise
achieved, heart rate and blood pressure levels during testing, and the reason(s) for terminating
the test (including limiting signs or symptoms) must be recorded.
3. What are exercise tests and what are they used for?
a. Exercise tests have you perform physical activity and record how your cardiovascular
system responds. Exercise tests usually involve walking on a treadmill, but other forms of
exercise, such as an exercise bicycle or an arm exercise machine, may be used. Exercise
testing may be done for various reasons; such as to evaluate the severity of your coronary
artery disease or peripheral vascular disease or to evaluate your progress after a cardiac
procedure or an acute event, like a myocardial infarction (heart attack). Exercise testing is the
most widely used testing for identifying the presence of myocardial ischemia and for estimating
maximal aerobic capacity (usually expressed in METs—metabolic equivalents) if you have
heart disease.
b. We include exercise tolerance test (ETT) criteria in 4.02B3 (chronic heart failure) and 4.04A
(ischemic heart disease). To meet the ETT criteria in these listings, the ETT must be a sign-or
symptom-limited test in which you exercise while connected to an ECG until you develop a
sign or symptom that indicates that you have exercised as much as is considered safe for you.
c. In 4.12B, we also refer to exercise testing for peripheral vascular disease. In this test, you
walk on a treadmill, usually for a specified period of time, and the individual who administers
the test measures the effect of exercise on the flow of blood in your legs, usually by using
ultrasound. The test is also called an exercise Doppler test. Even though this test is intended
to evaluate peripheral vascular disease, it will be stopped for your safety if you develop
abnormal signs or symptoms because of heart disease.
d. Each type of test is done in a certain way following specific criteria, called a protocol. For our
program, we also specify certain aspects of how any exercise test we purchase is to be done.
See 4.00C10 and 4.00C17.
4. Do ETTs have limitations? An ETT provides an estimate of aerobic capacity for walking on a
grade, bicycling, or moving one's arms in an environmentally controlled setting. Therefore, ETT

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results do not correlate with the ability to perform other types of exertional activities, such as
lifting and carrying heavy loads, and do not provide an estimate of the ability to perform
activities required for work in all possible work environments or throughout a workday. Also,
certain medications (such as beta blockers) and conduction disorders (such as left or right
bundle branch blocks) can cause false-negative or false-positive results. Therefore, we must
consider the results of an ETT together with all the other relevant evidence in your case
record.
5. How does an ETT with measurement of maximal or peak oxygen uptake VO2) differ from
other ETTs? Occasionally, medical evidence will include the results of an ETT with VO2. While
ETTs without measurement of VO2 provide only an estimate of aerobic capacity, measured
maximal or peak oxygen uptake provides an accurate measurement of aerobic capacity, which
is often expressed in METs (metabolic equivalents). The MET level may not be indicated in the
report of attained maximal or peak VO2 testing, but can be calculated as follows: 1 MET = 3.5
milliliters (ml) of oxygen uptake per kilogram (kg) of body weight per minute. For example, a 70
kg (154 lb.) individual who achieves a maximal or peak VO2 of 1225 ml in 1 minute has
attained 5 METs (1225 ml/70 kg/1 min = 17.5 ml/kg/min. 17.5/3.5 = 5 METs).
6. When will we consider whether to purchase an exercise test?
a. We will consider whether to purchase an exercise test when:
(i) There is a question whether your cardiovascular impairment meets or medically equals the
severity of one of the listings, or there is no timely test in the evidence we have (see 4.00C9),
and we cannot find you disabled on some other basis; or
(ii) We need to assess your residual functional capacity and there is insufficient evidence in the
record to make a determination or decision.
b. We will not purchase an exercise test when we can make our determination or decision
based on the evidence we already have.
7. What must we do before purchasing an exercise test?
a. Before we purchase an exercise test, an MC, preferably one with experience in the care of
patients with cardiovascular disease, must review the pertinent history, physical examinations,
and laboratory tests that we have to determine whether the test would present a significant risk
to you or if there is some other medical reason not to purchase the test (see 4.00C8).
b. If you are under the care of a treating source (see §§404.1502 and 416.902) for a
cardiovascular impairment, this source has not performed an exercise test, and there are no
reported significant risks to testing, we will request a statement from that source explaining
why it was not done or should not be done before we decide whether we will purchase the test.
c. The MC, in accordance with the regulations and other instructions on consultative
examinations, will generally give great weight to the treating source's opinion about the risk of
exercise testing to you and will generally not override it. In the rare situation in which the MC
does override the treating source's opinion, the MC must prepare a written rationale

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documenting the reasons for overriding the opinion.
d. If you do not have a treating source or we cannot obtain a statement from your treating
source, the MC is responsible for assessing the risk to exercise testing based on a review of
the records we have before purchasing an exercise test for you.
e. We must also provide your records to the medical source who performs the exercise test for
review prior to conducting the test if the source does not already have them. The medical
source who performs the exercise test has the ultimate responsibility for deciding whether you
would be at risk.
8. When will we not purchase an exercise test or wait before we purchase an exercise test?
a. We will not purchase an exercise test when an MC finds that you have one of the following
significant risk factors:
(i) Unstable angina not previously stabilized by medical treatment.
(ii) Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise.
(iii) An implanted cardiac defibrillator.
(iv) Symptomatic severe aortic stenosis.
(v) Uncontrolled symptomatic heart failure.
(vi) Aortic dissection.
(vii) Severe pulmonary hypertension (pulmonary artery systolic pressure greater than 60 mm
Hg).
(viii) Left main coronary stenosis of 50 percent or greater that has not been bypassed.
(ix) Moderate stenotic valvular disease with a systolic gradient across the aortic valve of 50
mm Hg or greater.
(x) Severe arterial hypertension (systolic greater than 200 mm Hg or diastolic greater than 110
mm Hg).
(xi) Hypertrophic cardiomyopathy with a systolic gradient of 50 mm Hg or greater.
b. We also will not purchase an exercise test when you are prevented from performing
exercise testing due to another impairment affecting your ability to use your arms and legs.
c. We will not purchase an ETT to document the presence of a cardiac arrhythmia.
d. We will wait to purchase an exercise test until 3 months after you have had one of the
following events. This will allow for maximal, attainable restoration of functional capacity.

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(i) Acute myocardial infarction.
(ii) Surgical myocardial revascularization (bypass surgery).
(iii) Other open-heart surgical procedures.
(iv) Percutaneous transluminal coronary angioplasty with or without stenting.
e. If you are deconditioned after an extended period of bedrest or inactivity and could improve
with activity, or if you are in acute heart failure and are expected to improve with treatment, we
will wait an appropriate period of time for you to recuperate before we purchase an exercise
test.
9. What do we mean by a "timely" test?
a. We consider exercise test results to be timely for 12 months after the date they are
performed, provided there has been no change in your clinical status that may alter the
severity of your cardiovascular impairment.
b. However, an exercise test that is older than 12 months, especially an abnormal one, can still
provide information important to our adjudication. For example, a test that is more than 12
months old can provide evidence of ischemic heart disease or peripheral vascular disease,
information on decreased aerobic capacity, or information about the duration or onset of your
impairment. Such tests can be an important component of the longitudinal record.
c. When we evaluate a test that is more than 12 months old, we must consider the results in
the context of all the relevant evidence, including why the test was performed and whether
there has been an intervening event or improvement or worsening of your impairment.
d. We will purchase a new exercise test only if we cannot make a determination or decision
based on the evidence we have.
10. How must ETTs we purchase be performed?
a. The ETT must be a sign- or symptom-limited test characterized by a progressive multistage
regimen. It must be performed using a generally accepted protocol consistent with the
prevailing state of medical knowledge and clinical practice. A description of the protocol that
was followed must be provided, and the test must meet the requirements of 4.00C2b and this
section. A radionuclide perfusion scan may be useful for detecting or confirming ischemia
when resting ECG abnormalities, medications, or other factors may decrease the accuracy of
ECG interpretation of ischemia. (The perfusion imaging is done at the termination of exercise,
which may be at a higher MET level than that at which ischemia first occurs. If the imaging
confirms the presence of reversible ischemia, the exercise ECG may be useful for detecting
the MET level at which ischemia initially appeared.) Exercise tests may also be performed
using echocardiography to detect stress-induced ischemia and left ventricular dysfunction (see
4.00C12 and 4.00C13).
b. The exercise test must be paced to your capabilities and be performed following the
generally accepted standards for adult exercise test laboratories. With a treadmill test, the
speed, grade (incline), and duration of exercise must be recorded for each exercise test stage

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performed. Other exercise test protocols or techniques should use similar workloads. The
exercise protocol may need to be modified in individual cases to allow for a lower initial
workload with more slowly graded increments than the standard Bruce protocol.
c. Levels of exercise must be described in terms of workload and duration of each stage; for
example, treadmill speed and grade, or bicycle ergometer work rate in kpm/min or watts.
d. The exercise laboratory's physical environment, staffing, and equipment must meet the
generally accepted standards for adult exercise test laboratories.
11. How do we evaluate ETT results? We evaluate ETT results on the basis of the work level
at which the test becomes abnormal, as documented by onset of signs or symptoms and any
ECG or imaging abnormalities. The absence of an ischemic response on an ETT alone does
not exclude the diagnosis of ischemic heart disease. We must consider the results of an ETT
in the context of all of the other evidence in your case record.
12. When are ETTs done with imaging? When resting ECG abnormalities preclude
interpretation of ETT tracings relative to ischemia, a radionuclide (for example, thallium-201 or
technetium-99m) perfusion scan or echocardiography in conjunction with an ETT provides
better results. You may have resting ECG abnormalities when you have a conduction defect—
for example, Wolff-Parkinson-White syndrome, left bundle branch block, left ventricular
hypertrophy—or when you are taking digitalis or other antiarrhythmic drugs, or when resting
ST changes are present. Also, these techniques can provide a reliable estimate of ejection
fraction.
13. Will we purchase ETTs with imaging? We may purchase an ETT with imaging in your case
after an MC, preferably one with experience in the care of patients with cardiovascular
disease, has reviewed your medical history and physical examination, any report(s) of
appropriate medically acceptable imaging, ECGs, and other appropriate tests. We will consider
purchasing an ETT with imaging when other information we have is not adequate for us to
assess whether you have severe ventricular dysfunction or myocardial ischemia, there is no
significant risk involved (see 4.00C8a), and we cannot make our determination or decision
based on the evidence we already have.
14. What are drug-induced stress tests? These tests are designed primarily to provide
evidence about myocardial ischemia or prior myocardial infarction, but do not require you to
exercise. These tests are used when you cannot exercise or cannot exercise enough to
achieve the desired cardiac stress. Drug-induced stress tests can also provide evidence about
heart chamber dimensions and function; however, these tests do not provide information about
your aerobic capacity and cannot be used to help us assess your ability to function. Some of
these tests use agents, such as Persantine or adenosine, that dilate the coronary arteries and
are used in combination with nuclear agents, such as thallium or technetium (for example,
Cardiolyte or Myoview), and a myocardial scan. Other tests use agents, such as dobutamine,
that stimulate the heart to contract more forcefully and faster to simulate exercise and are used
in combination with a 2-dimensional echocardiogram. We may, when appropriate, purchase a
drug-induced stress test to confirm the presence of myocardial ischemia after a review of the
evidence in your file by an MC, preferably one with experience in the care of patients with
cardiovascular disease.
15. How do we evaluate cardiac catheterization evidence?

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a. We will not purchase cardiac catheterization; however, if you have had catheterization, we
will make every reasonable effort to obtain the report and any ancillary studies. We will
consider the quality and type of data provided and its relevance to the evaluation of your
impairment. For adults, we generally see two types of catheterization reports: Coronary
arteriography and left ventriculography.
b. For coronary arteriography, the report should provide information citing the method of
assessing coronary arterial lumen diameter and the nature and location of obstructive lesions.
Drug treatment at baseline and during the procedure should be reported. Some individuals
with significant coronary atherosclerotic obstruction have collateral vessels that supply the
myocardium distal to the arterial obstruction so that there is no evidence of myocardial damage
or ischemia, even with exercise. When the results of quantitative computer measurements and
analyses are included in your case record, we will consider them in interpreting the severity of
stenotic lesions.
c. For left ventriculography, the report should describe the wall motion of the myocardium with
regard to any areas of hypokinesis (abnormally decreased motion), akinesis (lack of motion),
or dyskinesis (distortion of motion), and the overall contraction of the ventricle as measured by
the ejection fraction. Measurement of chamber volumes and pressures may be useful.
Quantitative computer analysis provides precise measurement of segmental left ventricular
wall thickness and motion. There is often a poor correlation between left ventricular function at
rest and functional capacity for physical activity.
16. What details should exercise Doppler test reports contain? The reports of exercise Doppler
tests must describe the level of exercise; for example, the speed and grade of the treadmill
settings, the duration of exercise, symptoms during exercise, and the reasons for stopping
exercise if the expected level of exercise was not attained. They must also include the blood
pressures at the ankle and other pertinent sites measured after exercise and the time required
for the systolic blood pressure to return toward or to the pre-exercise level. The graphic
tracings, if available, should also be included with the report. All tracings must be annotated
with the standardization used by the testing facility.
17. How must exercise Doppler tests we purchase be performed? When we purchase an
exercise Doppler test, you must exercise on a treadmill at 2 mph on a 12 percent grade for up
to 5 minutes. The reports must include the information specified in 4.00C16. Because this is an
exercise test, we must evaluate whether such testing would put you at significant risk, in
accordance with the guidance found in 4.00C6, 4.00C7, and 4.00C8.
D. Evaluating Chronic Heart Failure
1. What is chronic heart failure (CHF)?
a. CHF is the inability of the heart to pump enough oxygenated blood to body tissues. This
syndrome is characterized by symptoms and signs of pulmonary or systemic congestion (fluid
retention) or limited cardiac output. Certain laboratory findings of cardiac functional and
structural abnormality support the diagnosis of CHF. There are two main types of CHF:
(i) Predominant systolic dysfunction (the inability of the heart to contract normally and expel
sufficient blood), which is characterized by a dilated, poorly contracting left ventricle and
reduced ejection fraction (abbreviated EF, it represents the percentage of the blood in the

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ventricle actually pumped out with each contraction), and
(ii) Predominant diastolic dysfunction (the inability of the heart to relax and fill normally), which
is characterized by a thickened ventricular muscle, poor ability of the left ventricle to distend,
increased ventricular filling pressure, and a normal or increased EF.
b. CHF is considered in these listings as a single category whether due to atherosclerosis
(narrowing of the arteries), cardiomyopathy, hypertension, or rheumatic, congenital, or other
heart disease. However, if the CHF is the result of primary pulmonary hypertension secondary
to disease of the lung (cor pulmonale), we will evaluate your impairment using 3.09, in the
respiratory system listings.
2. What evidence of CHF do we need?
a. Cardiomegaly or ventricular dysfunction must be present and demonstrated by appropriate
medically acceptable imaging, such as chest x-ray, echocardiography (M-Mode, 2dimensional, and Doppler), radionuclide studies, or cardiac catheterization.
(i) Abnormal cardiac imaging showing increased left ventricular end diastolic diameter
(LVEDD), decreased EF, increased left atrial chamber size, increased ventricular filling
pressures measured at cardiac catheterization, or increased left ventricular wall or septum
thickness, provides objective measures of both left ventricular function and structural
abnormality in heart failure.
(ii) An LVEDD greater than 6.0 cm or an EF of 30 percent or less measured during a period of
stability (that is, not during an episode of acute heart failure) may be associated clinically with
systolic failure.
(iii) Left ventricular posterior wall thickness added to septal thickness totaling 2.5 cm or greater
with left atrium enlarged to 4.5 cm or greater may be associated clinically with diastolic failure.
(iv) However, these measurements alone do not reflect your functional capacity, which we
evaluate by considering all of the relevant evidence. In some situations, we may need to
purchase an ETT to help us assess your functional capacity.
(v) Other findings on appropriate medically acceptable imaging may include increased
pulmonary vascular markings, pleural effusion, and pulmonary edema. These findings need
not be present on each report, since CHF may be controlled by prescribed treatment.
b. To establish that you have chronic heart failure, your medical history and physical
examination should describe characteristic symptoms and signs of pulmonary or systemic
congestion or of limited cardiac output associated with the abnormal findings on appropriate
medically acceptable imaging. When an acute episode of heart failure is triggered by a
remediable factor, such as an arrhythmia, dietary sodium overload, or high altitude, cardiac
function may be restored and a chronic impairment may not be present.
(i) Symptoms of congestion or of limited cardiac output include easy fatigue, weakness,
shortness of breath (dyspnea), cough, or chest discomfort at rest or with activity. Individuals
with CHF may also experience shortness of breath on lying flat (orthopnea) or episodes of
shortness of breath that wake them from sleep (paroxysmal nocturnal dyspnea). They may

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also experience cardiac arrhythmias resulting in palpitations, lightheadedness, or fainting.
(ii) Signs of congestion may include hepatomegaly, ascites, increased jugular venous
distention or pressure, rales, peripheral edema, or rapid weight gain. However, these signs
need not be found on all examinations because fluid retention may be controlled by prescribed
treatment.
3. Is it safe for you to have an ETT, if you have CHF? The presence of CHF is not necessarily
a contraindication to an ETT, unless you are having an acute episode of heart failure.
Measures of cardiac performance are valuable in helping us evaluate your ability to do workrelated activities. Exercise testing has been safely used in individuals with CHF; therefore, we
may purchase an ETT for evaluation under 4.02B3 if an MC, preferably one experienced in the
care of patients with cardiovascular disease, determines that there is no significant risk to you.
(See 4.00C6 for when we will consider the purchase of an ETT. See 4.00C7-4.00C8 for what
we must do before we purchase an ETT and when we will not purchase one.) ST segment
changes from digitalis use in the treatment of CHF do not preclude the purchase of an ETT.
4. How do we evaluate CHF using 4.02?
a. We must have objective evidence, as described in 4.00D2, that you have chronic heart
failure.
b. To meet the required level of severity for this listing, your impairment must satisfy the
requirements of one of the criteria in A and one of the criteria in B.
c. In 4.02B2, the phrase periods of stabilization means that, for at least 2 weeks between
episodes of acute heart failure, there must be objective evidence of clearing of the pulmonary
edema or pleural effusions and evidence that you returned to, or you were medically
considered able to return to, your prior level of activity.
d. Listing 4.02B3c requires a decrease in systolic blood pressure below the baseline level
(taken in the standing position immediately prior to exercise) or below any systolic pressure
reading recorded during exercise. This is because, normally, systolic blood pressure and heart
rate increase gradually with exercise. Decreases in systolic blood pressure below the baseline
level that occur during exercise are often associated with ischemia-induced left ventricular
dysfunction resulting in decreased cardiac output. However, a blunted response (that is, failure
of the systolic blood pressure to rise 10 mm Hg or more), particularly in the first 3 minutes of
exercise, may be drug-related and is not necessarily associated with left ventricular
dysfunction. Also, some individuals with increased sympathetic responses because of
deconditioning or apprehension may increase their systolic blood pressure and heart rate
above their baseline level just before and early into exercise. This can be associated with a
drop in systolic pressure in early exercise that is not due to left ventricular dysfunction.
Therefore, an early decrease in systolic blood pressure must be interpreted within the total
context of the test; that is, the presence or absence of symptoms such as lightheadedness,
ischemic changes, or arrhythmias on the ECG.
E. Evaluating Ischemic Heart Disease
1. What is ischemic heart disease (IHD)? IHD results when one or more of your coronary
arteries is narrowed or obstructed or, in rare situations, constricted due to vasospasm,

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interfering with the normal flow of blood to your heart muscle (ischemia). The obstruction may
be the result of an embolus, a thrombus, or plaque. When heart muscle tissue dies as a result
of the reduced blood supply, it is called a myocardial infarction (heart attack).
2. What causes chest discomfort of myocardial origin?
a. Chest discomfort of myocardial ischemic origin, commonly known as angina pectoris, is
usually caused by coronary artery disease (often abbreviated CAD). However, ischemic
discomfort may be caused by a noncoronary artery impairment, such as aortic stenosis,
hypertrophic cardiomyopathy, pulmonary hypertension, or anemia.
b. Instead of typical angina pectoris, some individuals with IHD experience atypical angina,
anginal equivalent, variant angina, or silent ischemia, all of which we may evaluate using 4.04.
We discuss the various manifestations of ischemia in 4.00E3-4.00E7.
3. What are the characteristics of typical angina pectoris? Discomfort of myocardial ischemic
origin (angina pectoris) is discomfort that is precipitated by effort or emotion and promptly
relieved by rest, sublingual nitroglycerin (that is, nitroglycerin tablets that are placed under the
tongue), or other rapidly acting nitrates. Typically, the discomfort is located in the chest
(usually substernal) and described as pressing, crushing, squeezing, burning, aching, or
oppressive. Sharp, sticking, or cramping discomfort is less common. Discomfort occurring with
activity or emotion should be described specifically as to timing and usual inciting factors (type
and intensity), character, location, radiation, duration, and response to nitrate treatment or rest.
4. What is atypical angina? Atypical angina describes discomfort or pain from myocardial
ischemia that is felt in places other than the chest. The common sites of cardiac pain are the
inner aspect of the left arm, neck, jaw(s), upper abdomen, and back, but the discomfort or pain
can be elsewhere. When pain of cardiac ischemic origin presents in an atypical site in the
absence of chest discomfort, the source of the pain may be difficult to diagnose. To represent
atypical angina, your discomfort or pain should have precipitating and relieving factors similar
to those of typical chest discomfort, and we must have objective medical evidence of
myocardial ischemia; for example, ECG or ETT evidence or appropriate medically acceptable
imaging.
5. What is anginal equivalent? Often, individuals with IHD will complain of shortness of breath
(dyspnea) on exertion without chest pain or discomfort. In a minority of such situations, the
shortness of breath is due to myocardial ischemia; this is called anginal equivalent. To
represent anginal equivalent, your shortness of breath should have precipitating and relieving
factors similar to those of typical chest discomfort, and we must have objective medical
evidence of myocardial ischemia; for example, ECG or ETT evidence or appropriate medically
acceptable imaging. In these situations, it is essential to establish objective evidence of
myocardial ischemia to ensure that you do not have effort dyspnea due to non-ischemic or
non-cardiac causes.
6. What is variant angina?
a. Variant angina (Prinzmetal's angina, vasospastic angina) refers to the occurrence of anginal
episodes at rest, especially at night, accompanied by transitory ST segment elevation (or, at
times, ST depression) on an ECG. It is due to severe spasm of a coronary artery, causing
ischemia of the heart wall, and is often accompanied by major ventricular arrhythmias, such as

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ventricular tachycardia. We will consider variant angina under 4.04 only if you have spasm of a
coronary artery in relation to an obstructive lesion of the vessel. If you have an arrhythmia as a
result of variant angina, we may consider your impairment under 4.05.
b. Variant angina may also occur in the absence of obstructive coronary disease. In this
situation, an ETT will not demonstrate ischemia. The diagnosis will be established by showing
the typical transitory ST segment changes during attacks of pain, and the absence of
obstructive lesions shown by catheterization. Treatment in cases where there is no obstructive
coronary disease is limited to medications that reduce coronary vasospasm, such as calcium
channel blockers and nitrates. In such situations, we will consider the frequency of anginal
episodes despite prescribed treatment when evaluating your residual functional capacity.
c. Vasospasm that is catheter-induced during coronary angiography is not variant angina.
7. What is silent ischemia?
a. Myocardial ischemia, and even myocardial infarction, can occur without perception of pain
or any other symptoms; when this happens, we call it silent ischemia. Pain sensitivity may be
altered by a variety of diseases, most notably diabetes mellitus and other neuropathic
disorders. Individuals also vary in their threshold for pain.
b. Silent ischemia occurs most often in:
(i) Individuals with documented past myocardial infarction or established angina without prior
infarction who do not have chest pain on ETT, but have a positive test with ischemic
abnormality on ECG, perfusion scan, or other appropriate medically acceptable imaging.
(ii) Individuals with documented past myocardial infarction or angina who have ST segment
changes on ambulatory monitoring (Holter monitoring) that are similar to those that occur
during episodes of angina. ST depression shown on the ambulatory recording should not be
interpreted as positive for ischemia unless similar depression is also seen during chest pain
episodes annotated in the diary that the individual keeps while wearing the Holter monitor.
c. ST depression can result from a variety of factors, such as postural changes and variations
in cardiac sympathetic tone. In addition, there are differences in how different Holter monitors
record the electrical responses. Therefore, we do not consider the Holter monitor reliable for
the diagnosis of silent ischemia except in the situation described in 4.00E7b(ii).
8. What other sources of chest discomfort are there? Chest discomfort of nonischemic origin
may result from other cardiac impairments, such as pericarditis. Noncardiac impairments may
also produce symptoms mimicking that of myocardial ischemia. These impairments include
acute anxiety or panic attacks, gastrointestinal tract disorders, such as esophageal spasm,
esophagitis, hiatal hernia, biliary tract disease, gastritis, peptic ulcer, and pancreatitis, and
musculoskeletal syndromes, such as chest wall muscle spasm, chest wall syndrome
(especially after coronary bypass surgery), costochondritis, and cervical or dorsal spine
arthritis. Hyperventilation may also mimic ischemic discomfort. Thus, in the absence of
documented myocardial ischemia, such disorders should be considered as possible causes of
chest discomfort.
9. How do we evaluate IHD using 4.04?

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a. We must have objective evidence, as described under 4.00C, that your symptoms are due
to myocardial ischemia.
b. Listing-level changes on the ECG in 4.04A1 are the classically accepted changes of
horizontal or downsloping ST depression occurring both during exercise and recovery.
Although we recognize that ischemic changes may at times occur only during exercise or
recovery, and may at times be upsloping with only junctional ST depression, such changes can
be false positive; that is, occur in the absence of ischemia. Diagnosis of ischemia in this
situation requires radionuclide or echocardiogram confirmation. See 4.00C12 and 4.00C13.
c. Also in 4.04A1, we require that the depression of the ST segment last for at least 1 minute of
recovery because ST depression that occurs during exercise but that rapidly normalizes in
recovery is a common false-positive response.
d. In 4.04A2, we specify that the ST elevation must be in non-infarct leads during both exercise
and recovery. This is because, in the absence of ECG signs of prior infarction, ST elevation
during exercise denotes ischemia, usually severe, requiring immediate termination of exercise.
However, if there is baseline ST elevation in association with a prior infarction or ventricular
aneurysm, further ST elevation during exercise does not necessarily denote ischemia and
could be a false-positive ECG response. Diagnosis of ischemia in this situation requires
radionuclide or echocardiogram confirmation. See 4.00C12 and 4.00C13.
e. Listing 4.04A3 requires a decrease in systolic blood pressure below the baseline level
(taken in the standing position immediately prior to exercise) or below any systolic pressure
reading recorded during exercise. This is the same finding required in 4.02B3c. See 4.00D4d
for full details.
f. In 4.04B, each of the three ischemic episodes must require revascularization or be not
amenable to treatment. Revascularization means angioplasty (with or without stent placement)
or bypass surgery. However, reocclusion that occurs after a revascularization procedure but
during the same hospitalization and that requires a second procedure during the same
hospitalization will not be counted as another ischemic episode. Not amenable means that the
revascularization procedure could not be done because of another medical impairment or
because the vessel was not suitable for revascularization.
g. We will use 4.04C only when you have symptoms due to myocardial ischemia as described
in 4.00E3-4.00E7 while on a regimen of prescribed treatment, you are at risk for exercise
testing (see 4.00C8), and we do not have a timely ETT or a timely normal drug-induced stress
test for you. See 4.00C9 for what we mean by a timely test.
h. In 4.04C1 the term nonbypassed means that the blockage is in a vessel that is potentially
bypassable; that is, large enough to be bypassed and considered to be a cause of your
ischemia. These vessels are usually major arteries or one of a major artery's major branches.
A vessel that has become obstructed again after angioplasty or stent placement and has
remained obstructed or is not amenable to another revascularization is considered a
nonbypassed vessel for purposes of this listing. When you have had revascularization, we will
not use the pre-operative findings to assess the current severity of your coronary artery
disease under 4.04C, although we will consider the severity and duration of your impairment
prior to your surgery in making our determination or decision.

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F. Evaluating Arrhythmias
1. What is an arrhythmia? An arrhythmia is a change in the regular beat of the heart. Your
heart may seem to skip a beat or beat irregularly, very quickly (tachycardia), or very slowly
(bradycardia).
2. What are the different types of arrhythmias?
a. There are many types of arrhythmias. Arrhythmias are identified by where they occur in the
heart (atria or ventricles) and by what happens to the heart's rhythm when they occur.
b. Arrhythmias arising in the cardiac atria (upper chambers of the heart) are called atrial or
supraventricular arrhythmias. Ventricular arrhythmias begin in the ventricles (lower chambers).
In general, ventricular arrhythmias caused by heart disease are the most serious.
3. How do we evaluate arrhythmias using 4.05?
a. We will use 4.05 when you have arrhythmias that are not fully controlled by medication, an
implanted pacemaker, or an implanted cardiac defibrillator and you have uncontrolled recurrent
episodes of syncope or near syncope. If your arrhythmias are controlled, we will evaluate your
underlying heart disease using the appropriate listing. For other considerations when we
evaluate arrhythmias in the presence of an implanted cardiac defibrillator, see 4.00F4.
b. We consider near syncope to be a period of altered consciousness, since syncope is a loss
of consciousness or a faint. It is not merely a feeling of light-headedness, momentary
weakness, or dizziness.
c. For purposes of 4.05, there must be a documented association between the syncope or
near syncope and the recurrent arrhythmia. The recurrent arrhythmia, not some other cardiac
or non-cardiac disorder, must be established as the cause of the associated symptom. This
documentation of the association between the symptoms and the arrhythmia may come from
the usual diagnostic methods, including Holter monitoring (also called ambulatory
electrocardiography) and tilt-table testing with a concurrent ECG. Although an arrhythmia may
be a coincidental finding on an ETT, we will not purchase an ETT to document the presence of
a cardiac arrhythmia.
4. What will we consider when you have an implanted cardiac defibrillator and you do not have
arrhythmias that meet the requirements of 4.05?
a. Implanted cardiac defibrillators are used to prevent sudden cardiac death in individuals who
have had, or are at high risk for, cardiac arrest from life-threatening ventricular arrhythmias.
The largest group at risk for sudden cardiac death consists of individuals with cardiomyopathy
(ischemic or non-ischemic) and reduced ventricular function. However, life-threatening
ventricular arrhythmias can also occur in individuals with little or no ventricular dysfunction.
The shock from the implanted cardiac defibrillator is a unique form of treatment; it rescues an
individual from what may have been cardiac arrest. However, as a consequence of the shock
(s), individuals may experience psychological distress, which we may evaluate under the
mental disorders listings in 12.00ff.
b. Most implantable cardiac defibrillators have rhythm-correcting and pacemaker capabilities.

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In some individuals, these functions may result in the termination of ventricular arrhythmias
without an otherwise painful shock. (The shock is like being kicked in the chest.) Implanted
cardiac defibrillators may deliver inappropriate shocks, often repeatedly, in response to benign
arrhythmias or electrical malfunction. Also, exposure to strong electrical or magnetic fields,
such as from MRI (magnetic resonance imaging), can trigger or reprogram an implanted
cardiac defibrillator, resulting in inappropriate shocks. We must consider the frequency of, and
the reason(s) for, the shocks when evaluating the severity and duration of your impairment.
c. In general, the exercise limitations imposed on individuals with an implanted cardiac
defibrillator are those dictated by the underlying heart impairment. However, the exercise
limitations may be greater when the implanted cardiac defibrillator delivers an inappropriate
shock in response to the increase in heart rate with exercise, or when there is exerciseinduced ventricular arrhythmia.
G. Evaluating Peripheral Vascular Disease
1. What is peripheral vascular disease (PVD)? Generally, PVD is any impairment that affects
either the arteries (peripheral arterial disease) or the veins (venous insufficiency) in the
extremities, particularly the lower extremities. The usual effect is blockage of the flow of blood
either from the heart (arterial) or back to the heart (venous). If you have peripheral arterial
disease, you may have pain in your calf after walking a distance that goes away when you rest
(intermittent claudication); at more advanced stages, you may have pain in your calf at rest or
you may develop ulceration or gangrene. If you have venous insufficiency, you may have
swelling, varicose veins, skin pigmentation changes, or skin ulceration.
2. How do we assess limitations resulting from PVD? We will assess your limitations based on
your symptoms together with physical findings, Doppler studies, other appropriate non-invasive
studies, or angiographic findings. However, if the PVD has resulted in amputation, we will
evaluate any limitations related to the amputation under the musculoskeletal listings, 1.00ff.
3. What is brawny edema? Brawny edema (4.11A) is swelling that is usually dense and feels
firm due to the presence of increased connective tissue; it is also associated with characteristic
skin pigmentation changes. It is not the same thing as pitting edema. Brawny edema generally
does not pit (indent on pressure), and the terms are not interchangeable. Pitting edema does
not satisfy the requirements of 4.11A.
4. What is lymphedema and how will we evaluate it?
a. Lymphedema is edema of the extremities due to a disorder of the lymphatic circulation; at its
worst, it is called elephantiasis. Primary lymphedema is caused by abnormal development of
lymph vessels and may be present at birth (congenital lymphedema), but more often develops
during the teens (lymphedema praecox). It may also appear later, usually after age 35
(lymphedema tarda). Secondary lymphedema is due to obstruction or destruction of normal
lymphatic channels due to tumor, surgery, repeated infections, or parasitic infection such as
filariasis. Lymphedema most commonly affects one extremity.
b. Lymphedema does not meet the requirements of 4.11, although it may medically equal the
severity of that listing. We will evaluate lymphedema by considering whether the underlying
cause meets or medically equals any listing or whether the lymphedema medically equals a
cardiovascular listing, such as 4.11, or a musculoskeletal listing, such as 1.02A or 1.03. If no

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listing is met or medically equaled, we will evaluate any functional limitations imposed by your
lymphedema when we assess your residual functional capacity.
5. When will we purchase exercise Doppler studies for evaluating peripheral arterial disease
(PAD)? If we need additional evidence of your PAD, we will generally purchase exercise
Doppler studies (see 4.00C16 and 4.00C17) when your resting ankle/brachial systolic blood
pressure ratio is at least 0.50 but less than 0.80, and only rarely when it is 0.80 or above. We
will not purchase exercise Doppler testing if you have a disease that results in abnormal
arterial calcification or small vessel disease, but will use your resting toe systolic blood
pressure or resting toe/brachial systolic blood pressure ratio. (See 4.00G7c and 4.00G8.)
There are no current medical standards for evaluating exercise toe pressures. Because any
exercise test stresses your entire cardiovascular system, we will purchase exercise Doppler
studies only after an MC, preferably one with experience in the care of patients with
cardiovascular disease, has determined that the test would not present a significant risk to you
and that there is no other medical reason not to purchase the test (see 4.00C6, 4.00C7, and
4.00C8).
6. Are there any other studies that are helpful in evaluating PAD? Doppler studies done using
a recording ultrasonic Doppler unit and strain-gauge plethysmography are other useful tools for
evaluating PAD. A recording Doppler, which prints a tracing of the arterial pulse wave in the
femoral, popliteal, dorsalis pedis, and posterior tibial arteries, is an excellent evaluation tool to
compare wave forms in normal and compromised peripheral blood flow. Qualitative analysis of
the pulse wave is very helpful in the overall assessment of the severity of the occlusive
disease. Tracings are especially helpful in assessing severity if you have small vessel disease
related to diabetes mellitus or other diseases with similar vascular changes, or diseases
causing medial calcifications when ankle pressure is either normal or falsely high.
7. How do we evaluate PAD under 4.12?
a. The ankle blood pressure referred to in 4.12A and B is the higher of the pressures recorded
from the posterior tibial and dorsalis pedis arteries in the affected leg. The higher pressure
recorded from the two sites is the more significant measurement in assessing the extent of
arterial insufficiency. Techniques for obtaining ankle systolic blood pressures include Doppler
(See 4.00C16 and 4.00C17), plethysmographic studies, or other techniques. We will request
any available tracings generated by these studies so that we can review them.
b. In 4.12A, the ankle/brachial systolic blood pressure ratio is the ratio of the systolic blood
pressure at the ankle to the systolic blood pressure at the brachial artery; both taken at the
same time while you are lying on your back. We do not require that the ankle and brachial
pressures be taken on the same side of your body. This is because, as with the ankle
pressure, we will use the higher brachial systolic pressure measured. Listing 4.12A is met
when your resting ankle/brachial systolic blood pressure ratio is less than 0.50. If your resting
ankle/brachial systolic blood pressure ratio is 0.50 or above, we will use 4.12B to evaluate the
severity of your PAD, unless you also have a disease causing abnormal arterial calcification or
small vessel disease, such as diabetes mellitus. See 4.00G7c and 4.00G8.
c. We will use resting toe systolic blood pressures or resting toe/brachial systolic blood
pressure ratios (determined the same way as ankle/brachial ratios, see 4.00G7b) when you
have intermittent claudication and a disease that results in abnormal arterial calcification (for
example, Monckeberg's sclerosis or diabetes mellitus) or small vessel disease (for example,

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diabetes mellitus). These diseases may result in misleadingly high blood pressure readings at
the ankle. However, high blood pressures due to vascular changes related to these diseases
seldom occur at the toe level. While the criteria in 4.12C and 4.12D are intended primarily for
individuals who have a disease causing abnormal arterial calcification or small vessel disease,
we may also use them for evaluating anyone with PAD.
8. How are toe pressures measured? Toe pressures are measured routinely in most vascular
laboratories through one of three methods: most frequently, photoplethysmography; less
frequently, plethysmography using strain gauge cuffs; and Doppler ultrasound. Toe pressure
can also be measured by using any blood pressure cuff that fits snugly around the big toe and
is neither too tight nor too loose. A neonatal cuff or a cuff designed for use on fingers or toes
can be used in the measurement of toe pressure.
9. How do we use listing 4.12 if you have had a peripheral graft? Peripheral grafting serves the
same purpose as coronary grafting; that is, to bypass a narrow or obstructed arterial segment.
If intermittent claudication recurs or persists after peripheral grafting, we may purchase
Doppler studies to assess the flow of blood through the bypassed vessel and to establish the
current severity of the peripheral arterial impairment. However, if you have had peripheral
grafting done for your PAD, we will not use the findings from before the surgery to assess the
current severity of your impairment, although we will consider the severity and duration of your
impairment prior to your surgery in making our determination or decision.
H. Evaluating Other Cardiovascular Impairments
1. How will we evaluate hypertension? Because hypertension (high blood pressure) generally
causes disability through its effects on other body systems, we will evaluate it by reference to
the specific body system(s) affected (heart, brain, kidneys, or eyes) when we consider its
effects under the listings. We will also consider any limitations imposed by your hypertension
when we assess your residual functional capacity.
2. How will we evaluate symptomatic congenital heart disease? Congenital heart disease is
any abnormality of the heart or the major blood vessels that is present at birth. Because of
improved treatment methods, more children with congenital heart disease are living to
adulthood. Although some types of congenital heart disease may be corrected by surgery,
many individuals with treated congenital heart disease continue to have problems throughout
their lives (symptomatic congenital heart disease). If you have congenital heart disease that
results in chronic heart failure with evidence of ventricular dysfunction or in recurrent
arrhythmias, we will evaluate your impairment under 4.02 or 4.05. Otherwise, we will evaluate
your impairment under 4.06.
3. What is cardiomyopathy and how will we evaluate it? Cardiomyopathy is a disease of the
heart muscle. The heart loses its ability to pump blood (heart failure), and in some instances,
heart rhythm is disturbed, leading to irregular heartbeats (arrhythmias). Usually, the exact
cause of the muscle damage is never found (idiopathic cardiomyopathy). There are various
types of cardiomyopathy, which fall into two major categories: Ischemic and nonischemic
cardiomyopathy. Ischemic cardiomyopathy typically refers to heart muscle damage that results
from coronary artery disease, including heart attacks. Nonischemic cardiomyopathy includes
several types: Dilated, hypertrophic, and restrictive. We will evaluate cardiomyopathy under
4.02, 4.04, 4.05, or 11.04, depending on its effects on you.

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4. How will we evaluate valvular heart disease? We will evaluate valvular heart disease under
the listing appropriate for its effect on you. Thus, we may use 4.02, 4.04, 4.05, 4.06, or an
appropriate neurological listing in 11.00ff.
5. What do we consider when we evaluate heart transplant recipients?
a. After your heart transplant, we will consider you disabled for 1 year following the surgery
because there is a greater likelihood of rejection of the organ and infection during the first year.
b. However, heart transplant patients generally meet our definition of disability before they
undergo transplantation. We will determine the onset of your disability based on the facts in
your case.
c. We will not assume that you became disabled when your name was placed on a transplant
waiting list. This is because you may be placed on a waiting list soon after diagnosis of the
cardiac disorder that may eventually require a transplant. Physicians recognize that candidates
for transplantation often have to wait months or even years before a suitable donor heart is
found, so they place their patients on the list as soon as permitted.
d. When we do a continuing disability review to determine whether you are still disabled, we
will evaluate your residual impairment(s), as shown by symptoms, signs, and laboratory
findings, including any side effects of medication. We will consider any remaining symptoms,
signs, and laboratory findings indicative of cardiac dysfunction in deciding whether medical
improvement (as defined in §§404.1594 and 416.994) has occurred.
6. When does an aneurysm have "dissection not controlled by prescribed treatment," as
required under 4.10? An aneurysm (or bulge in the aorta or one of its major branches) is
dissecting when the inner lining of the artery begins to separate from the arterial wall. We
consider the dissection not controlled when you have persistence of chest pain due to
progression of the dissection, an increase in the size of the aneurysm, or compression of one
or more branches of the aorta supplying the heart, kidneys, brain, or other organs. An
aneurysm with dissection can cause heart failure, renal (kidney) failure, or neurological
complications. If you have an aneurysm that does not meet the requirements of 4.10 and you
have one or more of these associated conditions, we will evaluate the condition(s) using the
appropriate listing.
7. What is hyperlipidemia and how will we evaluate it? Hyperlipidemia is the general term for
an elevation of any or all of the lipids (fats or cholesterol) in the blood; for example,
hypertriglyceridemia, hypercholesterolemia, and hyperlipoproteinemia. These disorders of
lipoprotein metabolism and transport can cause defects throughout the body. The effects most
likely to interfere with function are those produced by atherosclerosis (narrowing of the
arteries) and coronary artery disease. We will evaluate your lipoprotein disorder by considering
its effects on you.
8. What is Marfan syndrome and how will we evaluate it?
a. Marfan syndrome is a genetic connective tissue disorder that affects multiple body systems,
including the skeleton, eyes, heart, blood vessels, nervous system, skin, and lungs. There is
no specific laboratory test to diagnose Marfan syndrome. The diagnosis is generally made by
medical history, including family history, physical examination, including an evaluation of the

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ratio of arm/leg size to trunk size, a slit lamp eye examination, and a heart test(s), such as an
echocardiogram. In some cases, a genetic analysis may be useful, but such analyses may not
provide any additional helpful information.
b. The effects of Marfan syndrome can range from mild to severe. In most cases, the disorder
progresses as you age. Most individuals with Marfan syndrome have abnormalities associated
with the heart and blood vessels. Your heart's mitral valve may leak, causing a heart murmur.
Small leaks may not cause symptoms, but larger ones may cause shortness of breath, fatigue,
and palpitations. Another effect is that the wall of the aorta may be weakened and abnormally
stretch (aortic dilation). This aortic dilation may tear, dissect, or rupture, causing serious heart
problems or sometimes sudden death. We will evaluate the manifestations of your Marfan
syndrome under the appropriate body system criteria, such as 4.10, or if necessary, consider
the functional limitations imposed by your impairment.
I. Other Evaluation Issues
1. What effect does obesity have on the cardiovascular system and how will we evaluate it?
Obesity is a medically determinable impairment that is often associated with disorders of the
cardiovascular system. Disturbance of this system can be a major cause of disability if you
have obesity. Obesity may affect the cardiovascular system because of the increased
workload the additional body mass places on the heart. Obesity may make it harder for the
chest and lungs to expand. This can mean that the respiratory system must work harder to
provide needed oxygen. This in turn would make the heart work harder to pump blood to carry
oxygen to the body. Because the body would be working harder at rest, its ability to perform
additional work would be less than would otherwise be expected. Thus, the combined effects
of obesity with cardiovascular impairments can be greater than the effects of each of the
impairments considered separately. We must consider any additional and cumulative effects of
obesity when we determine whether you have a severe cardiovascular impairment or a listinglevel cardiovascular impairment (or a combination of impairments that medically equals the
severity of a listed impairment), and when we assess your residual functional capacity.
2. How do we relate treatment to functional status? In general, conclusions about the severity
of a cardiovascular impairment cannot be made on the basis of type of treatment rendered or
anticipated. The amount of function restored and the time required for improvement after
treatment (medical, surgical, or a prescribed program of progressive physical activity) vary with
the nature and extent of the disorder, the type of treatment, and other factors. Depending upon
the timing of this treatment in relation to the alleged onset date of disability, we may need to
defer evaluation of the impairment for a period of up to 3 months from the date treatment
began to permit consideration of treatment effects, unless we can make a determination or
decision using the evidence we have. See 4.00B4.
3. How do we evaluate impairments that do not meet one of the cardiovascular listings?
a. These listings are only examples of common cardiovascular impairments that we consider
severe enough to prevent you from doing any gainful activity. If your severe impairment(s)
does not meet the criteria of any of these listings, we must also consider whether you have an
impairment(s) that satisfies the criteria of a listing in another body system.
b. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will determine whether your impairments(s) medically equals a listing. (See §§404.1526 and

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416.926.) If you have a severe impairment(s) that does not meet or medically equal the criteria
of a listing, you may or may not have the residual functional capacity to engage in substantial
gainful activity. Therefore, we proceed to the fourth and, if necessary, the fifth steps of the
sequential evaluation process in §§404.1520 and 416.920. If you are an adult, we use the
rules in §§404.1594 or 416.994, as appropriate, when we decide whether you continue to be
disabled.
4.01 Category of Impairments, Cardiovascular System
4.02 Chronic heart failure while on a regimen of prescribed treatment, with symptoms and
signs described in 4.00D2. The required level of severity for this impairment is met when the
requirements in both A and B are satisfied.
A. Medically documented presence of one of the following:
1. Systolic failure (see 4.00D1a(i)), with left ventricular end diastolic dimensions greater than
6.0 cm or ejection fraction of 30 percent or less during a period of stability (not during an
episode of acute heart failure); or
2. Diastolic failure (see 4.00D1a(ii)), with left ventricular posterior wall plus septal thickness
totaling 2.5 cm or greater on imaging, with an enlarged left atrium greater than or equal to 4.5
cm, with normal or elevated ejection fraction during a period of stability (not during an episode
of acute heart failure);
AND
B. Resulting in one of the following:
1. Persistent symptoms of heart failure which very seriously limit the ability to independently
initiate, sustain, or complete activities of daily living in an individual for whom an MC,
preferably one experienced in the care of patients with cardiovascular disease, has concluded
that the performance of an exercise test would present a significant risk to the individual; or
2. Three or more separate episodes of acute congestive heart failure within a consecutive 12month period (see 4.00A3e), with evidence of fluid retention (see 4.00D2b(ii)) from clinical and
imaging assessments at the time of the episodes, requiring acute extended physician
intervention such as hospitalization or emergency room treatment for 12 hours or more,
separated by periods of stabilization (see 4.00D4c); or
3. Inability to perform on an exercise tolerance test at a workload equivalent to 5 METs or less
due to:
a. Dyspnea, fatigue, palpitations, or chest discomfort; or
b. Three or more consecutive premature ventricular contractions (ventricular tachycardia), or
increasing frequency of ventricular ectopy with at least 6 premature ventricular contractions per
minute; or
c. Decrease of 10 mm Hg or more in systolic pressure below the baseline systolic blood
pressure or the preceding systolic pressure measured during exercise (see 4.00D4d) due to

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left ventricular dysfunction, despite an increase in workload; or
d. Signs attributable to inadequate cerebral perfusion, such as ataxic gait or mental confusion.
4.04 Ischemic heart disease, with symptoms due to myocardial ischemia, as described in
4.00E3-4.00E7, while on a regimen of prescribed treatment (see 4.00B3 if there is no regimen
of prescribed treatment), with one of the following:
A. Sign-or symptom-limited exercise tolerance test demonstrating at least one of the following
manifestations at a workload equivalent to 5 METs or less:
1. Horizontal or downsloping depression, in the absence of digitalis glycoside treatment or
hypokalemia, of the ST segment of at least -0.10 millivolts (-1.0 mm) in at least 3 consecutive
complexes that are on a level baseline in any lead other than aVR, and depression of at least 0.10 millivolts lasting for at least 1 minute of recovery; or
2. At least 0.1 millivolt (1 mm) ST elevation above resting baseline in non-infarct leads during
both exercise and 1 or more minutes of recovery; or
3. Decrease of 10 mm Hg or more in systolic pressure below the baseline blood pressure or
the preceding systolic pressure measured during exercise (see 4.00E9e) due to left ventricular
dysfunction, despite an increase in workload; or
4. Documented ischemia at an exercise level equivalent to 5 METs or less on appropriate
medically acceptable imaging, such as radionuclide perfusion scans or stress
echocardiography.
OR
B. Three separate ischemic episodes, each requiring revascularization or not amenable to
revascularization (see 4.00E9f), within a consecutive 12-month period (see 4.00A3e).
OR
C. Coronary artery disease, demonstrated by angiography (obtained independent of Social
Security disability evaluation) or other appropriate medically acceptable imaging, and in the
absence of a timely exercise tolerance test or a timely normal drug-induced stress test, an MC,
preferably one experienced in the care of patients with cardiovascular disease, has concluded
that performance of exercise tolerance testing would present a significant risk to the individual,
with both 1 and 2:
1. Angiographic evidence showing:
a. 50 percent or more narrowing of a nonbypassed left main coronary artery; or
b. 70 percent or more narrowing of another nonbypassed coronary artery; or
c. 50 percent or more narrowing involving a long (greater than 1 cm) segment of a
nonbypassed coronary artery; or

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d. 50 percent or more narrowing of at least two nonbypassed coronary arteries; or
e. 70 percent or more narrowing of a bypass graft vessel; and
2. Resulting in very serious limitations in the ability to independently initiate, sustain, or
complete activities of daily living.
4.05 Recurrent arrhythmias, not related to reversible causes, such as electrolyte abnormalities
or digitalis glycoside or antiarrhythmic drug toxicity, resulting in uncontrolled (see 4.00A3f),
recurrent (see 4.00A3c) episodes of cardiac syncope or near syncope (see 4.00F3b), despite
prescribed treatment (see 4.00B3 if there is no prescribed treatment), and documented by
resting or ambulatory (Holter) electrocardiography, or by other appropriate medically
acceptable testing, coincident with the occurrence of syncope or near syncope (see 4.00F3c).
4.06 Symptomatic congenital heart disease (cyanotic or acyanotic), documented by
appropriate medically acceptable imaging (see 4.00A3d) or cardiac catheterization, with one of
the following:
A. Cyanosis at rest, and:
1. Hematocrit of 55 percent or greater; or
2. Arterial O2 saturation of less than 90 percent in room air, or resting arterial PO2 of 60 Torr or
less.
OR
B. Intermittent right-to-left shunting resulting in cyanosis on exertion (e.g., Eisenmenger's
physiology) and with arterial PO2 of 60 Torr or less at a workload equivalent to 5 METs or less.
OR
C. Secondary pulmonary vascular obstructive disease with pulmonary arterial systolic pressure
elevated to at least 70 percent of the systemic arterial systolic pressure.
4.09 Heart transplant. Consider under a disability for 1 year following surgery; thereafter,
evaluate residual impairment under the appropriate listing.
4.10 Aneurysm of aorta or major branches, due to any cause (e.g., atherosclerosis, cystic
medial necrosis, Marfan syndrome, trauma), demonstrated by appropriate medically
acceptable imaging, with dissection not controlled by prescribed treatment (see 4.00H6).
4.11 Chronic venous insufficiency of a lower extremity with incompetency or obstruction of the
deep venous system and one of the following:
A. Extensive brawny edema (see 4.00G3) involving at least two-thirds of the leg between the
ankle and knee or the distal one-third of the lower extremity between the ankle and hip.
OR

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B. Superficial varicosities, stasis dermatitis, and either recurrent ulceration or persistent
ulceration that has not healed following at least 3 months of prescribed treatment.
4.12 Peripheral arterial disease, as determined by appropriate medically acceptable imaging
(see 4.00A3d, 4.00G2, 4.00G5, and 4.00G6), causing intermittent claudication (see 4.00G1)
and one of the following:
A. Resting ankle/brachial systolic blood pressure ratio of less than 0.50.
OR
B. Decrease in systolic blood pressure at the ankle on exercise (see 4.00G7a and 4.00C164.00C17) of 50 percent or more of pre-exercise level and requiring 10 minutes or more to
return to pre-exercise level.
OR
C. Resting toe systolic pressure of less than 30 mm Hg (see 4.00G7c and 4.00G8).
OR
D. Resting toe/brachial systolic blood pressure ratio of less than 0.40 (see 4.00G7c).
5.00 Digestive System
A. Disorders of the digestive system which result in a marked impairment usually do so
because of interference with nutrition, multiple recurrent inflammatory lesions, or complications
of disease, such as fistulae, abscesses, or recurrent obstruction. Such complications usually
respond to treatment. These complications must be shown to persist on repeated
examinations despite therapy for a reasonable presumption to be made that a marked
impairment will last for a continuous period of at least 12 months.
B. Malnutrition or weight loss from gastrointestinal disorders. When the primary disorder of the
digestive tract has been established (e.g. enterocolitis, chronic pancreatitis,
postgastrointestinal resection, or esophageal stricture, stenosis, or obstruction), the resultant
interference with nutrition will be considered under the criteria in 5.08. This will apply whether
the weight loss is due to primary or secondary disorders of malabsorption, malassimilation or
obstruction.
C. Surgical diversion of the intestinal tract, including colostomy or ileostomy, are not listed
since they do not represent impairments which preclude all work activity if the individual is able
to maintain adequate nutrition and function of the stoma. Dumping syndrome which may follow
gastric resection rarely represents a marked impairment which would continue for 12 months.
Peptic ulcer disease with recurrent ulceration after definitive surgery ordinarily responds to
treatment. To be considered a severe impairment which will last for at least 12 months, a
recurrent ulcer after definitive surgery must be demonstrated, despite therapy, by repeated
appropriate medically acceptable imaging of the upper gastrointestinal tract or by gastroscopic
examinations. Medically acceptable imaging includes, but is not limited to, x-ray imaging,
computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI), with or
without contrast material, myelography, and radionuclear bone scans. "Appropriate" means

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that the technique used is the proper one to support the evaluation and diagnosis of the
impairment. Definitive surgical procedures are those designed to control the ulcer disease
process (i.e., vagotomy and pyloroplasty, subtotal gastrectomy, etc.). Simple closure of a
perforated ulcer does not constitute definitive surgical therapy for peptic ulcer disease.
5.01 Category of Impairments, Digestive System
5.02 Recurrent upper gastrointestinal hemorrhage from undetermined cause with anemia
manifested by hematocrit of 30 percent or less on repeated examinations.
5.03 Stricture, stenosis, or obstruction of the esophagus (demonstrated by endoscopy or other
appropriate medically acceptable imaging) with weight loss as described under listing 5.08.
5.04 Peptic ulcer disease (demonstrated by endoscopy or other appropriate medically
acceptable imaging). With:
A. Recurrent ulceration after definitive surgery persistent despite therapy; or
B. Inoperable fistula formation; or
C. Recurrent obstruction demonstrated by endoscopy or other appropriate medically
acceptable imaging; or,
D. Weight loss as described under §5.08.
5.05 Chronic liver disease (e.g., portal, postnecrotic, or biliary cirrhosis; chronic active
hepatitis; Wilson's disease). With:
A. Esophageal varices (demonstrated by endoscopy or other appropriate medically acceptable
imaging) with a documented history of massive hemorrhage attributable to these varices.
Consider under a disability for 3 years following the last massive hemorrhage; thereafter,
evaluate the residual impairment; or
B. Performance of a shunt operation for esophageal varices. Consider under a disability for 3
years following surgery; thereafter, evaluate the residual impairment; or
C. Serum bilirubin of 2.5 mg. per deciliter (100 ml.) or greater persisting on repeated
examinations for at least 5 months; or
D. Ascites, not attributable to other causes, recurrent or persisting for at least 5 months,
demonstrated by abdominal paracentesis or associated with persistent hypoalbuminemia of
3.0 gm. per deciliter (100 ml.) or less; or
E. Hepatic encephalopathy. Evaluate under the criteria in listing 12.02; or
F. Confirmation of chronic liver disease by liver biopsy (obtained independent of Social
Security disability evaluation) and one of the following:
1. Ascites not attributable to other causes, recurrent or persisting for at least 3 months,
demonstrated by abdominal paracentesis or associated with persistent hypoalbuminemia of

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3.0 gm. per deciliter (100 ml.) or less; or
2. Serum bilirubin of 2.5 mg. per deciliter (100 ml) or greater on repeated examinations for at
least 3 months; or
3. Hepatic cell necrosis or inflammation, persisting for at least 3 months, documented by
repeated abnormalities of prothrombin time and enzymes indicative of hepatic dysfunction.
5.06 Chronic ulcerative or granulomatous colitis (demonstrated by endoscopy, barium enema,
biopsy, or operative findings). With:
A. Recurrent bloody stools documented on repeated examinations and anemia manifested by
hematocrit of 30 percent or less on repeated examinations; or
B. Persistent or recurrent systemic manifestations, such as arthritis, iritis, fever, or liver
dysfunction, not attributable to other causes; or
C. Intermittent obstruction due to intractable abscess, fistula formation, or stenosis; or
D. Recurrence of findings of A, B, or C above after total colectomy; or
E. Weight loss as described under §5.08.
5.07 Regional enteritis (demonstrated by operative findings, barium studies, biopsy, or
endoscopy). With:
A. Persistent or recurrent intestinal obstruction evidenced by abdominal pain, distention,
nausea, and vomiting and accompanied by stenotic areas of small bowel with proximal
intestinal dilation; or
B. Persistent or recurrent systemic manifestations such as arthritis, iritis, fever, or liver
dysfunction, not attributable to other causes; or
C. Intermittent obstruction due to intractable abscess or fistula formation; or
D. Weight loss as described under §5.08.
5.08 Weight loss due to any persisting gastrointestinal disorder: (The following weights are to
be demonstrated to have persisted for at least 3 months despite prescribed therapy and
expected to persist at this level for at least 12 months.) With:
A. Weight equal to or less than the values specified in table I or II; or
B. Weight equal to or less than the values specified in table III or IV and one of the following
abnormal findings on repeated examinations:
1. Serum albumin of 3.0 gm. per deciliter (100 ml.) or less; or
2. Hematocrit of 30 percent or less; or

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3. Serum calcium of 8.0 mg. per deciliter (100 ml.) (4.0 mEq./L) or less; or
4. Uncontrolled diabetes mellitus due to pancreatic dysfunction with repeated hyperglycemia,
hypoglycemia, or ketosis; or
5. Fat in stool of 7 gm. or greater per 24-hour stool specimen; or
6. Nitrogen in stool of 3 gm, or greater per 24-hour specimen; or
7. Persistent or recurrent ascites or edema not attributable to other causes.
Tables of weight reflecting malnutrition scaled according to height and sex—To be used only in
connection with 5.08.
Table I—Men
Height (inches)[1] Weight (pounds)
61
90
62
92
63
94
64
97
65
99
66
102
67
106
68
109
69
112
70
115
71
118
72
122
73
125
74
128
75
131
76
134
[1]Height

measured without shoes.
Table II—Women

Height (inches)[1] Weight (pounds)
58
77
59
79
60
82
61
84
62
86
63
89
64
91
65
94

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66
67
68
69
70
71
72
73
[1]Height

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98
101
104
107
110
114
117
120
measured without shoes.
Table III—Men

Height (inches)[1] Weight (pounds)
61
95
62
98
63
100
64
103
65
106
66
109
67
112
68
116
69
119
70
122
71
126
72
129
73
133
74
136
75
139
76
143
[1]Height

measured without shoes.
Table IV—Women

Height (inches)[1] Weight (pounds)
58
82
59
84
60
87
61
89
62
92
63
94
64
97
65
100
66
104

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67
68
69
70
71
72
73
[1]Height

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107
111
114
117
121
124
128
measured without shoes.

5.09 Liver transplant. Consider under a disability for 12 months following the date of surgery;
thereafter, evaluate the residual impairment(s).
6.00 Genitourinary Impairments
A. What impairments do these listings cover?
1. We use these listings to evaluate genitourinary impairments resulting from chronic renal
disease.
2. We use the criteria in 6.02 to evaluate renal dysfunction due to any chronic renal disease,
such as chronic glomerulonephritis, hypertensive renal vascular disease, diabetic nephropathy,
chronic obstructive uropathy, and hereditary nephropathies.
3. We use the criteria in 6.06 to evaluate nephrotic syndrome due to glomerular disease.
B. What do we mean by the following terms in these listings?
1. Anasarca is generalized massive edema (swelling).
2. Creatinine is a normal product of muscle metabolism.
3. Creatinine clearance test is a test for renal function based on the rate at which creatinine is
excreted by the kidney.
4. Diastolic hypertension is elevated diastolic blood pressure.
5. Fluid overload syndrome associated with renal disease occurs when there is excessive
sodium and water retention in the body that cannot be adequately removed by the diseased
kidneys. Symptoms and signs of vascular congestion may include fatigue, shortness of breath,
hypertension, congestive heart failure, accumulation of fluid in the abdomen (ascites) or chest
(pleural effusions), and peripheral edema.
6. Glomerular disease can be classified into two broad categories, nephrotic and nephritic.
Nephrotic conditions are associated with increased urinary protein excretion and nephritic
conditions are associated with inflammation of the internal structures of the kidneys.
7. Hemodialysis, or dialysis, is the removal of toxic metabolic byproducts from the blood by

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diffusion in an artificial kidney machine.
8. Motor neuropathy is neuropathy or polyneuropathy involving only the motor nerves.
9. Nephrotic syndrome is a general name for a group of diseases involving defective kidney
glomeruli, characterized by heavy proteinuria, hypoalbuminemia, hyperlipidemia, and varying
degrees of edema.
10. Neuropathy is a problem in peripheral nerve function (that is, in any part of the nervous
system except the brain and spinal cord) that causes pain, numbness, tingling, and muscle
weakness in various parts of the body.
11. Osteitis fibrosa is fibrous degeneration with weakening and deformity of bones.
12. Osteomalacia is a softening of the bones.
13. Osteoporosis is a thinning of the bones with reduction in bone mass resulting from the
depletion of calcium and bone protein.
14. Pathologic fractures are fractures resulting from weakening of the bone structure by
pathologic processes, such as osteomalacia and osteoporosis.
15. Peritoneal dialysis is a method of hemodialysis in which the dialyzing solution is introduced
into and removed from the peritoneal cavity either continuously or intermittently.
16. Proteinuria is excess protein in the urine.
17. Renal means pertaining to the kidney.
18. Renal osteodystrophy refers to a variety of bone disorders usually caused by chronic
kidney failure.
19. Sensory neuropathy is neuropathy or polyneuropathy that involves only the sensory
nerves.
20. Serum albumin is a major plasma protein that is responsible for much of the plasma
colloidal osmotic pressure and serves as a transport protein.
21. Serum creatinine is the amount of creatinine in the blood and is measured to evaluate
kidney function.
C. What evidence do we need?
1. We need a longitudinal record of your medical history that includes records of treatment,
response to treatment, hospitalizations, and laboratory evidence of renal disease that indicates
its progressive nature. The laboratory or clinical evidence will indicate deterioration of renal
function, such as elevation of serum creatinine.
2. We generally need a longitudinal clinical record covering a period of at least 3 months of

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observations and treatment, unless we can make a fully favorable determination or decision
without it. The record should include laboratory findings, such as serum creatinine or serum
albumin values, obtained on more than one examination over the 3-month period.
3. When you are undergoing dialysis, we should have laboratory findings showing your renal
function before you started dialysis.
4. The medical evidence establishing the clinical diagnosis of nephrotic syndrome must include
a description of the extent of edema, including pretibial, periorbital, or presacral edema. The
medical evidence should describe any ascites, pleural effusion, or pericardial effusion. Levels
of serum albumin and proteinuria must be included.
5. If a renal biopsy has been performed, the evidence should include a copy of the report of the
microscopic examination of the specimen. However, if we do not have a copy of the
microscopic examination in the evidence, we can accept a statement from an acceptable
medical source that a biopsy was performed, with a description of the results.
D. How do we consider the effects of treatment?
We consider factors such as the:
1. Type of therapy.
2. Response to therapy.
3. Side effects of therapy.
4. Effects of any post-therapeutic residuals.
5. Expected duration of treatment.
E. What other things do we consider when we evaluate your chronic renal disease under
specific listings?
1. Chronic hemodialysis or peritoneal dialysis (6.02A). A report from an acceptable medical
source describing the chronic renal disease and the need for ongoing dialysis is sufficient to
satisfy the requirements in 6.02A.
2. Kidney transplantation (6.02B). If you have undergone kidney transplantation, we will
consider you to be disabled for 12 months following the surgery because, during the first year,
there is a greater likelihood of rejection of the organ and recurrent infection. After the first year
posttransplantation, we will base our continuing disability evaluation on your residual
impairment(s). We will include absence of symptoms, signs, and laboratory findings indicative
of kidney dysfunction in our consideration of whether medical improvement (as defined in
§§404.1579(b)(1) and (c)(1), 404.1594(b)(1) and (c)(1), 416.994(b)(1)(i) and (b)(2)(i), or
416.994a, as appropriate) has occurred. We will consider the:
a. Occurrence of rejection episodes.
b. Side effects of immunosuppressants, including corticosteroids.

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c. Frequency of any renal infections.
d. Presence of systemic complications such as other infections, neuropathy, or deterioration of
other organ systems.
3. Renal osteodystrophy (6.02C1). This condition is bone deterioration resulting from chronic
renal disease. The resultant bone disease includes the impairments described in 6.02C1.
4. Persistent motor or sensory neuropathy (6.02C2). The longitudinal clinical record must show
that the neuropathy is a "severe" impairment as defined in §§404.1520(c) and 416.920(c) that
has lasted or can be expected to last for a continuous period of at least 12 months.
5. Nephrotic syndrome (6.06). The longitudinal clinical record should include a description of
prescribed therapy, response to therapy, and any side effects of therapy. In order for your
nephrotic syndrome to meet 6.06A or B, the medical evidence must document that you have
the appropriate laboratory findings required by these listings and that your anasarca has
persisted for at least 3 months despite prescribed therapy. However, we will not delay
adjudication if we can make a fully favorable determination or decision based on the evidence
in your case record. We may also evaluate complications of your nephrotic syndrome, such as
orthostatic hypotension, recurrent infections, or venous thromboses, under the appropriate
listing for the resultant impairment.
F. What does the term "persistent" mean in these listings?
Persistent means that the longitudinal clinical record shows that, with few exceptions, the
required finding(s) has been at, or is expected to be at, the level specified in the listing for a
continuous period of at least 12 months.
G. How do we evaluate impairments that do not meet one of the genitourinary listings?
1. These listings are only examples of common genitourinary impairments that we consider
severe enough to prevent you from doing any gainful activity. If your severe impairment(s)
does not meet the criteria of any of these listings, we must also consider whether you have an
impairment(s) that satisfies the criteria of a listing in another body system.
2. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will determine whether your impairment(s) medically equals a listing. (See §§404.1526 and
416.926.) If you have a severe impairment(s) that does not meet or medically equal the criteria
of a listing, you may or may not have the residual functional capacity to engage in substantial
gainful activity. Therefore, we proceed to the fourth and, if necessary, the fifth steps of the
sequential evaluation process in §§404.1520 and 416.920. When we decide whether you
continue to be disabled, we use the rules in §§404.1579(b)(1) and (c)(1), 404.1594(b)(1) and
(c)(1), 416.994(b)(1)(i) and (b)(2)(i), or 416.994a, as appropriate.
6.01 Category of Impairments, Genitourinary Impairments
6.02 Impairment of renal function, due to any chronic renal disease that has lasted or can be
expected to last for a continuous period of at least 12 months. With:
A. Chronic hemodialysis or peritoneal dialysis (see 6.00E1).

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or
B. Kidney transplantation. Consider under a disability for 12 months following surgery;
thereafter, evaluate the residual impairment (see 6.00E2).
or
C. Persistent elevation of serum creatinine to 4 mg per deciliter (dL) (100 ml) or greater or
reduction of creatinine clearance to 20 ml per minute or less, over at least 3 months, with one
of the following:
1. Renal osteodystrophy (see 6.00E3) manifested by severe bone pain and appropriate
medically acceptable imaging demonstrating abnormalities such as osteitis fibrosa, significant
osteoporosis, osteomalacia, or pathologic fractures; or
2. Persistent motor or sensory neuropathy (see 6.00E4); or
3. Persistent fluid overload syndrome with:
a. Diastolic hypertension greater than or equal to diastolic blood pressure of 110 mm Hg; or
b. Persistent signs of vascular congestion despite prescribed therapy (see 6.00B5); or
4. Persistent anorexia with recent weight loss and current weight meeting the values in 5.08,
table III or IV.
6.06 Nephrotic syndrome, with anasarca, persisting for at least 3 months despite prescribed
therapy (see 6.00E5). With:
A. Serum albumin of 3.0 g per dL (100 ml) or less and proteinuria of 3.5 g or greater per 24
hours.
or
B. Proteinuria of 10.0 g or greater per 24 hours.
7.00 Hematological Disorders
A. Impairment caused by anemia should be evaluated according to the ability of the individual
to adjust to the reduced oxygen carrying capacity of the blood. A gradual reduction in red cell
mass, even to very low values, is often well tolerated in individuals with a healthy
cardiovascular system.
B. Chronicity is indicated by persistence of the condition for at least 3 months. The laboratory
findings cited must reflect the values reported on more than one examination over that 3month period. Medically acceptable imaging includes, but is not limited to, x-ray imaging,
computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI), with or
without contrast material, myelography, and radionuclear bone scans. "Appropriate" means
that the technique used is the proper one to support the evaluation and diagnosis of the
impairment.

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C. Sickle cell disease refers to a chronic hemolytic anemia associated with sickle cell
hemoglobin, either homozygous or in combination with thalassemia or with another abnormal
hemoglobin (such as C or F).
Appropriate hematologic evidence for sickle cell disease, such as hemoglobin electrophoresis,
must be included. Vasoocclusive or aplastic episodes should be documented by description of
severity, frequency, and duration.
Major visceral episodes include meningitis, osteomyelitis, pulmonary infections or infarctions,
cerebrovascular accidents, congestive heart failure, genito-urinary involvement, etc.
D. Coagulation defects. Chronic inherited coagulation disorders must be documented by
appropriate laboratory evidence. Prophylactic therapy such as with antihemophilic globulin
(AHG) concentrate does not in itself imply severity.
7.01 Category of Impairments, Hemic and Lymphatic System
7.02 Chronic anemia (hematocrit persisting at 30 percent or less due to any cause). With:
A. Requirement of one or more blood transfusions on an average of at least once every 2
months; or
B. Evaluation of the resulting impairment under criteria for the affected body system.
7.05 Sickle cell disease, or one of its variants. With:
A. Documented painful (thrombotic) crises occurring at least three times during the 5 months
prior to adjudication; or
B. Requiring extended hospitalization (beyond emergency care) at least three times during the
12 months prior to adjudication; or
C. Chronic, severe anemia with persistence of hematocrit of 26 percent or less; or
D. Evaluate the resulting impairment under the criteria for the affected body system.
7.06 Chronic thrombocytopenia (due to any cause) with platelet counts repeatedly below
40,000/cubic millimeter. With:
A. At least one spontaneous hemorrhage, requiring transfusion, within 5 months prior to
adjudication; or
B. Intracranial bleeding within 12 months prior to adjudication.
7.07 Hereditary telangiectasia with hemorrhage requiring transfusion at least three times
during the 5 months prior to adjudication.
7.08 Coagulation defects (hemophilia or a similar disorder) with spontaneous hemorrhage
requiring transfusion at least three times during the 5 months prior to adjudication.

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7.09 Polycythemia vera (with erythrocytosis, splenomegaly, and leukocytosis or
thrombocytosis). Evaluate the resulting impairment under the criteria for the affected body
system.
7.10 Myelofibrosis (myeloproliferative syndrome). With:
A. Chronic anemia. Evaluate according to the criteria of §7.02; or
B. Documented recurrent systemic bacterial infections occurring at least 3 times during the 5
months prior to adjudication; or
C. Intractable bone pain with radiologic evidence of osteosclerosis.
7.11-7.14 [Reserved]
7.15 Chronic granulocytopenia (due to any cause). With both A and B:
A. Absolute neutrophil counts repeatedly below 1,000 cells/cubic millimeter; and
B. Documented recurrent systemic bacterial infections occurring at least 3 times during the 5
months prior to adjudication.
7.16 [Reserved]
7.17 Aplastic anemias with bone marrow or stem cell transplantation. Consider under a
disability for 12 months following transplantation; thereafter, evaluate according to the primary
characteristics of the residual impairment.
8.00 Skin Disorders
A. What skin disorders do we evaluate with these listings? We use these listings to evaluate
skin disorders that may result from hereditary, congenital, or acquired pathological processes.
The kinds of impairments covered by these listings are: Ichthyosis, bullous diseases, chronic
infections of the skin or mucous membranes, dermatitis, hidradenitis suppurativa, genetic
photosensitivity disorders, and burns.
B. What documentation do we need? When we evaluate the existence and severity of your
skin disorder, we generally need information about the onset, duration, frequency of flareups,
and prognosis of your skin disorder; the location, size, and appearance of lesions; and, when
applicable, history of exposure to toxins, allergens, or irritants, familial incidence, seasonal
variation, stress factors, and your ability to function outside of a highly protective environment.
To confirm the diagnosis, we may need laboratory findings (for example, results of a biopsy
obtained independently of Social Security disability evaluation or blood tests) or evidence from
other medically acceptable methods consistent with the prevailing state of medical knowledge
and clinical practice.
C. How do we assess the severity of your skin disorder(s)? We generally base our assessment
of severity on the extent of your skin lesions, the frequency of flareups of your skin lesions,
how your symptoms (including pain) limit you, the extent of your treatment, and how your
treatment affects you.

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1. Extensive skin lesions. Extensive skin lesions are those that involve multiple body sites or
critical body areas, and result in a very serious limitation. Examples of extensive skin lesions
that result in a very serious limitation include but are not limited to:
a. Skin lesions that interfere with the motion of your joints and that very seriously limit your use
of more than one extremity; that is, two upper extremities, two lower extremities, or one upper
and one lower extremity.
b. Skin lesions on the palms of both hands that very seriously limit your ability to do fine and
gross motor movements.
c. Skin lesions on the soles of both feet, the perineum, or both inguinal areas that very
seriously limit your ability to ambulate.
2. Frequency of flareups. If you have skin lesions, but they do not meet the requirements of
any of the listings in this body system, you may still have an impairment that prevents you from
doing any gainful activity when we consider your condition over time, especially if your flareups
result in extensive skin lesions, as defined in C1 of this section. Therefore, if you have frequent
flareups, we may find that your impairment(s) is medically equal to one of these listings even
though you have some periods during which your condition is in remission. We will consider
how frequent and serious your flareups are, how quickly they resolve, and how you function
between flareups to determine whether you have been unable to do any gainful activity for a
continuous period of at least 12 months or can be expected to be unable to do any gainful
activity for a continuous period of at least 12 months. We will also consider the frequency of
your flareups when we determine whether you have a severe impairment and when we need
to assess your residual functional capacity.
3. Symptoms (including pain). Symptoms (including pain) may be important factors contributing
to the severity of your skin disorder(s). We assess the impact of symptoms as explained in
§§404.1528, 404.1529, 416.928, and 416.929 of this chapter.
4. Treatment. We assess the effects of medication, therapy, surgery, and any other form of
treatment you receive when we determine the severity and duration of your impairment(s).
Skin disorders frequently respond to treatment; however, response to treatment can vary
widely, with some impairments becoming resistant to treatment. Some treatments can have
side effects that can in themselves result in limitations.
a. We assess the effects of continuing treatment as prescribed by determining if there is
improvement in the symptoms, signs, and laboratory findings of your disorder, and if you
experience side effects that result in functional limitations. To assess the effects of your
treatment, we may need information about:
i. The treatment you have been prescribed (for example, the type, dosage, method, and
frequency of administration of medication or therapy);
ii. Your response to the treatment;
iii. Any adverse effects of the treatment; and
iv. The expected duration of the treatment.

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b. Because treatment itself or the effects of treatment may be temporary, in most cases
sufficient time must elapse to allow us to evaluate the impact and expected duration of
treatment and its side effects. Except under 8.07 and 8.08, you must follow continuing
treatment as prescribed for at least 3 months before your impairment can be determined to
meet the requirements of a skin disorder listing. (See 8.00H if you are not undergoing
treatment or did not have treatment for 3 months.) We consider your specific response to
treatment when we evaluate the overall severity of your impairment.
D. How do we assess impairments that may affect the skin and other body systems? When
your impairment affects your skin and has effects in other body systems, we first evaluate the
predominant feature of your impairment under the appropriate body system. Examples include,
but are not limited to the following.
1. Tuberous sclerosis primarily affects the brain. The predominant features are seizures, which
we evaluate under the neurological listings in 11.00, and developmental delays or other mental
disorders, which we evaluate under the mental disorders listings in 12.00.
2. Malignant tumors of the skin (for example, malignant melanomas) are cancers, or neoplastic
diseases, which we evaluate under the listings in 13.00.
3. Connective tissue disorders and other immune system disorders (for example, systemic
lupus erythematosus, scleroderma, human immunodeficiency virus (HIV) infection, and
Sjögren's syndrome) often involve more than one body system. We first evaluate these
disorders under the immune system listings in 14.00. We evaluate lupus erythematosus under
14.02, scleroderma under 14.04, symptomatic HIV infection under 14.08, and Sjögren's
syndrome under 14.03, 14.09, or any other appropriate listing in section 14.00.
4. Disfigurement or deformity resulting from skin lesions may result in loss of sight, hearing,
speech, and the ability to chew (mastication). We evaluate these impairments and their effects
under the special senses and speech listings in 2.00 and the digestive system listings in 5.00.
Facial disfigurement or other physical deformities may also have effects we evaluate under the
mental disorders listings in 12.00, such as when they affect mood or social functioning.
E. How do we evaluate genetic photosensitivity disorders?
1. Xeroderma pigmentosum (XP). When you have XP, your impairment meets the
requirements of 8.07A if you have clinical and laboratory findings showing that you have the
disorder. (See 8.00E3.) People who have XP have a lifelong hypersensitivity to all forms of
ultraviolet light and generally lead extremely restricted lives in highly protective environments
in order to prevent skin cancers from developing. Some people with XP also experience
problems with their eyes, neurological problems, mental disorders, and problems in other body
systems.
2. Other genetic photosensitivity disorders. Other genetic photosensitivity disorders may vary
in their effects on different people, and may not result in an inability to engage in any gainful
activity for a continuous period of at least 12 months. Therefore, if you have a genetic
photosensitivity disorder other than XP (established by clinical and laboratory findings as
described in 8.00E3), you must show that you have either extensive skin lesions or an inability
to function outside of a highly protective environment to meet the requirements of 8.07B. You
must also show that your impairment meets the duration requirement. By inability to function

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outside of a highly protective environment we mean that you must avoid exposure to ultraviolet
light (including sunlight passing through windows and light from unshielded fluorescent bulbs),
wear protective clothing and eyeglasses, and use opaque broad-spectrum sunscreens in order
to avoid skin cancer or other serious effects. Some genetic photosensitivity disorders can have
very serious effects in other body systems, especially special senses and speech (2.00),
neurological (11.00), mental (12.00), and neoplastic (13.00). We will evaluate the predominant
feature of your impairment under the appropriate body system, as explained in 8.00D.
3. Clinical and laboratory findings.
a. General. We need documentation from an acceptable medical source, as defined in
§§404.1513(a) and 416.913(a), to establish that you have a medically determinable
impairment. In general, we must have evidence of appropriate laboratory testing showing that
you have XP or another genetic photosensitivity disorder. We will find that you have XP or
another genetic photosensitivity disorder based on a report from an acceptable medical source
indicating that you have the impairment, supported by definitive genetic laboratory studies
documenting appropriate chromosomal changes, including abnormal DNA repair or another
DNA or genetic abnormality specific to your type of photosensitivity disorder.
b. What we will accept as medical evidence instead of the actual laboratory report. When we
do not have the actual laboratory report, we need evidence from an acceptable medical source
that includes appropriate clinical findings for your impairment and that is persuasive that a
positive diagnosis has been confirmed by appropriate laboratory testing at some time prior to
our evaluation. To be persuasive, the report must state that the appropriate definitive genetic
laboratory study was conducted and that the results confirmed the diagnosis. The report must
be consistent with other evidence in your case record.
F. How do we evaluate burns? Electrical, chemical, or thermal burns frequently affect other
body systems; for example, musculoskeletal, special senses and speech, respiratory,
cardiovascular, renal, neurological, or mental. Consequently, we evaluate burns the way we
evaluate other disorders that can affect the skin and other body systems, using the listing for
the predominant feature of your impairment. For example, if your soft tissue injuries are under
continuing surgical management (as defined in 1.00M), we will evaluate your impairment under
1.08. However, if your burns do not meet the requirements of 1.08 and you have extensive
skin lesions that result in a very serious limitation (as defined in 8.00C1) that has lasted or can
be expected to last for a continuous period of at least 12 months, we will evaluate them under
8.08.
G. How do we determine if your skin disorder(s) will continue at a disabling level of severity in
order to meet the duration requirement? For all of these skin disorder listings except 8.07 and
8.08, we will find that your impairment meets the duration requirement if your skin disorder
results in extensive skin lesions that persist for at least 3 months despite continuing treatment
as prescribed. By persist, we mean that the longitudinal clinical record shows that, with few
exceptions, your lesions have been at the level of severity specified in the listing. For 8.07A,
we will presume that you meet the duration requirement. For 8.07B and 8.08, we will consider
all of the relevant medical and other information in your case record to determine whether your
skin disorder meets the duration requirement.
H. How do we assess your skin disorder(s) if your impairment does not meet the requirements
of one of these listings?

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1. These listings are only examples of common skin disorders that we consider severe enough
to prevent you from engaging in any gainful activity. For most of these listings, if you do not
have continuing treatment as prescribed, if your treatment has not lasted for at least 3 months,
or if you do not have extensive skin lesions that have persisted for at least 3 months, your
impairment cannot meet the requirements of these skin disorder listings. (This provision does
not apply to 8.07 and 8.08.) However, we may still find that you are disabled because your
impairment(s) meets the requirements of a listing in another body system or medically equals
the severity of a listing. (See §§404.1526 and 416.926 of this chapter.) We may also find you
disabled at the last step of the sequential evaluation process.
2. If you have not received ongoing treatment or do not have an ongoing relationship with the
medical community despite the existence of a severe impairment(s), or if your skin lesions
have not persisted for at least 3 months but you are undergoing continuing treatment as
prescribed, you may still have an impairment(s) that meets a listing in another body system or
that medically equals a listing. If you do not have an impairment(s) that meets or medically
equals a listing, we will assess your residual functional capacity and proceed to the fourth and,
if necessary, the fifth step of the sequential evaluation process in §§404.1520 and 416.920 of
this chapter. When we decide whether you continue to be disabled, we use the rules in
§§404.1594 and 416.994 of this chapter.
8.01 Category of Impairments, Skin Disorders
8.02 Ichthyosis, with extensive skin lesions that persist for at least 3 months despite continuing
treatment as prescribed.
8.03 Bullous disease (for example, pemphigus, erythema multiforme bullosum, epidermolysis
bullosa, bullous pemphigoid, dermatitis herpetiformis), with extensive skin lesions that persist
for at least 3 months despite continuing treatment as prescribed.
8.04 Chronic infections of the skin or mucous membranes, with extensive fungating or
extensive ulcerating skin lesions that persist for at least 3 months despite continuing treatment
as prescribed.
8.05 Dermatitis (for example, psoriasis, dyshidrosis, atopic dermatitis, exfoliative dermatitis,
allergic contact dermatitis), with extensive skin lesions that persist for at least 3 months despite
continuing treatment as prescribed.
8.06 Hidradenitis suppurativa, with extensive skin lesions involving both axillae, both inguinal
areas or the perineum that persist for at least 3 months despite continuing treatment as
prescribed.
8.07 Genetic photosensitivity disorders, established as described in 8.00E.
A. Xeroderma pigmentosum. Consider the individual disabled from birth.
B. Other genetic photosensitivity disorders, with:
1. Extensive skin lesions that have lasted or can be expected to last for a continuous period of
at least 12 months, or

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2. Inability to function outside of a highly protective environment for a continuous period of at
least 12 months (see 8.00E2).
8.08 Burns, with extensive skin lesions that have lasted or can be expected to last for a
continuous period of at least 12 months (see 8.00F).
9.00 Endocrine System
Cause of impairment. Impairment is caused by overproduction or underproduction of
hormones, resulting in structural or functional changes in the body. Where involvement of other
organ systems has occurred as a result of a primary endocrine disorder, these impairments
should be evaluated according to the criteria under the appropriate sections. Medically
acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial
tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast
material, myelography, and radionuclear bone scans. "Appropriate" means that the technique
used is the proper one to support the evaluation and diagnosis of the impairment.
9.01 Category of Impairments, Endocrine System
9.02 Thyroid Disorders.
Evaluate the resulting impairment under the criteria for the affected body system.
9.03 Hyperparathyroidism. With:
A. Generalized decalcification of bone on appropriate medically acceptable imaging study and
elevation of plasma calcium to 11 mg. per deciliter (100 ml.) or greater; or
B. A resulting impairment. Evaluate according to the criteria in the affected body system.
9.04 Hypoparathyroidism. With:
A. Severe recurrent tetany; or
B. Recurrent generalized convulsions; or
C. Lenticular cataracts. Evaluate under the criteria in 2.00ff.
9.05 Neurohypophyseal insufficiency (diabetes insipidus). With urine specific gravity of 1.005
or below, persistent for at least 3 months and recurrent dehydration.
9.06 Hyperfunction of the adrenal cortex. Evaluate the resulting impairment under the criteria
for the affected body system.
9.08 Diabetes mellitus. With:
A. Neuropathy demonstrated by significant and persistent disorganization of motor function in
two extremities resulting in sustained disturbance of gross and dexterous movements, or gait
and station (see 11.00C); or

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B. Acidosis occurring at least on the average of once every 2 months documented by
appropriate blood chemical tests (pH or PCO2 or bicarbonate levels); or
C. Retinitis proliferans; evaluate the visual impairment under the criteria in 2.02, 2.03, or 2.04.
10.00 Impairments That Affect Multiple Body Systems
A. What Impairment Do We Evaluate Under This Body System?
1. General. We evaluate non-mosaic Down syndrome under this body system.
2. What is Down syndrome? Down syndrome is a condition in which there are three copies of
chromosome 21 within the cells of the body instead of the normal two copies per cell. The
three copies may be separate (trisomy), or one chromosome 21 copy may be attached to a
different chromosome (translocation). This extra chromosomal material changes the orderly
development of the body and brain. Down syndrome is characterized by a complex of physical
characteristics, delayed physical development, and mental retardation. Down syndrome exists
in non-mosaic and mosaic forms.
3. What is non-mosaic Down syndrome?
a. Non-mosaic Down syndrome occurs when you have an extra copy of chromosome 21 in
every cell of your body. At least 98 percent of people with Down syndrome have this form
(which includes either trisomy or translocation type chromosomal abnormalities). Virtually all
cases of non-mosaic Down syndrome affect the mental, neurological, and skeletal systems,
and they are often accompanied by heart disease, impaired vision, hearing problems, and
other conditions.
b. We evaluate adults with confirmed non-mosaic Down syndrome under 10.06. If you have
confirmed non-mosaic Down syndrome, we consider you disabled from birth.
4. What is mosaic Down syndrome?
a. Mosaic Down syndrome occurs when you have some cells with the normal two copies of
chromosome 21 and some cells with an extra copy of chromosome 21. When this occurs,
there is a mixture of two types of cells. Mosaic Down syndrome occurs in only 1-2 percent of
people with Down syndrome, and there is a wide range in the level of severity of the
impairment. Mosaic Down syndrome can be profound and disabling, but it can also be so slight
as to be undetected clinically.
b. We evaluate adults with confirmed mosaic Down syndrome under the listing criteria in any
affected body system(s) on an individual case basis, as described in 10.00C.
B. What Documentation Do We Need To Establish That You Have Non-Mosaic Down
Syndrome?
1. General. We need documentation from an acceptable medical source, as defined in
§§404.1513(a) and 416.913(a), to establish that you have a medically determinable
impairment.

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2. Definitive chromosomal analysis. We will find that you have non-mosaic Down syndrome
based on a report from an acceptable medical source that indicates that you have the
impairment and that includes the actual laboratory report of definitive chromosomal analysis
showing that you have the impairment. Definitive chromosomal analysis means karyotype
analysis. In this case, we do not additionally require a clinical description of the diagnostic
physical features of your impairment.
3. What if we do not have the results of definitive chromosomal analysis? When we do not
have the actual laboratory report of definitive chromosomal analysis, we need evidence from
an acceptable medical source that includes a clinical description of the diagnostic physical
features of Down syndrome, and that is persuasive that a positive diagnosis has been
confirmed by definitive chromosomal analysis at some time prior to our evaluation. To be
persuasive, the report must state that definitive chromosomal analysis was conducted and that
the results confirmed the diagnosis. The report must be consistent with other evidence in your
case record; for example, evidence showing your limitations in adaptive functioning or signs of
a mental disorder that can be associated with non-mosaic Down syndrome, your educational
history, or the results of psychological testing.
C. How Do We Evaluate Other Impairments That Affect Multiple Body Systems?
1. Non-mosaic Down syndrome (10.06) is an example of an impairment that commonly affects
multiple body systems and that we consider significant enough to prevent you from doing any
gainful activity. If you have a different severe impairment(s) that affects multiple body systems,
we must also consider whether your impairment(s) meets the criteria of a listing in another
body system.
2. There are many other impairments that can cause deviation from, or interruption of, the
normal function of the body or interfere with development; for example, congenital anomalies,
chromosomal disorders, dysmorphic syndromes, metabolic disorders, and perinatal infectious
diseases. In these impairments, the degree of deviation or interruption may vary widely from
individual to individual. Therefore, the resulting functional limitations and the progression of
those limitations also vary widely. For this reason, we evaluate the specific effects of these
impairments on you under the listing criteria in any affected body system(s) on an individual
case basis. Examples of such impairments include triple X syndrome (XXX syndrome), fragile
X syndrome, phenylketonuria (PKU), caudal regression syndrome, and fetal alcohol syndrome.
3. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will consider whether your impairment(s) medically equals a listing. (See §§404.1526 and
416.926.) If your impairment(s) does not meet or medically equal a listing, you may or may not
have the residual functional capacity to engage in substantial gainful activity. In that situation,
we proceed to the fourth and, if necessary, the fifth step of the sequential evaluation process in
§§404.1520 and 416.920. We use the rules in §§404.1594 and 416.994, as appropriate, when
we decide whether you continue to be disabled.
10.01 Category of Impairments, Impairments That Affect Multiple Body Systems
10.06 Non-mosaic Down syndrome, established as described in 10.00B.
11.00 Neurological

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A. Epilepsy. In epilepsy, regardless of etiology, degree of impairment will be determined
according to type, frequency, duration, and sequelae of seizures. At least one detailed
description of a typical seizure is required. Such description includes the presence or absence
of aura, tongue bites, sphincter control, injuries associated with the attack, and postictal
phenomena. The reporting physician should indicate the extent to which description of
seizures reflects his own observations and the source of ancillary information. Testimony of
persons other than the claimant is essential for description of type and frequency of seizures if
professional observation is not available.
Under 11.02 and 11.03, the criteria can be applied only if the impairment persists despite the
fact that the individual is following prescribed antiepileptic treatment. Adherence to prescribed
antiepileptic therapy can ordinarily be determined from objective clinical findings in the report
of the physician currently providing treatment for epilepsy. Determination of blood levels of
phenytoin sodium or other antiepileptic drugs may serve to indicate whether the prescribed
medication is being taken. When seizures are occurrring at the frequency stated in 11.02 or
11.03, evalution of the severity of the impairment must include consideration of the serum drug
levels. Should serum drug levels appear therapeutically inadequate, consideration should be
given as to whether this is caused by individual idiosyncrasy in absorption of metabolism of the
drug. Blood drug levels should be evaluated in conjunction with all the other evidence to
determine the extent of compliance. When the reported blood drug levels are low, therefore,
the information obtained from the treating source should include the physician's statement as
to why the levels are low and the results of any relevant diagnostic studies concerning the
blood levels. Where adequate seizure control is obtained only with unusually large doses, the
possibility of impairment resulting from the side effects of this medication must be also
assessed. Where documentation shows that use of alcohol or drugs affects adherence to
prescribed therapy or may play a part in the precipitation of seizures, this must also be
considered in the overall assessment of impairment level.
B. Brain tumors. We evaluate malignant brain tumors under the criteria in 13.13. For benign
brain tumors, we determine the severity and duration of the impairment on the basis of
symptoms, signs, and laboratory findings (11.05).
C. Persistent disorganization of motor function in the form of paresis or paralysis, tremor or
other involuntary movements, ataxia and sensory disturbances (any or all of which may be due
to cerebral, cerebellar, brain stem, spinal cord, or peripheral nerve dysfunction) which occur
singly or in various combinations, frequently provides the sole or partial basis for decision in
cases of neurological impairment. The assessment of impairment depends on the degree of
interference with locomotion and/or interference with the use of fingers, hands, and arms.
D. In conditions which are episodic in character, such as multiple sclerosis or myasthenia
gravis, consideration should be given to frequency and duration of exacerbations, length of
remissions, and permanent residuals.
E. Multiple sclerosis. The major criteria for evaluating impairment caused by multiple sclerosis
are discussed in listing 11.09. Paragraph A provides criteria for evaluating disorganization of
motor function and gives reference to 11.04B (11.04B then refers to 11.00C). Paragraph B
provides references to other listings for evaluating visual or mental impairments caused by
multiple sclerosis. Paragraph C provides criteria for evaluating the impairment of individuals
who do not have muscle weakness or other significant disorganization of motor function at
rest, but who do develop muscle weakness on activity as a result of fatigue.

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Use of the criteria in 11.09C is dependent upon (1) documenting a diagnosis of multiple
sclerosis, (2) obtaining a description of fatigue considered to be characteristic of multiple
sclerosis, and (3) obtaining evidence that the system has actually become fatigued. The
evaluation of the magnitude of the impairment must consider the degree of exercise and the
severity of the resulting muscle weakness.
The criteria in 11.09C deals with motor abnormalities which occur on activity. If the
disorganization of motor function is present at rest, paragraph A must be used, taking into
account any further increase in muscle weakness resulting from activity.
Sensory abnormalities may occur, particularly involving central visual acuity. The decrease in
visual acuity may occur after brief attempts at activity involving near vision, such as reading.
This decrease in visual acuity may not persist when the specific activity is terminated, as with
rest, but is predictably reproduced with resumption of the activity. The impairment of central
visual acuity in these cases should be evaluated under the criteria in listing 2.02, taking into
account the fact that the decrease in visual acuity will wax and wane.
Clarification of the evidence regarding central nervous system dysfunction responsible for the
symptoms may require supporting technical evidence of functional impairment such as evoked
response tests during exercise.
F. Traumatic brain injury (TBI). The guidelines for evaluating impairments caused by cerebral
trauma are contained in 11.18. Listing 11.18 states that cerebral trauma is to be evaluated
under 11.02, 11.03, 11.04, and 12.02, as applicable.
TBI may result in neurological and mental impairments with a wide variety of posttraumatic
symptoms and signs. The rate and extent of recovery can be highly variable and the long-term
outcome may be difficult to predict in the first few months post-injury. Generally, the
neurological impairment(s) will stabilize more rapidly than any mental impairment(s).
Sometimes a mental impairment may appear to improve immediately following TBI and then
worsen, or, conversely, it may appear much worse initially but improve after a few months.
Therefore, the mental findings immediately following TBI may not reflect the actual severity of
your mental impairment(s). The actual severity of a mental impairment may not become
apparent until 6 months post-injury.
In some cases, evidence of a profound neurological impairment is sufficient to permit a finding
of disability within 3 months post-injury. If a finding of disability within 3 months post-injury is
not possible based on any neurological impairment(s), we will defer adjudication of the claim
until we obtain evidence of your neurological or mental impairments at least 3 months postinjury. If a finding of disability still is not possible at that time, we will again defer adjudication of
the claim until we obtain evidence at least 6 months post-injury. At that time, we will fully
evaluate any neurological and mental impairments and adjudicate the claim.
G. Amyotrophic Lateral Sclerosis (ALS). 1. Amyotrophic lateral sclerosis (ALS), sometimes
called Lou Gehrig's disease, is a progressive, invariably fatal neurological disease that attacks
the nerve cells (motor neurons) responsible for controlling voluntary muscles. Eventually, all
muscles under voluntary control are affected, and individuals with ALS ultimately lose their
ability to move their arms and legs, and their capacity to swallow, speak, and breath. Most
people with ALS die from respiratory failure. There is currently no cure for ALS, and most
treatments are designed only to relieve symptoms and improve the quality of life.

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2. Diagnosis of ALS is based on history, neurological findings consistent with the diagnosis of
ALS, and electrophysiological and neuroimaging testing to rule out other impairments that may
cause similar signs and symptoms. The diagnosis may also be supported by
electrophysiological studies (electromyography or nerve conduction studies), but these tests
may be negative or only suggestive of the diagnosis. There is no single test that establishes
the existence of ALS.
3. For purposes of 11.10, documentation of the diagnosis must be by generally accepted
methods consistent with the prevailing state of medical knowledge and clinical practice. The
evidence should include documentation of a clinically appropriate medical history, neurological
findings consistent with the diagnosis of ALS, and the results of any electrophysiological and
neuroimaging testing.
11.01 Category of Impairments, Neurological
11.02 Epilepsy—convulsive epilepsy, (grand mal or psychomotor), documented by detailed
description of a typical seizure pattern, including all associated phenomena; occurring more
frequently than once a month in spite of at least 3 months of prescribed treatment. With:
A. Daytime episodes (loss of consciousness and convulsive seizures) or
B. Nocturnal episodes manifesting residuals which interfere significantly with activity during the
day.
11.03 Epilepsy—nonconvulsive epilepsy (petit mal, psychomotor, or focal), documented by
detailed description of a typical seizure pattern, including all associated phenomena; occurring
more frequently than once weekly in spite of at least 3 months of prescribed treatment. With
alteration of awareness or loss of consciousness and transient postictal manifestations of
unconventional behavior or significant interference with activity during the day.
11.04 Central nervous system vascular accident. With one of the following more than 3 months
post-vascular accident:
A. Sensory or motor aphasia resulting in ineffective speech or communication; or
B. Significant and persistent disorganization of motor function in two extremities, resulting in
sustained disturbance of gross and dexterous movements, or gait and station (see 11.00C).
11.05 Benign brain tumors. Evaluate under 11.02, 11.03, 11.04, or the criteria of the affected
body system.
11.06 Parkinsonian syndrome with the following signs: Significant rigidity, brady kinesia, or
tremor in two extremities, which, singly or in combination, result in sustained disturbance of
gross and dexterous movements, or gait and station.
11.07 Cerebral palsy. With:
A. IQ of 70 or less; or
B. Abnormal behavior patterns, such as destructiveness or emotional instability: or

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C. Significant interference in communication due to speech, hearing, or visual defect; or
D. Disorganization of motor function as described in 11.04B.
11.08 Spinal cord or nerve root lesions, due to any cause with disorganization of motor
function as described in 11.04B.
11.09 Multiple sclerosis. With:
A. Disorganization of motor function as described in 11.04B; or
B. Visual or mental impairment as described under the criteria in 2.02, 2.03, 2.04, or 12.02; or
C. Significant, reproducible fatigue of motor function with substantial muscle weakness on
repetitive activity, demonstrated on physical examination, resulting from neurological
dysfunction in areas of the central nervous system known to be pathologically involved by the
multiple sclerosis process.
11.10 Amyotrophic lateral sclerosis established by clinical and laboratory findings, as
described in 11.00G.
11.11 Anterior poliomyelitis. With:
A. Persistent difficulty with swallowing or breathing; or
B. Unintelligible speech; or
C. Disorganization of motor function as described in 11.04B.
11.12 Myasthenia gravis. With:
A. Significant difficulty with speaking, swallowing, or breathing while on prescribed therapy; or
B. Significant motor weakness of muscles of extremities on repetitive activity against
resistance while on prescribed therapy.
11.13 Muscular dystrophy with disorganization of motor function as described in 11.04B.
11.14 Peripheral neuropathies.
With disorganization of motor function as described in 11.04B, in spite of prescribed treatment.
11.15 [Reserved]
11.16 Subacute combined cord degeneration (pernicious anemia) with disorganization of
motor function as decribed in 11.04B or 11.15B, not significantly improved by prescribed
treatment.
11.17 Degenerative disease not listed elsewhere, such as Huntington's chorea, Friedreich's

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ataxia, and spino-cerebellar degeneration. With:
A. Disorganization of motor function as described in 11.04B; or
B. Chronic brain syndrome. Evaluate under 12.02.
11.18 Cerebral trauma:
Evaluate under the provisions of 11.02, 11.03, 11.04 and 12.02, as applicable.
11.19 Syringomyelia.
With:
A. Significant bulbar signs; or
B. Disorganization of motor function as described in 11.04B.
12.00 Mental Disorders
A. Introduction. The evaluation of disability on the basis of mental disorders requires
documentation of a medically determinable impairment(s), consideration of the degree of
limitation such impairment(s) may impose on your ability to work, and consideration of whether
these limitations have lasted or are expected to last for a continuous period of at least 12
months. The listings for mental disorders are arranged in nine diagnostic categories: Organic
mental disorders (12.02); schizophrenic, paranoid and other psychotic disorders (12.03);
affective disorders (12.04); mental retardation (12.05); anxiety-related disorders (12.06);
somatoform disorders (12.07); personality disorders (12.08); substance addiction disorders
(12.09); and autistic disorder and other pervasive developmental disorders (12.10). Each
listing, except 12.05 and 12.09, consists of a statement describing the disorder(s) addressed
by the listing, paragraph A criteria (a set of medical findings), and paragraph B criteria (a set of
impairment-related functional limitations). There are additional functional criteria (paragraph C
criteria) in 12.02, 12.03, 12.04, and 12.06, discussed herein. We will assess the paragraph B
criteria before we apply the paragraph C criteria. We will assess the paragraph C criteria only if
we find that the paragraph B criteria are not satisfied. We will find that you have a listed
impairment if the diagnostic description in the introductory paragraph and the criteria of both
paragraphs A and B (or A and C, when appropriate) of the listed impairment are satisfied.
The criteria in paragraph A substantiate medically the presence of a particular mental disorder.
Specific symptoms, signs, and laboratory findings in the paragraph A criteria of any of the
listings in this section cannot be considered in isolation from the description of the mental
disorder contained at the beginning of each listing category. Impairments should be analyzed
or reviewed under the mental category(ies) indicated by the medical findings. However, we
may also consider mental impairments under physical body system listings, using the concept
of medical equivalence, when the mental disorder results in physical dysfunction. (See, for
instance, 12.00D12 regarding the evaluation of anorexia nervosa and other eating disorders.)
The criteria in paragraphs B and C describe impairment-related functional limitations that are
incompatible with the ability to do any gainful activity. The functional limitations in paragraphs
B and C must be the result of the mental disorder described in the diagnostic description, that

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is manifested by the medical findings in paragraph A.
The structure of the listing for mental retardation (12.05) is different from that of the other
mental disorders listings. Listing 12.05 contains an introductory paragraph with the diagnostic
description for mental retardation. It also contains four sets of criteria (paragraphs A through
D). If your impairment satisfies the diagnostic description in the introductory paragraph and any
one of the four sets of criteria, we will find that your impairment meets the listing. Paragraphs A
and B contain criteria that describe disorders we consider severe enough to prevent your doing
any gainful activity without any additional assessment of functional limitations. For paragraph
C, we will assess the degree of functional limitation the additional impairment(s) imposes to
determine if it significantly limits your physical or mental ability to do basic work activities, i.e.,
is a "severe" impairment(s), as defined in §§404.1520(c) and 416.920(c). If the additional
impairment(s) does not cause limitations that are "severe" as defined in §§404.1520(c) and
416.920(c), we will not find that the additional impairment(s) imposes "an additional and
significant work-related limitation of function," even if you are unable to do your past work
because of the unique features of that work. Paragraph D contains the same functional criteria
that are required under paragraph B of the other mental disorders listings.
The structure of the listing for substance addiction disorders, 12.09, is also different from that
for the other mental disorder listings. Listing 12.09 is structured as a reference listing; that is, it
will only serve to indicate which of the other listed mental or physical impairments must be
used to evaluate the behavioral or physical changes resulting from regular use of addictive
substances.
The listings are so constructed that an individual with an impairment(s) that meets or is
equivalent in severity to the criteria of a listing could not reasonably be expected to do any
gainful activity. These listings are only examples of common mental disorders that are
considered severe enough to prevent an individual from doing any gainful activity. When you
have a medically determinable severe mental impairment that does not satisfy the diagnostic
description or the requirements of the paragraph A criteria of the relevant listing, the
assessment of the paragraph B and C criteria is critical to a determination of equivalence.
If your impairment(s) does not meet or is not equivalent in severity to the criteria of any listing,
you may or may not have the residual functional capacity (RFC) to do substantial gainful
activity (SGA). The determination of mental RFC is crucial to the evaluation of your capacity to
do SGA when your impairment(s) does not meet or equal the criteria of the listings, but is
nevertheless severe.
RFC is a multidimensional description of the work-related abilities you retain in spite of your
medical impairments. An assessment of your RFC complements the functional evaluation
necessary for paragraphs B and C of the listings by requiring consideration of an expanded list
of work-related capacities that may be affected by mental disorders when your impairment(s) is
severe but neither meets nor is equivalent in severity to a listed mental disorder.
B. Need for medical evidence. We must establish the existence of a medically determinable
impairment(s) of the required duration by medical evidence consisting of symptoms, signs, and
laboratory findings (including psychological test findings). Symptoms are your own description
of your physical or mental impairment(s). Psychiatric signs are medically demonstrable
phenomena that indicate specific psychological abnormalities, e.g., abnormalities of behavior,
mood, thought, memory, orientation, development, or perception, as described by an

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appropriate medical source. Symptoms and signs generally cluster together to constitute
recognizable mental disorders described in the listings. The symptoms and signs may be
intermittent or continuous depending on the nature of the disorder.
C. Assessment of severity. We measure severity according to the functional limitations
imposed by your medically determinable mental impairment(s). We assess functional
limitations using the four criteria in paragraph B of the listings: Activities of daily living; social
functioning; concentration, persistence, or pace; and episodes of decompensation. Where we
use "marked" as a standard for measuring the degree of limitation, it means more than
moderate but less than extreme. A marked limitation may arise when several activities or
functions are impaired, or even when only one is impaired, as long as the degree of limitation
is such as to interfere seriously with your ability to function independently, appropriately,
effectively, and on a sustained basis. See §§404.1520a and 416.920a.
1. Activities of daily living include adaptive activities such as cleaning, shopping, cooking,
taking public transportation, paying bills, maintaining a residence, caring appropriately for your
grooming and hygiene, using telephones and directories, and using a post office. In the context
of your overall situation, we assess the quality of these activities by their independence,
appropriateness, effectiveness, and sustainability. We will determine the extent to which you
are capable of initiating and participating in activities independent of supervision or direction.
We do not define "marked" by a specific number of different activities of daily living in which
functioning is impaired, but by the nature and overall degree of interference with function. For
example, if you do a wide range of activities of daily living, we may still find that you have a
marked limitation in your daily activities if you have serious difficulty performing them without
direct supervision, or in a suitable manner, or on a consistent, useful, routine basis, or without
undue interruptions or distractions.
2. Social functioning refers to your capacity to interact independently, appropriately, effectively,
and on a sustained basis with other individuals. Social functioning includes the ability to get
along with others, such as family members, friends, neighbors, grocery clerks, landlords, or
bus drivers. You may demonstrate impaired social functioning by, for example, a history of
altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, or
social isolation. You may exhibit strength in social functioning by such things as your ability to
initiate social contacts with others, communicate clearly with others, or interact and actively
participate in group activities. We also need to consider cooperative behaviors, consideration
for others, awareness of others' feelings, and social maturity. Social functioning in work
situations may involve interactions with the public, responding appropriately to persons in
authority (e.g., supervisors), or cooperative behaviors involving coworkers.
We do not define "marked" by a specific number of different behaviors in which social
functioning is impaired, but by the nature and overall degree of interference with function. For
example, if you are highly antagonistic, uncooperative, or hostile but are tolerated by local
storekeepers, we may nevertheless find that you have a marked limitation in social functioning
because that behavior is not acceptable in other social contexts.
3. Concentration, persistence, or pace refers to the ability to sustain focused attention and
concentration sufficiently long to permit the timely and appropriate completion of tasks
commonly found in work settings. Limitations in concentration, persistence, or pace are best
observed in work settings, but may also be reflected by limitations in other settings. In addition,

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major limitations in this area can often be assessed through clinical examination or
psychological testing. Wherever possible, however, a mental status examination or
psychological test data should be supplemented by other available evidence.
On mental status examinations, concentration is assessed by tasks such as having you
subtract serial sevens or serial threes from 100. In psychological tests of intelligence or
memory, concentration is assessed through tasks requiring short-term memory or through
tasks that must be completed within established time limits.
In work evaluations, concentration, persistence, or pace is assessed by testing your ability to
sustain work using appropriate production standards, in either real or simulated work tasks
(e.g., filing index cards, locating telephone numbers, or disassembling and reassembling
objects). Strengths and weaknesses in areas of concentration and attention can be discussed
in terms of your ability to work at a consistent pace for acceptable periods of time and until a
task is completed, and your ability to repeat sequences of action to achieve a goal or an
objective.
We must exercise great care in reaching conclusions about your ability or inability to complete
tasks under the stresses of employment during a normal workday or work week based on a
time-limited mental status examination or psychological testing by a clinician, or based on your
ability to complete tasks in other settings that are less demanding, highly structured, or more
supportive. We must assess your ability to complete tasks by evaluating all the evidence, with
an emphasis on how independently, appropriately, and effectively you are able to complete
tasks on a sustained basis.
We do not define "marked" by a specific number of tasks that you are unable to complete, but
by the nature and overall degree of interference with function. You may be able to sustain
attention and persist at simple tasks but may still have difficulty with complicated tasks.
Deficiencies that are apparent only in performing complex procedures or tasks would not
satisfy the intent of this paragraph B criterion. However, if you can complete many simple
tasks, we may nevertheless find that you have a marked limitation in concentration,
persistence, or pace if you cannot complete these tasks without extra supervision or
assistance, or in accordance with quality and accuracy standards, or at a consistent pace
without an unreasonable number and length of rest periods, or without undue interruptions or
distractions.
4. Episodes of decompensation are exacerbations or temporary increases in symptoms or
signs accompanied by a loss of adaptive functioning, as manifested by difficulties in performing
activities of daily living, maintaining social relationships, or maintaining concentration,
persistence, or pace. Episodes of decompensation may be demonstrated by an exacerbation
in symptoms or signs that would ordinarily require increased treatment or a less stressful
situation (or a combination of the two). Episodes of decompensation may be inferred from
medical records showing significant alteration in medication; or documentation of the need for
a more structured psychological support system (e.g., hospitalizations, placement in a halfway
house, or a highly structured and directing household); or other relevant information in the
record about the existence, severity, and duration of the episode.
The term repeated episodes of decompensation, each of extended duration in these listings
means three episodes within 1 year, or an average of once every 4 months, each lasting for at
least 2 weeks. If you have experienced more frequent episodes of shorter duration or less

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frequent episodes of longer duration, we must use judgment to determine if the duration and
functional effects of the episodes are of equal severity and may be used to substitute for the
listed finding in a determination of equivalence.
D. Documentation. The evaluation of disability on the basis of a mental disorder requires
sufficient evidence to (1) establish the presence of a medically determinable mental
impairment(s), (2) assess the degree of functional limitation the impairment(s) imposes, and
(3) project the probable duration of the impairment(s). See §§404.1512 and 416.912 for a
discussion of what we mean by "evidence" and how we will assist you in developing your
claim. Medical evidence must be sufficiently complete and detailed as to symptoms, signs, and
laboratory findings to permit an independent determination. In addition, we will consider
information you provide from other sources when we determine how the established
impairment(s) affects your ability to function. We will consider all relevant evidence in your
case record.
1. Sources of evidence.
a. Medical evidence. There must be evidence from an acceptable medical source showing that
you have a medically determinable mental impairment. See §§404.1508, 404.1513, 416.908,
and 416.913. We will make every reasonable effort to obtain all relevant and available medical
evidence about your mental impairment(s), including its history, and any records of mental
status examinations, psychological testing, and hospitalizations and treatment. Whenever
possible, and appropriate, medical source evidence should reflect the medical source's
considerations of information from you and other concerned persons who are aware of your
activities of daily living; social functioning; concentration, persistence, or pace; or episodes of
decompensation. Also, in accordance with standard clinical practice, any medical source
assessment of your mental functioning should take into account any sensory, motor, or
communication abnormalities, as well as your cultural and ethnic background.
b. Information from the individual. Individuals with mental impairments can often provide
accurate descriptions of their limitations. The presence of a mental impairment does not
automatically rule you out as a reliable source of information about your own functional
limitations. When you have a mental impairment and are willing and able to describe your
limitations, we will try to obtain such information from you. However, you may not be willing or
able to fully or accurately describe the limitations resulting from your impairment(s). Thus, we
will carefully examine the statements you provide to determine if they are consistent with the
information about, or general pattern of, the impairment as described by the medical and other
evidence, and to determine whether additional information about your functioning is needed
from you or other sources.
c. Other information. Other professional health care providers (e.g., psychiatric nurse,
psychiatric social worker) can normally provide valuable functional information, which should
be obtained when available and needed. If necessary, information should also be obtained
from nonmedical sources, such as family members and others who know you, to supplement
the record of your functioning in order to establish the consistency of the medical evidence and
longitudinality of impairment severity, as discussed in 12.00D2. Other sources of information
about functioning include, but are not limited to, records from work evaluations and
rehabilitation progress notes.
2. Need for longitudinal evidence. Your level of functioning may vary considerably over time.

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The level of your functioning at a specific time may seem relatively adequate or, conversely,
rather poor. Proper evaluation of your impairment(s) must take into account any variations in
the level of your functioning in arriving at a determination of severity over time. Thus, it is vital
to obtain evidence from relevant sources over a sufficiently long period prior to the date of
adjudication to establish your impairment severity.
3. Work attempts. You may have attempted to work or may actually have worked during the
period of time pertinent to the determination of disability. This may have been an independent
attempt at work or it may have been in conjunction with a community mental health or
sheltered program, and it may have been of either short or long duration. Information
concerning your behavior during any attempt to work and the circumstances surrounding
termination of your work effort are particularly useful in determining your ability or inability to
function in a work setting. In addition, we should also examine the degree to which you require
special supports (such as those provided through supported employment or transitional
employment programs) in order to work.
4. Mental status examination. The mental status examination is performed in the course of a
clinical interview and is often partly assessed while the history is being obtained. A
comprehensive mental status examination generally includes a narrative description of your
appearance, behavior, and speech; thought process (e.g., loosening of associations); thought
content (e.g., delusions); perceptual abnormalities (e.g., hallucinations); mood and affect (e.g.,
depression, mania); sensorium and cognition (e.g., orientation, recall, memory, concentration,
fund of information, and intelligence); and judgment and insight. The individual case facts
determine the specific areas of mental status that need to be emphasized during the
examination.
5. Psychological testing.
a. Reference to a "standardized psychological test" indicates the use of a psychological test
measure that has appropriate validity, reliability, and norms, and is individually administered by
a qualified specialist. By "qualified," we mean the specialist must be currently licensed or
certified in the State to administer, score, and interpret psychological tests and have the
training and experience to perform the test.
b. Psychological tests are best considered as standardized sets of tasks or questions designed
to elicit a range of responses. Psychological testing can also provide other useful data, such as
the specialist's observations regarding your ability to sustain attention and concentration, relate
appropriately to the specialist, and perform tasks independently (without prompts or
reminders). Therefore, a report of test results should include both the objective data and any
clinical observations.
c. The salient characteristics of a good test are: (1) Validity, i.e., the test measures what it is
supposed to measure; (2) reliability, i.e., the consistency of results obtained over time with the
same test and the same individual; (3) appropriate normative data, i.e., individual test scores
can be compared to test data from other individuals or groups of a similar nature,
representative of that population; and (4) wide scope of measurement, i.e., the test should
measure a broad range of facets/aspects of the domain being assessed. In considering the
validity of a test result, we should note and resolve any discrepancies between formal test
results and the individual's customary behavior and daily activities.

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6. Intelligence tests.
a. The results of standardized intelligence tests may provide data that help verify the presence
of mental retardation or organic mental disorder, as well as the extent of any compromise in
cognitive functioning. However, since the results of intelligence tests are only part of the overall
assessment, the narrative report that accompanies the test results should comment on
whether the IQ scores are considered valid and consistent with the developmental history and
the degree of functional limitation.
b. Standardized intelligence test results are essential to the adjudication of all cases of mental
retardation that are not covered under the provisions of 12.05A. Listing 12.05A may be the
basis for adjudicating cases where the results of standardized intelligence tests are
unavailable, e.g., where your condition precludes formal standardized testing.
c. Due to such factors as differing means and standard deviations, identical IQ scores obtained
from different tests do not always reflect a similar degree of intellectual functioning. The IQ
scores in 12.05 reflect values from tests of general intelligence that have a mean of 100 and a
standard deviation of 15; e.g., the Wechsler series. IQs obtained from standardized tests that
deviate from a mean of 100 and a standard deviation of 15 require conversion to a percentile
rank so that we can determine the actual degree of limitation reflected by the IQ scores. In
cases where more than one IQ is customarily derived from the test administered, e.g., where
verbal, performance, and full scale IQs are provided in the Wechsler series, we use the lowest
of these in conjunction with 12.05.
d. Generally, it is preferable to use IQ measures that are wide in scope and include items that
test both verbal and performance abilities. However, in special circumstances, such as the
assessment of individuals with sensory, motor, or communication abnormalities, or those
whose culture and background are not principally English-speaking, measures such as the
Test of Nonverbal Intelligence, Third Edition (TONI-3), Leiter International Performance ScaleRevised (Leiter-R), or Peabody Picture Vocabulary Test—Third Edition (PPVT-III) may be
used.
e. We may consider exceptions to formal standardized psychological testing when an
individual qualified by training and experience to perform such an evaluation is not available, or
in cases where appropriate standardized measures for your social, linguistic, and cultural
background are not available. In these cases, the best indicator of severity is often the level of
adaptive functioning and how you perform activities of daily living and social functioning.
7. Personality measures and projective testing techniques. Results from standardized
personality measures, such as the Minnesota Multiphasic Personality Inventory-Revised
(MMPI-II), or from projective types of techniques, such as the Rorschach and the Thematic
Apperception Test (TAT), may provide useful data for evaluating several types of mental
disorders. Such test results may be useful for disability evaluation when corroborated by other
evidence, including results from other psychological tests and information obtained in the
course of the clinical evaluation, from treating and other medical sources, other professional
health care providers, and nonmedical sources. Any inconsistency between test results and
clinical history and observation should be explained in the narrative description.
8. Neuropsychological assessments. Comprehensive neuropsychological examinations may
be used to establish the existence and extent of compromise of brain function, particularly in

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cases involving organic mental disorders. Normally, these examinations include assessment of
cerebral dominance, basic sensation and perception, motor speed and coordination, attention
and concentration, visual-motor function, memory across verbal and visual modalities,
receptive and expressive speech, higher-order linguistic operations, problem-solving,
abstraction ability, and general intelligence. In addition, there should be a clinical interview
geared toward evaluating pathological features known to occur frequently in neurological
disease and trauma, e.g., emotional lability, abnormality of mood, impaired impulse control,
passivity and apathy, or inappropriate social behavior. The specialist performing the
examination may administer one of the commercially available comprehensive
neuropsychological batteries, such as the Luria-Nebraska or the Halstead-Reitan, or a battery
of tests selected as relevant to the suspected brain dysfunction. The specialist performing the
examination must be properly trained in this area of neuroscience.
9. Screening tests. In conjunction with clinical examinations, sources may report the results of
screening tests; i.e., tests used for gross determination of level of functioning. Screening
instruments may be useful in uncovering potentially serious impairments, but often must be
supplemented by other data. However, in some cases the results of screening tests may show
such obvious abnormalities that further testing will clearly be unnecessary.
10. Traumatic brain injury (TBI). In cases involving TBI, follow the documentation and
evaluation guidelines in 11.00F.
11. Anxiety disorders. In cases involving agoraphobia and other phobic disorders, panic
disorders, and posttraumatic stress disorders, documentation of the anxiety reaction is
essential. At least one detailed description of your typical reaction is required. The description
should include the nature, frequency, and duration of any panic attacks or other reactions, the
precipitating and exacerbating factors, and the functional effects. If the description is provided
by a medical source, the reporting physician or psychologist should indicate the extent to
which the description reflects his or her own observations and the source of any ancillary
information. Statements of other persons who have observed you may be used for this
description if professional observation is not available.
12. Eating disorders. In cases involving anorexia nervosa and other eating disorders, the
primary manifestations may be mental or physical, depending upon the nature and extent of
the disorder. When the primary functional limitation is physical, e.g., when severe weight loss
and associated clinical findings are the chief cause of inability to work, we may evaluate the
impairment under the appropriate physical body system listing. Of course, we must also
consider any mental aspects of the impairment, unless we can make a fully favorable
determination or decision based on the physical impairment(s) alone.
E. Chronic mental impairments. Particular problems are often involved in evaluating mental
impairments in individuals who have long histories of repeated hospitalizations or prolonged
outpatient care with supportive therapy and medication. For instance, if you have chronic
organic, psychotic, and affective disorders, you may commonly have your life structured in
such a way as to minimize your stress and reduce your symptoms and signs. In such a case,
you may be much more impaired for work than your symptoms and signs would indicate. The
results of a single examination may not adequately describe your sustained ability to function.
It is, therefore, vital that we review all pertinent information relative to your condition, especially
at times of increased stress. We will attempt to obtain adequate descriptive information from all
sources that have treated you in the time period relevant to the determination or decision.

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F. Effects of structured settings. Particularly in cases involving chronic mental disorders, overt
symptomatology may be controlled or attenuated by psychosocial factors such as placement in
a hospital, halfway house, board and care facility, or other environment that provides similar
structure. Highly structured and supportive settings may also be found in your home. Such
settings may greatly reduce the mental demands placed on you. With lowered mental
demands, overt symptoms and signs of the underlying mental disorder may be minimized. At
the same time, however, your ability to function outside of such a structured or supportive
setting may not have changed. If your symptomatology is controlled or attenuated by
psychosocial factors, we must consider your ability to function outside of such highly structured
settings. For these reasons, identical paragraph C criteria are included in 12.02, 12.03, and
12.04. The paragraph C criterion of 12.06 reflects the uniqueness of agoraphobia, an anxiety
disorder manifested by an overwhelming fear of leaving the home.
G. Effects of medication. We must give attention to the effects of medication on your
symptoms, signs, and ability to function. While drugs used to modify psychological functions
and mental states may control certain primary manifestations of a mental disorder, e.g.,
hallucinations, impaired attention, restlessness, or hyperactivity, such treatment may not affect
all functional limitations imposed by the mental disorder. In cases where overt symptomatology
is attenuated by the use of such drugs, particular attention must be focused on the functional
limitations that may persist. We will consider these functional limitations in assessing the
severity of your impairment. See the paragraph C criteria in 12.02, 12.03, 12.04, and 12.06.
Drugs used in the treatment of some mental illnesses may cause drowsiness, blunted effect, or
other side effects involving other body systems. We will consider such side effects when we
evaluate the overall severity of your impairment. Where adverse effects of medications
contribute to the impairment severity and the impairment(s) neither meets nor is equivalent in
severity to any listing but is nonetheless severe, we will consider such adverse effects in the
RFC assessment.
H. Effects of treatment. With adequate treatment some individuals with chronic mental
disorders not only have their symptoms and signs ameliorated, but they also return to a level of
function close to the level of function they had before they developed symptoms or signs of
their mental disorders. Treatment may or may not assist in the achievement of a level of
adaptation adequate to perform sustained SGA. See the paragraph C criteria in 12.02, 12.03,
12.04, and 12.06.
I. Technique for reviewing evidence in mental disorders claims to determine the level of
impairment severity. We have developed a special technique to ensure that we obtain,
consider, and properly evaluate all the evidence we need to evaluate impairment severity in
claims involving mental impairment(s). We explain this technique in §§404.1520a and
416.920a.
12.01 Category of Impairments—Mental
12.02 Organic Mental Disorders: Psychological or behaviorial abnormalities associated with a
dysfunction of the brain. History and physical examination or laboratory tests demonstrate the
presence of a specific organic factor judged to be etiologically related to the abnormal mental
state and loss of previously acquired functional abilities.
The required level of severity for these disorders is met when the requirements in both A and B

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are satisfied, or when the requirements in C are satisfied.
A. Demonstration of a loss of specific cognitive abilities or affective changes and the medically
documented persistence of at least one of the following:
1. Disorientation to time and place; or
2. Memory impairment, either short-term (inability to learn new information), intermediate, or
long-term (inability to remember information that was known sometime in the past); or
3. Perceptual or thinking disturbances (e.g., hallucinations, delusions); or
4. Change in personality; or
5. Disturbance in mood; or
6. Emotional lability (e.g., explosive temper outbursts, sudden crying, etc.) and impairment in
impulse control; or
7. Loss of measured intellectual ability of at least 15 I.Q. points from premorbid levels or
overall impairment index clearly within the severely impaired range on neuropsychological
testing, e.g., the Luria-Nebraska, Halstead-Reitan, etc.;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration;
OR
C. Medically documented history of a chronic organic mental disorder of at least 2 years'
duration that has caused more than a minimal limitation of ability to do basic work activities,
with symptoms or signs currently attenuated by medication or psychosocial support, and one
of the following:
1. Repeated episodes of decompensation, each of extended duration; or
2. A residual disease process that has resulted in such marginal adjustment that even a
minimal increase in mental demands or change in the environment would be predicted to
cause the individual to decompensate; or
3. Current history of 1 or more years' inability to function outside a highly supportive living

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arrangement, with an indication of continued need for such an arrangement.
12.03 Schizophrenic, Paranoid and Other Psychotic Disorders: Characterized by the onset of
psychotic features with deterioration from a previous level of functioning.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied, or when the requirements in C are satisfied.
A. Medically documented persistence, either continuous or intermittent, of one or more of the
following:
1. Delusions or hallucinations; or
2. Catatonic or other grossly disorganized behavior; or
3. Incoherence, loosening of associations, illogical thinking, or poverty of content of speech if
associated with one of the following:
a. Blunt affect; or
b. Flat affect; or
c. Inappropriate affect;
or
4. Emotional withdrawal and/or isolation;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration;
OR
C. Medically documented history of a chronic schizophrenic, paranoid, or other psychotic
disorder of at least 2 years' duration that has caused more than a minimal limitation of ability to
do basic work activities, with symptoms or signs currently attenuated by medication or
psychosocial support, and one of the following:
1. Repeated episodes of decompensation, each of extended duration; or

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2. A residual disease process that has resulted in such marginal adjustment that even a
minimal increase in mental demands or change in the environment would be predicted to
cause the individual to decompensate; or
3. Current history of 1 or more years' inability to function outside a highly supportive living
arrangement, with an indication of continued need for such an arrangement.
12.04 Affective Disorders: Characterized by a disturbance of mood, accompanied by a full or
partial manic or depressive syndrome. Mood refers to a prolonged emotion that colors the
whole psychic life; it generally involves either depression or elation.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied, or when the requirements in C are satisfied.
A. Medically documented persistence, either continuous or intermittent, of one of the following:
1. Depressive syndrome characterized by at least four of the following:
a. Anhedonia or pervasive loss of interest in almost all activites; or
b. Appetite disturbance with change in weight; or
c. Sleep disturbance; or
d. Psychomotor agitation or retardation; or
e. Decreased energy; or
f. Feelings of guilt or worthlessness; or
g. Difficulty concentrating or thinking; or
h. Thoughts of suicide; or
i. Hallucinations, delusions, or paranoid thinking; or
2. Manic syndrome characterized by at least three of the following:
a. Hyperactivity; or
b. Pressure of speech; or
c. Flight of ideas; or
d. Inflated self-esteem; or
e. Decreased need for sleep; or
f. Easy distractability; or

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g. Involvement in activities that have a high probability of painful consequences which are not
recognized; or
h. Hallucinations, delusions or paranoid thinking;
or
3. Bipolar syndrome with a history of episodic periods manifested by the full symptomatic
picture of both manic and depressive syndromes (and currently characterized by either or both
syndromes);
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration;
OR
C. Medically documented history of a chronic affective disorder of at least 2 years' duration
that has caused more than a minimal limitation of ability to do basic work activities, with
symptoms or signs currently attenuated by medication or psychosocial support, and one of the
following:
1. Repeated episodes of decompensation, each of extended duration; or
2. A residual disease process that has resulted in such marginal adjustment that even a
minimal increase in mental demands or change in the environment would be predicted to
cause the individual to decompensate; or
3. Current history of 1 or more years' inability to function outside a highly supportive living
arrangement, with an indication of continued need for such an arrangement.
12.05 Mental retardation: Mental retardation refers to significantly subaverage general
intellectual functioning with deficits in adaptive functioning initially manifested during the
developmental period; i.e., the evidence demonstrates or supports onset of the impairment
before age 22.
The required level of severity for this disorder is met when the requirements in A, B, C, or D
are satisfied.
A. Mental incapacity evidenced by dependence upon others for personal needs (e.g., toileting,
eating, dressing, or bathing) and inability to follow directions, such that the use of standardized

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measures of intellectual functioning is precluded;
OR
B. A valid verbal, performance, or full scale IQ of 59 or less;
OR
C. A valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental
impairment imposing an additional and significant work-related limitation of function;
OR
D. A valid verbal, performance, or full scale IQ of 60 through 70, resulting in at least two of the
following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
12.06 Anxiety Related Disorders: In these disorders anxiety is either the predominant
disturbance or it is experienced if the individual attempts to master symptoms; for example,
confronting the dreaded object or situation in a phobic disorder or resisting the obsessions or
compulsions in obsessive compulsive disorders.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied, or when the requirements in both A and C are satisfied.
A. Medically documented findings of at least one of the following:
1. Generalized persistent anxiety accompanied by three out of four of the following signs or
symptoms:
a. Motor tension; or
b. Autonomic hyperactivity; or
c. Apprehensive expectation; or
d. Vigilance and scanning;
or
2. A persistent irrational fear of a specific object, activity, or situation which results in a
compelling desire to avoid the dreaded object, activity, or situation; or

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3. Recurrent severe panic attacks manifested by a sudden unpredictable onset of intense
apprehension, fear, terror and sense of impending doom occurring on the average of at least
once a week; or
4. Recurrent obsessions or compulsions which are a source of marked distress; or
5. Recurrent and intrusive recollections of a traumatic experience, which are a source of
marked distress;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
OR
C. Resulting in complete inability to function independently outside the area of one's home.
12.07 Somatoform Disorders: Physical symptoms for which there are no demonstrable organic
findings or known physiological mechanisms.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented by evidence of one of the following:
1. A history of multiple physical symptoms of several years duration, beginning before age 30,
that have caused the individual to take medicine frequently, see a physician often and alter life
patterns significantly; or
2. Persistent nonorganic disturbance of one of the following:
a. Vision; or
b. Speech; or
c. Hearing; or
d. Use of a limb; or
e. Movement and its control (e.g., coordination disturbance, psychogenic seizures, akinesia,
dyskinesia; or

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f. Sensation (e.g., diminished or heightened).
3. Unrealistic interpretation of physical signs or sensations associated with the preoccupation
or belief that one has a serious disease or injury;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
12.08 Personality Disorders: A personality disorder exists when personality traits are inflexible
and maladaptive and cause either significant impairment in social or occupational functioning
or subjective distress. Characteristic features are typical of the individual's long-term
functioning and are not limited to discrete episodes of illness.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Deeply ingrained, maladaptive patterns of behavior associated with one of the following:
1. Seclusiveness or autistic thinking; or
2. Pathologically inappropriate suspiciousness or hostility; or
3. Oddities of thought, perception, speech and behavior; or
4. Persistent disturbances of mood or affect; or
5. Pathological dependence, passivity, or aggressivity; or
6. Intense and unstable interpersonal relationships and impulsive and damaging behavior;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or

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4. Repeated episodes of decompensation, each of extended duration.
12.09 Substance Addiction Disorders: Behavioral changes or physical changes associated
with the regular use of substances that affect the central nervous system.
The required level of severity for these disorders is met when the requirements in any of the
following (A through I) are satisfied.
A. Organic mental disorders. Evaluate under 12.02.
B. Depressive syndrome. Evaluate under 12.04.
C. Anxiety disorders. Evaluate under 12.06.
D. Personality disorders. Evaluate under 12.08.
E. Peripheral neuropathies. Evaluate under 11.14.
F. Liver damage. Evaluate under 5.05.
G. Gastritis. Evaluate under 5.04.
H. Pancreatitis. Evaluate under 5.08.
I. Seizures. Evaluate under 11.02 or 11.03.
12.10 Autistic disorder and other pervasive developmental disorders: Characterized by
qualitative deficits in the development of reciprocal social interaction, in the development of
verbal and nonverbal communication skills, and in imaginative activity. Often, there is a
markedly restricted repertoire of activities and interests, which frequently are stereotyped and
repetitive.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented findings of the following:
1. For autistic disorder, all of the following:
a. Qualitative deficits in reciprocal social interaction; and
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity; and
c. Markedly restricted repertoire of activities and interests;
OR
2. For other pervasive developmental disorders, both of the following:

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a. Qualitative deficits in reciprocal social interaction; and
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
13.00 Malignant Neoplastic Diseases
A. What impairments do these listings cover? We use these listings to evaluate all malignant
neoplasms except certain neoplasms associated with human immunodeficiency virus (HIV)
infection. We use the criteria in 14.08E to evaluate carcinoma of the cervix, Kaposi's sarcoma,
lymphoma, and squamous cell carcinoma of the anus if you also have HIV infection.
B. What do we consider when we evaluate malignant neoplastic diseases under these listings?
We consider factors such as the:
1. Origin of the malignancy.
2. Extent of involvement.
3. Duration, frequency, and response to antineoplastic therapy. Antineoplastic therapy means
surgery, irradiation, chemotherapy, hormones, immunotherapy, or bone marrow or stem cell
transplantation. When we refer to surgery as an antineoplastic treatment, we mean surgical
excision for treatment, not for diagnostic purposes.
4. Effects of any post-therapeutic residuals.
C. How do we apply these listings? We apply the criteria in a specific listing to a malignancy
originating from that specific site.
D. What evidence do we need?
1. We need medical evidence that specifies the type, extent, and site of the primary, recurrent,
or metastatic lesion. When the primary site cannot be identified, we will use evidence
documenting the site(s) of metastasis to evaluate the impairment under 13.27.
2. For operative procedures, including a biopsy or a needle aspiration, we generally need a
copy of both the:

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a. Operative note.
b. Pathology report.
3. When we cannot get these documents, we will accept the summary of hospitalization(s) or
other medical reports. This evidence should include details of the findings at surgery and,
whenever appropriate, the pathological findings.
4. In some situations we may also need evidence about recurrence, persistence, or
progression of the malignancy, the response to therapy, and any significant residuals. (See
13.00G.)
E. When do we need longitudinal evidence?
1. Tumors with distant metastases. We generally do not need longitudinal evidence for tumors
that have metastasized beyond the regional lymph nodes because these tumors usually meet
the requirements of a listing. Exceptions are for tumors with distant metastases that are
expected to respond to antineoplastic therapy. For these exceptions, we usually need a
longitudinal record of 3 months after therapy starts to determine whether the intended effect of
therapy has been achieved and is likely to persist.
2. Other malignancies. When there are no distant metastases, many of the listings require that
we consider your response to initial antineoplastic therapy; that is, the initial planned treatment
regimen. This therapy may consist of a single modality or a combination of modalities
(multimodal) given in close proximity as a unified whole, and is usually planned before any
treatment(s) is initiated. Examples of multimodal therapy include:
a. Surgery followed by chemotherapy or radiation.
b. Chemotherapy followed by surgery.
c. Chemotherapy and concurrent radiation.
3. Types of treatment. Whenever the initial planned therapy is a single modality, enough time
must pass to allow a determination about whether the therapy will achieve its intended effect. If
the treatment fails, the failure will often happen within 6 months after the treatment starts, and
there will often be a change in the treatment regimen. Whenever the initial planned therapy is
multimodal, a determination about the effectiveness of the therapy usually cannot be made
until the effects of all the planned modalities can be determined. In some cases, we may need
to defer adjudication until the effectiveness of therapy can be assessed. However, we do not
need to defer adjudication to determine whether the therapy will achieve its intended effect if
we can make a fully favorable determination or decision based on the length and effects of
therapy, or the residuals of the malignancy or therapy (see 13.00G).
F. How do we evaluate impairments that do not meet one of the malignant neoplastic diseases
listings?
1. These listings are only examples of malignant neoplastic diseases that we consider severe
enough to prevent you from doing any gainful activity. If your severe impairment(s) does not
meet the criteria of any of these listings, we must also consider whether you have an

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impairment(s) that meets the criteria of a listing in another body system.
2. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will determine whether your impairment(s) medically equals a listing. (See §§404.1526 and
416.926.) If your impairment(s) does not meet or medically equal a listing, you may or may not
have the residual functional capacity to engage in substantial gainful activity. In that situation,
we proceed to the fourth, and, if necessary, the fifth steps of the sequential evaluation process
in §§404.1520 and 416.920. If you are an adult, we use the rules in §§404.1594 and 416.994,
as appropriate, when we decide whether you continue to be disabled.
G. How do we consider the effects of therapy?
1. How we consider the effects of therapy under the listings. In many cases, malignancies
meet listing criteria only if the therapy does not achieve the intended effect: the malignancy
persists, progresses, or recurs despite treatment. However, as explained in the following
paragraphs, we will not delay adjudication if we can make a fully favorable determination or
decision based on the evidence in the case record.
2. Effects can vary widely.
a. Because the therapy and its toxicity may vary widely, we consider each case on an
individual basis. We will request a specific description of the therapy, including these items:
i. Drugs given.
ii. Dosage.
iii. Frequency of drug administration.
iv. Plans for continued drug administration.
v. Extent of surgery.
vi. Schedule and fields of radiation therapy.
b. We will also request a description of the complications or adverse effects of therapy, such
as the following:
i. Continuing gastrointestinal symptoms.
ii. Persistent weakness.
iii. Neurological complications.
iv. Cardiovascular complications.
v. Reactive mental disorders.
3. Effects of therapy may change. Because the severity of the adverse effects of antineoplastic

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therapy may change during treatment, enough time must pass to allow us to evaluate the
therapy's effect. The residual effects of treatment are temporary in most instances. But on
occasion, the effects may be disabling for a consecutive period of at least 12 months.
4. When the initial antineoplastic therapy is effective. We evaluate any post-therapeutic
residual impairment(s) not included in these listings under the criteria for the affected body
system. We must consider any complications of therapy. When the residual impairment(s)
does not meet or medically equal a listing, we must consider its effect on your ability to do
substantial gainful activity.
H. How long do we consider your impairment to be disabling?
1. In some listings, we specify that we will consider your impairment to be disabling until a
particular point in time (for example, at least 18 months from the date of diagnosis). We may
consider your impairment to be disabling beyond this point when the medical and other
evidence justifies it.
2. When a listing does not contain such a specification, we will consider an impairment(s) that
meets or medically equals a listing in this body system to be disabling until at least 3 years
after onset of complete remission. When the impairment(s) has been in complete remission for
at least 3 years, that is, the original tumor and any metastases have not been evident for at
least 3 years, the impairment(s) will no longer meet or medically equal the criteria of a listing in
this body system.
3. Following the appropriate period, we will consider any residuals, including residuals of the
malignancy or therapy (see 13.00G), in determining whether you are disabled.
I. What do these terms in the listings mean?
1. Inoperable: Surgery is thought to be of no therapeutic value or the surgery cannot be
performed. Examples of when surgery cannot be performed include a tumor that is too large or
that invades crucial structures, or an intolerance of anesthesia or surgery due to other medical
conditions. This term does not include situations in which the tumor could have been surgically
removed but another method of treatment was chosen; for example, an attempt at organ
preservation. The determination whether a tumor is inoperable usually occurs before attempts
to shrink the tumor with chemotherapy or radiation.
2. Unresectable: The operation was performed, but the malignant tumor was not removed.
This term includes situations in which a tumor is incompletely resected or the surgical margins
are positive.
3. Persistent: Failure to achieve a complete remission.
4. Progressive: The malignancy became more extensive after treatment.
5. Recurrent, relapse: A malignancy that had been in complete remission or entirely removed
by surgery has returned.
J. Can we establish the existence of a disabling impairment prior to the date of the evidence
that shows the malignancy satisfies the criteria of a listing? Yes. We will consider factors such

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as:
1. The type of malignancy and its location.
2. The extent of involvement when the malignancy was first demonstrated.
3. Your symptoms.
K. How do we evaluate specific malignant neoplastic diseases?
1. Lymphoma.
a. Many low grade or indolent (non-aggressive) lymphomas are controlled by well-tolerated
treatment modalities, although they may produce intermittent symptoms and signs. Therefore,
we may defer adjudication of these cases for an appropriate period after initiation of therapy to
determine whether the therapy will achieve its intended effect. (See 13.00E3.) For a low grade
or indolent lymphoma, the intended effect of therapy is usually stability of the disease process.
When stability has been achieved, we will assess severity on the basis of the extent of
involvement of other organ systems and residuals from therapy.
b. A change in therapy for low grade or indolent lymphomas is usually an indicator that the
therapy is not achieving its intended effect. However, it does not indicate this if the change is
based on your (or your physician's) choice rather than a failure to achieve stability. If the
therapy is changed due solely to choice, the requirements of listing 13.05A2 are not met.
c. We consider Hodgkin's disease that recurs more than 12 months after completing initial
antineoplastic therapy to be a new disease rather than a recurrence.
2. Leukemia.
a. Acute leukemia. The initial diagnosis of acute leukemia, including the accelerated or blast
phase of chronic myelogenous (granulocytic) leukemia, is based upon definitive bone marrow
examination. Additional diagnostic information is based on chromosomal analysis,
cytochemical and surface marker studies on the abnormal cells, or other methods consistent
with the prevailing state of medical knowledge and clinical practice. Recurrent disease must be
documented by peripheral blood, bone marrow, or cerebrospinal fluid examination. The initial
and follow-up pathology reports should be included.
b. Chronic myelogenous leukemia (CML). The diagnosis of CML should be based upon
documented granulocytosis, including immature forms such as differentiated or
undifferentiated myelocytes and myeloblasts, and a chromosomal analysis that demonstrates
the Philadelphia chromosome. In the absence of a chromosomal analysis, or if the
Philadelphia chromosome is not present, the diagnosis may be made by other methods
consistent with the prevailing state of medical knowledge and clinical practice.
c. Chronic lymphocytic leukemia.
i. The diagnosis of chronic lymphocytic leukemia (CLL) must be documented by evidence of a
chronic lymphocytosis of at least 10,000/mm[3] for 3 months or longer, or other acceptable

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diagnostic techniques consistent with the prevailing state of medical knowledge and clinical
practice.
ii. We evaluate the complications and residual impairment(s) from CLL under the appropriate
listings, such as 13.05A2, 7.02, and 7.15.
d. Elevated white cell count. In cases of chronic leukemia (either myelogenous or lymphocytic),
an elevated white cell count, in itself, is not ordinarily a factor in determining the severity of the
impairment.
3. Macroglobulinemia or heavy chain disease. The diagnosis of these diseases must be
confirmed by protein electrophoresis or immunoelectrophoresis. We evaluate the resulting
impairment(s) under the criteria of 7.02, 7.06, 7.08, or any other affected body system.
4. Bilateral primary breast cancer. We evaluate bilateral primary breast cancer (synchronous or
metachronous) under 13.10A, which covers local primary disease, and not as a primary
disease that has metastasized.
5. Carcinoma-in-situ. Carcinoma-in-situ, or preinvasive carcinoma, usually responds to
treatment. When we use the term "carcinoma" in these listings, it does not include carcinomain-situ.
6. Brain tumors. We use the criteria in 13.13 to evaluate malignant brain tumors. We will
evaluate any complications of malignant brain tumors, such as resultant neurological or
psychological impairments, under the criteria for the affected body system. We evaluate
benign brain tumors under 11.05.
L. How do we evaluate malignant neoplastic diseases treated by bone marrow or stem cell
transplantation? Bone marrow or stem cell transplantation is performed for a variety of
malignant neoplastic diseases.
1. Acute leukemia (including T-cell lymphoblastic lymphoma) or accelerated or blast phase of
CML. If you undergo bone marrow or stem cell transplantation for any of these disorders, we
will consider you to be disabled until at least 24 months from the date of diagnosis or relapse,
or at least 12 months from the date of transplantation, whichever is later.
2. Lymphoma, multiple myeloma, or chronic phase of CML. If you undergo bone marrow or
stem cell transplantation for any of these disorders, we will consider you to be disabled until at
least 12 months from the date of transplantation.
3. Other malignancies. We will evaluate any other malignant neoplastic disease treated with
bone marrow or stem cell transplantation under 13.28, regardless of whether there is another
listing that addresses that impairment. The length of time we will consider you to be disabled
depends on whether you undergo allogeneic or autologous transplantation.
a. Allogeneic bone marrow or stem cell transplantation. If you undergo allogeneic
transplantation (transplantation from an unrelated donor or a related donor other than an
identical twin), we will consider you to be disabled until at least 12 months from the date of
transplantation.

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b. Autologous bone marrow or stem cell transplantation. If you undergo autologous
transplantation (transplantation of your own cells or cells from your identical twin (syngeneic
transplantation)), we will consider you to be disabled until at least 12 months from the date of
the first treatment under the treatment plan that includes transplantation. The first treatment
usually refers to the initial therapy given to prepare you for transplantation.
4. Evaluating disability after the appropriate time period has elapsed. We consider any residual
impairment(s), such as complications arising from:
a. Graft-versus-host (GVH) disease.
b. Immunosuppressant therapy, such as frequent infections.
c. Significant deterioration of other organ systems.
13.01 Category of Impairments, Malignant Neoplastic Diseases
13.02 Soft tissue tumors of the head and neck (except salivary glands—13.08—and thyroid
gland—13.09).
A. Inoperable or unresectable.
OR
B. Persistent disease following initial multimodal antineoplastic therapy.
OR
C. Recurrent disease following initial antineoplastic therapy, except local vocal cord
recurrence.
OR
D. With metastases beyond the regional lymph nodes.
OR
E. Soft tissue tumors of the head and neck not addressed in A-D, with multimodal
antineoplastic therapy. Consider under a disability until at least 18 months from the date of
diagnosis. Thereafter, evaluate any residual impairment(s) under the criteria for the affected
body system.
13.03 Skin.
A. Sarcoma or carcinoma with metastases to or beyond the regional lymph nodes.
OR
B. Melanoma, with either 1 or 2:

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1. Recurrent after wide excision (except an additional primary melanoma at a different site,
which is not considered to be recurrent disease).
2. Palpable nodal metastases or metastases to adjacent skin (satellite lesions) or elsewhere.
13.04 Soft tissue sarcoma.
A. With regional or distant metastases.
OR
B. Persistent or recurrent following initial antineoplastic therapy.
13.05 Lymphoma (including mycosis fungoides, but excluding T-cell lymphoblastic
lymphoma—13.06). (See 13.00K1 and 13.00K2c.)
A. Non-Hodgkin's lymphoma, as described in 1 or 2:
1. Intermediate or high-grade lymphoma persistent or recurrent following initial antineoplastic
therapy.
2. Low-grade or indolent lymphoma requiring initiation of more than one antineoplastic
treatment regimen within a consecutive 12-month period. Consider under a disability from at
least the date of initiation of the treatment regimen that failed within 12 months.
OR
B. Hodgkin's disease with failure to achieve clinically complete remission, or recurrent disease
within 12 months of completing initial antineoplastic therapy.
OR
C. With bone marrow or stem cell transplantation. Consider under a disability until at least 12
months from the date of transplantation. Thereafter, evaluate any residual impairment(s) under
the criteria for the affected body system.
13.06 Leukemia. (See 13.00K2.)
A. Acute leukemia (including T-cell lymphoblastic lymphoma). Consider under a disability until
at least 24 months from the date of diagnosis or relapse, or at least 12 months from the date of
bone marrow or stem cell transplantation, whichever is later. Thereafter, evaluate any residual
impairment(s) under the criteria for the affected body system.
OR
B. Chronic myelogenous leukemia, as described in 1 or 2:
1. Accelerated or blast phase. Consider under a disability until at least 24 months from the
date of diagnosis or relapse, or at least 12 months from the date of bone marrow or stem cell

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transplantation, whichever is later. Thereafter, evaluate any residual impairment(s) under the
criteria for the affected body system.
2. Chronic phase, as described in a or b:
a. Consider under a disability until at least 12 months from the date of bone marrow or stem
cell transplantation. Thereafter, evaluate any residual impairment(s) under the criteria for the
affected body system.
b. Progressive disease following initial antineoplastic therapy.
13.07 Multiple myeloma (confirmed by appropriate serum or urine protein electrophoresis and
bone marrow findings).
A. Failure to respond or progressive disease following initial antineoplastic therapy.
OR
B. With bone marrow or stem cell transplantation. Consider under a disability until at least 12
months from the date of transplantation. Thereafter, evaluate any residual impairment(s) under
the criteria for the affected body system.
13.08 Salivary glands—carcinoma or sarcoma with metastases beyond the regional lymph
nodes.
13.09 Thyroid gland.
A. Anaplastic (undifferentiated) carcinoma.
OR
B. Carcinoma with metastases beyond the regional lymph nodes progressive despite
radioactive iodine therapy.
13.10 Breast (except sarcoma—13.04). (See 13.00K4.)
A. Locally advanced carcinoma (inflammatory carcinoma, tumor of any size with direct
extension to the chest wall or skin, tumor of any size with metastases to the ipsilateral internal
mammary nodes).
OR
B. Carcinoma with distant metastases.
OR
C. Recurrent carcinoma, except local recurrence that remits with antineoplastic therapy.
13.11 Skeletal system—carcinoma or sarcoma.

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A. Inoperable or unresectable.
OR
B. Recurrent tumor (except local recurrence) after initial antineoplastic therapy.
OR
C. With distant metastases.
OR
D. All other tumors originating in bone with multimodal antineoplastic therapy. Consider under
a disability for 12 months from the date of diagnosis. Thereafter, evaluate any residual
impairment(s) under the criteria for the affected body system.
13.12 Maxilla, orbit, or temporal fossa.
A. Sarcoma or carcinoma of any type with regional or distant metastases.
OR
B. Carcinoma of the antrum with extension into the orbit or ethmoid or sphenoid sinus.
OR
C. Tumors with extension to the base of the skull, orbit, meninges, or sinuses.
13.13 Nervous system. (See 13.00K6.)
A. Central nervous system neoplasms (brain and spinal cord), as described in 1 or 2:
1. Highly malignant tumors, such as Grades III and IV astrocytomas, glioblastoma multiforme,
ependymoblastoma, medulloblastoma or other primitive neuroectodermal tumors (PNETs) with
documented metastases, diffuse intrinsic brain stem gliomas, or primary sarcomas.
2. Any central nervous system neoplasm progressive or recurrent following initial
antineoplastic therapy.
OR
B. Peripheral nerve or spinal root neoplasm, as described in 1 or 2:
1. Metastatic.
2. Progressive or recurrent following initial antineoplastic therapy.
13.14 Lungs.

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A. Non-small-cell carcinoma—inoperable, unresectable, recurrent, or metastatic disease to or
beyond the hilar nodes.
OR
B. Small-cell (oat cell) carcinoma.
13.15 Pleura or mediastinum.
A. Malignant mesothelioma of pleura.
OR
B. Tumors of the mediastinum, as described in 1 or 2:
1. With metastases to or beyond the regional lymph nodes.
2. Persistent or recurrent following initial antineoplastic therapy.
13.16 Esophagus or stomach.
A. Carcinoma or sarcoma of the esophagus.
OR
B. Carcinoma or sarcoma of the stomach, as described in 1 or 2:
1. Inoperable, unresectable, extending to surrounding structures, or recurrent.
2. With metastases to or beyond the regional lymph nodes.
13.17 Small intestine—carcinoma, sarcoma, or carcinoid.
A. Inoperable, unresectable, or recurrent.
OR
B. With metastases beyond the regional lymph nodes.
13.18 Large intestine (from ileocecal valve to and including anal canal).
A. Adenocarcinoma that is inoperable, unresectable, or recurrent.
OR
B. Squamous cell carcinoma of the anus, recurrent after surgery.
OR

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C. With metastases beyond the regional lymph nodes.
13.19 Liver or gallbladder—tumors of the liver, gallbladder, or bile ducts.
13.20 Pancreas.
A. Carcinoma (except islet cell carcinoma).
OR
B. Islet cell carcinoma that is inoperable or unresectable and physiologically active.
13.21 Kidneys, adrenal glands, or ureters—carcinoma.
A. Inoperable, unresectable, or recurrent.
OR
B. With metastases to or beyond the regional lymph nodes.
13.22 Urinary bladder—carcinoma.
A. With infiltration beyond the bladder wall.
OR
B. Recurrent after total cystectomy.
OR
C. Inoperable or unresectable.
OR
D. With metastases to or beyond the regional lymph nodes.
13.23 Cancers of the female genital tract—carcinoma or sarcoma.
A. Uterus (corpus), as described in 1, 2, or 3:
1. Invading adjoining organs.
2. With metastases to or beyond the regional lymph nodes.
3. Persistent or recurrent following initial antineoplastic therapy.
OR
B. Uterine cervix, as described in 1 or 2:

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1. Extending to the pelvic wall, lower portion of the vagina, or adjacent or distant organs.
2. Persistent or recurrent following initial antineoplastic therapy.
OR
C. Vulva, as described in 1, 2, or 3:
1. Invading adjoining organs.
2. With metastases to or beyond the regional lymph nodes.
3. Persistent or recurrent following initial antineoplastic therapy.
OR
D. Fallopian tubes, as described in 1 or 2:
1. Extending to the serosa or beyond.
2. Persistent or recurrent following initial antineoplastic therapy.
OR
E. Ovaries, as described in 1 or 2:
1. All tumors except germ-cell tumors, with at least one of the following:
a. Tumor extension beyond the pelvis; for example, tumor implants on peritoneal, omental, or
bowel surfaces.
b. Metastases to or beyond the regional lymph nodes.
c. Ruptured ovarian capsule, tumor on the serosal surface of the ovary, ascites with malignant
cells, or positive peritoneal washings.
d. Recurrent following initial antineoplastic therapy.
2. Germ-cell tumors—progressive or recurrent following initial antineoplastic therapy.
13.24 Prostate gland—carcinoma.
A. Progressive or recurrent despite initial hormonal intervention.
OR
B. With visceral metastases.
13.25 Testicles—tumor with metastatic disease progressive or recurrent following initial

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chemotherapy.
13.26 Penis—carcinoma with metastases to or beyond the regional lymph nodes.
13.27 Primary site unknown after appropriate search for primary—metastatic carcinoma or
sarcoma, except for solitary squamous cell carcinoma in the neck.
13.28 Malignant neoplastic diseases treated by bone marrow or stem cell transplantation. (See
13.00L.)
A. Allogeneic transplantation. Consider under a disability until at least 12 months from the date
of transplantation. Thereafter, evaluate any residual impairment(s) under the criteria for the
affected body system.
OR
B. Autologous transplantation. Consider under a disability until at least 12 months from the
date of the first treatment under the treatment plan that includes transplantation. Thereafter,
evaluate any residual impairment(s) under the criteria for the affected body system.
14.00 Immune System
A. Listed disorders include impairments involving deficiency of one or more components of the
immune system (i.e., antibody-producing B cells; a number of different types of cells
associated with cell-mediated immunity including T-lymphocytes, macrophages and
monocytes; and components of the complement system).
B. Dysregulation of the immune system may result in the development of a connective tissue
disorder. Connective tissue disorders include several chronic multisystem disorders that differ
in their clinical manifestation, course, and outcome. They generally evolve and persist for
months or years, may result in loss of functional abilities, and may require long-term, repeated
evaluation and management.
The documentation needed to establish the existence of a connective tissue disorder is
medical history, physical examination, selected laboratory studies, appropriate medically
acceptable imaging, and, in some instances, tissue biopsy. Medically acceptable imaging
includes, but is not limited to, x-ray imaging, computerized axial tomography (CAT scan) or
magnetic resonance imaging (MRI), with or without contrast material, myelography, and
radionuclear bone scans. "Appropriate" means that the technique used is the proper one to
support the evaluation and diagnosis of the impairment. However, the Social Security
Administration will not purchase diagnostic tests or procedures that may involve significant
risk, such as biopsies or angiograms. Generally, the existing medical evidence will contain this
information.
A longitudinal clinical record of at least 3 months demonstrating active disease despite
prescribed treatment during this period with the expectation that the disease will remain active
for 12 months is necessary for assessment of severity and duration of impairment.
To permit appropriate application of a listing, the specific diagnostic features that should be
documented in the clinical record for each of the disorders are summarized for systemic lupus

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erythematosus (SLE), systemic vasculitis, systemic sclerosis and scleroderma, polymyositis or
dermatomyositis, undifferentiated connective tissue disorders, and the inflammatory arthritides.
In addition to the limitations caused by the connective tissue disorder per se, the chronic
adverse effects of treatment (e.g., corticosteroid-related ischemic necrosis of bone) may result
in functional loss.
These disorders may preclude performance of any gainful activity by reason of serious loss of
function because of disease affecting a single organ or body system, or lesser degrees of
functional loss because of disease affecting two or more organs/body systems associated with
significant constitutional symptoms and signs of severe fatigue, fever, malaise, weight loss,
and joint pain and stiffness. We use the term "severe" in these listings to describe medical
severity; the term does not have the same meaning as it does when we use it in connection
with a finding at the second step of the sequential evaluation processes in §§404.1520,
416.920, and 416.924.
1. Systemic lupus erythematosus (14.02)—This disease is characterized clinically by
constitutional symptoms and signs (e.g., fever, fatigability, malaise, weight loss), multisystem
involvement and, frequently, anemia, leukopenia, or thrombocytopenia. Immunologically, an
array of circulating serum auto-antibodies can occur, but are highly variable in pattern.
Generally the medical evidence will show that patients with this disease will fulfill The 1982
Revised Criteria for the Classification of Systemic Lupus Erythematosus of the American
College of Rheumatology. (Tan, E.M., et al., Arthritis Rheum. 25: 11271-1277, 1982).
2. Systemic vasculitis (14.03)—This disease occurs acutely in association with adverse drug
reactions, certain chronic infections and, occasionally, malignancies. More often it is idiopathic
and chronic. There are several clinical patterns, including classical polyarteritis nodosa, aortic
arch arteritis, giant cell arteritis, Wegener's granulomatosis, and vasculitis associated with
other connective tissue disorders (e.g., rheumatoid arthritis, SLE, Sjögren's syndrome,
cryoglobulinemia). Cutaneous vasculitis may or may not be associated with systemic
involvement and the patterns of vascular and ischemic involvement are highly variable. The
diagnosis is confirmed by angiography or tissue biopsy when the disease is suspected
clinically. Most patients who are stated to have this disease will have the results of the
confirmatory angiogram or biopsy in their medical records.
3. Systemic sclerosis and scleroderma (14.04)—These disorders constitute a spectrum of
disease in which thickening of the skin is the clinical hallmark. Raynaud's phenomena, often
severe and progressive, are especially frequent and may be the peripheral manifestation of a
generalized vasospastic abnormality in the heart, lungs, and kidneys. The CREST syndrome
(calcinosis, Raynaud's phenomena, esophageal dysmotility, sclerodactyly, telangiectasia) is a
variant that may slowly progress to the generalized process, systemic sclerosis, over years. In
addition to skin and blood vessels, the major organ/body system involvement includes the
gastrointestinal tract, lungs, heart, kidneys, and muscle. Although arthritis can occur, joint
dysfunction results primarily from soft tissue/cutaneous thickening, fibrosis, and contractures.
4. Polymyositis or dermatomyositis (14.05)—This disorder is primarily an inflammatory process
in striated muscle, which can occur alone or in association with other connective tissue
disorders or malignancy. Weakness and, less frequently, pain and tenderness of the proximal
limb-girdle musculature are the cardinal manifestations. Involvement of the cervical muscles,
the cricopharyngeals, the intercostals, and diaphragm may occur in those with listing-level

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disease. Weakness of the pelvic girdle, as contemplated in Listing 14.05A, may result in
significant difficulty climbing stairs or rising from a chair without use of the arms. Proximal limb
weakness in the upper extremities may result in inability to lift objects, and interference with
dressing and combing hair. Weakness of anterior neck flexors may impair the ability to lift the
head from the pillow in bed. The diagnosis is supported by elevated serum muscle enzymes
(creatine phosphokinase (CPK), aminotransferases, aldolase), characteristic abnormalities on
electromyography, and myositis on muscle biopsy.
5. Undifferentiated connective tissue disorder (14.06)—This listing includes syndromes with
clinical and immunologic features of several connective tissue disorders, but that do not satisfy
the criteria for any of the disorders described; for instance, the individual may have clinical
features of systemic lupus erythematosus and systemic vasculitis and the serologic findings of
rheumatoid arthritis. It also includes overlap syndromes with clinical features of more than one
established connective tissue disorder. For example, the individual may have features of both
rheumatoid arthritis and scleroderma. The correct designation of this disorder is important for
assessment of prognosis.
6. Inflammatory arthritis (14.09) includes a vast array of disorders that differ in cause, course,
and outcome. For example, inflammatory spondyloarthropathies include ankylosing spondylitis,
Reiter's syndrome and other reactive arthropathies, psoriatic arthropathy, Behçet's disease,
and Whipple's disease, as well as undifferentiated spondylitis. Inflammatory arthritis of
peripheral joints likewise comprises many disorders, including rheumatoid arthritis, Sjögren's
syndrome, psoriatic arthritis, crystal deposition disorders, and Lyme disease. Clinically,
inflammation of major joints may be the dominant problem causing difficulties with ambulation
or fine and gross movements, or the arthritis may involve other joints or cause less restriction
of ambulation or other movements but be complicated by extra-articular features that
cumulatively result in serious functional deficit. When persistent deformity without ongoing
inflammation is the dominant feature of the impairment, it should be evaluated under 1.02, or, if
there has been surgical reconstruction, 1.03.
a. In 14.09A, the term major joints refers to the major peripheral joints, which are the hip, knee,
shoulder, elbow, wrist-hand, and ankle-foot, as opposed to other peripheral joints (e.g., the
joints of the hand or forefoot) or axial joints (i.e., the joints of the spine.) The wrist and hand are
considered together as one major joint, as are the ankle and foot. Since only the ankle joint,
which consists of the juncture of the bones of the lower leg (tibia and fibula) with the hindfoot
(tarsal bones), but not the forefoot, is crucial to weight bearing, the ankle and foot are
considered separately in evaluating weight bearing.
b. The terms inability to ambulate effectively and inability to perform fine and gross movements
effectively in 14.09A have the same meaning as in 1.00B2b and 1.00B2c and must have
lasted, or be expected to last, for at least 12 months.
c. Inability to ambulate effectively is implicit in 14.09B. Even though individuals who
demonstrate the findings of 14.09B will not ordinarily require bilateral upper limb assistance,
the required ankylosis of the cervical or dorsolumbar spine will result in an extreme loss of the
ability to see ahead, above, and to the side.
d. As in 14.02 through 14.06, extra-articular features of an inflammatory arthritis may satisfy
the criteria for a listing in an involved extra-articular body system. Such impairments may be
found to meet a criterion of 14.09C. Extra-articular impairments of lesser severity should be

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evaluated under 14.09D and 14.09E. Commonly occurring extra-articular impairments include
keratoconjunctivitis sicca, uveitis, iridocyclitis, pleuritis, pulmonary fibrosis or nodules,
restrictive lung disease, pericarditis, myocarditis, cardiac arrhythmias, aortic valve
insufficiency, coronary arteritis, Raynaud's phenomena, systemic vasculitis, amyloidosis of the
kidney, chronic anemia, thrombocytopenia, hypersplenism with compromised immune
competence (Felty's syndrome), peripheral neuropathy, radiculopathy, spinal cord or cauda
equina compression with sensory and motor loss, and heel enthesopathy with functionally
limiting pain.
e. The fact that an individual is dependent on steroids, or any other drug, for the control of
inflammatory arthritis is, in and of itself, insufficient to find disability. Advances in the treatment
of inflammatory connective tissue disease and in the administration of steroids for its treatment
have corrected some of the previously disabling consequences of continuous steroid use.
Therefore, each case must be evaluated on its own merits, taking into consideration the
severity of the underlying impairment and any adverse effects of treatment.
C. Allergic disorders (e.g., asthma or atopic dermatitis) are discussed and evaluated under the
appropriate listing of the affected body system.
D. Human immunodeficiency virus (HIV) infection.
1. HIV infection is caused by a specific retrovirus and may be characterized by susceptibility to
one or more opportunistic diseases, cancers, or other conditions, as described in 14.08. Any
individual with HIV infection, including one with a diagnosis of acquired immunodeficiency
syndrome (AIDS), may be found disabled under this listing if his or her impairment meets any
of the criteria in 14.08 or is of equivalent severity to any impairment in 14.08.
2. Definitions. In 14.08, the terms "resistant to treatment," "recurrent," and "disseminated" have
the same general meaning as used by the medical community. The precise meaning of any of
these terms will depend upon the specific disease or condition in question, the body system
affected, the usual course of the disorder and its treatment, and the other circumstances of the
case.
"Resistant to treatment" means that a condition did not respond adequately to an appropriate
course of treatment. Whether a response is adequate, or a course of treatment appropriate,
will depend on the facts of the particular case.
"Recurrent" means that a condition that responded adequately to an appropriate course of
treatment has returned after a period of remission or regression. The extent of response (or
remission) and the time periods involved will depend on the facts of the particular case.
"Disseminated" means that a condition is spread widely over a considerable area or body
system(s). The type and extent of the spread will depend on the specific disease.
As used in 14.08I, "significant involuntary weight loss" does not correspond to a specific
minimum amount or percentage of weight loss. Although, for purposes of this listing, an
involuntary weight loss of at least 10 percent of baseline is always considered significant, loss
of less than 10 percent may or may not be significant, depending on the individual's baseline
weight and body habitus. (For example, a 7-pound weight loss in a 100-pound female who is
63 inches tall might be considered significant; but a 14-pound weight loss in a 200-pound

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female who is the same height might not be significant.)
3. Documentation of HIV infection. The medical evidence must include documentation of HIV
infection. Documentation may be by laboratory evidence or by other generally acceptable
methods consistent with the prevailing state of medical knowledge and clinical practice.
a. Documentation of HIV infection by definitive diagnosis. A definitive diagnosis of HIV infection
is documented by one or more of the following laboratory tests:
i. A serum specimen that contains HIV antibodies. HIV antibodies are usually detected by a
screening test. The most commonly used screening test is the ELISA. Although this test is
highly sensitive, it may yield false positive results. Therefore, positive results from an ELISA
must be confirmed by a more definitive test (e.g., Western blot, immunofluorescence assay).
ii. A specimen that contains HIV antigen (e.g., serum specimen, lymphocyte culture, or
cerebrospinal fluid (CSF) specimen).
iii. Other test(s) that are highly specific for detection of HIV (e.g., polymerase chain reaction
(PCR)), or that are acceptable methods of detection consistent with the prevailing state of
medical knowledge.
When laboratory testing for HIV infection has been performed, every reasonable effort must be
made to obtain reports of the results of that testing.
Individuals who have HIV infection or other disorders of the immune system may undergo tests
to determine T-helper lymphocyte (CD4) counts. The extent of immune depression correlates
with the level or rate of decline of the CD4 count. In general, when the CD4 count is 200/mm[3]
or less (14 percent or less), the susceptibility to opportunistic disease is considerably
increased. However, a reduced CD4 count alone does not establish a definitive diagnosis of
HIV infection, or document the severity or functional effects of HIV infection.
b. Other acceptable documentation of HIV infection.
HIV infection may also be documented without the definitive laboratory evidence described in
paragraph a, provided that such documentation is consistent with the prevailing state of
medical knowledge and clinical practice and is consistent with the other evidence. If no
definitive laboratory evidence is available, HIV infection may be documented by the medical
history, clinical and laboratory findings, and diagnosis(es) indicated in the medical evidence.
For example, a diagnosis of HIV infection will be accepted without definitive laboratory
evidence if the individual has an opportunistic disease (e.g., toxoplasmosis of the brain,
pneumocystis carinii pneumonia (PCP)) predictive of a defect in cell-mediated immunity, and
there is no other known cause of diminished resistance to that disease (e.g., long-term steroid
treatment, lymphoma). In such cases, every reasonable effort must be made to obtain full
details of the history, medical findings, and results of testing.
4. Documentation of the manifestations of HIV infection. The medical evidence must also
include documentation of the manifestations of HIV infection. Documentation may be by
laboratory evidence or by other generally acceptable methods consistent with the prevailing
state of medical knowledge and clinical practice.

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a. Documentation of the manifestations of HIV infection by definitive diagnosis.
The definitive method of diagnosing opportunistic diseases or conditions that are
manifestations of HIV infection is by culture, serological test, or microscopic examination of
biopsied tissue or other material (e.g., bronchial washings). Therefore, every reasonable effort
must be made to obtain specific laboratory evidence of an opportunistic disease or other
condition whenever this information is available. If a histological or other test has been
performed, the evidence should include a copy of the appropriate report. If the report is not
obtainable, the summary of hospitalization or a report from the treating source should include
details of the findings and results of the diagnostic studies (including radiographic studies) or
microscopic examination of the appropriate tissues or body fluids.
Although a reduced CD4 lymphocyte count may show that there is an increased susceptibility
to opportunistic infections and diseases (see 14.00D3a, above), that alone does not establish
the presence, severity, or functional effects of a manifestation of HIV infection.
b. Other acceptable documentation of the manifestations of HIV infection.
Manifestations of HIV infection may also be documented without the definitive laboratory
evidence described in paragraph a, provided that such documentation is consistent with the
prevailing state of medical knowledge and clinical practice and is consistent with the other
evidence. If no definitive laboratory evidence is available, manifestations of HIV infection may
be documented by medical history, clinical and laboratory findings, and diagnosis(es) indicated
in the medical evidence. In such cases, every reasonable effort must be made to obtain full
details of the history, medical findings, and results of testing.
Documentation of cytomegalovirus (CMV) disease (14.08D) presents special problems
because diagnosis requires identification of viral inclusion bodies or a positive culture from the
affected organ, and the absence of any other infectious agent. A positive serology test
identifies infection with the virus, but does not confirm a disease process. With the exception of
chorioretinitis (which may be diagnosed by an ophthalmologist), documentation of CMV
disease requires confirmation by biopsy or other generally acceptable methods consistent with
the prevailing state of medical knowledge and clinical practice.
5. Manifestations specific to women. Most women with severe immunosuppression secondary
to HIV infection exhibit the typical opportunistic infections and other conditions, such as
pneumocystis carinii pneumonia (PCP), candida esophagitis, wasting syndrome,
cryptococcosis, and toxoplasmosis. However, HIV infection may have different manifestations
in women than in men. Adjudicators must carefully scrutinize the medical evidence and be
alert to the variety of medical conditions specific to or common in women with HIV infection
that may affect their ability to function in the workplace.
Many of these manifestations (e.g. vulvovaginal candidiasis, pelvic inflammatory disease)
occur in women with or without HIV infection, but can be more severe or resistant to treatment,
or occur more frequently in a woman whose immune system is suppressed. Therefore, when
evaluating the claim of a woman with HIV infection, it is important to consider gynecologic and
other problems specific to women, including any associated symptoms (e.g., pelvic pain), in
assessing the severity of the impairment and resulting functional limitations. Manifestations of
HIV infection in women may be evaluated under the specific criteria (e.g., cervical cancer
under 14.08E), under an applicable general category (e.g., pelvic inflammatory disease under

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14.08A5) or, in appropriate cases, under 14.08N.
6. Evaluation. The criteria in 14.08 do not describe the full spectrum of diseases or conditions
manifested by individuals with HIV infection. As in any case, consideration must be given to
whether an individual's impairment(s) meets or equals in severity any other listing in appendix
1 of subpart P (e.g., a neoplastic disorder listed in 13.00ff). Although 14.08 includes crossreferences to other listings for the more common manifestations of HIV infection, other listings
may apply.
In addition, the impact of all impairments, whether or not related to HIV infection, must be
considered. For example, individuals with HIV infection may manifest signs and symptoms of a
mental impairment (e.g., anxiety, depression), or of another physical impairment. Medical
evidence should include documentation of all physical and mental impairments, and the
impairment(s) should be evaluated not only under the relevant listing(s) in 14.08, but under any
other appropriate listing(s).
It is also important to remember that individuals with HIV infection, like all other individuals, are
evaluated under the full five-step sequential evaluation process described in §404.1520 and
§416.920. If an individual with HIV infection is working and engaging in substantial gainful
activity (SGA), or does not have a severe impairment, the case will be decided at the first or
second step of the sequential evaluation process, and does not require evaluation under these
listings. For an individual with HIV infection who is not engaging in SGA and has a severe
impairment, but whose impairment(s) does not meet or equal in severity the criteria of a listing,
evaluation must proceed through the final steps of the sequential evaluation process (or, as
appropriate, the steps in the medical improvement review standard) before any conclusion can
be reached on the issue of disability.
7. Effect of treatment. Medical treatment must be considered in terms of its effectiveness in
ameliorating the signs, symptoms, and laboratory abnormalities of the specific disorder, or of
the HIV infection itself (e.g., antiretroviral agents) and in terms of any side effects of treatment
that may further impair the individual.
Response to treatment and adverse or beneficial consequences of treatment may vary widely.
For example, an individual with HIV infection who develops pneumonia or tuberculosis may
respond to the same antibiotic regimen used in treating individuals without HIV infection, but
another individual with HIV infection may not respond to the same regimen. Therefore, each
case must be considered on an individual basis, along with the effects of treatment on the
individual's ability to function.
A specific description of the drugs or treatment given (including surgery), dosage, frequency of
administration, and a description of the complications or response to treatment should be
obtained. The effects of treatment may be temporary or long term. As such, the decision
regarding the impact of treatment should be based on a sufficient period of treatment to permit
proper consideration.
8. Functional criteria. Paragraph N of 14.08 establishes standards for evaluating
manifestations of HIV infection that do not meet the requirements listed in 14.08A-M.
Paragraph N is applicable for manifestations that are not listed in 14.08A-M, as well as those
listed in 14.08A-M that do not meet the criteria of any of the rules in 14.08A-M.

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For individuals with HIV infection evaluated under 14.08N, listing-level severity will be
assessed in terms of the functional limitations imposed by the impairment. The full impact of
signs, symptoms, and laboratory findings on the claimant's ability to function must be
considered. Important factors to be considered in evaluating the functioning of individuals with
HIV infection include, but are not limited to: symptoms, such as fatigue and pain;
characteristics of the illness, such as the frequency and duration of manifestations or periods
of exacerbation and remission in the disease course; and the functional impact of treatment for
the disease, including the side effects of medication.
As used in 14.08N, "repeated" means that the conditions occur on an average of 3 times a
year, or once every 4 months, each lasting 2 weeks or more; or the conditions do not last for 2
weeks but occur substantially more frequently than 3 times in a year or once every 4 months;
or they occur less often than an average of 3 times a year or once every 4 months but last
substantially longer than 2 weeks.
To meet the criteria in 14.08N, an individual with HIV infection must demonstrate a marked
level of restriction in one of three general areas of functioning: activities of daily living; social
functioning; and difficulties in completing tasks due to deficiencies in concentration,
persistence, or pace. Functional restrictions may result from the impact of the disease process
itself on mental or physical functioning, or both. This could result from extended or intermittent
symptoms, such as depression, fatigue, or pain, resulting in a limitation of the ability to
concentrate, to persevere at a task, or to perform the task at an acceptable rate of speed.
Limitations may also result from the side effects of medication.
When "marked" is used as a standard for measuring the degree of functional limitation, it
means more than moderate, but less than extreme. A marked limitation does not represent a
quantitative measure of the individual's ability to do an activity for a certain percentage of the
time. A marked limitation may be present when several activities or functions are impaired or
even when only one is impaired. However, an individual need not be totally precluded from
performing an activity to have a marked limitation, as long as the degree of limitation is such as
to seriously interfere with the ability to function independently, appropriately, and effectively.
The term "marked" does not imply that the impaired individual is confined to bed, hospitalized,
or in a nursing home.
Activities of daily living include, but are not limited to, such activities as doing household
chores, grooming and hygiene, using a post office, taking public transportation, and paying
bills. An individual with HIV infection who, because of symptoms such as pain imposed by the
illness or its treatment, is not able to maintain a household or take public transportation on a
sustained basis or without assistance (even though he or she is able to perform some self-care
activities) would have marked limitation of activities of daily living.
Social functioning includes the capacity to interact appropriately and communicate effectively
with others. An individual with HIV infection who, because of symptoms or a pattern of
exacerbation and remission caused by the illness or its treatment, cannot engage in social
interaction on a sustained basis (even though he or she is able to communicate with close
friends or relatives) would have marked difficulty maintaining social functioning.
Completing tasks in a timely manner involves the ability to sustain concentration, persistence,
or pace to permit timely completion of tasks commonly found in work settings. An individual
with HIV infection who, because of HIV-related fatigue or other symptoms, is unable to sustain

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concentration or pace adequate to complete simple work-related tasks (even though he or she
is able to do routine activities of daily living) would have marked difficulty completing tasks.
14.01 Category of Impairments, Immune System
14.02 Systemic lupus erythematosus. Documented as described in 14.00B1, with:
A. One of the following:
1. Joint involvement, as described under the criteria in 1.00; or
2. Muscle involvement, as described under the criteria in 14.05; or
3. Ocular involvement, as described under the criteria in 2.00ff; or
4. Respiratory involvement, as described under the criteria in 3.00ff; or
5. Cardiovascular involvement, as described under the criteria in 4.00ff or 14.04D; or
6. Digestive involvement, as described under the criteria in 5.00ff; or
7. Renal involvement, as described under the criteria in 6.00ff; or
8. Hematologic involvement, as described under the criteria in 7.00ff; or
9. Skin involvement, as described under the criteria in 8.00ff; or
10. Neurological involvement, as described under the criteria in 11.00ff; or
11. Mental involvement, as described under the criteria in 12.00ff.
or
B. Lesser involvement of two or more organs/body systems listed in paragraph A, with
significant, documented, constitutional symptoms and signs of severe fatigue, fever, malaise,
and weight loss. At least one of the organs/body systems must be involved to at least a
moderate level of severity.
14.03 Systemic vasculitis. Documented as described in 14.00B2, including documentation by
angiography or tissue biopsy, with:
A. Involvement of a single organ or body system, as described under the criteria in 14.02A.
or
B. Lesser involvement of two or more organs/body systems listed in 14.02A, with significant,
documented, constitutional symptoms and signs of severe fatigue, fever, malaise, and weight
loss. At least one of the organs/body systems must be involved to at least a moderate level of
severity.

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14.04 Systemic sclerosis and scleroderma. Documented as described in 14.00B3, with:
A. One of the following:
1. Muscle involvement, as described under the criteria in 14.05; or
2. Respiratory involvement, as described under the criteria in 3.00ff; or
3. Cardiovascular involvement, as described under the criteria in 4.00ff; or
4. Digestive involvement, as described under the criteria in 5.00ff; or
5. Renal involvement, as described under the criteria in 6.00ff.
or
B. Lesser involvement of two or more organs/body systems listed in paragraph A, with
significant, documented, constitutional symptoms and signs of severe fatigue, fever, malaise,
and weight loss. At least one of the organs/body systems must be involved to at least a
moderate level of severity.
or
C. Generalized scleroderma with digital contractures.
or
D. Severe Raynaud's phenomena, characterized by digital ulcerations, ischemia, or gangrene.
14.05 Polymyositis or dermatomyositis. Documented as described in 14.00B4, with:
A. Severe proximal limb-girdle (shoulder and/or pelvic) muscle weakness, as described in
14.00B4.
or
B. Less severe limb-girdle muscle weakness than in 14.05A, associated with cervical muscle
weakness and one of the following to at least a moderate level of severity:
1. Impaired swallowing with dysphagia and episodes of aspiration due to cricopharyngeal
weakness, or
2. Impaired respiration due to intercostal and diaphragmatic muscle weakness.
or
C. If associated with malignant tumor, as described under the criteria in 13.00ff.
or

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D. If associated with generalized connective tissue disease, described under the criteria in
14.02, 14.03, 14.04, or 14.06.
14.06 Undifferentiated connective tissue disorder. Documented as described in 14.00B5, and
with impairment as described under the criteria in 14.02A, 14.02B, or 14.04.
14.07 Immunoglobulin deficiency syndromes or deficiencies of cell-mediated immunity,
excepting HIV infection. Associated with documented, recurrent severe infection occurring 3 or
more times within a 5-month period.
14.08 Human immunodeficiency virus (HIV) infection. With documentation as described in
14.00D3 and one of the following:
A. Bacterial infections:
1. Mycobacterial infection (e.g., caused by M. avium-intracellulare, M. kansasii, or M.
tuberculosis) at a site other than the lungs, skin, or cervical or hilar lymph nodes; or pulmonary
tuberculosis resistant to treatment; or
2. Nocardiosis; or
3. Salmonella bacteremia, recurrent non-typhoid; or
4. Syphilis or neurosyphilis—evaluate sequelae under the criteria for the affected body system
(e.g., 2.00 Special Senses and Speech, 4.00 Cardiovascular System, 11.00 Neurological); or
5. Multiple or recurrent bacterial infection(s), including pelvic inflammatory disease, requiring
hospitalization or intravenous antibiotic treatment 3 or more times in 1 year.
or
B. Fungal infections:
1. Aspergillosis; or
2. Candidiasis, at a site other than the skin, urinary tract, intestinal tract, or oral or vulvovaginal
mucous membranes; or candidiasis involving the esophagus, trachea, bronchi, or lungs; or
3. Coccidioidomycosis, at a site other than the lungs or lymph nodes; or
4. Cryptococcosis, at a site other than the lungs (e.g., cryptococcal meningitis); or
5. Histoplasmosis, at a site other than the lungs or lymph nodes; or
6. Mucormycosis.
or
C. Protozoan or helminthic infections:

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1. Cryptosporidiosis, isosporiasis, or microsporidiosis, with diarrhea lasting for 1 month or
longer; or
2. Pneumocystis carinii pneumonia or extrapulmonary pneumocystis carinii infection; or
3. Strongyloidiasis, extra-intestinal; or
4. Toxoplasmosis of an organ other than the liver, spleen, or lymph nodes.
or
D. Viral infections:
1. Cytomegalovirus disease (documented as described in 14.00D4b) at a site other than the
liver, spleen, or lymph nodes; or
2. Herpes simplex virus causing:
a. Mucocutaneous infection (e.g., oral, genital, perianal) lasting for 1 month or longer; or
b. Infection at a site other than the skin or mucous membranes (e.g., bronchitis, pneumonitis,
esophagitis, or encephalitis); or
c. Disseminated infection; or
3. Herpes zoster, either disseminated or with multidermatomal eruptions that are resistant to
treatment; or
4. Progressive multifocal leukoencephalopathy; or
5. Hepatitis, as described under the criteria in 5.05.
or
E. Malignant neoplasms:
1. Carcinoma of the cervix, invasive, FIGO stage II and beyond; or
2. Kaposi's sarcoma with:
a. Extensive oral lesions; or
b. Involvement of the gastrointestinal tract, lungs, or other visceral organs; or
c. Involvement of the skin or mucous membranes, as described under the criteria in 14.08F; or
3. Lymphoma (e.g., primary lymphoma of the brain, Burkitt's lymphoma, immunoblastic
sarcoma, other non-Hodgkins lymphoma, Hodgkin's disease); or

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4. Squamous cell carcinoma of the anus.
or
F. Conditions of the skin or mucous membranes (other than described in B2, D2, or D3, above)
with extensive fungating or ulcerating lesions not responding to treatment (e.g., dermatological
conditions such as eczema or psoriasis, vulvovaginal or other mucosal candida, condyloma
caused by human papillomavirus, genital ulcerative disease), or evaluate under the criteria in
8.00ff.
or
G. Hematologic abnormalities:
1. Anemia, as described under the criteria in 7.02; or
2. Granulocytopenia, as described under the criteria in 7.15; or
3. Thrombocytopenia, as described under the criteria in 7.06.
or
H. Neurological abnormalities:
1. HIV encephalopathy, characterized by cognitive or motor dysfunction that limits function and
progresses; or
2. Other neurological manifestations of HIV infection (e.g., peripheral neuropathy) as described
under the criteria in 11.00ff.
or
I. HIV wasting syndrome, characterized by involuntary weight loss of 10 percent or more of
baseline (or other significant involuntary weight loss, as described in 14.00D2) and, in the
absence of a concurrent illness that could explain the findings, either:
1. Chronic diarrhea with two or more loose stools daily lasting for 1 month or longer; or
2. Chronic weakness and documented fever greater than 38 °C (100.4 °F) for the majority of 1
month or longer.
or
J. Diarrhea, lasting for 1 month or longer, resistant to treatment, and requiring intravenous
hydration, intravenous alimentation, or tube feeding.
or
K. Cardiomyopathy, as described under the criteria in 4.00ff or 11.04.

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or
L. Nephropathy, as described under the criteria in 6.00ff.
or
M. One or more of the following infections (other than described in A-L, above), resistant to
treatment or requiring hospitalization or intravenous treatment 3 or more times in 1 year (or
evaluate sequelae under the criteria for the affected body system).
1. Sepsis; or
2. Meningitis; or
3. Pneumonia; or
4. Septic arthritis; or
5. Endocarditis; or
6. Sinusitis documented by appropriate medically acceptable imaging.
or
N. Repeated (as defined in 14.00D8) manifestations of HIV infection (including those listed in
14.08A-M, but without the requisite findings, e.g., carcinoma of the cervix not meeting the
criteria in 14.08E, diarrhea not meeting the criteria in 14.08J, or other manifestations, e.g., oral
hairy leukoplakia, myositis) resulting in significant, documented symptoms or signs (e.g.,
fatigue, fever, malaise, weight loss, pain, night sweats) and one of the following at the marked
level (as defined in 14.00D8):
1. Restriction of activities of daily living; or
2. Difficulties in maintaining social functioning; or
3. Difficulties in completing tasks in a timely manner due to deficiencies in concentration,
persistence, or pace.
14.09 Inflammatory arthritis. Documented as described in 14.00B6, with one of the following:
A. History of joint pain, swelling, and tenderness, and signs on current physical examination of
joint inflammation or deformity in two or more major joints resulting in inability to ambulate
effectively or inability to perform fine and gross movements effectively, as defined in 14.00B6b
and 1.00B2b and B2c;
or
B. Ankylosing spondylitis or other spondyloarthropathy, with diagnosis established by findings
of unilateral or bilateral sacroiliitis (e.g., erosions or fusions), shown by appropriate medically

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acceptable imaging, with both:
1. History of back pain, tenderness, and stiffness, and
2. Findings on physical examination of ankylosis (fixation) of the dorsolumbar or cervical spine
at 45° or more of flexion measured from the vertical position (zero degrees);
or
C. An impairment as described under the criteria in 14.02A.
or
D. Inflammatory arthritis, with signs of peripheral joint inflammation on current examination, but
with lesser joint involvement than in A and lesser extra-articular features than in C, and:
1. Significant, documented constitutional symptoms and signs (e.g., fatigue, fever, malaise,
weight loss), and
2. Involvement of two or more organs/body systems (see 14.00B6d). At least one of the
organs/body systems must be involved to at least a moderate level of severity.
or
E. Inflammatory spondylitis or other inflammatory spondyloarthropathies, with lesser deformity
than in B and lesser extra-articular features than in C, with signs of unilateral or bilateral
sacroiliitis on appropriate medically acceptable imaging; and with the extra-articular features
described in 14.09D.
Part B
Medical criteria for the evaluation of impairments of children under age 18 (where criteria in
part A do not give appropriate consideration to the particular disease process in childhood).
Sec.
100.00 Growth Impairment.
101.00 Musculoskeletal System.
102.00 Special Senses and Speech.
103.00 Respiratory System.
104.00 Cardiovascular System.
105.00 Digestive System.
106.00 Genitourinary Impairments.

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107.00 Hematological Disorders.
108.00 Skin Disorders
109.00 Endocrine System.
110.00 Impairments That Affect Multiple Body Systems.
111.00 Neurological.
112.00 Mental Disorders.
113.00 Malignant Neoplastic Diseases.
114.00 Immune System.
100.00 Growth Impairment
A. Impairment of growth may be disabling in itself or it may be an indicator of the severity of
the impairment due to a specific disease process.
Determinations of growth impairment should be based upon the comparison of current height
with at least three previous determinations, including length at birth, if available. Heights (or
lengths) should be plotted on a standard growth chart, such as derived from the National
Center for Health Statistics: NCHS Growth Charts. Height should be measured without shoes.
Body weight corresponding to the ages represented by the heights should be furnished. The
adult heights of the child's natural parents and the heights and ages of siblings should also be
furnished. This will provide a basis upon which to identify those children whose short stature
represents a familial characteristic rather than a result of disease. This is particularly true for
adjudication under 100.02B.
B. Bone age determinations should include a full descriptive report of medically acceptable
imaging specifically obtained to determine bone age and must cite the standardization method
used. Where appropriate medically acceptable imaging must be obtained currently as a basis
for adjudication under 100.03, views or scans of the left hand and wrist should be ordered. In
addition appropriate medically acceptable imaging of the knee and ankle should be obtained
when cessation of growth is being evaluated in an older child at, or past, puberty. Medically
acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial
tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast
material, myeolgraphy, and radionuclear bone scans. "Appropriate" means that the technique
used is the proper one to support the evaluation and diagnosis of the impairment.
C. The criteria in this section are applicable until closure of the major epiphyses. The cessation
of significant increase in height at that point would prevent the application of these criteria.
100.01 Category of Impairments, Growth
100.02 Growth impairment, considered to be related to an additional specific medically
determinable impairment, and one of the following:

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A. Fall of greater than 15 percentiles in height which is sustained; or
B. Fall to, or persistence of, height below the third percentile.
100.03 Growth impairment, not identified as being related to a
101.00 Musculoskeletal System
A. Disorders of the musculoskeletal system may result from hereditary, congenital, or acquired
pathologic processes. Impairments may result from infectious, inflammatory, or degenerative
processes, traumatic or developmental events, or neoplastic, vascular, or toxic/metabolic
diseases.
B. Loss of Function
1. General. Under this section, loss of function may be due to bone or joint deformity or
destruction from any cause; miscellaneous disorders of the spine with or without radiculopathy
or other neurological deficits; amputation; or fractures or soft tissue injuries, including burns,
requiring prolonged periods of immobility or convalescence. For inflammatory arthritides that
result in loss of function because of inflammatory peripheral joint or axial arthritis or sequelae,
or because of extra-articular features, see 114.00E. Impairments with neurological causes are
to be evaluated under 111.00ff.
2. How We Define Loss of Function in These Listings
a. General. Regardless of the cause(s) of a musculoskeletal impairment, functional loss for
purposes of these listings is defined as the inability to ambulate effectively on a sustained
basis for any reason, including pain associated with the underlying musculoskeletal
impairment, or the inability to perform fine and gross movements effectively on a sustained
basis for any reason, including pain associated with the underlying musculoskeletal
impairment. The inability to ambulate effectively or the inability to perform fine and gross
movements effectively must have lasted, or be expected to last, for at least 12 months. For the
purposes of these criteria, consideration of the ability to perform these activities must be from a
physical standpoint alone. When there is an inability to perform these activities due to a mental
impairment, the criteria in 112.00ff are to be used. We will determine whether a child can
ambulate effectively or can perform fine and gross movements effectively based on the
medical and other evidence in the case record, generally without developing additional
evidence about the child's ability to perform the specific activities listed as examples in
101.00B2b(2) and (3) and 101.00B2c(2) and (3).
b. What We Mean by Inability To Ambulate Effectively
(1) Definition. Inability to ambulate effectively means an extreme limitation of the ability to walk;
i.e., an impairment that interferes very seriously with the child's ability to independently initiate,
sustain, or complete activities. Ineffective ambulation is defined generally as having insufficient
lower extremity functioning (see 101.00J) to permit independent ambulation without the use of
a hand-held assistive device(s) that limits the functioning of both upper extremities. (Listing
101.05C is an exception to this general definition because the child has the use of only one
upper extremity due to amputation of a hand.)

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(2) How we assess inability to ambulate effectively for children too young to be expected to
walk independently. For children who are too young to be expected to walk independently,
consideration of function must be based on assessment of limitations in the ability to perform
comparable age-appropriate activities with the lower extremities, given normal developmental
expectations. For such children, an extreme level of limitation means skills or performance at
no greater than one-half of age-appropriate expectations based on an overall developmental
assessment rather than on one or two isolated skills.
(3) How we assess inability to ambulate effectively for older children. Older children, who
would be expected to be able to walk when compared to other children the same age who do
not have impairments, must be capable of sustaining a reasonable walking pace over a
sufficient distance to be able to carry out age-appropriate activities. They must have the ability
to travel age-appropriately without extraordinary assistance to and from school or a place of
employment. Therefore, examples of ineffective ambulation for older children include, but are
not limited to, the inability to walk without the use of a walker, two crutches or two canes, the
inability to walk a block at a reasonable pace on rough or uneven surfaces, the inability to use
standard public transportation, the inability to carry out age-appropriate school activities
independently, and the inability to climb a few steps at a reasonable pace with the use of a
single hand rail. The ability to walk independently about the child's home or a short distance at
school without the use of assistive devices does not, in and of itself, constitute effective
ambulation.
c. What We Mean by Inability To Perform Fine and Gross Movements Effectively
(1) Definition. Inability to perform fine and gross movements effectively means an extreme loss
of function of both upper extremities; i.e., an impairment that interferes very seriously with the
child's ability to independently initiate, sustain, or complete activities. To use their upper
extremities effectively, a child must be capable of sustaining such functions as reaching,
pushing, pulling, grasping, and fingering in an age-appropriate manner to be able to carry out
age-appropriate activities.
(2) How we assess inability to perform fine and gross movements in very young children. For
very young children, we consider limitations in the ability to perform comparable ageappropriate activities involving the upper extremities compared to the ability of children the
same age who do not have impairments. For such children, an extreme level of limitation
means skills or performance at no greater than one-half of age-appropriate expectations based
on an overall developmental assessment.
(3) How we assess inability to perform fine and gross movements in older children. For older
children, examples of inability to perform fine and gross movements effectively include, but are
not limited to, the inability to prepare a simple meal and feed oneself, the inability to take care
of personal hygiene, or the inability to sort and handle papers or files, depending upon which
activities are age-appropriate.
d. Pain or other symptoms. Pain or other symptoms may be an important factor contributing to
functional loss. In order for pain or other symptoms to be found to affect a child's ability to
function in an age-appropriate manner or to perform basic work activities, medical signs or
laboratory findings must show the existence of a medically determinable impairment(s) that
could reasonably be expected to produce the pain or other symptoms. The musculoskeletal
listings that include pain or other symptoms among their criteria also include criteria for

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limitations in functioning as a result of the listed impairment, including limitations caused by
pain. It is, therefore, important to evaluate the intensity and persistence of such pain or other
symptoms carefully in order to determine their impact on the child's functioning under these
listings. See also §§404.1525(f) and 404.1529 of this part, and §§416.925(f) and 416.929 of
part 416 of this chapter.
C. Diagnosis and Evaluation
1. General. Diagnosis and evaluation of musculoskeletal impairments should be supported, as
applicable, by detailed descriptions of the joints, including ranges of motion, condition of the
musculature (e.g., weakness, atrophy), sensory or reflex changes, circulatory deficits, and
laboratory findings, including findings on x-ray or other appropriate medically acceptable
imaging. Medically acceptable imaging includes, but is not limited to, x-ray imaging,
computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI), with or
without contrast material, myelography, and radionuclear bone scans. "Appropriate" means
that the technique used is the proper one to support the evaluation and diagnosis of the
impairment.
2. Purchase of certain medically acceptable imaging. While any appropriate medically
acceptable imaging is useful in establishing the diagnosis of musculoskeletal impairments,
some tests, such as CAT scans and MRIs, are quite expensive, and we will not routinely
purchase them. Some, such as myelograms, are invasive and may involve significant risk. We
will not order such tests. However, when the results of any of these tests are part of the
existing evidence in the case record we will consider them together with the other relevant
evidence.
3. Consideration of electrodiagnostic procedures. Electrodiagnostic procedures may be useful
in establishing the clinical diagnosis, but do not constitute alternative criteria to the
requirements of 101.04.
D. The physical examination must include a detailed description of the rheumatological,
orthopedic, neurological, and other findings appropriate to the specific impairment being
evaluated. These physical findings must be determined on the basis of objective observation
during the examination and not simply a report of the child's allegation; e.g., "He says his leg is
weak, numb." Alternative testing methods should be used to verify the abnormal findings; e.g.,
a seated straight-leg raising test in addition to a supine straight-leg raising test. Because
abnormal physical findings may be intermittent, their presence over a period of time must be
established by a record of ongoing management and evaluation. Care must be taken to
ascertain that the reported examination findings are consistent with the child's age and
activities.
E. Examination of the Spine
1. General. Examination of the spine should include a detailed description of gait, range of
motion of the spine given quantitatively in degrees from the vertical position (zero degrees) or,
for straight-leg raising from the sitting and supine position (zero degrees), any other
appropriate tension signs, motor and sensory abnormalities, muscle spasm, when present, and
deep tendon reflexes. Observations of the child during the examination should be reported;
e.g., how he or she gets on and off the examination table. Inability to walk on the heels or toes,
to squat, or to arise from a squatting position, when appropriate, may be considered evidence

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of significant motor loss. However, a report of atrophy is not acceptable as evidence of
significant motor loss without circumferential measurements of both thighs and lower legs, or
both upper and lower arms, as appropriate, at a stated point above and below the knee or
elbow given in inches or centimeters. Additionally, a report of atrophy should be accompanied
by measurement of the strength of the muscle(s) in question generally based on a grading
system of 0 to 5, with 0 being complete loss of strength and 5 being maximum strength. A
specific description of atrophy of hand muscles is acceptable without measurements of atrophy
but should include measurements of grip and pinch strength. However, because of the
unreliability of such measurement in younger children, these data are not applicable to children
under 5 years of age.
2. When neurological abnormalities persist. Neurological abnormalities may not completely
subside after treatment or with the passage of time. Therefore, residual neurological
abnormalities that persist after it has been determined clinically or by direct surgical or other
observation that the ongoing or progressive condition is no longer present will not satisfy the
required findings in 101.04. More serious neurological deficits (paraparesis, paraplegia) are to
be evaluated under the criteria in 111.00ff.
F. Major joints refers to the major peripheral joints, which are the hip, knee, shoulder, elbow,
wrist-hand, and ankle-foot, as opposed to other peripheral joints (e.g., the joints of the hand or
forefoot) or axial joints (i.e., the joints of the spine.) The wrist and hand are considered
together as one major joint, as are the ankle and foot. Since only the ankle joint, which
consists of the juncture of the bones of the lower leg (tibia and fibula) with the hindfoot (tarsal
bones), but not the forefoot, is crucial to weight bearing, the ankle and foot are considered
separately in evaluating weight bearing.
G. Measurements of joint motion are based on the techniques described in the chapter on the
extremities, spine, and pelvis in the current edition of the "Guides to the Evaluation of
Permanent Impairment" published by the American Medical Association.
H. Documentation.
1. General. Musculoskeletal impairments frequently improve with time or respond to treatment.
Therefore, a longitudinal clinical record is generally important for the assessment of severity
and expected duration of an impairment unless the child is a newborn or the claim can be
decided favorably on the basis of the current evidence.
2. Documentation of medically prescribed treatment and response. Many children, especially
those who have listing-level impairments, will have received the benefit of medically prescribed
treatment. Whenever evidence of such treatment is available it must be considered.
3. When there is no record of ongoing treatment. Some children will not have received ongoing
treatment or have an ongoing relationship with the medical community despite the existence of
a severe impairment(s). In such cases, evaluation will be made on the basis of the current
objective medical evidence and other available evidence, taking into consideration the child's
medical history, symptoms, and medical source opinions. Even though a child who does not
receive treatment may not be able to show an impairment that meets the criteria of one of the
musculoskeletal listings, the child may have an impairment(s) that is either medically or, in the
case of a claim for benefits under part 416 of this chapter, functionally equivalent in severity to
one of the listed impairments.

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4. Evaluation when the criteria of a musculoskeletal listing are not met. These listings are only
examples of common musculoskeletal disorders that are severe enough to find a child
disabled. Therefore, in any case in which a child has a medically determinable impairment that
is not listed, an impairment that does not meet the requirements of a listing, or a combination
of impairments no one of which meets the requirements of a listing, we will consider whether
the child's impairment(s) is medically or, in the case of a claim for benefits under part 416 of
this chapter, functionally equivalent in severity to the criteria of a listing. (See §§404.1526,
416.926, and 416.926a.) Individuals with claims for benefits under part 404, who have an
impairment(s) with a level of severity that does not meet or equal the criteria of the
musculoskeletal listings may or may not have the RFC that would enable them to engage in
substantial gainful activity. Evaluation of the impairment(s) of these individuals should proceed
through the final steps of the sequential evaluation process in §404.1520 (or, as appropriate,
the steps in the medical improvement review standard in §404.1594).
I. Effects of Treatment
1. General. Treatments for musculoskeletal disorders may have beneficial effects or adverse
side effects. Therefore, medical treatment (including surgical treatment) must be considered in
terms of its effectiveness in ameliorating the signs, symptoms, and laboratory abnormalities of
the disorder, and in terms of any side effects that may further limit the child.
2. Response to treatment. Response to treatment and adverse consequences of treatment
may vary widely. For example, a pain medication may relieve a child's pain completely,
partially, or not at all. It may also result in adverse effects, e.g., drowsiness, dizziness, or
disorientation, that compromise the child's ability to function. Therefore, each case must be
considered on an individual basis, and include consideration of the effects of treatment on the
child's ability to function.
3. Documentation. A specific description of the drugs or treatment given (including surgery),
dosage, frequency of administration, and a description of the complications or response to
treatment should be obtained. The effects of treatment may be temporary or long-term. As
such, the finding regarding the impact of treatment must be based on a sufficient period of
treatment to permit proper consideration or judgment about future functioning.
J. Orthotic, Prosthetic, or Assistive Devices
1. General. Consistent with clinical practice, children with musculoskeletal impairments may be
examined with and without the use of any orthotic, prosthetic, or assistive devices as explained
in this section.
2. Orthotic devices. Examination should be with the orthotic device in place and should include
an evaluation of the child's maximum ability to function effectively with the orthosis. It is
unnecessary to routinely evaluate the child's ability to function without the orthosis in place. If
the child has difficulty with, or is unable to use, the orthotic device, the medical basis for the
difficulty should be documented. In such cases, if the impairment involves a lower extremity or
extremities, the examination should include information on the child's ability to ambulate
effectively without the device in place unless contraindicated by the medical judgment of a
physician who has treated or examined the child.
3. Prosthetic devices. Examination should be with the prosthetic device in place. In

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amputations involving a lower extremity or extremities, it is unnecessary to evaluate the child's
ability to walk without the prosthesis in place. However, the child's medical ability to use a
prosthesis to ambulate effectively, as defined in 101.00B2b, should be evaluated. The
condition of the stump should be evaluated without the prosthesis in place.
4. Hand-held assistive devices. When a child with an impairment involving a lower extremity or
extremities uses a hand-held assistive device, such as a cane, crutch or walker, examination
should be with and without the use of the assistive device unless contraindicated by the
medical judgment of a physician who has treated or examined the child. The child's ability to
ambulate with and without the device provides information as to whether, or the extent to
which, the child is able to ambulate without assistance. The medical basis for the use of any
assistive device (e.g., instability, weakness) should be documented. The requirement to use a
hand-held assistive device may also impact on the child's functional capacity by virtue of the
fact that one or both upper extremities are not available for such activities as lifting, carrying,
pushing, and pulling.
K. Disorders of the spine, listed in 101.04, result in limitations because of distortion of the bony
and ligamentous architecture of the spine and associated impingement on nerve roots
(including the cauda equina) or spinal cord. Such impingement on nerve tissue may result from
a herniated nucleus pulposus or other miscellaneous conditions. Neurological abnormalities
resulting from these disorders are to be evaluated by referral to the neurological listings in
111.00ff, as appropriate. (See also 101.00B and E.)
1. Herniated nucleus pulposus is a disorder frequently associated with the impingement of a
nerve root, but occurs infrequently in children. Nerve root compression results in a specific
neuro-anatomic distribution of symptoms and signs depending upon the nerve root(s)
compromised.
2. Other miscellaneous conditions that may cause weakness of the lower extremities, sensory
changes, areflexia, trophic ulceration, bladder or bowel incontinence, and that should be
evaluated under 101.04 include, but are not limited to, lysosomal disorders, metabolic
disorders, vertebral osteomyelitis, vertebral fractures and achondroplasia. Disorders such as
spinal dysrhaphism, (e.g., spina bifida) diastematomyelia, and tethered cord syndrome may
also cause such abnormalities. In these cases, there may be gait difficulty and deformity of the
lower extremities based on neurological abnormalities, and the neurological effects are to be
evaluated under the criteria in 111.00ff.
L. Abnormal curvatures of the spine. Abnormal curvatures of the spine (specifically, scoliosis,
kyphosis and kyphoscoliosis) can result in impaired ambulation, but may also adversely affect
functioning in body systems other than the musculoskeletal system. For example, a child's
ability to breathe may be affected; there may be cardiac difficulties (e.g., impaired myocardial
function); or there may be disfigurement resulting in withdrawal or isolation. When there is
impaired ambulation, evaluation of equivalence may be made by reference to 114.09A. When
the abnormal curvature of the spine results in symptoms related to fixation of the dorsolumbar
or cervical spine, evaluation of equivalence may be made by reference to 114.09B. When
there is respiratory or cardiac involvement or an associated mental disorder, evaluation may
be made under 103.00ff, 104.00ff, or 112.00ff, as appropriate. Other consequences should be
evaluated according to the listing for the affected body system.
M. Under continuing surgical management, as used in 101.07 and 101.08, refers to surgical

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procedures and any other associated treatments related to the efforts directed toward the
salvage or restoration of functional use of the affected part. It may include such factors as
post-surgical procedures, surgical complications, infections, or other medical complications,
related illnesses, or related treatments that delay the child's attainment of maximum benefit
from therapy. When burns are not under continuing surgical management, see 108.00F.
N. After maximum benefit from therapy has been achieved in situations involving fractures of
an upper extremity (101.07), or soft tissue injuries (101.08), i.e., there have been no significant
changes in physical findings or on appropriate medically acceptable imaging for any 6-month
period after the last definitive surgical procedure or other medical intervention, evaluation must
be made on the basis of the demonstrable residuals, if any. A finding that 101.07 or 101.08 is
met must be based on a consideration of the symptoms, signs, and laboratory findings
associated with recent or anticipated surgical procedures and the resulting recuperative
periods, including any related medical complications, such as infections, illnesses, and
therapies which impede or delay the efforts toward restoration of function. Generally, when
there has been no surgical or medical intervention for 6 months after the last definitive surgical
procedure, it can be concluded that maximum therapeutic benefit has been reached.
Evaluation at this point must be made on the basis of the demonstrable residual limitations, if
any, considering the child's impairment-related symptoms, signs, and laboratory findings, any
residual symptoms, signs, and laboratory findings associated with such surgeries,
complications, and recuperative periods, and other relevant evidence.
O. Major function of the face and head, for purposes of listing 101.08, relates to impact on any
or all of the activities involving vision, hearing, speech, mastication, and the initiation of the
digestive process.
P. When surgical procedures have been performed, documentation should include a copy of
the operative notes and available pathology reports.
101.01 Category of Impairments, Musculoskeletal
101.02 Major dysfunction of a joint(s) (due to any cause): Characterized by gross anatomical
deformity (e.g., subluxation, contracture, bony or fibrous ankylosis, instability) and chronic joint
pain and stiffness with signs of limitation of motion or other abnormal motion of the affected
joint(s), and findings on appropriate medically acceptable imaging of joint space narrowing,
bony destruction, or ankylosis of the affected joint(s). With:
A. Involvement of one major peripheral weight-bearing joint (i.e., hip, knee, or ankle), resulting
in inability to ambulate effectively, as defined in 101.00B2b;
or
B. Involvement of one major peripheral joint in each upper extremity (i.e., shoulder, elbow, or
wrist-hand), resulting in inability to perform fine and gross movements effectively, as defined in
101.00B2c.
101.03 Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint, with
inability to ambulate effectively, as defined in 101.00B2b, and return to effective ambulation did
not occur, or is not expected to occur, within 12 months of onset.

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101.04 Disorders of the spine (e.g., lysosomal disorders, metabolic disorders, vertebral
osteomyelitis, vertebral fracture, achondroplasia) resulting in compromise of a nerve root
(including the cauda equina) or the spinal cord, with evidence of nerve root compression
characterized by neuro-anatomic distribution of pain, limitation of motion of the spine, motor
loss (atrophy with associated muscle weakness or muscle weakness) accompanied by
sensory or reflex loss and, if there is involvement of the lower back, positive straight-leg raising
test (sitting and supine).
101.05 Amputation (due to any cause).
A. Both hands;
or
B. One or both lower extremities at or above the tarsal region, with stump complications
resulting in medical inability to use a prosthetic device to ambulate effectively, as defined in
101.00B2b, which have lasted or are expected to last for at least 12 months;
or
C. One hand and one lower extremity at or above the tarsal region, with inability to ambulate
effectively, as defined in 101.00B2b;
or
D. Hemipelvectomy or hip disarticulation.
101.06 Fracture of the femur, tibia, pelvis, or one or more of the tarsal bones. With:
A. Solid union not evident on appropriate medically acceptable imaging, and not clinically solid;
and
B. Inability to ambulate effectively, as defined in 101.00B2b, and return to effective ambulation
did not occur or is not expected to occur within 12 months of onset.
101.07 Fracture of an upper extremity with nonunion of a fracture of the shaft of the humerus,
radius, or ulna, under continuing surgical management, as defined in 101.00M, directed toward
restoration of functional use of the extremity, and such function was not restored or expected
to be restored within 12 months of onset.
101.08 Soft tissue injury (e.g., burns) of an upper or lower extremity, trunk, or face and head,
under continuing surgical management, as defined in 101.00M, directed toward the salvage or
restoration of major function, and such major function was not restored or expected to be
restored within 12 months of onset. Major function of the face and head is described in
101.00O.
102.00 Special Senses and Speech
A. How do we evaluate visual disorders?

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1. What are visual disorders? Visual disorders are abnormalities of the eye, the optic nerve,
the optic tracts, or the brain that may cause a loss of visual acuity or visual fields. A loss of
visual acuity limits your ability to distinguish detail, read, do fine work, or perform other ageappropriate activities. A loss of visual fields limits your ability to perceive visual stimuli in the
peripheral extent of vision.
2. How do we define statutory blindness? Statutory blindness is blindness as defined in
sections 216(i)(1) and 1614(a)(2) of the Social Security Act (the Act). The Act defines
blindness as visual acuity of 20/200 or less in the better eye with the use of a correcting lens.
We use your best-corrected visual acuity for distance in the better eye when we determine if
this definition is met. The Act also provides that an eye that has a visual field limitation such
that the widest diameter of the visual field subtends an angle no greater than 20 degrees is
considered as having visual acuity of 20/200 or less. You have statutory blindness only if your
visual disorder meets the criteria of 102.02 or 102.03A. You do not have statutory blindness if
your visual disorder medically equals the criteria of 102.02 or 102.03A, or if it meets or
medically equals 102.03B, 102.03C, or 102.04. If your visual disorder medically equals the
criteria of 102.02 or 102.03A, or if it meets or medically equals 102.03B, 102.03C, or 102.04,
we will find that you have a disability if your visual disorder also meets the duration
requirement.
3. What evidence do we need to establish statutory blindness under title XVI? For title XVI, the
only evidence we need to establish statutory blindness is evidence showing that your visual
acuity in your better eye or your visual field in your better eye meets the criteria in 102.00A2,
provided that those measurements are consistent with the other evidence in your case record.
We do not need to document the cause of your blindness. Also, there is no duration
requirement for statutory blindness under title XVI (see §§416.981 and 416.983).
4. What evidence do we need to evaluate visual disorders, including those that result in
statutory blindness under title II?
a. To evaluate your visual disorder, we usually need a report of an eye examination that
includes measurements of the best-corrected visual acuity or the extent of the visual fields, as
appropriate. If there is a loss of visual acuity or visual fields, the cause of the loss must be
documented. A standard eye examination will usually reveal the cause of any visual acuity
loss. An eye examination can also reveal the cause of some types of visual field deficits. If the
eye examination does not reveal the cause of the visual loss, we will request the information
that was used to establish the presence of the visual disorder.
b. A cortical visual disorder is a disturbance of the posterior visual pathways or occipital lobes
of the brain in which the visual system does not interpret what the eyes are seeing. It may
result from such causes as traumatic brain injury, stroke, cardiac arrest, near drowning, a
central nervous system infection such as meningitis or encephalitis, a tumor, or surgery. It can
be temporary or permanent, and the amount of visual loss can vary. It is possible to have a
cortical visual disorder and not have any abnormalities observed in a standard eye
examination. Therefore, a diagnosis of a cortical visual disorder must be confirmed by
documentation of the cause of the brain lesion. If neuroimaging or visual evoked response
(VER) testing was performed, we will request a copy of the report or other medical evidence
that describes the findings in the report.
c. If your visual disorder does not satisfy the criteria in 102.02, 102.03, or 102.04, we will also

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request a description of how your visual disorder impacts your ability to function.
5. How do we measure best-corrected visual acuity?
a. Testing for visual acuity.
(i) When we need to measure your best-corrected visual acuity, we will use visual acuity
testing that was carried out using Snellen methodology or any other testing methodology that
is comparable to Snellen methodology.
(ii) We consider tests such as the Landolt C test or the tumbling-E test, which are used to
evaluate young children who are unable to participate in testing using Snellen methodology, to
be comparable to testing using Snellen methodology. These alternate methods for measuring
visual acuity should be performed by specialists with expertise in assessment of childhood
vision.
(iii) If you are unable to participate in testing using Snellen methodology or other comparable
testing, we will consider your fixation and visual-following behavior. If both these behaviors are
absent, we will consider the anatomical findings or the results of neuroimaging,
electroretinogram, or VER testing when this testing has been performed.
b. Determining best-corrected visual acuity. (i) Best-corrected visual acuity is the optimal visual
acuity attainable with the use of a corrective lens. In some instances, this assessment may be
performed using a specialized lens; for example, a contact lens. We will use the visual acuity
measurements obtained with a specialized lens only if you have demonstrated the ability to
use the specialized lens on a sustained basis. However, we will not use visual acuity
measurements obtained with telescopic lenses because they significantly reduce the visual
field. If you have an absent response to VER testing in an eye, we can determine that your
best-corrected visual acuity is 20/200 or less in that eye. However, if you have a positive
response to VER testing in an eye, we will not use that result to determine your best-corrected
visual acuity in that eye. Additionally, we will not use the results of pinhole testing or automated
refraction acuity to determine your best-corrected visual acuity.
(ii) We will use the best-corrected visual acuity for distance in your better eye when we
determine whether your loss of visual acuity satisfies the criteria in 102.02A. The bestcorrected visual acuity for distance is usually measured by determining what you can see from
20 feet. If your visual acuity is measured for a distance other than 20 feet, we will convert it to
a 20-foot measurement. For example, if your visual acuity is measured at 10 feet and is
reported as 10/40, we will convert this to 20/80.
(iii) If you cannot participate in visual acuity testing, we will determine that your best-corrected
visual acuity is 20/200 or less in your better eye if your visual disorder meets the criteria in
102.02B. To meet 102.02B1, your impairment must result in the absence of fixation and visualfollowing behavior and abnormal anatomical findings indicating a visual acuity of 20/200 or less
in your better eye. Such abnormal anatomical findings include, but are not limited to, the
presence of Stage III or worse retinopathy of prematurity despite surgery, hypoplasia of the
optic nerve, albinism with macular aplasia, and bilateral optic atrophy. To meet 102.02B2, your
impairment must result in the absence of fixation and visual-following behavior and abnormal
neuroimaging documenting damage to the cerebral cortex which would be expected to prevent
the development of a visual acuity better than 20/200 in your better eye. Such abnormal

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neuroimaging includes, but is not limited to, neuroimaging showing bilateral encephalomyelitis
or bilateral encephalomalacia.
6. How do we measure visual fields?
a. Testing for visual fields.
(i) We generally need visual field testing when you have a visual disorder that could result in
visual field loss, such as glaucoma, retinitis pigmentosa, or optic neuropathy, or when you
display behaviors that suggest a visual field loss.
(ii) When we need to measure the extent of your visual field loss, we will use visual field
measurements obtained with an automated static threshold perimetry test performed on a
perimeter, like the Humphrey Field Analyzer, that satisfies all of the following requirements:
A. The perimeter must use optical projection to generate the test stimuli.
B. The perimeter must have an internal normative database for automatically comparing your
performance with that of the general population.
C. The perimeter must have a statistical analysis package that is able to calculate visual field
indices, particularly mean deviation.
D. The perimeter must demonstrate the ability to correctly detect visual field loss and correctly
identify normal visual fields.
E. The perimeter must demonstrate good test-retest reliability.
F. The perimeter must have undergone clinical validation studies by three or more independent
laboratories with results published in peer-reviewed ophthalmic journals.
(iii) The test must use a white size III Goldmann stimulus and a 31.5 apostilb (10 cd/m[2]) white
background. The stimuli locations must be no more than 6 degrees apart horizontally or
vertically. Measurements must be reported on standard charts and include a description of the
size and intensity of the test stimulus.
(iv) To determine statutory blindness based on visual field loss (102.03A), we need a test that
measures the central 24 to 30 degrees of the visual field; that is, the area measuring 24 to 30
degrees from the point of fixation. Acceptable tests include the Humphrey 30-2 or 24-2 tests.
(v) The criterion in 102.03B is based on the use of a test performed on a Humphrey Field
Analyzer that measures the central 30 degrees of the visual field. We can also use comparable
results from other acceptable perimeters; for example, a mean defect of 22 on an acceptable
Octopus test, to determine that the criterion in 102.03B is met. We cannot use tests that do not
measure the central 30 degrees of the visual field, such as the Humphrey 24-2 test, to
determine if your impairment meets or medically equals 102.03B.
(vi) We measure the extent of visual field loss by determining the portion of the visual field in
which you can see a white III4e stimulus. The "III" refers to the standard Goldmann test

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stimulus size III, and the "4e" refers to the standard Goldmann intensity filters used to
determine the intensity of the stimulus.
(vii) In automated static threshold perimetry, the intensity of the stimulus varies. The intensity
of the stimulus is expressed in decibels (dB). We need to determine the dB level that
corresponds to a 4e intensity for the particular perimeter being used. We will then use the dB
printout to determine which points would be seen at a 4e intensity level. For example, in
Humphrey Field Analyzers, a 10 dB stimulus is equivalent to a 4e stimulus. A dB level that is
higher than 10 represents a dimmer stimulus, while a dB level that is lower than 10 represents
a brighter stimulus. Therefore, for tests performed on Humphrey Field Analyzers, any point
seen at 10 dB or higher is a point that would be seen with a 4e stimulus.
(viii) We can also use visual field measurements obtained using kinetic perimetry, such as the
Humphrey "SSA Test Kinetic" or Goldmann perimetry, instead of automated static threshold
perimetry. The kinetic test must use a white III4e stimulus projected on a white 31.5 apostilb
(10 cd/m[2]) background. In automated kinetic tests, such as the Humphrey "SSA Test Kinetic,"
testing along a meridian stops when you see the stimulus. Because of this, automated kinetic
testing does not detect limitations in the central visual field. If your visual disorder has
progressed to the point at which it is likely to result in a significant limitation in the central visual
field, such as a scotoma (see 102.00A8c), we will not use automated kinetic perimetry to
evaluate your visual field loss. Instead, we will assess your visual field loss using automated
static threshold perimetry or manual kinetic perimetry.
(ix) We will not use the results of visual field screening tests, such as confrontation tests,
tangent screen tests, or automated static screening tests, to determine that your impairment
meets or medically equals a listing, or functionally equals the listings. However, we can
consider normal results from visual field screening tests to determine whether your visual
disorder is severe when these test results are consistent with the other evidence in your case
record. (See §416.924(c).) We will not consider normal test results to be consistent with the
other evidence if either of the following applies:
A. The clinical findings indicate that your visual disorder has progressed to the point that it is
likely to cause visual field loss; or
B. You have a history of an operative procedure for retinal detachment.
b. Use of corrective lenses. You must not wear eyeglasses during the visual field examination
because they limit your field of vision. Contact lenses or perimetric lenses may be used to
correct visual acuity during the visual field examination in order to obtain the most accurate
visual field measurements. For this single purpose, you do not need to demonstrate that you
have the ability to use the contact or perimetric lenses on a sustained basis.
7. How do we calculate visual efficiency?
a. Visual acuity efficiency. We use the percentage shown in Table 1 that corresponds to the
best-corrected visual acuity for distance in your better eye.
b. Visual field efficiency. We use kinetic perimetry to calculate visual field efficiency by adding
the number of degrees seen along the eight principal meridians in your better eye and dividing
by 500. (See Table 2.)

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c. Visual efficiency. We calculate the percent of visual efficiency by multiplying the visual acuity
efficiency by the visual field efficiency and converting the decimal to a percentage. For
example, if your visual acuity efficiency is 75 percent and your visual field efficiency is 64
percent, we will multiply 0.75 × 0.64 to determine that your visual efficiency is 0.48, or 48
percent.
8. How do we evaluate specific visual problems?
a. Statutory blindness. Most test charts that use Snellen methodology do not have lines that
measure visual acuity between 20/100 and 20/200. Newer test charts, such as the BaileyLovie or the Early Treatment Diabetic Retinopathy Study (ETDRS), do have lines that measure
visual acuity between 20/100 and 20/200. If your visual acuity is measured with one of these
newer charts, and you cannot read any of the letters on the 20/100 line, we will determine that
you have statutory blindness based on a visual acuity of 20/200 or less. For example, if your
best-corrected visual acuity for distance in the better eye was determined to be 20/160 using
an ETDRS chart, we will find that you have statutory blindness. Regardless of the type of test
chart used, you do not have statutory blindness if you can read at least one letter on the
20/100 line. For example, if your best-corrected visual acuity for distance in the better eye was
determined to be 20/125+1 using an ETDRS chart, we will find that you do not have statutory
blindness as you are able to read one letter on the 20/100 line.
b. Blepharospasm. This movement disorder is characterized by repetitive, bilateral, involuntary
closure of the eyelids. If you have this disorder, you may have measurable visual acuities and
visual fields that do not satisfy the criteria of 102.02 or 102.03. Blepharospasm generally
responds to therapy. However, if therapy is not effective, we will consider how the involuntary
closure of your eyelids affects your ability to maintain visual functioning over time.
c. Scotoma. A scotoma is a non-seeing area in the visual field surrounded by a seeing area.
When we measure the visual field, we subtract the length of any scotoma, other than the
normal blind spot, from the overall length of any diameter on which it falls.
B. Hearing impairments in children. The criteria for hearing impairments in children take into
account that a lesser impairment in hearing which occurs at an early age may result in a
severe speech and language disorder.
Improvement by a hearing aid, as predicted by the testing procedure, must be demonstrated to
be feasible in that child, since younger children may be unable to use a hearing aid effectively.
The type of audiometric testing performed must be described and a copy of the results must be
included. The pure tone air conduction hearing levels in 102.08 are based on American
National Standard Institute Specifications for Audiometers, S3.6-1969 (ANSI-1969). The report
should indicate the specifications used to calibrate the audiometer.
The finding of a severe impairment will be based on the average hearing levels at 500, 1000,
2000, and 3000 Hertz (Hz) in the better ear, and on speech discrimination, as specified in
§102.08.
C. How do we evaluate impairments that do not meet one of the special senses and speech
listings?

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1. These listings are only examples of common special senses and speech disorders that we
consider severe enough to result in marked and severe functional limitations. If your
impairment(s) does not meet the criteria of any of these listings, we must also consider
whether you have an impairment(s) that satisfies the criteria of a listing in another body
system.
2. If you have a medically determinable impairment(s) that does not meet a listing, we will
determine whether the impairment(s) medically equals a listing or functionally equals the
listings. (See §§416.926 and 416.926a.) We use the rules in §416.994a when we decide
whether you continue to be disabled.
102.01 Category of Impairments, Special Senses and Speech
102.02 Loss of visual acuity.
A. Remaining vision in the better eye after best correction is 20/200 or less;
OR
B. An inability to participate in testing using Snellen methodology or other comparable visual
acuity testing and clinical findings that fixation and visual-following behavior are absent in the
better eye, and:
1. Abnormal anatomical findings indicating a visual acuity of 20/200 or less in the better eye; or
2. Abnormal neuroimaging documenting damage to the cerebral cortex which would be
expected to prevent the development of a visual acuity better than 20/200 in the better eye; or
3. Abnormal electroretinogram documenting the presence of Leber's congenital amaurosis or
achromatopsia; or
4. An absent response to VER testing in the better eye.
102.03 Contraction of the visual field in the better eye, with:
A. The widest diameter subtending an angle around the point of fixation no greater than 20
degrees;
OR
B. A mean deviation of -22 or worse, determined by automated static threshold perimetry as
described in 102.00A6a(v);
OR
C. A visual field efficiency of 20 percent or less as determined by kinetic perimetry (see
102.00A7b).
102.04 Loss of visual efficiency. Visual efficiency of the better eye of 20 percent or less after

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best correction (see 102.00A7c).
102.08 Hearing impairments.
A. For children below 5 years of age at time of adjudication, inability to hear air conduction
thresholds at an average of 40 decibels (db) hearing level or greater in the better ear; or
B. For children 5 years of age and above at time of adjudication:
1. Inability to hear air conduction thresholds at an average of 70 decibels (db) or greater in the
better ear; or
2. Speech discrimination scores at 40 percent or less in the better ear; or
3. Inability to hear air conduction thresholds at an average of 40 decibels (db) or greater in the
better ear, and a speech and language disorder which significantly affects the clarity and
content of the speech and is attributable to the hearing impairment.
Table 1.—Percentage of
Visual Acuity Efficiency
Corresponding to the
Best-Corrected Visual
Acuity Measurement for
Distance in the Better
Eye
Percent
Snellen
visual
acuity
English Metric efficiency
20/16
6/5
100
20/20
6/6
100
20/25
6/7.5
95
20/30
6/9
90
20/40
6/12
85
20/50
6/15
75
20/60
6/18
70
20/70
6/21
65
20/80
6/24
60
20/100
6/30
50
Table
2.—
Chart
of
Visual
Fields

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1. The diagram of the right eye illustrates the extent of a normal visual field as measured with a
III4e stimulus. The sum of the eight principal meridians of this field is 500 degrees.
2. The diagram of the left eye illustrates a visual field contracted to 30 degrees in two
meridians and to 20 degrees in the remaining six meridians. The percent of visual field
efficiency of this field is: (2 × 30) + (6 × 20) = 180 ÷ 500 = 0.36 or 36 percent visual field
efficiency.
103.00 Respiratory System
A. Introduction. The listings in this section describe impairments resulting from respiratory
disorder based on symptoms, physical signs, laboratory test abnormalities, and response to a
regimen of treatment prescribed by a treating source. Respiratory disorders, along with any
associated impairment(s) must be established by medical evidence. Evidence must be
provided in sufficient detail to permit an independent reviewer to evaluate the severity of the
impairment. Reasonable efforts should be made to ensure evaluation by a program physician
specializing in childhood respiratory impairments or a qualified pediatrician.
Many children, especially those who have listing-level impairments, will have received the
benefit of medically prescribed treatment. Whenever there is such evidence, the longitudinal
clinical record must include a description of the treatment prescribed by the treating source
and response, in addition to information about the nature and severity of the impairment. It is
important to document any prescribed treatment and response because this medical
management may have improved the child's functional status. The longitudinal record should
provide information regarding functional recovery, if any.
Some children will not have received ongoing treatment or have an ongoing relationship with
the medical community, despite the existence of a severe impairment(s). A child who does not
receive treatment may or may not be able to show an impairment that meets the criteria of
these listings. Even if a child does not show that his or her impairment meets the criteria of
these listings, the child may have an impairment(s) that medically or functionally equals the
listings. Unless the claim can be decided favorably on the basis of the current evidence, a
longitudinal record is still important because it will provide information about such things as the
ongoing medical severity of the impairment, the level of the child's functioning, and the
frequency, severity, and duration of symptoms. Also, the asthma listing specifically includes a
requirement for continuing signs and symptoms despite a regimen of prescribed treatment.

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Evaluation should include consideration of adverse effects of respiratory impairment in all
relevant body systems, and especially on the child's growth and development or mental
functioning, as described under the growth impairment (100.00), neurological (111.00), and
mental disorders (112.00) listings.
It must be remembered that these listings are only examples of common respiratory disorders
that are severe enough to find a child disabled. When a child has a medically determinable
impairment that is not listed, an impairment that does not meet the requirements of a listing, or
a combination of impairments no one of which meets the requirements of a listing, we will
make a determination whether the child's impairment(s) medically or functionally equals the
listings. (See §§404.1526, 416.926, and 416.926a.)
B. Documentation of Pulmonary Function Testing. The results of spirometry that are used for
adjudication, under the 103.02 A and B, 103.03, and 103.04 of these listings should be
expressed in liters (L), body temperature and pressure saturated with water vapor (BTPS). The
reported one-second forced expiratory volume (FEV1) and forced vital capacity (FVC) should
represent the largest of at least three satisfactory forced expiratory maneuvers. Two of the
satisfactory spirograms should be reproducible for both pre-bronchodilator tests and, if
indicated, post-bronchodilator tests. A value is considered reproducible if it does not differ from
the largest value by more than 5 percent or 0.1 L, whichever is greater. The highest values of
the FEV1 and FVC, whether from the same or different tracings, should be used to assess the
severity of the respiratory impairment. Peak flow should be achieved early in expiration, and
the spirogram should have a smooth contour with gradually decreasing flow throughout
expiration. The zero time for measurement of the FEV1 and FVC, if not distinct, should be
derived by linear back-extrapolation of peak flow to zero volume. A spirogram is satisfactory for
measurement of the FEV1 if the expiratory volume at the back-extrapolated zero time is less
than 5 percent of the FVC or 0.1 L, whichever is greater. The spirogram is satisfactory for
measurement of the FVC if maximal expiratory effort continues for at least 6 seconds, or if
there is a plateau in the volume-time curve with no detectable change in expired volume (VE)
during the last 2 seconds of maximal expiratory effort.
Spirometry should be repeated after administration of an aerosolized bronchodilator under
supervision of the testing personnel if the pre-bronchodilator FEV1 value is less than the
appropriate reference value in table I or III, as appropriate. If a bronchodilator is not
administered, the reason should be clearly stated in the report. Pulmonary function studies
should not be performed unless the clinical status is stable (e.g., the child is not having an
asthmatic attack or suffering from an acute respiratory infection or other chronic illness).
Wheezing is common in asthma, chronic bronchitis, or chronic obstructive pulmonary disease
and does not preclude testing. Pulmonary function studies performed to assess airflow
obstruction without testing after bronchodilators cannot be used to assess levels of impairment
in the range that prevents a child from performing age-appropriate activities, unless the use of
bronchodilators is contraindicated. Post-bronchodilator testing should be performed 10 minutes
after bronchodilator administration. The dose and name of the bronchodilator administered
should be specified. The values in 103.02 and 103.04 must only be used as criteria for the
level of ventilatory impairment that exists during the child's most stable state of health (i.e., any
period in time except during or shortly after an exacerbation).
The appropriately labeled spirometric tracing, showing the child's name, date of testing,
distance per second on the abscissa and distance per liter (L) on the ordinate, must be

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incorporated into the file. The manufacturer and model number of the device used to measure
and record the spirogram should be stated. The testing device must accurately measure both
time and volume, the latter to within 1 percent of a 3 L calibrating volume. If the spirogram was
generated by any means other than direct pen linkage to a mechanical displacement-type
spirometer, the testing device must have had a recorded calibration performed previously on
the day of the spirometric measurement.
If the spirometer directly measures flow, and volume is derived by electronic integration, the
linearity of the device must be documented by recording volume calibrations at three different
flow rates of approximately 30 L/min (3 L/6 sec), 60 L/min (3 L/3 sec), and 180 L/min (3 L/sec).
The volume calibrations should agree to within 1 percent of a 3 L calibrating volume. The
proximity of the flow sensor to the child should be noted, and it should be stated whether or not
a BTPS correction factor was used for the calibration recordings and for the child's actual
spirograms.
The spirogram must be recorded at a speed of at least 20 mm/sec and the recording device
must provide a volume excursion of at least 10 mm/L. If reproductions of the original
spirometric tracings are submitted, they must be legible and have a time scale of at least 20
mm/sec and a volume scale of at least 10 mm/L to permit independent measurements.
Calculation of FEV1 from a flow volume tracing is not acceptable, i.e., the spirogram and
calibrations must be presented in a volume-time format at a speed of at least 20 mm/sec and a
volume excursion of at least 10 mm/L to permit independent evaluation.
A statement should be made in the pulmonary function test report of the child's ability to
understand directions, as well as his or her efforts and cooperation in performing the
pulmonary function tests.
Purchase of a pulmonary function test is appropriate only when the child is capable of
performing reproducible forced expiratory maneuvers. This capability usually occurs around
age 6. Purchase of a pulmonary function test may be appropriate when there is a question of
whether an impairment meets or is equivalent in severity to a listing, and the claim cannot
otherwise be favorably decided.
The pulmonary function tables in 103.02 and 103.04 are based on measurement of standing
height without shoes. If a child has marked spinal deformities (e.g., kyphoscoliosis), the
measured span between the fingertips with the upper extremities abducted 90 degrees should
be substituted for height when this measurement is greater than the standing height without
shoes.
C. Documentation of chronic impairment of gas exchange.
1. Arterial blood gas studies (ABGS). An ABGS performed at rest (while breathing room air,
awake and sitting or standing) should be analyzed in a laboratory certified by a State or
Federal agency. If the laboratory is not certified, it must submit evidence of participation in a
national proficiency testing program as well as acceptable quality control at the time of testing.
The report should include the altitude of the facility and the barometric pressure on the date of
analysis.
Purchase of resting ABGS may be appropriate when there is a question of whether an
impairment meets or is equivalent in severity to a listing, and the claim cannot otherwise be

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favorably decided. Before purchasing resting ABGS, a program physician, preferably one
experienced in the care of children with pulmonary disease, must review the clinical and
laboratory data short of this procedure, including spirometry, to determine whether obtaining
the test would present a significant risk to the child.
2. Oximetry. Pulse oximetry may be substituted for arterial blood gases in children under 12
years of age. The oximetry unit should employ the basic technology of spectrophotometric
plethysmography as described in Taylor, M.B., and Whitwain, J.G., "Current Status of Pulse
Oximetry," "Anesthesia," Vol. 41, No. 9, pp. 943-949, 1986. The unit should provide a visual
display of the pulse signal and the corresponding oxygen saturation. A hard copy of the
readings (heart rate and saturation) should be provided. Readings should be obtained for a
minimum of 5 minutes. The written report should describe patient activity during the recording,
i.e., sleep rate, feeding, or exercise. Correlation between the actual heart rate determined by a
trained observer and that displayed by the oximeter should be provided. A statement should be
made in the report of the child's effort and cooperation during the test.
Purchase of oximetry may be appropriate when there is a question of whether an impairment
meets or is equivalent in severity to a listing, and the claim cannot otherwise be favorably
decided.
D. Cystic fibrosis is a disorder that affects either the respiratory or digestive body systems or
both and may impact on a child's growth and development. It is responsible for a wide and
variable spectrum of clinical manifestations and complications. Confirmation of the diagnosis is
based upon an elevated sweat sodium concentration or chloride concentration accompanied
by one or more of the following: the presence of chronic obstructive pulmonary disease,
insufficiency of exocrine pancreatic function, meconium ileus, or a positive family history. The
quantitative pilocarpine iontophoresis procedure for collection of sweat content must be
utilized. Two methods are acceptable: the "Procedure for the Quantitative Iontophoretic Sweat
Test for Cystic Fibrosis," published by the Cystic Fibrosis Foundation and contained in, "A Test
for Concentration of Electrolytes in Sweat in Cystic Fibrosis of the Pancreas Utilizing
Pilocarpine Iontophoresis," Gibson, I.E., and Cooke, R.E., "Pediatrics," Vol 23: 545, 1959; or
the "Wescor Macroduct System." To establish the diagnosis of cystic fibrosis, the sweat
sodium or chloride content must be analyzed quantitatively using an acceptable laboratory
technique. Another diagnostic test is the "CF gene mutation analysis" for homozygosity of the
cystic fibrosis gene. The pulmonary manifestations of this disorder should be evaluated under
103.04. The nonpulmonary aspects of cystic fibrosis should be evaluated under the listings for
the digestive system (105.00) or growth impairments (100.00). Because cystic fibrosis may
involve the respiratory and digestive body systems, as well as impact on a child's growth and
development, the combined effects of this involvement must be considered in case
adjudication.
Medically acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial
tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast
material, myelography, and radionuclear bone scans. "Appropriate" means that the technique
used is the proper one to support the evaluation and diagnosis of the impairment.
E. Bronchopulmonary dysplasia (BPD). Bronchopulmonary dysplasia is a form of chronic
obstructive pulmonary disease that arises as a consequence of acute lung injury in the
newborn period and treatment of hyaline membrane disease, meconium aspiration, neonatal
pneumonia and apnea of prematurity. The diagnosis is established by the requirement for

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continuous or nocturnal supplemental oxygen for more than 30 days, in association with
characteristic changes on medically acceptable imaging and clinical signs of respiratory
dysfunction, including retractions, rales, wheezing, and tachypnea.
103.01 Category of Impairments, Respiratory System
103.02 Chronic pulmonary insufficiency. With:
A. Chronic obstructive pulmonary disease, due to any cause, with the FEV1 equal to or less
than the value specified in table I corresponding to the child's height without shoes. (In cases
of marked spinal deformity, see 103.00B.);
Table I
FEV1 equal to or less than (L,
Height without shoes
Height without shoes
BTPS)
(centimeters)
(inches)
119 or less
46 or less
0.65
0.75
120-129
47-50
130-139
51-54
0.95
140-149
55-58
1.15
150-159
59-62
1.35
160-164
63-64
1.45
165-169
65-66
1.55
170 or more
67 or more
1.65
Or
B. Chronic restrictive ventilatory disease, due to any cause, with the FVC equal to or less than
the value specified in table II corresponding to the child's height without shoes. (In cases of
marked spinal deformity, see 103.00B.);
Table II
Height without shoes
Height without shoes
FVC equal to or less than (L,
(centimeters)
(inches)
BTPS)
119 or less
46 or less
0.65
120-129
47-50
0.85
130-139
51-54
1.05
140-149
55-58
1.25
150-159
59-62
1.45
160-164
63-64
1.65
165-169
65-66
1.75
170 or more
67 or more
2.05
Or
C. Frequent need for:
1. Mechanical ventilation; or

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2. Nocturnal supplemental oxygen as required by persistent or recurrent episodes of
hypoxemia;
Or
D. The presence of a tracheostomy in a child under 3 years of age;
Or
E. Bronchopulmonary dysplasia characterized by two of the following:
1. Prolonged expirations; or
2. Intermittent wheezing or increased respiratory effort as evidenced by retractions, flaring and
tachypnea; or
3. Hyperinflation and scarring on a chest radiograph or other appropriate imaging techniques;
or
4. Bronchodilator or diuretic dependency; or
5. A frequent requirement for nocturnal supplemental oxygen; or
6. Weight disturbance with:
a. An involuntary weight loss (or failure to gain weight at an appropriate rate for age) resulting
in a fall of 15 percentiles from established growth curve (on standard growth charts) which
persists for 2 months or longer; or
b. An involuntary weight loss (or failure to gain weight at an appropriate rate for age) resulting
in a fall to below the third percentile from established growth curve (on standard growth charts)
which persists for 2 months or longer;
Or
F. Two required hospital admissions (each longer than 24 hours) within a 6-month period for
recurrent lower respiratory tract infections or acute respiratory distress associated with:
1. Chronic wheezing or chronic respiratory distress; or
2. Weight disturbance with:
a. An involuntary weight loss (or failure to gain weight at an appropriate rate for age) resulting
in a fall of 15 percentiles from established growth curve (on standard growth charts) which
persists for 2 months or longer; or
b. An involuntary weight loss (or failure to gain weight at an appropriate rate for age) resulting
in a fall to below the third percentile from established growth curve (on standard growth charts)
which persists for 2 months or longer;

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Or
G. Chronic hypoventilation (PaCO2 greater than 45 mm Hg) or chronic cor pulmonale as
described under the appropriate criteria in 104.02;
Or
H. Growth impairment as described under the criteria in 100.00.
103.03 Asthma. With:
A. FEV1 equal to or less than the value specified in table I of 103.02A;
Or
B. Attacks (as defined in 3.00C), in spite of prescribed treatment and requiring physician
intervention, occurring at least once every 2 months or at least six times a year. Each inpatient
hospitalization for longer than 24 hours for control of asthma counts as two attacks, and an
evaluation period of at least 12 consecutive months must be used to determine the frequency
of attacks;
Or
C. Persistent low-grade wheezing between acute attacks or absence of extended symptomfree periods requiring daytime and nocturnal use of sympathomimetic bronchodilators with one
of the following:
1. Persistent prolonged expiration with radiographic or other appropriate imaging techniques
evidence of pulmonary hyperinflation or peribronchial disease; or
2. Short courses of corticosteroids that average more than 5 days per month for at least 3
months during a 12-month period;
Or
D. Growth impairment as described under the criteria in 100.00.
103.04 Cystic fibrosis. With:
A. An FEV1 equal to or less than the appropriate value specified in table III corresponding to
the child's height without shoes. (In cases of marked spinal deformity, see 103.00B.);
Or
B. For children in whom pulmonary function testing cannot be performed, the presence of two
of the following:
1. History of dyspnea on exertion or accumulation of secretions as manifested by repetitive

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coughing or cyanosis; or
2. Persistent bilateral rales and rhonchi or substantial reduction of breath sounds related to
mucous plugging of the trachea or bronchi; or
3. Appropriate medically acceptable imaging evidence of extensive disease, such as
thickening of the proximal bronchial airways or persistence of bilateral peribronchial infiltrates;
Or
C. Persistent pulmonary infection accompanied by superimposed, recurrent, symptomatic
episodes of increased bacterial infection occurring at least once every 6 months and requiring
intravenous or nebulization antimicrobial treatment;
Or
D. Episodes of bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum) or
respiratory failure (documented according to 3.00C), requiring physician intervention, occurring
at least once every 2 months or at least six times a year. Each inpatient hospitalization for
longer than 24 hours for treatment counts as two episodes, and an evaluation period of at least
12 consecutive months must be used to determine the frequency of episodes;
Or
E. Growth impairment as described under the criteria in 100.00.
Table III
[Applicable only for evaluation under 103.04A—cystic fibrosis]

Height without shoes
(centimeters)
119 or less
120-129
130-139
140-149
150-159
160-164
165-169
170 or more

Height without shoes
(inches)
46 or less
47-50
51-54
55-58
59-62
63-64
65-66
67 or more

FEV1 equal to or less than (L,
BTPS)
0.75
0.85
1.05
1.35
1.55
1.85
2.05
2.25

103.05 Lung transplant. Consider under a disability for 12 months following the date of
surgery; thereafter, evaluate the residual impairment(s).
104.00 Cardiovascular System
A. General
1. What do we mean by a cardiovascular impairment?

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a. We mean any disorder that affects the proper functioning of the heart or the circulatory
system (that is, arteries, veins, capillaries, and the lymphatic drainage). The disorder can be
congenital or acquired.
b. Cardiovascular impairment results from one or more of four consequences of heart disease:
(i) Chronic heart failure or ventricular dysfunction.
(ii) Discomfort or pain due to myocardial ischemia, with or without necrosis of heart muscle.
(iii) Syncope, or near syncope, due to inadequate cerebral perfusion from any cardiac cause,
such as obstruction of flow or disturbance in rhythm or conduction resulting in inadequate
cardiac output.
(iv) Central cyanosis due to right-to-left shunt, reduced oxygen concentration in the arterial
blood, or pulmonary vascular disease.
c. Disorders of the veins or arteries (for example, obstruction, rupture, or aneurysm) may
cause impairments of the lower extremities (peripheral vascular disease), the central nervous
system, the eyes, the kidneys, and other organs. We will evaluate peripheral vascular disease
under 4.11 or 4.12 in part A, and impairments of another body system(s) under the listings for
that body system(s).
2. What do we consider in evaluating cardiovascular impairments? The listings in this section
describe cardiovascular impairments based on symptoms, signs, laboratory findings, response
to a regimen of prescribed treatment, and functional limitations.
3. What do the following terms or phrases mean in these listings?
a. Medical consultant is an individual defined in §§404.1616(a) and 416.1016(a). This term
does not include medical sources who provide consultative examinations for us. We use the
abbreviation "MC" throughout this section to designate a medical consultant.
b. Persistent means that the longitudinal clinical record shows that, with few exceptions, the
required finding(s) has been present, or is expected to be present, for a continuous period of at
least 12 months, such that a pattern of continuing severity is established.
c. Recurrent means that the longitudinal clinical record shows that, within a consecutive 12month period, the finding(s) occurs at least three times, with intervening periods of
improvement of sufficient duration that it is clear that separate events are involved.
d. Appropriate medically acceptable imaging means that the technique used is the proper one
to evaluate and diagnose the impairment and is commonly recognized as accurate for
assessing the cited finding.
e. A consecutive 12-month period means a period of 12 consecutive months, all or part of
which must occur within the period we are considering in connection with an application or
continuing disability review.
f. Currently present means that the finding is present at the time of adjudication.

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g. Uncontrolled means the impairment does not respond adequately to standard prescribed
medical treatment.
B. Documenting Cardiovascular Impairment
1. What basic documentation do we need? We need sufficiently detailed reports of history,
physical examinations, laboratory studies, and any prescribed treatment and response to allow
us to assess the severity and duration of your cardiovascular impairment. A longitudinal clinical
record covering a period of not less than 3 months of observations and treatment is usually
necessary, unless we can make a determination or decision based on the current evidence.
2. Why is a longitudinal clinical record important? We will usually need a longitudinal clinical
record to assess the severity and expected duration of your impairment(s). If you have a
listing-level impairment, you probably will have received medically prescribed treatment.
Whenever there is evidence of such treatment, your longitudinal clinical record should include
a description of the ongoing management and evaluation provided by your treating or other
medical source. It should also include your response to this medical management, as well as
information about the nature and severity of your impairment. The record will provide us with
information on your functional status over an extended period of time and show whether your
ability to function is improving, worsening, or unchanging.
3. What if you have not received ongoing medical treatment?
a. You may not have received ongoing treatment or have an ongoing relationship with the
medical community despite the existence of a severe impairment(s). In this situation, we will
base our evaluation on the current objective medical evidence and the other evidence we
have. If you do not receive treatment, you cannot show an impairment that meets the criteria of
these listings. However, we may find you disabled because you have another impairment(s)
that in combination with your cardiovascular impairment medically equals the severity of a
listed impairment or that functionally equals the listings.
b. Unless we can decide your claim favorably on the basis of the current evidence, a
longitudinal record is still important. In rare instances where there is no or insufficient
longitudinal evidence, we may purchase a consultative examination(s) to help us establish the
severity and duration of your impairment.
4. When will we wait before we ask for more evidence?
a. We will wait when we have information showing that your impairment is not yet stable and
the expected change in your impairment might affect our determination or decision. In these
situations, we need to wait to properly evaluate the severity and duration of your impairment
during a stable period. Examples of when we might wait are:
(i) If you have had a recent acute event; for example, acute rheumatic fever.
(ii) If you have recently had a corrective cardiac procedure; for example, open-heart surgery.
(iii) If you have started new drug therapy and your response to this treatment has not yet been
established; for example, beta-blocker therapy for dilated congestive cardiomyopathy.

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b. In these situations, we will obtain more evidence 3 months following the event before we
evaluate your impairment. However, we will not wait if we have enough information to make a
determination or decision based on all of the relevant evidence in your case.
5. Will we purchase any studies? In appropriate situations, we will purchase studies necessary
to substantiate the diagnosis or to document the severity of your impairment, generally after
we have evaluated the medical and other evidence we already have. We will not purchase
studies involving exercise testing if there is significant risk involved or if there is another
medical reason not to perform the test. We will follow sections 4.00C6, 4.00C7, 4.00C8, and
104.00B7 when we decide whether to purchase exercise testing. We will make a reasonable
effort to obtain any additional studies from a qualified medical source in an office or center
experienced in pediatric cardiac assessment. (See §416.919g.)
6. What studies will we not purchase? We will not purchase any studies involving cardiac
catheterization, such as coronary angiography, arteriograms, or electrophysiological studies.
However, if the results of catheterization are part of the existing evidence we have, we will
consider them together with the other relevant evidence. See 4.00C15a in part A.
7. Will we use exercise tolerance tests (ETTs) for evaluating children with cardiovascular
impairment?
a. ETTs, though increasingly used, are still less frequently indicated in children than in adults,
and can rarely be performed successfully by children under 6 years of age. An ETT may be of
value in the assessment of some arrhythmias, in the assessment of the severity of chronic
heart failure, and in the assessment of recovery of function following cardiac surgery or other
treatment.
b. We will purchase an ETT in a childhood claim only if we cannot make a determination or
decision based on the evidence we have and an MC, preferably one with experience in the
care of children with cardiovascular impairments, has determined that an ETT is needed to
evaluate your impairment. We will not purchase an ETT if you are less than 6 years of age. If
we do purchase an ETT for a child age 12 or younger, it must be performed by a qualified
medical source in a specialty center for pediatric cardiology or other facility qualified to perform
exercise tests of children.
c. For full details on ETT requirements and usage, see 4.00C in part A.
C. Evaluating Chronic Heart Failure
1. What is chronic heart failure (CHF)?
a. CHF is the inability of the heart to pump enough oxygenated blood to body tissues. This
syndrome is characterized by symptoms and signs of pulmonary or systemic congestion (fluid
retention) or limited cardiac output. Certain laboratory findings of cardiac functional and
structural abnormality support the diagnosis of CHF.
b. CHF is considered in these listings as a single category whether due to atherosclerosis
(narrowing of the arteries), cardiomyopathy, hypertension, or rheumatic, congenital, or other
heart disease. However, if the CHF is the result of primary pulmonary hypertension secondary
to disease of the lung (cor pulmonale), we will evaluate your impairment using 3.09 in the

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respiratory system listings in part A.
2. What evidence of CHF do we need?
a. Cardiomegaly or ventricular dysfunction must be present and demonstrated by appropriate
medically acceptable imaging, such as chest x-ray, echocardiography (M-Mode, 2dimensional, and Doppler), radionuclide studies, or cardiac catheterization.
(i) Cardiomegaly is present when:
(A) Left ventricular diastolic dimension or systolic dimension is greater than 2 standard
deviations above the mean for the child's body surface area;
(B) Left ventricular mass is greater than 2 standard deviations above the mean for the child's
body surface area; or
(C) Chest x-ray (6 foot PA film) is indicative of cardiomegaly if the cardiothoracic ratio is over
60 percent at 1 year of age or less, or 55 percent or greater at more than 1 year of age.
(ii) Ventricular dysfunction is present when indices of left ventricular function, such as fractional
shortening or ejection fraction (the percentage of the blood in the ventricle actually pumped out
with each contraction), are greater than 2 standard deviations below the mean for the child's
age. (Fractional shortening, also called shortening fraction, reflects the left ventricular systolic
function in the absence of segmental wall motion abnormalities and has a linear correlation
with ejection fraction. In children, fractional shortening is more commonly used than ejection
fraction.)
(iii) However, these measurements alone do not reflect your functional capacity, which we
evaluate by considering all of the relevant evidence.
(iv) Other findings on appropriate medically acceptable imaging may include increased
pulmonary vascular markings, pleural effusion, and pulmonary edema. These findings need
not be present on each report, since CHF may be controlled by prescribed treatment.
b. To establish that you have chronic heart failure, your medical history and physical
examination should describe characteristic symptoms and signs of pulmonary or systemic
congestion or of limited cardiac output associated with the abnormal findings on appropriate
medically acceptable imaging. When an acute episode of heart failure is triggered by a
remediable factor, such as an arrhythmia, dietary sodium overload, or high altitude, cardiac
function may be restored and a chronic impairment may not be present.
(i) Symptoms of congestion or of limited cardiac output include easy fatigue, weakness,
shortness of breath (dyspnea), cough, or chest discomfort at rest or with activity. Children with
CHF may also experience shortness of breath on lying flat (orthopnea) or episodes of
shortness of breath that wake them from sleep (paroxysmal nocturnal dyspnea). They may
also experience cardiac arrhythmias resulting in palpitations, lightheadedness, or fainting.
Fatigue or exercise intolerance in an infant may be manifested by prolonged feeding time,
often associated with excessive respiratory effort and sweating.
(ii) During infancy, other manifestations of chronic heart failure may include failure to gain

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weight or involuntary loss of weight and repeated lower respiratory tract infections.
(iii) Signs of congestion may include hepatomegaly, ascites, increased jugular venous
distention or pressure, rales, peripheral edema, rapid shallow breathing (tachypnea), or rapid
weight gain. However, these signs need not be found on all examinations because fluid
retention may be controlled by prescribed treatment.
D. Evaluating Congenital Heart Disease
1. What is congenital heart disease? Congenital heart disease is any abnormality of the heart
or the major blood vessels that is present at birth. Examples include:
a. Abnormalities of cardiac septation, including ventricular septal defect or atrioventricular
canal;
b. Abnormalities resulting in cyanotic heart disease, including tetralogy of Fallot or
transposition of the great arteries;
c. Valvular defects or obstructions to ventricular outflow, including pulmonary or aortic stenosis
or coarctation of the aorta; and
d. Major abnormalities of ventricular development, including hypoplastic left heart syndrome or
pulmonary tricuspid atresia with hypoplastic right ventricle.
2. How will we evaluate symptomatic congenital heart disease?
a. Because of improved treatment methods, more children with congenital heart disease are
living longer. Although some types of congenital heart disease may be corrected by surgery,
many children with treated congenital heart disease continue to have problems throughout
their lives (symptomatic congenital heart disease). If you have congenital heart disease that
results in chronic heart failure with evidence of ventricular dysfunction or in recurrent
arrhythmias, we will evaluate your impairment under 104.02 or 104.05. Otherwise, we will
evaluate your impairment under 104.06.
b. For 104.06A2, we will accept pulse oximetry measurements instead of arterial O2, but the
arterial O2 values are preferred, if available.
c. For 104.06D, examples of impairments that in most instances will require life-saving surgery
or a combination of surgery and other major interventional procedures (for example, multiple
"balloon" catheter procedures) before age 1 include, but are not limited to, the following:
(i) Hypoplastic left heart syndrome,
(ii) Critical aortic stenosis with neonatal heart failure,
(iii) Critical coarctation of the aorta, with or without associated anomalies,
(iv) Complete atrioventricular canal defects,

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(v) Transposition of the great arteries,
(vi) Tetralogy of Fallot,
(vii) Pulmonary atresia with intact ventricular septum,
(viii) Single ventricle,
(ix) Tricuspid atresia, and
(x) Multiple ventricular septal defects.
E. Evaluating Arrhythmias
1. What is an arrhythmia? An arrhythmia is a change in the regular beat of the heart. Your
heart may seem to skip a beat or beat irregularly, very quickly (tachycardia), or very slowly
(bradycardia).
2. What are the different types of arrhythmias?
a. There are many types of arrhythmias. Arrhythmias are identified by where they occur in the
heart (atria or ventricles) and by what happens to the heart's rhythm when they occur.
b. Arrhythmias arising in the cardiac atria (upper chambers of the heart) are called atrial or
supraventricular arrhythmias. Ventricular arrhythmias begin in the ventricles (lower chambers).
In general, ventricular arrhythmias caused by heart disease are the most serious.
3. How do we evaluate arrhythmias using 104.05?
a. We will use 104.05 when you have arrhythmias that are not fully controlled by medication,
an implanted pacemaker, or an implanted cardiac defibrillator and you have uncontrolled
recurrent episodes of syncope or near syncope. If your arrhythmias are controlled, we will
evaluate your underlying heart disease using the appropriate listing. For other considerations
when we evaluate arrhythmias in the presence of an implanted cardiac defibrillator, see
104.00E4.
b. We consider near syncope to be a period of altered consciousness, since syncope is a loss
of consciousness or a faint. It is not merely a feeling of light-headedness, momentary
weakness, or dizziness.
c. For purposes of 104.05, there must be a documented association between the syncope or
near syncope and the recurrent arrhythmia. The recurrent arrhythmia, not some other cardiac
or non-cardiac disorder, must be established as the cause of the associated symptom. This
documentation of the association between the symptoms and the arrhythmia may come from
the usual diagnostic methods, including Holter monitoring (also called ambulatory
electrocardiography) and tilt-table testing with a concurrent ECG. Although an arrhythmia may
be a coincidental finding on an ETT, we will not purchase an ETT to document the presence of
a cardiac arrhythmia.
4. What will we consider when you have an implanted cardiac defibrillator and you do not have

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arrhythmias that meet the requirements of 104.05?
a. Implanted cardiac defibrillators are used to prevent sudden cardiac death in children who
have had, or are at high risk for, cardiac arrest from life-threatening ventricular arrhythmias.
The largest group of children at risk for sudden cardiac death consists of children with
cardiomyopathy (ischemic or non-ischemic) and reduced ventricular function. However, lifethreatening ventricular arrhythmias can also occur in children with little or no ventricular
dysfunction. The shock from the implanted cardiac defibrillator is a unique form of treatment; it
rescues a child from what may have been cardiac arrest. However, as a consequence of the
shock(s), children may experience psychological distress, which we may evaluate under the
mental disorders listings in 112.00ff.
b. Most implantable cardiac defibrillators have rhythm-correcting and pacemaker capabilities.
In some children, these functions may result in the termination of ventricular arrhythmias
without an otherwise painful shock. (The shock is like being kicked in the chest.) Implanted
cardiac defibrillators may deliver inappropriate shocks, often repeatedly, in response to benign
arrhythmias or electrical malfunction. Also, exposure to strong electrical or magnetic fields,
such as from MRI (magnetic resonance imaging), can trigger or reprogram an implanted
cardiac defibrillator, resulting in inappropriate shocks. We must consider the frequency of, and
the reason(s) for, the shocks when evaluating the severity and duration of your impairment.
c. In general, the exercise limitations imposed on children with an implanted cardiac
defibrillator are those dictated by the underlying heart impairment. However, the exercise
limitations may be greater when the implanted cardiac defibrillator delivers an inappropriate
shock in response to the increase in heart rate with exercise, or when there is exerciseinduced ventricular arrhythmia.
F. Evaluating Other Cardiovascular Impairments
1. What is ischemic heart disease (IHD) and how will we evaluate it in children? IHD results
when one or more of your coronary arteries is narrowed or obstructed or, in rare situations,
constricted due to vasospasm, interfering with the normal flow of blood to your heart muscle
(ischemia). The obstruction may be the result of an embolus, a thrombus, or plaque. When
heart muscle tissue dies as a result of the reduced blood supply, it is called a myocardial
infarction (heart attack). Ischemia is rare in children, but when it occurs, its effects on children
are the same as on adults. If you have IHD, we will evaluate it under 4.00E and 4.04 in part A.
2. How will we evaluate hypertension? Because hypertension (high blood pressure) generally
causes disability through its effects on other body systems, we will evaluate it by reference to
the specific body system(s) affected (heart, brain, kidneys, or eyes) when we consider its
effects under the listings. We will also consider any limitations imposed by your hypertension
when we consider whether you have an impairment that functionally equals the listings.
3. What is cardiomyopathy and how will we evaluate it? Cardiomyopathy is a disease of the
heart muscle. The heart loses its ability to pump blood (heart failure), and in some instances,
heart rhythm is disturbed, leading to irregular heartbeats (arrhythmias). Usually, the exact
cause of the muscle damage is never found (idiopathic cardiomyopathy). There are various
types of cardiomyopathy, which fall into two major categories: Ischemic and nonischemic
cardiomyopathy. Ischemic cardiomyopathy typically refers to heart muscle damage that results
from coronary artery disease, including heart attacks. Nonischemic cardiomyopathy includes

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several types: Dilated, hypertrophic, and restrictive. We will evaluate cardiomyopathy under
4.04 in part A, 104.02, 104.05, or 111.06, depending on its effects on you.
4. How will we evaluate valvular heart disease? We will evaluate valvular heart disease under
the listing appropriate for its effect on you. Thus, we may use 4.04 in part A, 104.02, 104.05,
104.06, or an appropriate neurological listing in 111.00ff.
5. What do we consider when we evaluate heart transplant recipients?
a. After your heart transplant, we will consider you disabled for 1 year following the surgery
because there is a greater likelihood of rejection of the organ and infection during the first year.
b. However, heart transplant patients generally meet our definition of disability before they
undergo transplantation. We will determine the onset of your disability based on the facts in
your case.
c. We will not assume that you became disabled when your name was placed on a transplant
waiting list. This is because you may be placed on a waiting list soon after diagnosis of the
cardiac disorder that may eventually require a transplant. Physicians recognize that candidates
for transplantation often have to wait months or even years before a suitable donor heart is
found, so they place their patients on the list as soon as permitted.
d. When we do a continuing disability review to determine whether you are still disabled, we
will evaluate your residual impairment(s), as shown by symptoms, signs, and laboratory
findings, including any side effects of medication. We will consider any remaining symptoms,
signs, and laboratory findings indicative of cardiac dysfunction in deciding whether medical
improvement (as defined in §416.994a) has occurred.
6. How will we evaluate chronic rheumatic fever or rheumatic heart disease? The diagnosis
should be made in accordance with the current revised Jones criteria for guidance in the
diagnosis of rheumatic fever. We will evaluate persistence of rheumatic fever activity under
104.13. If you have evidence of chronic heart failure or recurrent arrhythmias associated with
rheumatic heart disease, we will use 104.02 or 104.05.
7. What is hyperlipidemia and how will we evaluate it? Hyperlipidemia is the general term for
an elevation of any or all of the lipids (fats or cholesterol) in the blood; for example,
hypertriglyceridemia, hypercholesterolemia, and hyperlipoproteinemia. These disorders of
lipoprotein metabolism and transport can cause defects throughout the body. The effects most
likely to interfere with function are those produced by atherosclerosis (narrowing of the
arteries) and coronary artery disease. We will evaluate your lipoprotein disorder by considering
its effects on you.
8. How will we evaluate Kawasaki disease? We will evaluate Kawasaki disease under the
listing appropriate to its effects on you, which may include major coronary artery aneurysm or
heart failure. A major coronary artery aneurysm may cause ischemia or arrhythmia, which we
will evaluate under 4.04 in part A or 104.05. We will evaluate chronic heart failure under
104.02.
9. What is lymphedema and how will we evaluate it?

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a. Lymphedema is edema of the extremities due to a disorder of the lymphatic circulation; at its
worst, it is called elephantiasis. Primary lymphedema is caused by abnormal development of
lymph vessels and may be present at birth (congenital lymphedema), but more often develops
during the teens (lymphedema praecox). Secondary lymphedema is due to obstruction or
destruction of normal lymphatic channels due to tumor, surgery, repeated infections, or
parasitic infection such as filariasis. Lymphedema most commonly affects one extremity.
b. Lymphedema does not meet the requirements of 4.11 in part A, although it may medically
equal the severity of that listing. We will evaluate lymphedema by considering whether the
underlying cause meets or medically equals any listing or whether the lymphedema medically
equals a cardiovascular listing, such as 4.11, or a musculoskeletal listing, such as 101.02A or
101.03. If no listing is met or medically equaled, we will evaluate any functional limitations
imposed by your lymphedema when we consider whether you have an impairment that
functionally equals the listings.
10. What is Marfan syndrome and how will we evaluate it?
a. Marfan syndrome is a genetic connective tissue disorder that affects multiple body systems,
including the skeleton, eyes, heart, blood vessels, nervous system, skin, and lungs. There is
no specific laboratory test to diagnose Marfan syndrome. The diagnosis is generally made by
medical history, including family history, physical examination, including an evaluation of the
ratio of arm/leg size to trunk size, a slit lamp eye examination, and a heart test(s), such as an
echocardiogram. In some cases, a genetic analysis may be useful, but such analyses may not
provide any additional helpful information.
b. The effects of Marfan syndrome can range from mild to severe. In most cases, the disorder
progresses as you age. Most individuals with Marfan syndrome have abnormalities associated
with the heart and blood vessels. Your heart's mitral valve may leak, causing a heart murmur.
Small leaks may not cause symptoms, but larger ones may cause shortness of breath, fatigue,
and palpitations. Another effect is that the wall of the aorta may be weakened and stretch
(aortic dilation). This aortic dilation may tear, dissect, or rupture, causing serious heart
problems or sometimes sudden death. We will evaluate the manifestations of your Marfan
syndrome under the appropriate body system criteria, such as 4.10 in part A, or if necessary
consider the functional limitations imposed by your impairment.
G. Other Evaluation Issues
1. What effect does obesity have on the cardiovascular system and how will we evaluate it?
Obesity is a medically determinable impairment that is often associated with disorders of the
cardiovascular system. Disturbance of this system can be a major cause of disability in
children with obesity. Obesity may affect the cardiovascular system because of the increased
workload the additional body mass places on the heart. Obesity may make it harder for the
chest and lungs to expand. This can mean that the respiratory system must work harder to
provide needed oxygen. This in turn would make the heart work harder to pump blood to carry
oxygen to the body. Because the body would be working harder at rest, its ability to perform
additional work would be less than would otherwise be expected. Thus, the combined effects
of obesity with cardiovascular impairments can be greater than the effects of each of the
impairments considered separately. We must consider any additional and cumulative effects of
obesity when we determine whether you have a severe cardiovascular impairment or a listinglevel cardiovascular impairment (or a combination of impairments that medically equals a

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listing), and when we determine whether your impairment(s) functionally equals the listings.
2. How do we relate treatment to functional status? In general, conclusions about the severity
of a cardiovascular impairment cannot be made on the basis of type of treatment rendered or
anticipated. The amount of function restored and the time required for improvement after
treatment (medical, surgical, or a prescribed program of progressive physical activity) vary with
the nature and extent of the disorder, the type of treatment, and other factors. Depending upon
the timing of this treatment in relation to the alleged onset date of disability, we may need to
defer evaluation of the impairment for a period of up to 3 months from the date treatment
began to permit consideration of treatment effects, unless we can make a determination or
decision using the evidence we have. See 104.00B4.
3. How do we evaluate impairments that do not meet one of the cardiovascular listings?
a. These listings are only examples of common cardiovascular disorders that we consider
severe enough to result in marked and severe functional limitations. If your severe impairment
(s) does not meet the criteria of any of these listings, we must also consider whether you have
an impairment(s) that satisfies the criteria of a listing in another body system.
b. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will determine whether your impairment(s) medically equals a listing. (See §416.926.) If you
have a severe impairment(s) that does not meet or medically equal the criteria of a listing, we
will consider whether it functionally equals the listings. (See §416.926a.) When we decide
whether you continue to be disabled, we use the rules in §416.994a.
104.01 Category of Impairments, Cardiovascular System
104.02. Chronic heart failure while on a regimen of prescribed treatment, with symptoms and
signs described in 104.00C2, and with one of the following:
A. Persistent tachycardia at rest (see Table I);
OR
B. Persistent tachypnea at rest (see Table II) or markedly decreased exercise tolerance (see
104.00C2b);
OR
C. Growth disturbance with:
1. An involuntary weight loss or failure to gain weight at an appropriate rate for age, resulting in
a fall of 15 percentiles from an established growth curve (on current NCHS/CDC growth chart)
which is currently present (see 104.00A3f) and has persisted for 2 months or longer; or
2. An involuntary weight loss or failure to gain weight at an appropriate rate for age, resulting in
a fall to below the third percentile from an established growth curve (on current NCHS/CDC
growth chart) which is currently present (see 104.00A3f) and has persisted for 2 months or
longer.
Table I—Tachycardia at rest

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Apical heart rate
Age
(beats per minute)
Under 1 yr
150
1 through 3 yrs
130
4 through 9 yrs
120
10 through 15 yrs
110
Over 15 yrs
100
Table II—Tachypnea at rest
Respiratory rate over
Age
Under 1 yr
1 through 5 yrs
6 through 9 yrs
Over 9 yrs

(per minute)
40
35
30
25

104.05 Recurrent arrhythmias, not related to reversible causes such as electrolyte
abnormalities or digitalis glycoside or antiarrhythmic drug toxicity, resulting in uncontrolled (see
104.00A3g), recurrent (see 104.00A3c) episodes of cardiac syncope or near syncope (see
104.00E3b), despite prescribed treatment (see 104.00B3 if there is no prescribed treatment),
and documented by resting or ambulatory (Holter) electrocardiography, or by other appropriate
medically acceptable testing, coincident with the occurrence of syncope or near syncope (see
104.00E3c).
104.06 Congenital heart disease, documented by appropriate medically acceptable imaging
(see 104.00A3d) or cardiac catheterization, with one of the following:
A. Cyanotic heart disease, with persistent, chronic hypoxemia as manifested by:
1. Hematocrit of 55 percent or greater on two evaluations 3 months or more apart within a
consecutive 12-month period (see 104.00A3e); or
2. Arterial O2 saturation of less than 90 percent in room air, or resting arterial PO2 of 60 Torr or
less; or
3. Hypercyanotic spells, syncope, characteristic squatting, or other incapacitating symptoms
directly related to documented cyanotic heart disease; or
4. Exercise intolerance with increased hypoxemia on exertion.
OR
B. Secondary pulmonary vascular obstructive disease with pulmonary arterial systolic pressure
elevated to at least 70 percent of the systemic arterial systolic pressure.
OR

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C. Symptomatic acyanotic heart disease, with ventricular dysfunction interfering very seriously
with the ability to independently initiate, sustain, or complete activities.
OR
D. For infants under 12 months of age at the time of filing, with life-threatening congenital heart
impairment that will require or already has required surgical treatment in the first year of life,
and the impairment is expected to be disabling (because of residual impairment following
surgery, or the recovery time required, or both) until the attainment of at least 1 year of age,
consider the infant to be under disability until the attainment of at least age 1; thereafter,
evaluate impairment severity with reference to the appropriate listing.
104.09 Heart transplant. Consider under a disability for 1 year following surgery; thereafter,
evaluate residual impairment under the appropriate listing.
104.13 Rheumatic heart disease, with persistence of rheumatic fever activity manifested by
significant murmurs(s), cardiac enlargement or ventricular dysfunction (see 104.00C2a), and
other associated abnormal laboratory findings; for example, an elevated sedimentation rate or
ECG findings, for 6 months or more in a consecutive 12-month period (see 104.00A3e).
Consider under a disability for 18 months from the established onset of impairment, then
evaluate any residual impairment(s).
105.00 Digestive System
A. Disorders of the digestive system which result in disability usually do so because of
interference with nutrition and growth, multiple recurrent inflammatory lesions, or other
complications of the disease. Such lesions or complications usually respond to treatment. To
constitute a listed impairment, these must be shown to have persisted or be expected to
persist despite prescribed therapy for a continuous period of at least 12 months.
B. Documentation of gastrointestinal impairments should include pertinent operative findings,
appropriate medically acceptable imaging studies, endoscopy, and biopsy reports. Medically
acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial
tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast
material, myelography, and radionuclear bone scans. "Appropriate" means that the technique
used is the proper one to support the evaluation and diagnosis of the impairment.
C. Growth retardation and malnutrition. When the primary disorder of the digestive tract has
been documented, evaluate resultant malnutrition under the criteria described in 105.08.
Evaluate resultant growth impairment under the criteria described in 100.03. Intestinal
disorders, including surgical diversions and potentially correctable congenital lesions, do not
represent a severe impairment if the individual is able to maintain adequate nutrition growth
and development.
D. Multiple congenital anomalies. See related criteria, and consider as a combination of
impairments.
105.01 Category of Impairments, Digestive.
105.03 Esophageal obstruction, caused by atresia, stricture, or stenosis with malnutrition as

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described under the criteria in 105.08.
105.05 Chronic liver disease. With one of the following:
A. Inoperable biliary atresia demonstrated by appropriate medically acceptable imaging or
surgery; or
B. Intractable ascites not attributable to other causes, with serum albumin of 3.0 gm./100 ml. or
less; or
C. Esophageal varices (demonstrated by endoscopy or other appropriate medically acceptable
imaging); or
D. Hepatic coma, documentated by findings from hospital records; or
E. Hepatic encephalopathy. Evaluate under the criteria in 112.02; or
F. Chronic active inflammation or necrosis documented by SGOT persistently more than 100
units or serum bilirubin of 2.5 mg. percent or greater.
105.07 Chronic inflammatory bowel disease (such as ulcerative colitis, regional enteritis), as
documented in 105.00. With one of the following:
A. Intestinal manifestations or complications, such as obstruction, abscess, or fistula formation
which has lasted or is expected to last 12 months; or
B. Malnutrition as described under the criteria in 105.08; or
C. Growth impairment as described under the criteria in 100.03.
105.08 Malnutrition, due to demonstrable gastrointestinal disease causing either a fall of 15
percentiles of weight which persists or the persistence of weight which is less than the third
percentile (on standard growth charts). And one of the following:
A. Stool fat excretion per 24 hours:
1. More than 15 percent in infants less than 6 months.
2. More than 10 percent in infants 6-18 months.
3. More than 6 percent in children more than 18 months; or
B. Persistent hematocrit of 30 percent or less despite prescribed therapy; or
C. Serum carotene of 40 mcg./100 ml. or less; or
D. Serum albumin of 3.0 gm./100 ml. or less.
105.09 Liver transplant. Consider under a disability for 12 months following the date of surgery;

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thereafter, evaluate the residual impairment.
106.00 Genitourinary Impairments
A. What impairments do these listings cover?
1. We use these listings to evaluate genitourinary impairments resulting from chronic renal
disease and congenital genitourinary disorders.
2. We use the criteria in 106.02 to evaluate renal dysfunction due to any chronic renal disease,
such as chronic glomerulonephritis, hypertensive renal vascular disease, diabetic nephropathy,
chronic obstructive uropathy, and hereditary nephropathies.
3. We use the criteria in 106.06 to evaluate nephrotic syndrome due to glomerular disease.
4. We use the criteria in 106.07 to evaluate congenital genitourinary impairments such as
ectopic ureter, extrophic urinary bladder, urethral valves, and neurogenic bladder.
B. What do we mean by the following terms in these listings?
1. Anasarca is generalized massive edema (swelling).
2. Creatinine is a normal product of muscle metabolism.
3. Creatinine clearance test is a test for renal function based on the rate at which creatinine is
excreted by the kidney.
4. Glomerular disease can be classified into two broad categories, nephrotic and nephritic.
Nephrotic conditions are associated with increased urinary protein excretion and nephritic
conditions are associated with inflammation of the internal structures of the kidneys.
5. Hemodialysis, or dialysis, is the removal of toxic metabolic byproducts from the blood by
diffusion in an artificial kidney machine.
6. Nephrotic syndrome is a general name for a group of diseases involving defective kidney
glomeruli, characterized by heavy proteinuria, hypoalbuminemia, hyperlipidemia, and varying
degrees of edema.
7. Neuropathy is a problem in peripheral nerve function (that is, in any part of the nervous
system except the brain and spinal cord) that causes pain, numbness, tingling, and muscle
weakness in various parts of the body.
8. Parenteral antibiotics refer to the administration of antibiotics by intravenous, intramuscular,
or subcutaneous injection.
9. Peritoneal dialysis is a method of hemodialysis in which the dialyzing solution is introduced
into and removed from the peritoneal cavity either continuously or intermittently.
10. Proteinuria is excess protein in the urine.

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11. Renal means pertaining to the kidney.
12. Serum albumin is a major plasma protein that is responsible for much of the plasma
colloidal osmotic pressure and serves as a transport protein.
13. Serum creatinine is the amount of creatinine in the blood and is measured to evaluate
kidney function.
C. What evidence do we need?
1. We need a longitudinal record of your medical history that includes records of treatment,
response to treatment, hospitalizations, and laboratory evidence of renal disease that indicates
its progressive nature or of congenital genitourinary impairments that documents their
recurrent or episodic nature. The laboratory or clinical evidence will indicate deterioration of
renal function, such as elevation of serum creatinine, or changes in genitourinary function,
such as episodes of electrolyte disturbance.
2. We generally need a longitudinal clinical record covering a period of at least 3 months of
observations and treatment, unless we can make a fully favorable determination or decision
without it. The record should include laboratory findings, such as serum creatinine or serum
albumin values, obtained on more than one examination over the 3-month period.
3. When you are undergoing dialysis, we should have laboratory findings showing your renal
function before you started dialysis.
4. The medical evidence establishing the clinical diagnosis of nephrotic syndrome must include
a description of the extent of edema, including pretibial, periorbital, or presacral edema. The
medical evidence should describe any ascites, pleural effusion, or pericardial effusion. Levels
of serum albumin and proteinuria must be included.
5. If a renal biopsy has been performed, the evidence should include a copy of the report of the
microscopic examination of the specimen. However, if we do not have a copy of the
microscopic examination in the evidence, we can accept a statement from an acceptable
medical source that a biopsy was performed, with a description of the results.
6. The medical evidence documenting congenital genitourinary impairments should include
treating physician records, operative reports, and hospital records. It should describe the
frequency of your episodes, prescribed treatment, laboratory findings, and any surgical
procedures performed.
D. How do we consider the effects of treatment?
We consider factors such as the:
1. Type of therapy.
2. Response to therapy.
3. Side effects of therapy.

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4. Effects of any post-therapeutic residuals.
5. Expected duration of treatment.
E. What other things do we consider when we evaluate your genitourinary impairment under
specific listings?
1. Chronic hemodialysis or peritoneal dialysis (106.02A). A report from an acceptable medical
source describing the chronic renal disease and the need for ongoing dialysis is sufficient to
satisfy the requirements in 106.02A.
2. Kidney transplantation (106.02B). If you have undergone kidney transplantation, we will
consider you to be disabled for 12 months following the surgery because, during the first year,
there is a greater likelihood of rejection of the organ and recurrent infection. After the first year
posttransplantation, we will base our continuing disability evaluation on your residual
impairment(s). We will include absence of symptoms, signs, and laboratory findings indicative
of kidney dysfunction in our consideration of whether medical improvement (as defined in
§§404.1594(b)(1) and (c)(1) and 416.994a, as appropriate) has occurred. We will consider the:
a. Occurrence of rejection episodes.
b. Side effects of immunosuppressants, including corticosteroids.
c. Frequency of any renal infections.
d. Presence of systemic complications such as other infections, neuropathy, or deterioration of
other organ systems.
3. Nephrotic syndrome (106.06). The longitudinal clinical record should include a description of
prescribed therapy, response to therapy, and any side effects of therapy. In order for your
nephrotic syndrome to meet 106.06A or B, the medical evidence must document that you have
the appropriate laboratory findings required by these listings and that your anasarca has
persisted for at least 3 months despite prescribed therapy. However, we will not delay
adjudication if we can make a fully favorable determination or decision based on the evidence
in your case record. We may also evaluate complications of your nephrotic syndrome, such as
orthostatic hypotension, recurrent infections, or venous thromboses, under the appropriate
listing for the resultant impairment.
4. Congenital genitourinary impairments (106.07).
a. Each of the listings in 106.07 requires a longitudinal clinical record showing that at least
three events have occurred within a consecutive 12-month period with intervening periods of
improvement. Events include urologic surgical procedures, hospitalizations, and treatment with
parenteral antibiotics. To meet the requirements of these listings, there must be at least 1
month (that is, 30 days) between the events in order to ensure that we are evaluating separate
episodes.
b. Diagnostic cystoscopy does not satisfy the requirement for repeated urologic surgical
procedures in 106.07A.

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c. In 106.07B, systemic infection means an infection requiring an initial course of parenterally
administered antibiotics occurring at least once every 4 months or at least 3 times a year.
d. In 106.07C, appropriate laboratory and clinical evidence document electrolyte disturbance.
Hospitalizations are inpatient hospitalizations for 24 hours or more.
F. What does the term "persistent" mean in these listings?
Persistent means that the longitudinal clinical record shows that, with few exceptions, the
required finding(s) has been at, or is expected to be at, the level specified in the listing for a
continuous period of at least 12 months.
G. How do we evaluate impairments that do not meet one of the genitourinary listings?
1. These listings are only examples of common genitourinary impairments that we consider
severe enough to prevent you from doing any gainful activity or that result in marked and
severe functional limitations. If your severe impairment(s) does not meet the criteria of any of
these listings, we must also consider whether you have an impairment(s) that satisfies the
criteria of a listing in another body system.
2. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will determine whether your impairment(s) medically equals a listing, or, in the case of a claim
for SSI payments, functionally equals the listings. (See §§404.1526, 416.926, and 416.926a.)
When we decide whether a child receiving SSI payments continues to be disabled, we use the
rules in §416.994a.
106.01 Category of Impairments, Genitourinary Impairments
106.02 Impairment of renal function, due to any chronic renal disease that has lasted or can be
expected to last for a continuous period of at least 12 months. With:
A. Chronic hemodialysis or peritoneal dialysis (see 106.00E1).
or
B. Kidney transplantation. Consider under a disability for 12 months following surgery;
thereafter, evaluate the residual impairment (see 106.00E2).
or
C. Persistent elevation of serum creatinine to 3 mg per deciliter (dL) (100 ml) or greater, over
at least 3 months.
or
D. Reduction of creatinine clearance to 30 ml per minute (43 liters/24 hours) per 1.73 m2 of
body surface area over at least 3 months.
106.06 Nephrotic syndrome, with anasarca, persisting for at least 3 months despite prescribed
therapy. (See 106.00E3.) With:

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A. Serum albumin of 2.0 g/dL (100 ml) or less.
or
B. Proteinuria of 40 mg/m2/hr or greater.
106.07 Congenital genitourinary impairments (see 106.00E4) resulting in one of the following:
A. Repeated urologic surgical procedures, occurring at least 3 times in a consecutive 12-month
period.
or
B. Documented episodes of systemic infection requiring an initial course of parenteral
antibiotics, occurring at least 3 times in a consecutive 12-month period (see 106.00E4).
or
C. Hospitalization (see 106.00E4d) for episodes of electrolyte disturbance, occurring at least 3
times in a consecutive 12-month period.
107.00 Hematological Disorders
A. Sickle cell disease. Refers to a chronic hemolytic anemia associated with sickle cell
hemoglobin, either homozygous or in combination with thalassemia or with another abnormal
hemoglobin (such as C or F).
Appropriate hematologic evidence for sickle cell disease, such as hemoglobin electrophoresis
must be included. Vaso-occlusive, hemolytic, or aplastic episodes should be documented by
description of severity, frequency, and duration.
Disability due to sickle cell disease may be solely the result of a severe, persistent anemia or
may be due to the combination of chronic progressive or episodic manifestations in the
presence of a less severe anemia.
Major visceral episodes causing disability include meningitis, osteomyelitis, pulmonary
infections or infarctions, cerebrovascular accidents, congestive heart failure, genitourinary
involvement, etc.
B. Coagulation defects. Chronic inherited coagulation disorders must be documented by
appropriate laboratory evidence such as abnormal thromboplastin generation, coagulation
time, or factor assay.
107.01 Category of Impairments, Hemic and Lymphatic.
107.03 Hemolytic anemia (due to any cause). Manifested by persistence of hematocrit of 26
percent or less despite prescribed therapy, and reticulocyte count of 4 percent or greater.
107.05 Sickle cell disease. With:

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A. Recent, recurrent, severe vaso-occlusive crises (musculoskeletal, vertebral, abdominal); or
B. A major visceral complication in the 12 months prior to application; or
C. A hyperhemolytic or aplastic crisis within 12 months prior to application; or
D. Chronic, severe anemia with persistence of hematocrit of 26 percent or less; or
E. Congestive heart failure, cerebrovascular damage, or emotional disorder as described
under the criteria in 104.02, 111.00ff, or 112.00ff.
107.06 Chronic idiopathic thrombocytopenic purpura of childhood with purpura and
thrombocytopenia of 40,000 platelets/cu. mm. or less despite prescribed therapy or recurrent
upon withdrawal of treatment.
107.08 Inherited coagulation disorder. With:
A. Repeated spontaneous or inappropriate bleeding; or
B. Hemarthrosis with joint deformity.
108.00 Skin Disorders
A. What skin disorders do we evaluate with these listings? We use these listings to evaluate
skin disorders that may result from hereditary, congenital, or acquired pathological processes.
The kinds of impairments covered by these listings are: Ichthyosis, bullous diseases, chronic
infections of the skin or mucous membranes, dermatitis, hidradenitis suppurativa, genetic
photosensitivity disorders, and burns.
B. What documentation do we need? When we evaluate the existence and severity of your
skin disorder, we generally need information about the onset, duration, frequency of flareups,
and prognosis of your skin disorder; the location, size, and appearance of lesions; and, when
applicable, history of exposure to toxins, allergens, or irritants, familial incidence, seasonal
variation, stress factors, and your ability to function outside of a highly protective environment.
To confirm the diagnosis, we may need laboratory findings (for example, results of a biopsy
obtained independently of Social Security disability evaluation or blood tests) or evidence from
other medically acceptable methods consistent with the prevailing state of medical knowledge
and clinical practice.
C. How do we assess the severity of your skin disorders(s)? We generally base our
assessment of severity on the extent of your skin lesions, the frequency of flareups of your skin
lesions, how your symptoms (including pain) limit you, the extent of your treatment, and how
your treatment affects you.
1. Extensive skin lesions. Extensive skin lesions are those that involve multiple body sites or
critical body areas, and result in a very serious limitation. Examples of extensive skin lesions
that result in a very serious limitation include but are not limited to:
a. Skin lesions that interfere with the motion of your joints and that very seriously limit your use
of more than one extremity; that is, two upper extremities, two lower extremities, or one upper

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and one lower extremity.
b. Skin lesions on the palms of both hands that very seriously limit your ability to do fine and
gross motor movements.
c. Skin lesions on the soles of both feet, the perineum, or both inguinal areas that very
seriously limit your ability to ambulate.
2. Frequency of flareups. If you have skin lesions, but they do not meet the requirements of
any of the listings in this body system, you may still have an impairment that results in marked
and severe functional limitations when we consider your condition over time, especially if your
flareups result in extensive skin lesions, as defined in C1 of this section. Therefore, if you have
frequent flareups, we may find that your impairment(s) is medically equal to one of these
listings even though you have some periods during which your condition is in remission. We
will consider how frequent and serious your flareups are, how quickly they resolve, and how
you function between flareups to determine whether you have marked and severe functional
limitations that have lasted for a continuous period of at least 12 months or that can be
expected to last for a continuous period of at least 12 months. We will also consider the
frequency of your flareups when we determine whether you have a severe impairment and
when we need to assess functional equivalence.
3. Symptoms (including pain). Symptoms (including pain) may be important factors contributing
to the severity of your skin disorder(s). We assess the impact of symptoms as explained in
§§404.1528, 404.1529, 416.928, and 416.929 of this chapter.
4. Treatment. We assess the effects of medication, therapy, surgery, and any other form of
treatment you receive when we determine the severity and duration of your impairment(s).
Skin disorders frequently respond to treatment; however, response to treatment can vary
widely, with some impairments becoming resistant to treatment. Some treatments can have
side effects that can in themselves result in limitations.
a. We assess the effects of continuing treatment as prescribed by determining if there is
improvement in the symptoms, signs, and laboratory findings of your disorder, and if you
experience side effects that result in functional limitations. To assess the effects of your
treatment, we may need information about:
i. The treatment you have been prescribed (for example, the type, dosage, method and
frequency of administration of medication or therapy);
ii. Your response to the treatment;
iii. Any adverse effects of the treatment; and
iv. The expected duration of the treatment.
b. Because treatment itself or the effects of treatment may be temporary, in most cases
sufficient time must elapse to allow us to evaluate the impact and expected duration of
treatment and its side effects. Except under 108.07 and 108.08, you must follow continuing
treatment as prescribed for at least 3 months before your impairment can be determined to
meet the requirements of a skin disorder listing. (See 108.00H if you are not undergoing

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treatment or did not have treatment for 3 months.) We consider your specific response to
treatment when we evaluate the overall severity of your impairment.
D. How do we assess impairments that may affect the skin and other body systems? When
your impairment affects your skin and has effects in other body systems, we first evaluate the
predominant feature of your impairment under the appropriate body system. Examples include,
but are not limited to the following.
1. Tuberous sclerosis primarily affects the brain. The predominant features are seizures, which
we evaluate under the neurological listings in 111.00, and developmental delays or other
mental disorders, which we evaluate under the mental disorders listings in 112.00.
2. Malignant tumors of the skin (for example, malignant melanoma) are cancers, or neoplastic
diseases, which we evaluate under the listings in 113.00.
3. Connective tissue disorders and other immune system disorders (for example, systemic
lupus erythematosus, scleroderma, human immunodeficiency virus (HIV) infection, and
Sjögren's syndrome) often involve more than one body system. We first evaluate these
disorders under the immune system listings in 114.00. We evaluate lupus erythematosus
under 114.02, scleroderma under 114.04, symptomatic HIV infection under 114.08, and
Sjögren's syndrome under 114.03, 114.09, or any other appropriate listing in section 114.00.
4. Disfigurement or deformity resulting from skin lesions may result in loss of sight, hearing,
speech, and the ability to chew (mastication). We evaluate these impairments and their effects
under the special senses and speech listings in 102.00 and the digestive system listings in
105.00. Facial disfigurement or other physical deformities may also have effects we evaluate
under the mental disorders listings in 112.00, such as when they affect mood or social
functioning.
5. We evaluate erythropoietic porphyrias under the hemic and lymphatic listings in 107.00.
6. We evaluate hemangiomas associated with thrombocytopenia and hemorrhage (for
example, Kasabach-Merritt syndrome) involving coagulation defects, under the hemic and
lymphatic listings in 107.00. But, when hemangiomas impinge on vital structures or interfere
with function, we evaluate their primary effects under the appropriate body system.
E. How do we evaluate genetic photosensitivity disorders?
1. Xeroderma pigmentosum (XP). When you have XP, your impairment meets the
requirements of 108.07A if you have clinical and laboratory findings showing that you have the
disorder. (See 108.00E3.) People who have XP have a lifelong hypersensitivity to all forms of
ultraviolet light and generally lead extremely restricted lives in highly protective environments
in order to prevent skin cancers from developing. Some people with XP also experience
problems with their eyes, neurological problems, mental disorders, and problems in other body
systems.
2. Other genetic photosensitivity disorders. Other genetic photosensitivity disorders may vary
in their effects on different people, and may not result in marked and severe functional
limitations for a continuous period of at least 12 months. Therefore, if you have a genetic
photosensitivity disorder other than XP (established by clinical and laboratory findings as

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described in 108.00E3), you must show that you have either extensive skin lesions or an
inability to function outside of a highly protective environment to meet the requirements of
108.07B. You must also show that your impairment meets the duration requirement. By
inability to function outside of a highly protective environment we mean that you must avoid
exposure to ultraviolet light (including sunlight passing through windows and light from
unshielded fluorescent bulbs), wear protective clothing and eyeglasses, and use opaque
broad-spectrum sunscreens in order to avoid skin cancer or other serious effects. Some
genetic photosensitivity disorders can have very serious effects in other body systems,
especially special senses and speech (102.00), neurological (111.00), mental (112.00), and
neoplastic (113.00). We will evaluate the predominant feature of your impairment under the
appropriate body system, as explained in 108.00D.
3. Clinical and laboratory findings.
a. General. We need documentation from an acceptable medical source, as defined in
§§404.1513(a) and 416.913(a), to establish that you have a medically determinable
impairment. In general, we must have evidence of appropriate laboratory testing showing that
you have XP or another genetic photosensitivity disorder. We will find that you have XP or
another genetic photosensitivity disorder based on a report from an acceptable medical source
indicating that you have the impairment, supported by definitive genetic laboratory studies
documenting appropriate chromosomal changes, including abnormal DNA repair or another
DNA or genetic abnormality specific to your type of photosensitivity disorder.
b. What we will accept as medical evidence instead of the actual laboratory report. When we
do not have the actual laboratory report, we need evidence from an acceptable medical source
that includes appropriate clinical findings for your impairment and that is persuasive that a
positive diagnosis has been confirmed by appropriate laboratory testing at some time prior to
our evaluation. To be persuasive, the report must state that the appropriate definitive genetic
laboratory study was conducted and that the results confirmed the diagnosis. The report must
be consistent with other evidence in your case record.
F. How do we evaluate burns? Electrical, chemical, or thermal burns frequently affect other
body systems; for example, musculoskeletal, special senses and speech, respiratory,
cardiovascular, renal, neurological, or mental. Consequently, we evaluate burns the way we
evaluate other disorders that can affect the skin and other body systems, using the listing for
the predominant feature of your impairment. For example, if your soft tissue injuries are under
continuing surgical management (as defined in 101.00M), we will evaluate your impairment
under 101.08. However, if your burns do not meet the requirements of 101.08 and you have
extensive skin lesions that result in a very serious limitation (as defined in 108.00C1) that has
lasted or can be expected to last for a continuous period of at least 12 months, we will evaluate
them under 108.08.
G. How do we determine if your skin disorder(s) will continue at a disabling level of severity in
order to meet the duration requirement? For all of these skin disorder listings except 108.07
and 108.08, we will find that your impairment meets the duration requirement if your skin
disorder results in extensive skin lesions that persist for at least 3 months despite continuing
treatment as prescribed. By persist, we mean that the longitudinal clinical record shows that,
with few exceptions, your lesions have been at the level of severity specified in the listing. For
108.07A, we will presume that you meet the duration requirement. For 108.07B and 108.08,
we will consider all of the relevant medical and other information in your case record to

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determine whether your skin disorder meets the duration requirement.
H. How do we assess your skin disorder(s) if your impairment does not meet the requirements
of one of these listings?
1. These listings are only examples of common skin disorders that we consider severe enough
to result in marked and severe functional limitations. For most of these listings, if you do not
have continuing treatment as prescribed, if your treatment has not lasted for at least 3 months,
or if you do not have extensive skin lesions that have persisted for at least 3 months, your
impairment cannot meet the requirements of these skin disorder listings. (This provision does
not apply to 108.07 and 108.08.) However, we may still find that you are disabled because
your impairment(s) meets the requirements of a listing in another body system, medically
equals (see §§404.1526 and 416.926 of this chapter) the severity of a listing, or functionally
equals the severity of the listings.
2. If you have not received ongoing treatment or do not have an ongoing relationship with the
medical community despite the existence of a severe impairment(s), or if your skin lesions
have not persisted for at least 3 months but you are undergoing continuing treatment as
prescribed, you may still have an impairment(s) that meets a listing in another body system or
that medically equals a listing. If you do not have an impairment(s) that meets or medically
equals a listing, we will consider whether your impairment(s) functionally equals the listings.
(See §416.924 of this chapter.) When we decide whether you continue to be disabled, we use
the rules in §416.994a of this chapter.
108.01 Category of Impairments, Skin Disorders
108.02 Ichthyosis, with extensive skin lesions that persist for at least 3 months despite
continuing treatment as prescribed.
108.03 Bullous disease (for example, pemphigus, erythema multiforme bullosum,
epidermolysis bullosa, bullous pemphigoid, dermatitis herpetiformis), with extensive skin
lesions that persist for at least 3 months despite continuing treatment as prescribed.
108.04 Chronic infections of the skin or mucous membranes, with extensive fungating or
extensive ulcerating skin lesions that persist for at least 3 months despite continuing treatment
as prescribed.
108.05 Dermatitis (for example, psoriasis, dyshidrosis, atopic dermatitis, exfoliative dermatitis,
allergic contact dermatitis), with extensive skin lesions that persist for at least 3 months despite
continuing treatment as prescribed.
108.06 Hidradenitis suppurativa, with extensive skin lesions involving both axillae, both
inguinal areas, or the perineum that persist for at least 3 months despite continuing treatment
as prescribed.
108.07 Genetic photosensitivity disorders, established as described in 108.00E.
A. Xeroderma pigmentosum. Consider the individual disabled from birth.
B. Other genetic photosensitivity disorders, with:

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1. Extensive skin lesions that have lasted or can be expected to last for a continuous period of
at least 12 months, or
2. Inability to function outside of a highly protective environment for a continuous period of at
least 12 months (see 108.00E2).
108.08 Burns, with extensive skin lesions that have lasted or can be expected to last for a
continuous period of at least 12 months. (See 108.00F).
109.00 Endocrine System
A. Cause of disability. Disability is caused by a disturbance in the regulation of the secretion or
metabolism of one or more hormones which are not adequately controlled by therapy. Such
disturbances or abnormalities usually respond to treatment. To constitute a listed impairment
these must be shown to have persisted or be expected to persist despite prescribed therapy
for a continuous period of at least 12 months.
B. Growth. Normal growth is usually a sensitive indicator of health as well as of adequate
therapy in children. Impairment of growth may be disabling in itself or may be an indicator of a
severe disorder involving the endocrine system or other body systems. Where involvement of
other organ systems has occurred as a result of a primary endocrine disorder, these
impairments should be evaluated according to the criteria under the appropriate sections.
C. Documentation. Description of characteristic history, physical findings, and diagnostic
laboratory data must be included. Results of laboratory tests will be considered abnormal if
outside the normal range or greater than two standard deviations from the mean of the testing
laboratory. Reports in the file should contain the information provided by the testing laboratory
as to their normal values for that test.
D. Hyperfunction of the adrenal cortex. Evidence of growth retardation must be documented as
described in 100.00. Elevated blood or urinary free cortisol levels are not acceptable in lieu of
urinary 17-hydroxycorticosteroid excretion for the diagnosis of adrenal cortical hyperfunction.
E. Adrenal cortical insufficiency. Documentation must include persistent low plasma cortisol or
low urinary 17-hydroxycorticosteroids or 17-ketogenic steroids and evidence of
unresponsiveness to ACTH stimulation.
109.01 Category of Impairments, Endrocrine
109.02 Thyroid Disorders.
A. Hyperthyroidism (as documented in 109.00C). With clinical manifestations despite
prescribed therapy, and one of the following:
1. Elevated serum thyroxine (T4) and either elevated free T4 or resin T3 uptake; or
2. Elevated thyroid uptake of radioiodine; or
3. Elevated serum triiodothyronine (T3).

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B. Hypothyroidism. With one of the following, despite prescribed therapy:
1. IQ of 70 or less; or
2. Growth impairment as described under the criteria in 100.02 A and B; or
3. Precocious puberty.
109.03 Hyperparathyroidism (as documented in 109.00C). With:
A. Repeated elevated total or ionized serum calcium; or
B. Elevated serum parathyroid hormone.
109.04 Hypoparathyroidism or Pseudohypoparathyroidism. With:
A. Severe recurrent tetany or convulsions which are unresponsive to prescribed therapy; or
B. Growth retardation as described under criteria in 100.02 A and B.
109.05 Diabetes insipidus, documented by pathologic hypertonic saline or water deprivation
test. And one of the following:
A. Intracranial space-occupying lesion, before or after surgery; or
B. Unresponsiveness to Pitressin; or
C. Growth retardation as described under the criteria in 100.02 A and B; or
D. Unresponsive hypothalmic thirst center, with chronic or recurrent hypernatremia; or
E. Decreased visual fields attributable to a pituitary lesion.
109.06 Hyperfunction of the adrenal cortex (Primary or secondary). With:
A. Elevated urinary 17-hyroxycortico-steroids (or 17-ketogenic steroids) as documented in
109.00 C and D; and
B. Unresponsiveness to low-dose dexamethasone suppression.
109.07 Adrenal cortical insufficiency (as documented in 109.00 C and E) with recent, recurrent
episodes of circulatory collapse.
109.08 Juvenile diabetes mellitus (as documented in 109.00C) requiring parenteral insulin.
And one of the following, despite prescribed therapy:
A. Recent, recurrent hospitalizations with acidosis; or
B. Recent, recurrent episodes of hypoglycemia; or

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C. Growth retardation as described under the criteria in 100.02 A or B; or
D. Impaired renal function as described under the criteria in 106.00ff.
109.09 Iatrogenic hypercorticoid state.
With chronic glucocorticoid therapy resulting in one of the following:
A. Osteoporosis; or
B. Growth retardation as described under the criteria in 100.02 A or B; or
C. Diabetes mellitus as described under the criteria in 109.08; or
D. Myopathy as described under the criteria in 111.06; or
E. Emotional disorder as described under the criteria in 112.00ff.
109.10 Pituitary dwarfism (with documented growth hormone deficiency). And growth
impairment as described under the criteria in 100.02B.
109.11 Adrenogenital syndrome. With:
A. Recent, recurrent self-losing episodes despite prescribed therapy; or
B. Inadequate replacement therapy manifested by accelerated bone age and virilization, or
C. Growth impairment as described under the criteria in 100.02 A or B.
109.12 Hypoglycemia (as documented in 109.00C). With recent, recurrent hypoglycemic
episodes producing convulsion or coma.
109.13 Gonadal Dysgenesis (Turner's Syndrome), chromosomally proven. Evaluate the
resulting impairment under the criteria for the appropriate body system.
110.00 Impairments That Affect Multiple Body Systems
A. What Kinds of Impairments Do We Evaluate Under This Body System?
1. General. We use these listings when you have a single impairment that affects two or more
body systems. Under these listings, we evaluate impairments that affect multiple body systems
due to non-mosaic Down syndrome or a catastrophic congenital abnormality or disease. These
kinds of impairments generally produce long-term, if not lifelong, interference with ageappropriate activities. Some of them result in early death or interfere very seriously with
development. We use the term "very seriously" in these listings to describe an "extreme"
limitation of functioning as defined in §416.926a(e)(3).
2. What is Down syndrome? Down syndrome is a condition in which there are three copies of
chromosome 21 within the cells of the body instead of the normal two copies per cell. The

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three copies may be separate (trisomy), or one chromosome 21 copy may be attached to a
different chromosome (translocation). This extra chromosomal material changes the orderly
development of the body and brain. Down syndrome is characterized by a complex of physical
characteristics, delayed physical development, and mental retardation. Down syndrome exists
in non-mosaic and mosaic forms.
3. What is non-mosaic Down syndrome?
a. Non-mosaic Down syndrome occurs when you have an extra copy of chromosome 21 in
every cell of your body. At least 98 percent of people with Down syndrome have this form
(which includes either trisomy or translocation type chromosomal abnormalities). Virtually all
cases of non-mosaic Down syndrome affect the mental, neurological, and skeletal systems,
and they are often accompanied by heart disease, impaired vision, hearing problems, and
other conditions.
b. We evaluate children with confirmed non-mosaic Down syndrome under 110.06. If you have
confirmed non-mosaic Down syndrome, we consider you disabled from birth.
4. What is mosaic Down syndrome?
a. Mosaic Down syndrome occurs when you have some cells with the normal two copies of
chromosome 21 and some cells with an extra copy of chromosome 21. When this occurs,
there is a mixture of two types of cells. Mosaic Down syndrome occurs in only 1-2 percent of
people with Down syndrome, and there is a wide range in the level of severity of the
impairment. Mosaic Down syndrome can be profound and disabling, but it can also be so slight
as to be undetected clinically.
b. We evaluate children with confirmed mosaic Down syndrome under the listing criteria in any
affected body system(s) on an individual case basis, as described in 110.00C.
5. What are catastrophic congenital abnormalities or diseases?
a. Catastrophic congenital abnormalities or diseases are present at birth, although they may
not be apparent immediately. They cause deviation from, or interruption of, the normal function
of the body and are reasonably certain to result in early death or to interfere very seriously with
development.
b. We evaluate catastrophic congenital abnormalities or diseases under 110.08.
B. What Documentation Do We Need To Establish That You Have an Impairment That Affects
Multiple Body Systems?
1. General. We need documentation from an acceptable medical source, as defined in
§§404.1513(a) and 416.913(a), to establish that you have a medically determinable
impairment. In general, the documentation should include a clinical description of the
diagnostic physical features associated with your multiple body system impairment, and any
appropriate laboratory tests.
2. Non-mosaic Down syndrome (110.06).

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a. Definitive chromosomal analysis. We will find that you have non-mosaic Down syndrome
based on a report from an acceptable medical source that indicates that you have the
impairment and that includes the actual laboratory report of definitive chromosomal analysis
showing that you have the impairment. Definitive chromosomal analysis for Down syndrome
means karyotype analysis. When we have the laboratory report of the actual karyotype
analysis, we do not additionally require a clinical description of the physical features of Down
syndrome.
b. What if you have Down syndrome and we do not have the results of definitive chromosomal
analysis? When you have Down syndrome and we do not have the actual laboratory report of
definitive chromosomal analysis, we need evidence from an acceptable medical source that
includes a clinical description of the diagnostic physical features of your impairment, and that is
persuasive that a positive diagnosis has been confirmed by definitive chromosomal analysis at
some time prior to our evaluation. To be persuasive, the report must state that definitive
chromosomal analysis was conducted and that the results confirmed the diagnosis. The report
must be consistent with other evidence in your case record; for example, evidence showing
your limitations in adaptive functioning or signs of a mental disorder that can be associated
with non-mosaic Down syndrome, your educational history, or the results of psychological
testing.
3. Catastrophic congenital abnormalities or diseases (110.08).
a. Genetic disorders. For genetic multiple body system impairments (other than non-mosaic
Down syndrome), such as Trisomy 13 (Patau Syndrome or Trisomy D), Trisomy 18 (Edwards'
Syndrome or Trisomy E), chromosomal deletion syndromes (for example, deletion 5p
syndrome, also called cri du chat syndrome), or inborn metabolic disorders (for example, TaySachs disease), we need evidence from an acceptable medical source that includes a clinical
description of the diagnostic physical features of your impairment, and the report of the
definitive laboratory study (for example, genetic analysis or evidence of biochemical
abnormalities) that is diagnostic of your impairment. When we do not have the actual
laboratory report, we need evidence from an acceptable medical source that is persuasive that
a positive diagnosis was confirmed by appropriate laboratory analysis at some time prior to our
evaluation. To be persuasive, the report must state that the appropriate definitive laboratory
study was conducted and that the results confirmed the diagnosis. The report must be
consistent with other evidence in your case record.
b. Other disorders. For infants born with other kinds of catastrophic congenital abnormalities
(for example, anencephaly, cyclopia), we need evidence from an acceptable medical source
that includes a clinical description of the diagnostic physical features of the impairment.
C. How Do We Evaluate Impairments That Affect Multiple Body Systems and That Do Not
Meet the Criteria of the Listings in This Body System?
1. These listings are examples of impairments that commonly affect multiple body systems and
that we consider significant enough to result in marked and severe functional limitations. If your
severe impairment(s) does not meet the criteria of any of these listings, we must also consider
whether your impairment(s) meets the criteria of a listing in another body system.
2. There are many other impairments that can cause deviation from, or interruption of, the
normal function of the body or interfere with development; for example, congenital anomalies,

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chromosomal disorders, dysmorphic syndromes, metabolic disorders, and perinatal infectious
diseases. In these impairments, the degree of deviation or interruption may vary widely from
child to child. Therefore, the resulting functional limitations and the progression of those
limitations are more variable than with the catastrophic congenital abnormalities and diseases
we include in these listings. For this reason, we evaluate the specific effects of these
impairments on you under the listing criteria in any affected body system(s) on an individual
case basis. Examples of such impairments include, but are not limited to, triple X syndrome
(XXX syndrome), fragile X syndrome, phenylketonuria (PKU), caudal regression syndrome,
and fetal alcohol syndrome.
3. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will consider whether your impairment(s) medically equals a listing. If your impairment(s) does
not meet or medically equal a listing, we will consider whether it functionally equals the listings.
(See §§404.1526, 416.926, and 416.926a.) When we decide whether you continue to be
disabled, we use the rules in §416.994a.
110.01 Category of Impairments, Impairments That Affect Multiple Body Systems
110.06 Non-mosaic Down syndrome, established as described in 110.00B.
110.08 A catastrophic congenital abnormality or disease, established as described in 110.00B,
and:
A. Death usually is expected within the first months of life, and the rare individuals who survive
longer are profoundly impaired (for example, anencephaly, trisomy 13 or 18, cyclopia);
or
B. That interferes very seriously with development; for example, cri du chat syndrome (deletion
5p syndrome) or Tay-Sachs disease (acute infantile form).
111.00 Neurological
A. Convulsive epilepsy must be substantiated by at least one detailed description of a typical
seizure. Report of recent documentation should include a neurological examination with
frequency of episodes and any associated phenomena substantiated.
Young children may have convulsions in association with febrile illnesses. Proper use of
111.02 and 111.03 requires that epilepsy be established. Although this does not exclude
consideration of seizures occurring during febrile illnesses, it does require documentation of
seizures during nonfebrile periods.
There is an expected delay in control of epilepsy when treatment is started, particularly when
changes in the treatment regimen are necessary. Therefore, an epileptic disorder should not
be considered to meet the requirements of 111.02 or 111.03 unless it is shown that convulsive
episodes have persisted more than three months after prescribed therapy began.
B. Nonconvulsive epilepsy. Classical petit mal seizures must be documented by characteristic
EEG pattern, plus information as to age at onset and frequency of clinical seizures.

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C. Motor dysfunction. As described in 111.06, motor dysfunction may be due to any
neurological disorder. It may be due to static or progressive conditions involving any area of
the nervous system and producing any type of neurological impairment. This may include
weakness, spasticity, lack of coordination, ataxia, tremor, athetosis, or sensory loss.
Documentation of motor dysfunction must include neurologic findings and description of type of
neurologic abnormality (e.g., spasticity, weakness), as well as a description of the child's
functional impairment (i.e., what the child is unable to do because of the abnormality). Where a
diagnosis has been made, evidence should be included for substantiation of the diagnosis
(e.g., blood chemistries and muscle biopsy reports), wherever applicable.
D. Impairment of communication. The documentation should include a description of a recent
comprehensive evaluation, including all areas of affective and effective communication,
performed by a qualified professional.
E. Brain tumors. We evaluate malignant brain tumors under the criteria in 113.13. For benign
brain tumors, we determine the severity and duration of the impairment on the basis of
symptoms, signs, and laboratory findings (111.05).
111.01 Category of Impairment, Neurological
111.02 Major motor seizure disorder.
A. Convulsive epilepsy. In a child with an established diagnosis of epilepsy, the occurrence of
more than one major motor seizure per month despite at least three months of prescribed
treatment. With:
1. Daytime episodes (loss of consciousness and convulsive seizures); or
2. Nocturnal episodes manifesting residuals which interfere with activity during the day.
B. Convulsive epilepsy syndrome. In a child with an established diagnosis of epilepsy, the
occurrence of at least one major motor seizure in the year prior to application despite at least
three months of prescribed treatment. And one of the following:
1. IQ of 70 or less; or
2. Significant interference with communication due to speech, hearing, or visual defect; or
3. Significant mental disorder; or
4. Where significant adverse effects of medication interfere with major daily activities.
111.03 Nonconvulsive epilepsy. In a child with an established seizure disorder, the occurrence
of more than one minor motor seizure per week, with alteration of awareness or loss of
consciousness, despite at least three months of prescribed treatment.
111.05 Benign brain tumors. Evaluate under 111.02, 111.03, 111.06, 111.09 or the criteria of
the affected body system.
111.06 Motor dysfunction (due to any neurological disorder). Persistent disorganization or

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deficit of motor function for age involving two extremities, which (despite prescribed therapy)
interferes with age-appropriate major daily activities and results in disruption of:
A. Fine and gross movements; or
B. Gait and station.
111.07 Cerebral Palsy. With:
A. Motor dysfunction meeting the requirements of 101.02 or 111.06; or
B. Less severe motor dysfunction (but more than slight) and one of the following:
1. IQ of 70 or less; or
2. Seizure disorder, with at least one major motor seizure in the year prior to application; or
3. Significant interference with communication due to speech, hearing or visual defect; or
4. Significant emotional disorder.
111.08 Meningomyelocele (and related disorders). With one of the following despite prescribed
treatment:
A. Motor dysfunction meeting the requirements of 101.02 or 111.06; or
B. Less severe motor dysfunction (but more than slight), and:
1. Urinary or fecal incontinence when inappropriate for age; or
2. IQ of 70 or less; or
C. Four extremity involvement; or
D. Noncompensated hydrocephalus producing interference with mental or motor
developmental progression.
111.09 Communication impairment, associated with documented neurological disorder. And
one of the following:
A. Documented speech deficit which significantly affects the clarity and content of the speech;
or
B. Documented comprehension deficit resulting in ineffective verbal communication for age; or
C. Impairment of hearing as described under the criteria in 102.08.
112.00 Mental Disorders

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A. Introduction: The structure of the mental disorders listings for children under age 18
parallels the structure for the mental disorders listings for adults but is modified to reflect the
presentation of mental disorders in children. The listings for mental disorders in children are
arranged in 11 diagnostic categories: Organic mental disorders (112.02); schizophrenic,
delusional (paranoid), schizoaffective, and other psychotic disorders (112.03); mood disorders
(112.04); mental retardation (112.05); anxiety disorders (112.06); somatoform, eating, and tic
disorders (112.07); personality disorders (112.08); psychoactive substance dependence
disorders (112.09); autistic disorder and other pervasive developmental disorders (112.10);
attention deficit hyperactivity disorder (112.11); and developmental and emotional disorders of
newborn and younger infants (112.12).
There are significant differences between the listings for adults and the listings for children.
There are disorders found in children that have no real analogy in adults; hence, the
differences in the diagnostic categories for children. The presentation of mental disorders in
children, particularly the very young child, may be subtle and of a character different from the
signs and symptoms found in adults. For example, findings such as separation anxiety, failure
to mold or bond with the parents, or withdrawal may serve as findings comparable to findings
that mark mental disorders in adults. The activities appropriate to children, such as learning,
growing, playing, maturing, and school adjustment, are also different from the activities
appropriate to the adult and vary widely in the different childhood stages.
Each listing begins with an introductory statement that describes the disorder or disorders
addressed by the listing. This is followed (except in listings 112.05 and 112.12) by paragraph A
criteria (a set of medical findings) and paragraph B criteria (a set of impairment-related
functional limitations). An individual will be found to have a listed impairment when the criteria
of both paragraphs A and B of the listed impairment are satisfied.
The purpose of the criteria in paragraph A is to substantiate medically the presence of a
particular mental disorder. Specific symptoms and signs under any of the listings 112.02
through 112.12 cannot be considered in isolation from the description of the mental disorder
contained at the beginning of each listing category. Impairments should be analyzed or
reviewed under the mental category(ies) indicated by the medical findings.
Paragraph A of the listings is a composite of medical findings which are used to substantiate
the existence of a disorder and may or may not be appropriate for children at specific
developmental stages. However, a range of medical findings is included in the listings so that
no age group is excluded. For example, in listing 112.02A7, emotional lability and crying would
be inappropriate criteria to apply to older infants and toddlers, age 1 to attainment of age 3;
whereas in 112.02A1, developmental arrest, delay, or regression are appropriate criteria for
older infants and toddlers. Whenever the adjudicator decides that the requirements of
paragraph A of a particular mental listing are satisfied, then that listing should be applied
regardless of the age of the child to be evaluated.
The purpose of the paragraph B criteria is to describe impairment-related functional limitations
which are applicable to children. Standardized tests of social or cognitive function and adaptive
behavior are frequently available and appropriate for the evaluation of children and, thus, such
tests are included in the paragraph B functional parameters. The functional restrictions in
paragraph B must be the result of the mental disorder which is manifested by the medical
findings in paragraph A.

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We did not include separate C criteria for listings 112.02, 112.03, 112.04, and 112.06, as are
found in the adult listings, because for the most part we do not believe that the residual
disease processes described by these listings are commonly found in children. However, in
unusual cases where these disorders are found in children and are comparable to the severity
and duration found in adults, we may use the adult listings 12.02C, 12.03C, 12.04C, and
12.06C criteria to evaluate such cases.
The structure of the listings for Mental Retardation (112.05) and Developmental and Emotional
Disorders of Newborn and Younger Infants (112.12) is different from that of the other mental
disorders. Listing 112.05 (Mental Retardation) contains six sets of criteria. If an impairment
satisfies the diagnostic description in the introductory paragraph and any one of the six sets of
criteria, we will find that the child's impairment meets the listing. For listings 112.05D and
112.05F, we will assess the degree of functional limitation the additional impairment(s)
imposes to determine if it causes more than minimal functional limitations, i.e., is a "severe"
impairment(s), as defined in §416.924(c). If the additional impairment(s) does not cause
limitations that are "severe" as defined in §416.924(c), we will not find that the additional
impairment(s) imposes an additional and significant limitation of function. Listing 112.12
(Developmental and Emotional Disorders of Newborn and Younger Infants) contains five
criteria, any one of which, if satisfied, will result in a finding that the infant's impairment meets
the listing.
It must be remembered that these listings are only examples of common mental disorders that
are severe enough to find a child disabled. When a child has a medically determinable
impairment that is not listed, an impairment that does not meet the requirements of a listing, or
a combination of impairments no one of which meets the requirements of a listing, we will
make a determination whether the child's impairment(s) medically or functionally equals the
listings. (See §§404.1526, 416.926, and 416.926a.) This determination can be especially
important in older infants and toddlers (age 1 to attainment of age 3), who may be too young
for identification of a specific diagnosis, yet demonstrate serious functional limitations.
Therefore, the determination of equivalency is necessary to the evaluation of any child's case
when the child does not have an impairment that meets a listing.
B. Need for Medical Evidence: The existence of a medically determinable impairment of the
required duration must be established by medical evidence consisting of symptoms, signs, and
laboratory findings (including psychological or developmental test findings). Symptoms are
complaints presented by the child. Psychiatric signs are medically demonstrable phenomena
that indicate specific psychological abnormalities, e.g., abnormalities of behavior, mood,
thought, memory, orientation, development, or perception, as described by an appropriate
medical source. Symptoms and signs generally cluster together to constitute recognizable
mental disorders described in paragraph A of the listings. These findings may be intermittent or
continuous depending on the nature of the disorder.
C. Assessment of Severity: In childhood cases, as with adults, severity is measured according
to the functional limitations imposed by the medically determinable mental impairment.
However, the range of functions used to assess impairment severity for children varies at
different stages of maturation. The functional areas that we consider are: Motor function;
cognitive/communicative function; social function; personal function; and concentration,
persistence, or pace. In most functional areas, there are two alternative methods of
documenting the required level of severity: (1) Use of standardized tests alone, where
appropriate test instruments are available, and (2) use of other medical findings. (See 112.00D

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for explanation of these documentation requirements.) The use of standardized tests is the
preferred method of documentation if such tests are available.
Newborn and younger infants (birth to attainment of age 1) have not developed sufficient
personality differentiation to permit formulation of appropriate diagnoses. We have, therefore,
assigned listing 112.12 for Developmental and Emotional Disorders of Newborn and Younger
Infants for the evaluation of mental disorders of such children. Severity of these disorders is
based on measures of development in motor, cognitive/communicative, and social functions.
When older infants and toddlers (age 1 to attainment of age 3) do not clearly satisfy the
paragraph A criteria of any listing because of insufficient developmental differentiation, they
must be evaluated under the rules for equivalency. The principles for assessing the severity of
impairment in such children, described in the following paragraphs, must be employed.
Generally, when we assess the degree of developmental delay imposed by a mental
impairment, we will use an infant's or toddler's chronological age; i.e., the child's age based on
birth date. If the infant or toddler was born prematurely, however, we will follow the rules in
§416.924b(b) to determine whether we should use the infant's or toddler's corrected
chronological age; i.e., the chronological age adjusted by the period of gestational prematurity.
In defining the severity of functional limitations, two different sets of paragraph B criteria
corresponding to two separate age groupings have been established, in addition to listing
112.12, which is for children who have not attained age 1. These age groups are: older infants
and toddlers (age 1 to attainment of age 3) and children (age 3 to attainment of age 18).
However, the discussion below in 112.00C1, 2, 3, and 4, on the age-appropriate areas of
function, is broken down into four age groupings: older infants and toddlers (age 1 to
attainment of age 3), preschool children (age 3 to attainment of age 6), primary school children
(age 6 to attainment of age 12), and adolescents (age 12 to attainment of age 18). This was
done to provide specific guidance on the age group variances in disease manifestations and
methods of evaluation.
Where "marked" is used as a standard for measuring the degree of limitation it means more
than moderate but less than extreme. A marked limitation may arise when several activities or
functions are impaired, or even when only one is impaired, as long as the degree of limitation
is such as to interfere seriously with the ability to function (based upon age-appropriate
expectations) independently, appropriately, effectively, and on a sustained basis. When
standardized tests are used as the measure of functional parameters, a valid score that is two
standard deviations below the norm for the test will be considered a marked restriction.
1. Older infants and toddlers (age 1 to attainment of age 3). In this age group, impairment
severity is assessed in three areas: (a) Motor development, (b) cognitive/communicative
function, and (c) social function.
a. Motor development. Much of what we can discern about mental function in these children
frequently comes from observation of the degree of development of fine and gross motor
function. Developmental delay, as measured by a good developmental milestone history
confirmed by medical examination, is critical. This information will ordinarily be available in the
existing medical evidence from the claimant's treating sources and other medical sources,
supplemented by information from nonmedical sources, such as parents, who have observed
the child and can provide pertinent historical information. It may also be available from
standardized testing. If the delay is such that the older infant or toddler has not achieved motor

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development generally acquired by children no more than one-half the child's chronological
age, the criteria are satisfied.
b. Cognitive/communicative function. Cognitive/communicative function is measured using one
of several standardized infant scales. Appropriate tests for the measure of such function are
discussed in 112.00D. Screening instruments may be useful in uncovering potentially serious
impairments, but often must be supplemented by other data. However, in some cases, the
results of screening tests may show such obvious abnormalities that further testing will clearly
be unnecessary.
For older infants and toddlers, alternative criteria covering disruption in communication as
measured by their capacity to use simple verbal and nonverbal structures to communicate
basic needs are provided.
c. Social function. Social function in older infants and toddlers is measured in terms of the
development of relatedness to people (e.g., bonding and stranger anxiety) and attachment to
animate or inanimate objects. Criteria are provided that use standard social maturity scales or
alternative criteria that describe marked impairment in socialization.
2. Preschool children (age 3 to attainment of age 6). For the age groups including preschool
children through adolescence, the functional areas used to measure severity are: (a)
Cognitive/communicative function, (b) social function, (c) personal function, and (d)
deficiencies of concentration, persistence, or pace resulting in frequent failure to complete
tasks in a timely manner. After 36 months, motor function is no longer felt to be a primary
determinant of mental function, although, of course, any motor abnormalities should be
documented and evaluated.
a. Cognitive/communicative function. In the preschool years and beyond, cognitive function
can be measured by standardized tests of intelligence, although the appropriate instrument
may vary with age. A primary criterion for limited cognitive function is a valid verbal,
performance, or full scale IQ of 70 or less. The listings also provide alternative criteria,
consisting of tests of language development or bizarre speech patterns.
b. Social function. Social functioning refers to a child's capacity to form and maintain
relationships with parents, other adults, and peers. Social functioning includes the ability to get
along with others (e.g., family members, neighborhood friends, classmates, teachers).
Impaired social functioning may be caused by inappropriate externalized actions (e.g., running
away, physical aggression—but not self-injurious actions, which are evaluated in the personal
area of functioning), or inappropriate internalized actions (e.g., social isolation, avoidance of
interpersonal activities, mutism). Its severity must be documented in terms of intensity,
frequency, and duration, and shown to be beyond what might be reasonably expected for age.
Strength in social functioning may be documented by such things as the child's ability to
respond to and initiate social interaction with others, to sustain relationships, and to participate
in group activities. Cooperative behaviors, consideration for others, awareness of others'
feelings, and social maturity, appropriate to a child's age, also need to be considered. Social
functioning in play and school may involve interactions with adults, including responding
appropriately to persons in authority (e.g., teachers, coaches) or cooperative behaviors
involving other children. Social functioning is observed not only at home but also in preschool
programs.

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c. Personal function. Personal functioning in preschool children pertains to self-care; i.e.,
personal needs, health, and safety (feeding, dressing, toileting, bathing; maintaining personal
hygiene, proper nutrition, sleep, health habits; adhering to medication or therapy regimens;
following safety precautions). Development of self-care skills is measured in terms of the
child's increasing ability to help himself/herself and to cooperate with others in taking care of
these needs. Impaired ability in this area is manifested by failure to develop such skills, failure
to use them, or self-injurious actions. This function may be documented by a standardized test
of adaptive behavior or by a careful description of the full range of self-care activities. These
activities are often observed not only at home but also in preschool programs.
d. Concentration, persistence, or pace. This function may be measured through observations
of the child in the course of standardized testing and in the course of play.
3. Primary school children (age 6 to attainment of age 12). The measures of function here are
similar to those for preschool-age children except that the test instruments may change and
the capacity to function in the school setting is supplemental information. Standardized
measures of academic achievement, e.g., Wide Range Achievement Test-Revised, Peabody
Individual Achievement Test, etc., may be helpful in assessing cognitive impairment. Problems
in social functioning, especially in the area of peer relationships, are often observed firsthand
by teachers and school nurses. As described in 112.00D, Documentation, school records are
an excellent source of information concerning function and standardized testing and should
always be sought for school-age children.
As it applies to primary school children, the intent of the functional criterion described in
paragraph B2d, i.e., deficiencies of concentration, persistence, or pace resulting in failure to
complete tasks in a timely manner, is to identify the child who cannot adequately function in
primary school because of a mental impairment. Although grades and the need for special
education placement are relevant factors which must be considered in reaching a decision
under paragraph B2d, they are not conclusive. There is too much variability from school district
to school district in the expected level of grading and in the criteria for special education
placement to justify reliance solely on these factors.
4. Adolescents (age 12 to attainment of age 18). Functional criteria parallel to those for primary
school children (cognitive/communicative; social; personal; and concentration, persistence, or
pace) are the measures of severity for this age group. Testing instruments appropriate to
adolescents should be used where indicated. Comparable findings of disruption of social
function must consider the capacity to form appropriate, stable, and lasting relationships. If
information is available about cooperative working relationships in school or at part-time or fulltime work, or about the ability to work as a member of a group, it should be considered when
assessing the child's social functioning. Markedly impoverished social contact, isolation,
withdrawal, and inappropriate or bizarre behavior under the stress of socializing with others
also constitute comparable findings. (Note that self-injurious actions are evaluated in the
personal area of functioning.)
a. Personal functioning in adolescents pertains to self-care. It is measured in the same terms
as for younger children, the focus, however, being on the adolescent's ability to take care of
his or her own personal needs, health, and safety without assistance. Impaired ability in this
area is manifested by failure to take care of these needs or by self-injurious actions. This
function may be documented by a standardized test of adaptive behavior or by careful
descriptions of the full range of self-care activities.

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b. In adolescents, the intent of the functional criterion described in paragraph B2d is the same
as in primary school children, However, other evidence of this functional impairment may also
be available, such as from evidence of the child's performance in work or work-like settings.
D. Documentation: 1. The presence of a mental disorder in a child must be documented on the
basis of reports from acceptable sources of medical evidence. See §§404.1513 and 416.913.
Descriptions of functional limitations may be available from these sources, either in the form of
standardized test results or in other medical findings supplied by the sources, or both. (Medical
findings consist of symptoms, signs, and laboratory findings.) Whenever possible, a medical
source's findings should reflect the medical source's consideration of information from parents
or other concerned individuals who are aware of the child's activities of daily living, social
functioning, and ability to adapt to different settings and expectations, as well as the medical
source's findings and observations on examination, consistent with standard clinical practice.
As necessary, information from nonmedical sources, such as parents, should also be used to
supplement the record of the child's functioning to establish the consistency of the medical
evidence and longitudinality of impairment severity.
2. For some newborn and younger infants, it may be very difficult to document the presence or
severity of a mental disorder. Therefore, with the exception of some genetic diseases and
catastrophic congenital anomalies, it may be necessary to defer making a disability decision
until the child attains age 3 months of age in order to obtain adequate observation of behavior
or affect. See, also, 110.00 of this part. This period could be extended in cases of premature
infants depending on the degree of prematurity and the adequacy of documentation of their
developmental and emotional status.
3. For infants and toddlers, programs of early intervention involving occupational, physical, and
speech therapists, nurses, social workers, and special educators, are a rich source of data.
They can provide the developmental milestone evaluations and records on the fine and gross
motor functioning of these children. This information is valuable and can complement the
medical examination by a physician or psychologist. A report of an interdisciplinary team that
contains the evaluation and signature of an acceptable medical source is considered
acceptable medical evidence rather than supplemental data.
4. In children with mental disorders, particularly those requiring special placement, school
records are a rich source of data, and the required reevaluations at specified time periods can
provide the longitudinal data needed to trace impairment progression over time.
5. In some cases where the treating sources lack expertise in dealing with mental disorders of
children, it may be necessary to obtain evidence from a psychiatrist, psychologist, or
pediatrician with experience and skill in the diagnosis and treatment of mental disorders as
they appear in children. In these cases, however, every reasonable effort must be made to
obtain the records of the treating sources, since these records will help establish a longitudinal
picture that cannot be established through a single purchased examination.
6. Reference to a "standardized psychological test" indicates the use of a psychological test
measure that has appropriate validity, reliability, and norms, and is individually administered by
a qualified specialist. By "qualified," we mean the specialist must be currently licensed or
certified in the State to administer, score, and interpret psychological tests and have the
training and experience to perform the test.

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7. Psychological tests are best considered as standardized sets of tasks or questions designed
to elicit a range of responses. Psychological testing can also provide other useful data, such as
the specialist's observations regarding the child's ability to sustain attention and concentration,
relate appropriately to the specialist, and perform tasks independently (without prompts or
reminders). Therefore, a report of test results should include both the objective data and any
clinical observations.
8. The salient characteristics of a good test are: (1) Validity, i.e., the test measures what it is
supposed to measure; (2) reliability, i.e., the consistency of results obtained over time with the
same test and the same individual; (3) appropriate normative data, i.e., individual test scores
can be compared to test data from other individuals or groups of a similar nature,
representative of that population; and (4) wide scope of measurement, i.e., the test should
measure a broad range of facets/aspects of the domain being assessed. In considering the
validity of a test result, we should note and resolve any discrepancies between formal test
results and the child's customary behavior and daily activities.
9. Identical IQ scores obtained from different tests do not always reflect a similar degree of
intellectual functioning. The IQ scores in listing 112.05 reflect values from tests of general
intelligence that have a mean of 100 and a standard deviation of 15, e.g., the Wechsler series.
IQs obtained from standardized tests that deviate significantly from a mean of 100 and
standard deviation of 15 require conversion to a percentile rank so that the actual degree of
limitation reflected by the IQ scores can be determined. In cases where more than one IQ is
customarily derived from the test administered, e.g., where verbal, performance, and full scale
IQs are provided in the Wechsler series, the lowest of these is used in conjunction with listing
112.05.
10. IQ test results must also be sufficiently current for accurate assessment under 112.05.
Generally, the results of IQ tests tend to stabilize by the age of 16. Therefore, IQ test results
obtained at age 16 or older should be viewed as a valid indication of the child's current status,
provided they are compatible with the child's current behavior. IQ test results obtained
between ages 7 and 16 should be considered current for 4 years when the tested IQ is less
than 40, and for 2 years when the IQ is 40 or above. IQ test results obtained before age 7 are
current for 2 years if the tested IQ is less than 40 and 1 year if at 40 or above.
11. Standardized intelligence test results are essential to the adjudication of all cases of mental
retardation that are not covered under the provisions of listings 112.05A, 112.05B, and
112.05F. Listings 112.05A, 112.05B, and 112.05F may be the bases for adjudicating cases
where the results of standardized intelligence tests are unavailable, e.g., where the child's
young age or condition precludes formal standardized testing.
12. In conjunction with clinical examinations, sources may report the results of screening tests,
i.e., tests used for gross determination of level of functioning. Screening instruments may be
useful in uncovering potentially serious impairments, but often must be supplemented by other
data. However, in some cases the results of screening tests may show such obvious
abnormalities that further testing will clearly be unnecessary.
13. Where reference is made to developmental milestones, this is defined as the attainment of
particular mental or motor skills at an age-appropriate level, i.e., the skills achieved by an
infant or toddler sequentially and within a given time period in the motor and manipulative
areas, in general understanding and social behavior, in self-feeding, dressing, and toilet

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training, and in language. This is sometimes expressed as a developmental quotient (DQ), the
relation between developmental age and chronological age as determined by specific
standardized measurements and observations. Such tests include, but are not limited to, the
Cattell Infant Intelligence Scale, the Bayley Scales of Infant Development, and the Revised
Stanford-Binet. Formal tests of the attainment of developmental milestones are generally used
in the clinical setting for determination of the developmental status of infants and toddlers.
14. Formal psychological tests of cognitive functioning are generally in use for preschool
children, for primary school children, and for adolescents except for those instances noted
below.
15. Generally, it is preferable to use IQ measures that are wide in scope and include items that
test both verbal and performance abilities. However, in special circumstances, such as the
assessment of children with sensory, motor, or communication abnormalities, or those whose
culture and background are not principally English-speaking, measures such as the Test of
Nonverbal Intelligence, Third Edition (TONI-3), Leiter International Performance Scale-Revised
(Leiter-R), or Peabody Picture Vocabulary Test—Third Edition (PPVT-III) may be used.
16. We may consider exceptions for formal standardized psychological testing when an
individual qualified by training and experience to perform such an evaluation is not available, or
in cases where appropriate standardized measures for the child's social, linguistic, and cultural
background are not available. In these cases, the best indicator of severity is often the level of
adaptive functioning and how the child performs activities of daily living and social functioning.
17. Comprehensive neuropsychological examinations may be used to establish the existence
and extent of compromise of brain function, particularly in cases involving organic mental
disorders. Normally these examinations include assessment of cerebral dominance, basic
sensation and perception, motor speed and coordination, attention and concentration, visualmotor function, memory across verbal and visual modalities, receptive and expressive speech,
higher-order linguistic operations, problem-solving, abstraction ability, and general intelligence.
In addition, there should be a clinical interview geared toward evaluating pathological features
known to occur frequently in neurological disease and trauma, e.g., emotional lability,
abnormality of mood, impaired impulse control, passivity and apathy, or inappropriate social
behavior. The specialist performing the examination may administer one of the commercially
available comprehensive neuropsychological batteries, such as the Luria-Nebraska or
Halstead-Reitan, or a battery of tests selected as relevant to the suspected brain dysfunction.
The specialist performing the examination must be properly trained in this area of
neuroscience.
E. Effect of Hospitalization or Residential Placement: As with adults, children with mental
disorders may be placed in a variety of structured settings outside the home as part of their
treatment. Such settings include, but are not limited to, psychiatric hospitals, developmental
disabilities facilities, residential treatment centers and schools, community-based group
homes, and workshop facilities. The reduced mental demands of such structured settings may
attenuate overt symptomatology and superficially make the child's level of adaptive functioning
appear better than it is. Therefore, the capacity of the child to function outside highly structured
settings must be considered in evaluating impairment severity. This is done by determining the
degree to which the child can function (based upon age-appropriate expectations)
independently, appropriately, effectively, and on a sustained basis outside the highly structured
setting.

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On the other hand, there may be a variety of causes for placement of a child in a structured
setting which may or may not be directly related to impairment severity and functional ability.
Placement in a structured setting in and of itself does not equate with a finding of disability.
The severity of the impairment must be compared with the requirements of the appropriate
listing.
F. Effects of Medication: Attention must be given to the effect of medication on the child's
signs, symptoms, and ability to function. While drugs used to modify psychological functions
and mental states may control certain primary manifestations of a mental disorder, e.g.,
hallucinations, impaired attention, restlessness, or hyperactivity, such treatment may not affect
all functional limitations imposed by the mental disorder. In cases where overt symptomatology
is attenuated by the use of such drugs, particular attention must be focused on the functional
limitations that may persist. These functional limitations must be considered in assessing
impairment severity.
Psychotropic medicines used in the treatment of some mental illnesses may cause
drowsiness, blunted affect, or other side effects involving other body systems. Such side
effects must be considered in evaluating overall impairment severity.
112.01 Category of Impairments, Mental
112.02 Organic Mental Disorders: Abnormalities in perception, cognition, affect, or behavior
associated with dysfunction of the brain. The history and physical examination or laboratory
tests, including psychological or neuropsychological tests, demonstrate or support the
presence of an organic factor judged to be etiologically related to the abnormal mental state
and associated deficit or loss of specific cognitive abilities, or affective changes, or loss of
previously acquired functional abilities.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented persistence of at least one of the following:
1. Developmental arrest, delay or regression; or
2. Disorientation to time and place; or
3. Memory impairment, either short-term (inability to learn new information), intermediate, or
long-term (inability to remember information that was known sometime in the past); or
4. Perceptual or thinking disturbance (e.g., hallucinations, delusions, illusions, or paranoid
thinking); or
5. Disturbance in personality (e.g., apathy, hostility); or
6. Disturbance in mood (e.g., mania, depression); or
7. Emotional lability (e.g., sudden crying); or
8. Impairment of impulse control (e.g., disinhibited social behavior, explosive temper

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outbursts); or
9. Impairment of cognitive function, as measured by clinically timely standardized
psychological testing; or
10. Disturbance of concentration, attention, or judgment;
AND
B. Select the appropriate age group to evaluate the severity of the impairment:
1. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
following:
a. Gross or fine motor development at a level generally acquired by children no more than onehalf the child's chronological age, documented by:
(1) An appropriate standardized test; or
(2) Other medical findings (see 112.00C); or
b. Cognitive/communicative function at a level generally acquired by children no more than
one-half the child's chronological age, documented by:
(1) An appropriate standardized test; or
(2) Other medical findings of equivalent cognitive/communicative abnormality, such as the
inability to use simple verbal or nonverbal behavior to communicate basic needs or concepts;
or
c. Social function at a level generally acquired by children no more than one-half the child's
chronological age, documented by:
(1) An appropriate standardized test; or
(2) Other medical findings of an equivalent abnormality of social functioning, exemplified by
serious inability to achieve age-appropriate autonomy as manifested by excessive clinging or
extreme separation anxiety; or
d. Attainment of development or function generally acquired by children no more than twothirds of the child's chronological age in two or more areas covered by a., b., or c., as
measured by an appropriate standardized test or other appropriate medical findings.
2. For children (age 3 to attainment of age 18), resulting in at least two of the following:
a. Marked impairment in age-appropriate cognitive/communicative function, documented by
medical findings (including consideration of historical and other information from parents or
other individuals who have knowledge of the child, when such information is needed and
available) and including, if necessary, the results of appropriate standardized psychological

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tests, or for children under age 6, by appropriate tests of language and communication; or
b. Marked impairment in age-appropriate social functioning, documented by history and
medical findings (including consideration of information from parents or other individuals who
have knowledge of the child, when such information is needed and available) and including, if
necessary, the results of appropriate standardized tests; or
c. Marked impairment in age-appropriate personal functioning, documented by history and
medical findings (including consideration of information from parents or other individuals who
have knowledge of the child, when such information is needed and available) and including, if
necessary, appropriate standardized tests; or
d. Marked difficulties in maintaining concentration, persistence, or pace.
112.03 Schizophrenic, Delusional (Paranoid), Schizoaffective, and Other Psychotic Disorders:
Onset of psychotic features, characterized by a marked disturbance of thinking, feeling, and
behavior, with deterioration from a previous level of functioning or failure to achieve the
expected level of social functioning.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented persistence, for at least 6 months, either continuous or intermittent,
of one or more of the following:
1. Delusions or hallucinations; or
2. Catatonic, bizarre, or other grossly disorganized behavior; or
3. Incoherence, loosening of associations, illogical thinking, or poverty of content of speech; or
4. Flat, blunt, or inappropriate affect; or
5. Emotional withdrawal, apathy, or isolation;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02.
112.04 Mood Disorders: Characterized by a disturbance of mood (referring to a prolonged
emotion that colors the whole psychic life, generally involving either depression or elation),
accompanied by a full or partial manic or depressive syndrome.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented persistence, either continuous or intermittent, of one of the following:

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1. Major depressive syndrome, characterized by at least five of the following, which must
include either depressed or irritable mood or markedly diminished interest or pleasure:
a. Depressed or irritable mood; or
b. Markedly diminished interest or pleasure in almost all activities; or
c. Appetite or weight increase or decrease, or failure to make expected weight gains; or
d. Sleep disturbance; or
e. Psychomotor agitation or retardation; or
f. Fatigue or loss of energy; or
g. Feelings of worthlessness or guilt; or
h. Difficulty thinking or concentrating; or
i. Suicidal thoughts or acts; or
j. Hallucinations, delusions, or paranoid thinking;
OR
2. Manic syndrome, characterized by elevated, expansive, or irritable mood, and at least three
of the following:
a. Increased activity or psychomotor agitation; or
b. Increased talkativeness or pressure of speech; or
c. Flight of ideas or subjectively experienced racing thoughts; or
d. Inflated self-esteem or grandiosity; or
e. Decreased need for sleep; or
f. Easy distractibility; or
g. Involvement in activities that have a high potential of painful consequences which are not
recognized; or
h. Hallucinations, delusions, or paranoid thinking;
OR
3. Bipolar or cyclothymic syndrome with a history of episodic periods manifested by the full
symptomatic picture of both manic and depressive syndromes (and currently or most recently

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characterized by the full or partial symptomatic picture of either or both syndromes);
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02.
112.05 Mental Retardation: Characterized by significantly subaverage general intellectual
functioning with deficits in adaptive functioning.
The required level of severity for this disorder is met when the requirements in A, B, C, D, E, or
F are satisfied.
A. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02;
OR
B. Mental incapacity evidenced by dependence upon others for personal needs (grossly in
excess of age-appropriate dependence) and inability to follow directions such that the use of
standardized measures of intellectual functioning is precluded;
OR
C. A valid verbal, performance, or full scale IQ of 59 or less;
OR
D. A valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental
impairment imposing an additional and significant limitation of function;
OR
E. A valid verbal, performance, or full scale IQ of 60 through 70 and:
1. For older infants and toddlers (age 1 to attainment of age 3), resulting in attainment of
development or function generally acquired by children no more than two-thirds of the child's
chronological age in either paragraphs B1a or B1c of 112.02; or
2. For children (age 3 to attainment of age 18), resulting in at least one of paragraphs B2b or
B2c or B2d of 112.02;
OR
F. Select the appropriate age group:

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1. For older infants and toddlers (age 1 to attainment of age 3), resulting in attainment of
development or function generally acquired by children no more than two-thirds of the child's
chronological age in paragraph B1b of 112.02, and a physical or other mental impairment
imposing an additional and significant limitation of function;
OR
2. For children (age 3 to attainment of age 18), resulting in the satisfaction of 112.02B2a, and a
physical or other mental impairment imposing an additional and significant limitation of
function.
112.06 Anxiety Disorders: In these disorders, anxiety is either the predominant disturbance or
is experienced if the individual attempts to master symptoms, e.g., confronting the dreaded
object or situation in a phobic disorder, attempting to go to school in a separation anxiety
disorder, resisting the obsessions or compulsions in an obsessive compulsive disorder, or
confronting strangers or peers in avoidant disorders.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented findings of at least one of the following:
1. Excessive anxiety manifested when the child is separated, or separation is threatened, from
a parent or parent surrogate; or
2. Excessive and persistent avoidance of strangers; or
3. Persistent unrealistic or excessive anxiety and worry (apprehensive expectation),
accompanied by motor tension, autonomic hyperactivity, or vigilance and scanning; or
4. A persistent irrational fear of a specific object, activity, or situation which results in a
compelling desire to avoid the dreaded object, activity, or situation; or
5. Recurrent severe panic attacks, manifested by a sudden unpredictable onset of intense
apprehension, fear, or terror, often with a sense of impending doom, occurring on the average
of at least once a week; or
6. Recurrent obsessions or compulsions which are a source of marked distress; or
7. Recurrent and intrusive recollections of a traumatic experience, including dreams, which are
a source of marked distress;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02.
112.07 Somatoform, Eating, and Tic Disorders: Manifested by physical symptoms for which

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there are no demonstrable organic findings or known physiologic mechanisms; or eating or tic
disorders with physical manifestations.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented findings of one of the following:
1. An unrealistic fear and perception of fatness despite being underweight, and persistent
refusal to maintain a body weight which is greater than 85 percent of the average weight for
height and age, as shown in the most recent edition of the Nelson Textbook of Pediatrics,
Richard E. Behrman and Victor C. Vaughan, III, editors, Philadelphia: W. B. Saunders
Company; or
2. Persistent and recurrent involuntary, repetitive, rapid, purposeless motor movements
affecting multiple muscle groups with multiple vocal tics; or
3. Persistent nonorganic disturbance of one of the following:
a. Vision; or
b. Speech; or
c. Hearing; or
d. Use of a limb; or
e. Movement and its control (e.g., coordination disturbance, psychogenic seizures); or
f. Sensation (diminished or heightened); or
g. Digestion or elimination; or
4. Preoccupation with a belief that one has a serious disease or injury;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02.
112.08 Personality Disorders: Manifested by pervasive, inflexible, and maladaptive personality
traits, which are typical of the child's long-term functioning and not limited to discrete episodes
of illness.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.

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A. Deeply ingrained, maladaptive patterns of behavior, associated with one of the following:
1. Seclusiveness or autistic thinking; or
2. Pathologically inappropriate suspiciousness or hostility; or
3. Oddities of thought, perception, speech, and behavior; or
4. Persistent disturbances of mood or affect; or
5. Pathological dependence, passivity, or aggressiveness; or
6. Intense and unstable interpersonal relationships and impulsive and exploitative behavior; or
7. Pathological perfectionism and inflexibility;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02.
112.09 Psychoactive Substance Dependence Disorders: Manifested by a cluster of cognitive,
behavioral, and physiologic symptoms that indicate impaired control of psychoactive substance
use with continued use of the substance despite adverse consequences.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented findings of at least four of the following:
1. Substance taken in larger amounts or over a longer period than intended and a great deal of
time is spent in recovering from its effects; or
2. Two or more unsuccessful efforts to cut down or control use; or
3. Frequent intoxication or withdrawal symptoms interfering with major role obligations; or
4. Continued use despite persistent or recurring social, psychological, or physical problems; or
5. Tolerance, as characterized by the requirement for markedly increased amounts of
substance in order to achieve intoxication; or
6. Substance taken to relieve or avoid withdrawal symptoms;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the

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appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02.
112.10 Autistic Disorder and Other Pervasive Developmental Disorders: Characterized by
qualitative deficits in the development of reciprocal social interaction, in the development of
verbal and nonverbal communication skills, and in imaginative activity. Often, there is a
markedly restricted repertoire of activities and interests, which frequently are stereotyped and
repetitive.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented findings of the following:
1. For autistic disorder, all of the following:
a. Qualitative deficits in the development of reciprocal social interaction; and
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity; and
c. Markedly restricted repertoire of activities and interests;
OR
2. For other pervasive developmental disorders, both of the following:
a. Qualitative deficits in the development of reciprocal social interaction; and
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraphs B2 of
112.02.
112.11 Attention Deficit Hyperactivity Disorder: Manifested by developmentally inappropriate
degrees of inattention, impulsiveness, and hyperactivity.
The required level of severity for these disorders is met when the requirements in both A and B
are satisfied.
A. Medically documented findings of all three of the following:
1. Marked inattention; and
2. Marked impulsiveness; and

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3. Marked hyperactivity;
AND
B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the
appropriate age-group criteria in paragraph B1 of 112.02; or, for children (age 3 to attainment
of age 18), resulting in at least two of the appropriate age-group criteria in paragraph B2 of
112.02.
112.12 Developmental and Emotional Disorders of Newborn and Younger Infants (Birth to
attainment of age 1): Developmental or emotional disorders of infancy are evidenced by a
deficit or lag in the areas of motor, cognitive/communicative, or social functioning. These
disorders may be related either to organic or to functional factors or to a combination of these
factors.
The required level of severity for these disorders is met when the requirements of A, B, C, D,
or E are satisfied.
A. Cognitive/communicative functioning generally acquired by children no more than one-half
the child's chronological age, as documented by appropriate medical findings (e.g., in infants
0-6 months, markedly diminished variation in the production or imitation of sounds and severe
feeding abnormality, such as problems with sucking swallowing, or chewing) including, if
necessary, a standardized test;
OR
B. Motor development generally acquired by children no more than one-half the child's
chronological age, documented by appropriate medical findings, including if necessary, a
standardized test;
OR
C. Apathy, over-excitability, or fearfulness, demonstrated by an absent or grossly excessive
response to one of the following:
1. Visual stimulation; or
2. Auditory stimulation; or
3. Tactile stimulation;
OR
D. Failure to sustain social interaction on an ongoing, reciprocal basis as evidenced by:
1. Inability by 6 months to participate in vocal, visual, and motoric exchanges (including facial
expressions); or
2. Failure by 9 months to communicate basic emotional responses, such as cuddling or
exhibiting protest or anger; or

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3. Failure to attend to the caregiver's voice or face or to explore an inanimate object for a
period of time appropriate to the infant's age;
OR
E. Attainment of development or function generally acquired by children no more than twothirds of the child's chronological age in two or more areas (i.e., cognitive/communicative,
motor, and social), documented by appropriate medical findings, including if necessary,
standardized testing.
113.00 Malignant Neoplastic Diseases
A. What impairments do these listings cover? We use these listings to evaluate all malignant
neoplasms except certain neoplasms associated with human immunodeficiency virus (HIV)
infection. We use the criteria in 114.08E to evaluate carcinoma of the cervix, Kaposi's
sarcoma, lymphoma, and squamous cell carcinoma of the anus if you also have HIV infection.
B. What do we consider when we evaluate malignant neoplastic diseases under these listings?
We consider factors such as the:
1. Origin of the malignancy.
2. Extent of involvement.
3. Duration, frequency, and response to antineoplastic therapy. Antineoplastic therapy means
surgery, irradiation, chemotherapy, hormones, immunotherapy, or bone marrow or stem cell
transplantation. When we refer to surgery as an antineoplastic treatment, we mean surgical
excision for treatment, not for diagnostic purposes.
4. Effects of any post-therapeutic residuals.
C. How do we apply these listings? We apply the criteria in a specific listing to a malignancy
originating from that specific site.
D. What evidence do we need?
1. We need medical evidence that specifies the type, extent, and site of the primary, recurrent,
or metastatic lesion. In the rare situation in which the primary site cannot be identified, we will
use evidence documenting the site(s) of metastasis to evaluate the impairment under 13.27 in
part A.
2. For operative procedures, including a biopsy or a needle aspiration, we generally need a
copy of both the:
a. Operative note.
b. Pathology report.
3. When we cannot get these documents, we will accept the summary of hospitalization(s) or
other medical reports. This evidence should include details of the findings at surgery and,

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whenever appropriate, the pathological findings.
4. In some situations we may also need evidence about recurrence, persistence, or
progression of the malignancy, the response to therapy, and any significant residuals. (See
113.00G.)
E. When do we need longitudinal evidence?
1. Tumors with distant metastases. Most malignant tumors of childhood consist of a local
lesion with metastases to regional lymph nodes and, less often, distant metastases. We
generally do not need longitudinal evidence for tumors that have metastasized beyond the
regional lymph nodes because these tumors usually meet the requirements of a listing.
Exceptions are for tumors with distant metastases that are expected to respond to
antineoplastic therapy. For these exceptions, we usually need a longitudinal record of 3
months after therapy starts to determine whether the intended effect of therapy has been
achieved and is likely to persist.
2. Other malignancies. When there are no distant metastases, many of the listings require that
we consider your response to initial antineoplastic therapy; that is, the initial planned treatment
regimen. This therapy may consist of a single modality or a combination of modalities
(multimodal) given in close proximity as a unified whole, and is usually planned before any
treatment(s) is initiated. Examples of multimodal therapy include:
a. Surgery followed by chemotherapy or radiation.
b. Chemotherapy followed by surgery.
c. Chemotherapy and concurrent radiation.
3. Types of treatment. Whenever the initial planned therapy is a single modality, enough time
must pass to allow a determination about whether the therapy will achieve its intended effect. If
the treatment fails, the failure will often happen within 6 months after treatment starts, and
there will often be a change in the treatment regimen. Whenever the initial planned therapy is
multimodal, a determination about the effectiveness of the therapy usually cannot be made
until the effects of all the planned modalities can be determined. In some cases, we may need
to defer adjudication until the effectiveness of therapy can be assessed. However, we do not
need to defer adjudication to determine whether the therapy will achieve its intended effect if
we can make a fully favorable determination or decision based on the length and effects of
therapy, or the residuals of the malignancy or therapy (see 113.00G).
F. How do we evaluate impairments that do not meet one of the malignant neoplastic diseases
listings?
1. These listings are only examples of malignant neoplastic diseases that we consider severe
enough to result in marked and severe functional limitations. If your impairment(s) does not
meet the criteria of any of these listings, we must also consider whether you have an
impairment(s) that meets the criteria of a listing in another body system.
2. If you have a severe medically determinable impairment(s) that does not meet a listing, we
will determine whether your impairment(s) medically equals a listing. (See §§404.1526 and

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416.926.) If it does not, we will also consider whether you have an impairment(s) that
functionally equals the listings. (See §416.926a.) We use the rules in §416.994a when we
decide whether you continue to be disabled.
G. How do we consider the effects of therapy?
1. How we consider the effects of therapy under the listings. In many cases, malignancies
meet listing criteria only if the therapy does not achieve the intended effect: the malignancy
persists, progresses, or recurs despite treatment. However, as explained in the following
paragraphs, we will not delay adjudication if we can make a fully favorable determination or
decision based on the evidence in the case record.
2. Effects can vary widely.
a. Because the therapy and its toxicity may vary widely, we consider each case on an
individual basis. We will request a specific description of the therapy, including these items:
i. Drugs given.
ii. Dosage.
iii. Frequency of drug administration.
iv. Plans for continued drug administration.
v. Extent of surgery.
vi. Schedule and fields of radiation therapy.
b. We will also request a description of the complications or adverse effects of therapy, such
as the following:
i. Continuing gastrointestinal symptoms.
ii. Persistent weakness.
iii. Neurological complications.
iv. Cardiovascular complications.
v. Reactive mental disorders.
3. Effects of therapy may change. Because the severity of the adverse effects of antineoplastic
therapy may change during treatment, enough time must pass to allow us to evaluate the
therapy's effect. The residual effects of treatment are temporary in most instances. But on
occasion, the effects may be disabling for a consecutive period of at least 12 months.
4. When the initial antineoplastic therapy is effective. We evaluate any post-therapeutic
residual impairment(s) not included in these listings under the criteria for the affected body

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system. We must consider any complications of therapy. When the residual impairment(s)
does not meet a listed impairment, we must consider whether it medically equals a listing, or,
as appropriate, functionally equals the listings.
H. How long do we consider your impairment to be disabling?
1. In some listings, we specify that we will consider your impairment to be disabling until a
particular point in time (for example, at least 12 months from the date of diagnosis). We may
consider your impairment to be disabling beyond this point when the medical and other
evidence justifies it.
2. When a listing does not contain such a specification, we will consider an impairment(s) that
meets or medically equals a listing in this body system to be disabling until at least 3 years
after onset of complete remission. When the impairment(s) has been in complete remission for
at least 3 years, that is, the original tumor and any metastases have not been evident for at
least 3 years, the impairment(s) will no longer meet or equal the criteria of a listing in this body
system.
3. Following the appropriate period, we will consider any residuals, including residuals of the
malignancy or therapy (see 113.00G), in determining whether you are disabled.
I. What do these terms in the listings mean?
1. Persistent: Failure to achieve a complete remission.
2. Progressive: The malignancy became more extensive after treatment.
3. Recurrent, relapse: A malignancy that had been in complete remission or entirely removed
by surgery has returned.
J. Can we establish the existence of a disabling impairment prior to the date of the evidence
that shows the malignancy satisfies the criteria of a listing? Yes. We will consider factors such
as:
1. The type of malignancy and its location.
2. The extent of involvement when the malignancy was first demonstrated.
3. Your symptoms.
K. How do we evaluate specific malignant neoplastic diseases?
1. Lymphoma.
a. Listing 113.05 provides criteria for evaluating intermediate or high grade lymphomas that
have not responded to antineoplastic therapy. Low grade or indolent lymphomas are rare in
children. We will evaluate low grade or indolent lymphomas under 13.05 in part A.
b. We consider Hodgkin's disease that recurs more than 12 months after completing initial
antineoplastic therapy to be a new disease rather than a recurrence.

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c. Many children with lymphoma are treated according to a long-term protocol that can result in
significant adverse medical, social, and emotional consequences. (See 113.00G.)
2. Leukemia.
a. Acute leukemia. The initial diagnosis of acute leukemia, including the accelerated or blast
phase of chronic myelogenous (granulocytic) leukemia, is based upon definitive bone marrow
examination. Additional diagnostic information is based on chromosomal analysis,
cytochemical and surface marker studies on the abnormal cells, or other methods consistent
with the prevailing state of medical knowledge and clinical practice. Recurrent disease must be
documented by peripheral blood, bone marrow, or cerebrospinal fluid examination. The initial
and follow-up pathology reports should be included.
b. Chronic myelogenous leukemia (CML). The diagnosis of CML should be based upon
documented granulocytosis, including immature forms such as differentiated or
undifferentiated myelocytes and myeloblasts, and a chromosomal analysis that demonstrates
the Philadelphia chromosome. In the absence of a chromosomal analysis, or if the
Philadelphia chromosome is not present, the diagnosis may be made by other methods
consistent with the prevailing state of medical knowledge and clinical practice.
c. Juvenile chronic myelogenous leukemia (JCML). JCML is a rare, Philadelphia-chromosomenegative childhood leukemia that is aggressive and clinically similar to acute myelogenous
leukemia. We evaluate JCML under 113.06A.
d. Elevated white cell count. In cases of chronic leukemia, an elevated white cell count, in
itself, is not ordinarily a factor in determining the severity of the impairment.
3. Malignant solid tumors. The tumors we consider under 113.03 include the histiocytosis
syndromes except for solitary eosinophilic granuloma. Therefore, we will not evaluate brain
tumors (see 113.13) or thyroid tumors (see 113.09) under this listing.
4. Brain tumors. We use the criteria in 113.13 to evaluate malignant brain tumors. We will
evaluate any complications of malignant brain tumors, such as resultant neurological or
psychological impairments, under the criteria for the affected body system. We evaluate
benign brain tumors under 111.05.
5. Retinoblastoma. The treatment for bilateral retinoblastoma usually results in a visual
impairment. We will evaluate any resulting visual impairment under 102.02.
L. How do we evaluate malignant neoplastic diseases treated by bone marrow or stem cell
transplantation? Bone marrow or stem cell transplantation is performed for a variety of
malignant neoplastic diseases.
1. Acute leukemia (including T-cell lymphoblastic lymphoma and JCML) or accelerated or blast
phase of CML. If you undergo bone marrow or stem cell transplantation for any of these
disorders, we will consider you to be disabled until at least 24 months from the date of
diagnosis or relapse, or at least 12 months from the date of transplantation, whichever is later.
2. Lymphoma or chronic phase of CML. If you undergo bone marrow or stem cell
transplantation for any of these disorders, we will consider you to be disabled until at least 12

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months from the date of transplantation.
3. Evaluating disability after the appropriate time period has elapsed. We consider any residual
impairment(s), such as complications arising from:
a. Graft-versus-host (GVH) disease.
b. Immunosuppressant therapy, such as frequent infections.
c. Significant deterioration of other organ systems.
113.01 Category of Impairments, Malignant Neoplastic Diseases
113.03 Malignant solid tumors. Consider under a disability:
A. For 2 years from the date of initial diagnosis. Thereafter, evaluate any residual impairment
(s) under the criteria for the affected body system.
OR
B. For 2 years from the date of recurrence of active disease. Thereafter, evaluate any residual
impairment(s) under the criteria for the affected body system.
113.05 Lymphoma (excluding T-cell lymphoblastic lymphoma—113.06). (See 113.00K1.)
A. Non-Hodgkins lymphoma, including Burkitt's and anaplastic large cell. Persistent or
recurrent following initial antineoplastic therapy.
OR
B. Hodgkin's disease with failure to achieve clinically complete remission, or recurrent disease
within 12 months of completing initial antineoplastic therapy.
OR
C. With bone marrow or stem cell transplantation. Consider under a disability until at least 12
months from the date of transplantation. Thereafter, evaluate any residual impairment(s) under
the criteria of the affected body system.
113.06 Leukemia. (See 113.00K2.)
A. Acute leukemia (including T-cell lymphoblastic lymphoma and juvenile chronic myelogenous
leukemia (JCML)). Consider under a disability until at least 24 months from the date of
diagnosis or relapse, or at least 12 months from the date of bone marrow or stem cell
transplantation, whichever is later. Thereafter, evaluate any residual impairment(s) under the
criteria for the affected body system.
OR

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B. Chronic myelogenous leukemia (except JCML), as described in 1 or 2:
1. Accelerated or blast phase. Consider under a disability until at least 24 months from the
date of diagnosis or relapse, or at least 12 months from the date of bone marrow or stem cell
transplantation, whichever is later. Thereafter, evaluate any residual impairment(s) under the
criteria for the affected body system.
2. Chronic phase, as described in a or b:
a. Consider under a disability until at least 12 months from the date of bone marrow or stem
cell transplantation. Thereafter, evaluate any residual impairment(s) under the criteria for the
affected body system.
b. Progressive disease following initial antineoplastic therapy.
113.09 Thyroid gland.
A. Anaplastic (undifferentiated) carcinoma.
OR
B. Carcinoma with metastases beyond the regional lymph nodes progressive despite
radioactive iodine therapy.
113.12 Retinoblastoma.
A. With extension beyond the orbit.
OR
B. Persistent or recurrent following initial antineoplastic therapy.
OR
C. With regional or distant metastases.
113.13 Brain tumors. (See 113.00K4.) Highly malignant tumors, such as Grades III and IV
astrocytomas, glioblastoma multiforme, ependymoblastoma, medulloblastoma or other
primitive neuroectodermal tumors (PNETs) with documented metastases, diffuse intrinsic brain
stem gliomas, or primary sarcomas.
113.21 Neuroblastoma.
A. With extension across the midline.
OR
B. With distant metastases.

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OR
C. Recurrent.
OR
D. With onset at age 1 year or older.
114.00 Immune System
A. Listed disorders include impairments involving deficiency of one or more components of the
immune system (i.e., antibody-producing B cells; a number of different types of cells
associated with cell-mediated immunity including T-lymphocytes, macrophages and
monocytes; and components of the complement system).
B. Dysregulation of the immune system may result in the development of a connective tissue
disorder. Connective tissue disorders include several chronic multisystem disorders that differ
in their clinical manifestation, course, and outcome. These disorders are described in part A,
14.00B; inflammatory arthritis is also described in 114.00E.
Some of the features of connective tissue disorders in children may differ from the features in
adults. When the clinical features are the same as that seen in adults, the principles and
concepts in part A, 14.00B apply.
The documentation needed to establish the existence of a connective tissue disorder is
medical history, physical examination, selected laboratory studies, appropriate medically
acceptable imaging, and, in some instances, tissue biopsy. Medically acceptable imaging
includes, but is not limited to, x-ray imaging, computerized axial tomography (CAT scan) or
magnetic resonance imaging (MRI), with or without contrast material, myelography, and
radionuclear bone scans. "Appropriate" means that the technique used is the proper one to
support the evaluation and diagnosis of the impairment. However, the Social Security
Administration will not purchase diagnostic tests or procedures that may involve significant
risk, such as biopsies or angiograms. Generally, the existing medical evidence will contain this
information.
In addition to the limitations caused by the connective tissue disorder per se, the chronic
adverse effects of treatment (e.g., corticosteroid-related ischemic necrosis of bone) may result
in functional loss.
A longitudinal clinical record of at least 3 months demonstrating active disease despite
prescribed treatment during this period with the expectation that the disease will remain active
for 12 months is necessary for assessment of severity and duration of impairment.
In children the impairment may affect growth, development, attainment of age-appropriate
skills, and performance of age-appropriate activities. The limitations may be the result of
serious loss of function because of disease affecting a single organ or body system, or lesser
degrees of functional loss because of disease affecting two or more organs/body systems
associated with significant constitutional symptoms and signs of severe fatigue, fever, malaise,
weight loss, and joint pain and stiffness. We use the term "severe" in these listings to describe
medical severity; the term does not have the same meaning as it does when we use it in

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connection with a finding at the second step of the sequential evaluation processes in
§§404.1520, 416.920, and 416.924.
C. Allergies, growth impairments and Kawasaki disease.
1. Allergic disorders (e.g., asthma or atopic dermatitis) are discussed and evaluated under the
appropriate listing of the affected body system.
2. If growth is affected by the disorder or its treatment by immunosuppressive drugs, 100.00,
Growth impairment, may apply. Children may have growth impairment as a result of the
inflammatory arthritides because of the diseases' potential effects on the immature skeleton,
open epiphyses, and young cartilage and bone. In such situations, the growth impairment
should be evaluated under 100.00ff.
3. Kawasaki disease, also known as mucocutaneous lymph node syndrome, is characterized
by multisystem manifestations, but significant functional impairment is usually due to disease
of the coronary arteries, which should be evaluated under 104.00.
D. Human immunodeficiency virus (HIV) infection.
1. HIV infection is caused by a specific retrovirus and may be characterized by susceptibility to
one or more opportunistic diseases, cancers, or other conditions, as described in 114.08. Any
child with HIV infection, including one with a diagnosis of acquired immunodeficiency
syndrome (AIDS), may be found disabled under this listing if his or her impairment meets any
of the criteria in 114.08 or is of equivalent severity to an impairment in 114.08.
2. Definitions. In 114.08, the terms "resistant to treatment," "recurrent," and "disseminated"
have the same general meaning as used by the medical community. The precise meaning of
any of these terms will depend upon the specific disease or condition in question, the body
system affected, the usual course of the disorder and its treatment, and the other
circumstances of the case.
"Resistant to treatment" means that a condition did not respond adequately to an appropriate
course of treatment. Whether a response is adequate, or a course of treatment appropriate,
will depend on the facts of the particular case.
"Recurrent" means that a condition that responded adequately to an appropriate course of
treatment has returned after a period of remission or regression. The extent of response (or
remission) and the time periods involved will depend on the facts of the particular case.
"Disseminated" means that a condition is spread widely over a considerable area or body
system(s). The type and extent of the spread will depend on the specific disease.
3. Documentation of HIV infection in children. The medical evidence must include
documentation of HIV infection. Documentation may be by laboratory evidence or by other
generally acceptable methods consistent with the prevailing state of medical knowledge and
clinical practice.
a. Documentation of HIV infection in children by definitive diagnosis. A definitive diagnosis of
HIV infection in children is documented by one or more of the following laboratory tests:

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i. For a child 24 months of age or older, a serum specimen that contains HIV antibodies. HIV
antibodies are usually detected by a screening test. The most commonly used screening test is
the ELISA. Although this test is highly sensitive, it may yield false positive results. Therefore,
positive results from an ELISA must be confirmed by a more definitive test (e.g., Western blot,
immunofluorescence assay). (See paragraph b, below, for information about HIV antibody
testing in children younger than 24 months of age).
ii. A specimen that contains HIV antigen (e.g., serum specimen, lymphocyte culture, or
cerebrospinal fluid (CSF) specimen).
iii. An immunoglobulin A (IgA) serological assay specific for HIV.
iv. Other test(s) that are highly specific for detection of HIV in children (e.g., polymerase chain
reaction (PCR)), or that are acceptable methods of detection consistent with the prevailing
state of medical knowledge.
When laboratory testing for HIV infection has been performed, every reasonable effort must be
made to obtain reports of the results of that testing.
b. Other acceptable documentation of HIV infection in children.
As noted in paragraph a, above, HIV infection is not documented in children under 24 months
of age by a serum specimen containing HIV antibodies. This is because women with HIV
infection often transfer HIV antibodies to their newborns. The mother's antibodies can persist
in the infant for up to 24 months, even if the infant is not HIV-infected. Only 20 to 30 percent of
such infants are actually infected. Therefore, the presence of serum HIV antibodies alone does
not establish the presence of HIV infection in a child under 24 months of age. However, the
presence of HIV antibodies accompanied by evidence of significantly depressed T-helper
lymphocytes (CD4), an abnormal CD4/CD8 ratio, or abnormal immunoglobulin G (IgG) may be
used to document HIV infection in a child under 24 months of age, even though such testing is
not a basis for a definitive diagnosis.
For children from birth to the attainment of 24 months of age who have tested positive for HIV
antibodies (see D3a above), HIV infection may be documented by one or more of the
following:
i. For an infant 12 months of age or less, a CD4 (T4) count of 1500/mm[3] or less, or a CD4
count less than or equal to 20 percent of total lymphocytes.
ii. For an infant from 12 to 24 months of age, a CD4 (T4) count of 750/mm[3] or less, or a CD4
count less than or equal to 20 percent of total lymphocytes.
iii. An abnormal CD4/CD8 ratio.
iv. An IgG significantly greater than or less than the normal range for age.
HIV infection in children may also be documented without the definitive laboratory evidence
described in paragraph a, or the other laboratory evidence discussed above, provided that
such documentation is consistent with the prevailing state of medical knowledge and clinical

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practice and is consistent with the other evidence. If such laboratory evidence is not available,
HIV infection may be documented by the medical history, clinical and laboratory findings, and
diagnosis(es) indicated in the medical evidence. For example, a diagnosis of HIV infection in
children will be accepted without definitive laboratory evidence if the child has an opportunistic
disease (e.g., Pneumocystis carinii pneumonia (PCP)) predictive of a defect in cell-mediated
immunity, and there is no other known cause of diminished resistance to that disease (e.g.,
long-term steroid treatment, lymphoma). In such cases, every reasonable effort must be made
to obtain full details of the history, medical findings, and results of testing.
4. Documentation of the manifestations of HIV infection in children. The medical evidence must
also include documentation of the manifestations of HIV infection in children. Documentation
may be by laboratory evidence or by other generally acceptable methods consistent with the
prevailing state of medical knowledge and clinical practice.
a. Documentation of the manifestations of HIV infection in children by definitive diagnosis.
The definitive method of diagnosing opportunistic diseases or conditions that are
manifestations of HIV infection in children is by culture, serological test, or microscopic
examination of biopsied tissue or other material (e.g., bronchial washings). Therefore, every
reasonable effort must be made to obtain specific laboratory evidence of an opportunistic
disease or other condition whenever this information is available. If a histological or other test
has been performed, the evidence should include a copy of the appropriate report. If the report
is not obtainable, the summary of hospitalization or a report from the treating source should
include details of the findings and results of the diagnostic studies (including radiographic
studies) or microscopic examination of the appropriate tissues or body fluids.
Although a reduced CD4 lymphocyte count in a child may show that there is an increased
susceptibility to opportunistic infections and diseases, that alone does not document the
presence, severity, or functional effects of a manifestation of HIV infection in a child.
b. Other acceptable documentation of the manifestations of HIV infection in children.
Manifestations of HIV infection in children may also be documented without the definitive
laboratory evidence described in paragraph a, provided that such documentation is consistent
with the prevailing state of medical knowledge and clinical practice and is consistent with the
other evidence. If no definitive laboratory evidence is available, manifestations of HIV infection
may be documented by medical history, clinical and laboratory findings, and diagnosis(es)
indicated in the medical evidence. In such cases, every reasonable effort must be made to
obtain full details of the history, medical findings, and results of testing.
Documentation of cytomegalovirus (CMV) disease (114.08D) presents special problems
because diagnosis requires identification of viral inclusion bodies or a positive culture from the
affected organ, and the absence of any other infectious agent. A positive serology test
identifies infection with the virus, but does not confirm a disease process. With the exception of
chorioretinitis (which may be diagnosed by an ophthalmologist), documentation of CMV
disease requires confirmation by biopsy or other generally acceptable methods consistent with
the prevailing state of medical knowledge and clinical practice.
5. HIV infection in children. The clinical manifestation and course of disease in children who
become infected with HIV perinatally or in the first 6 years of life may differ from that in older

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children and adults. In addition, survival times are shorter for children infected in the first year
of life compared to those who become infected as older children or as adults. Infants may
present with failure to thrive or pneumocystis carinii pneumonia (PCP); young children may
present with recurrent infections, neurological problems, or developmental abnormalities. Older
children may also exhibit neurological abnormalities, such as HIV encephalopathy, or failure to
thrive.
The methods of identifying and evaluating neurological abnormalities may vary depending on a
child's age. For example, in an infant, impaired brain growth can be documented by a
decrease in the growth rate of the head. In older children, impaired brain growth can be
documented by brain atrophy on a CAT scan. Neurological abnormalities can also be observed
in a younger child in the loss of previously acquired, or marked delays in achieving,
developmental milestones. In an older child, this type of neurological abnormality would
generally be demonstrated by the loss of previously acquired intellectual abilities. Although
loss of previously acquired intellectual abilities can be documented by a decrease in
intelligence quotient (IQ) scores or demonstrated if a child forgets information he or she
previously learned, it can also be shown if the child is unable to learn new information. This
could include the sudden acquisition of a new learning disability.
Children with HIV infection may contract any of a broad range of bacterial infections. Certain
major infections caused by pyogenic bacteria, e.g., some pneumonias, can be severely
limiting, especially in pre-adolescent children. These major bacterial infections should be
evaluated under 114.08A5, which requires two or more such infections within a 2-year period.
Although 114.08A5 applies only to children less than 13 years of age, an older child may be
found to have an impairment of equivalent severity if the circumstances of the case warrant
(e.g., delayed puberty).
Otherwise, bacterial infections are evaluated under 114.08A6. The criteria of the listing are met
if one or more bacterial infection(s) occurs and requires hospitalization or intravenous antibiotic
treatment 3 or more times in 1 year. Pelvic inflammatory disease in older female children
should be evaluated under multiple or recurrent bacterial infections (114.08A6).
6. Evaluation of HIV infection in children. The criteria in 114.08 do not describe the full
spectrum of diseases or conditions manifested by children with HIV infection. As in any case,
consideration must be given to whether a child's impairment(s) meets, medically equals, or
functionally equals the severity of any other listing in appendix 1 of subpart P; e.g., a
neoplastic disorder listed in 113.00ff. (See §§404.1526, 416.926, and 416.926a.) Although
114.08 includes cross-references to other listings for the more common manifestations of HIV
infection, additional listings may also apply.
In addition, the impact of all impairments, whether or not related to the HIV infection, must be
considered. Children with HIV infection may manifest signs and symptoms of a mental
impairment (e.g., anxiety, depression), or of another physical impairment. Medical evidence
should include documentation of all physical and mental impairments and the impairment(s)
should be evaluated not only under the relevant listing(s) in 114.08, but under any other
appropriate listing(s).
It is also important to remember that children with HIV infection, like all others, are evaluated
under the full sequential evaluation process described in §416.924. If a child with HIV infection
is working and engaging in substantial gainful activity (SGA), or does not have a severe

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impairment, the case will be decided at the first or second step of the sequential evaluation
process, and does not require evaluation under these listings. For a child with HIV infection
who is not engaging in SGA and has a severe impairment, but whose impairment(s) does not
meet the criteria of a listing, consideration will be given to whether the child's impairment or
combination of impairments is either medically or functionally equivalent in severity to any
listed impairment.
7. Effect of treatment. Medical treatment must be considered in terms of its effectiveness in
ameliorating the signs, symptoms, and laboratory abnormalities of the specific disorder, or of
the HIV infection itself (e.g. antiretroviral agents) and in terms of any side effects of treatment
that may further impair the child.
Response to treatment and adverse or beneficial consequences of treatment may vary widely.
For example, a child with HIV infection who develops otitis media may respond to the same
antibiotic regimen used in treating children without HIV infection, but another child with HIV
infection may not respond to the same regimen. Therefore, each case must be considered on
an individual basis, along with the effects of treatment on the child's ability to function.
A specific description of the drugs or treatment given (including surgery), dosage, frequency of
administration, and a description of the complications or response to treatment should be
obtained. The effects of treatment may be temporary or long-term. As such, the decision
regarding the impact of treatment should be based on a sufficient period of treatment to permit
proper consideration.
8. Functional criteria. Paragraph O of 114.08 establishes standards for evaluating
manifestations of HIV infection that do not meet the requirements listed in 114.08A-N.
Paragraph O is applicable for manifestations that are not listed in 114.08A-N, as well as those
listed in 114.08A-N that do not meet the criteria of any of the rules in 114.08A-N.
For children with HIV infection evaluated under 114.08O, listing-level severity will be assessed
in terms of the functional limitations imposed by the impairment. The full impact of signs,
symptoms, and laboratory findings on the child's ability to function must be considered.
Important factors to be considered in evaluating the functioning of children with HIV infection
include, but are not limited to: symptoms, such as fatigue and pain; characteristics of the
illness, such as the frequency and duration of manifestations or periods of exacerbation and
remission in the disease course; and the functional impact of treatment for the disease,
including the side effects of medication.
To meet the criteria in 114.08O, a child with HIV infection must demonstrate a level of
restriction in either one or two (depending on the child's age) of the general areas of
functioning applicable to the child's age group. (See 112.00C for additional discussion of these
areas of functioning).
E. Inflammatory arthritis (114.09) includes a vast array of disorders that differ in cause, course,
and outcome. For example, in children inflammatory spondyloarthropathies include juvenile
ankylosing spondylitis, reactive arthropathies, psoriatic arthropathy, and Behçet's disease, as
well as undifferentiated spondylitis. Inflammatory arthritis of peripheral joints likewise
comprises many disorders, including juvenile rheumatoid arthritis, Sjögren's syndrome,
psoriatic arthritis, crystal deposition disorders, and Lyme disease. Clinically, inflammation of
major joints may be the dominant problem causing difficulties with ambulation or fine and gross

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movements, or the arthritis may involve other joints or cause less restriction of age-appropriate
ambulation or other movements but be complicated by extra-articular features that
cumulatively result in serious functional deficit. When persistent deformity without ongoing
inflammation is the dominant feature of the impairment, it should be evaluated under 101.02,
or, if there has been surgical reconstruction, 101.03.
1. Because the features of inflammatory connective tissue diseases in children are modified by
such factors as the child's limited antigenic exposure and immune reactivity, the acute
inflammatory connective tissue diseases must be differentiated from each other in order to
evaluate duration factors and responses to specific treatments. Chronic conditions must be
differentiated from short-term reversible disorders, and also from other connective tissue
diseases.
2. In 114.09A, the term major joints refers to the major peripheral joints, which are the hip,
knee, shoulder, elbow, wrist-hand, and ankle-foot, as opposed to other peripheral joints (e.g.,
the joints of the hand or forefoot) or axial joints (i.e., the joints of the spine.) The wrist and hand
are considered together as one major joint, as are the ankle and foot. Since only the ankle
joint, which consists of the juncture of the bones of the lower leg (tibia and fibula) with the
hindfoot (tarsal bones), but not the forefoot, is crucial to weight bearing, the ankle and foot are
considered separately in evaluating weight bearing.
3. The terms inability to ambulate effectively and inability to perform fine and gross movements
effectively in 114.09A have the same meaning as in 101.00B2b and 101.00B2c and must have
lasted, or be expected to last, for at least 12 months.
4. Inability to ambulate effectively is implicit in 114.09B. Even though children who
demonstrate the findings of 114.09B will not ordinarily require bilateral upper limb assistance,
the required ankylosis of the cervical or dorsolumbar spine will result in an extreme loss of the
ability to see ahead, above, and to the side.
5. As in 114.02 through 114.06, extra-articular features of an inflammatory arthritis may satisfy
the criteria for a listing in an involved extra-articular body system. Such impairments may be
found to meet a criterion of 114.09C. Extra-articular impairments of lesser severity should be
evaluated under 114.09D and 114.09E. Commonly occurring extra-articular impairments
include keratoconjunctivitis sicca, uveitis, iridocyclitis, pleuritis, pulmonary fibrosis or nodules,
restrictive lung disease, pericarditis, myocarditis, cardiac arrhythmias, aortic valve
insufficiency, coronary arteritis, Raynaud's phenomena, systemic vasculitis, amyloidosis of the
kidney, chronic anemia, thrombocytopenia, hypersplenism with compromised immune
competence (Felty's syndrome), peripheral neuropathy, radiculopathy, spinal cord or cauda
equina compression with sensory and motor loss, and heel enthesopathy with functionally
limiting pain.
6. The fact that a child is dependent on steroids, or any other drug, for the control of
inflammatory arthritis is, in and of itself, insufficient to find disability. Advances in the treatment
of inflammatory connective tissue disease and in the administration of steroids for its treatment
have corrected some of the previously disabling consequences of continuous steroid use.
Therefore, each case must be evaluated on its own merits, taking into consideration the
severity of the underlying impairment and any adverse effects of treatment.
114.01 Category of Impairments, Immune System

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114.02 Systemic lupus erythematosus. Documented as described in 14.00B1 and 114.00B,
with:
A. One of the following:
1. Growth impairment, as described under the criteria in 100.00ff; or
2. Musculoskeletal involvement, as described under the criteria in 101.00ff; or
3. Muscle involvement, as described under the criteria in 14.05; or
4. Ocular involvement, as described under the criteria in 102.00ff; or
5. Respiratory involvement, as described under the criteria in 103.00ff; or
6. Cardiovascular involvement, as described under the criteria in 104.00ff or 14.04D; or
7. Digestive involvement, as described under the criteria in 105.00ff; or
8. Renal involvement, as described under the criteria in 106.00ff; or
9. Hematologic involvement, as described under the criteria in 107.00ff; or
10. Skin involvement, as described under the criteria in 8.00ff; or
11. Endocrine involvement, as described under the criteria in 109.00ff; or
12. Neurological involvement, as described under the criteria in 111.00ff; or
13. Mental involvement, as described under the criteria in 112.00ff.
or
B. Lesser involvement of two or more organs/body systems listed in paragraph A, with
significant, documented, constitutional symptoms and signs of severe fatigue, fever, malaise,
and weight loss. At least one of the organs/body systems must be involved to at least a
moderate level of severity.
114.03 Systemic vasculitis. As described under the criteria in 14.03 or, if growth impairment,
as described under the criteria in 100.00ff.
114.04 Systemic sclerosis and scleroderma. Documented as described in 14.00B3 and
114.00B, and:
A. As described under the criteria in 14.04 or, if growth impairment, as described under the
criteria in 100.00ff.
or

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B. Linear scleroderma, with one of the following:
1. Fixed valgus or varus deformities of both hands or both feet; or
2. Marked destruction or marked atrophy of an extremity; or
3. Facial disfigurement from hypoplasia of the mandible, maxilla, or zygoma resulting in an
impairment as described under the criteria in 112.00ff; or
4. Seizure disorder, as described under the criteria in 111.00ff.
114.05 Polymyositis or dermatomyositis. Documented as described in 14.00B4 and 114.00B,
and:
A. As described under the criteria in 14.05.
or
B. With one of the following:
1. Multiple joint contractures; or
2. Diffuse cutaneous calcification with formation of an exoskeleton; or
3. Systemic vasculitis as described under the criteria in 14.03.
114.06 Undifferentiated connective tissue disorder. As described under the criteria in 114.02 or
114.04.
114.07 Congenital immune deficiency disease.
A. Hypogammaglobulinemia or dysgammaglobulinemia, with:
1. Documented, recurrent severe infections occurring 3 or more times within a 5-month period;
or
2. An associated disorder such as growth retardation, chronic lung disease, collagen disorder
or tumor. Evaluate according to the appropriate body system listing.
or
B. Thymic dysplastic syndromes (such as Swiss, diGeorge).
114.08 Human immunodeficiency virus (HIV) infection. With documentation as described in
114.00D3 and one of the following:
A. Bacterial infections:
1. Mycobacterial infection (e.g., caused by M. avium-intracellulare, M. kansasii, or M.

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tuberculosis) at a site other than the lungs, skin, or cervical or hilar lymph nodes; or pulmonary
tuberculosis resistant to treatment; or
2. Nocardiosis; or
3. Salmonella bacteremia, recurrent non-typhoid.
4. Syphilis or neurosyphilis—evaluate sequelae under the criteria for the affected body system
(e.g., 102.00 Special Senses and Speech, 104.00 Cardiovascular System, 111.00
Neurological); or
5. In a child less than 13 years of age, multiple or recurrent pyogenic bacterial infection(s) of
the following types: sepsis, pneumonia, meningitis, bone or joint infection, or abscess of an
internal organ or body cavity (excluding otitis media or superficial skin or mucosal abscesses)
occurring 2 or more times in 2 years; or
6. Other multiple or recurrent bacterial infection(s), including pelvic inflammatory disease,
requiring hospitalization or intravenous antibiotic treatment 3 or more times in 1 year.
or
B. Fungal infections:
1. Aspergillosis; or
2. Candidiasis, at a site other than the skin, urinary tract, intestinal tract, or oral or vulvovaginal
mucous membranes; or candidiasis involving the esophagus, trachea, bronchi, or lungs; or
3. Coccidioidomycosis, at a site other than the lungs or lymph nodes; or
4. Cryptococcosis, at a site other than the lungs (e.g., cryptococcal meningitis); or
5. Histoplasmosis, at a site other than the lungs or lymph nodes; or
6. Mucormycosis.
or
C. Protozoan or helminthic infections:
1. Cryptosporidiosis, isosporiasis, or microsporidiosis, with diarrhea lasting for 1 month or
longer; or
2. Pneumocystis carinii pneumonia or extrapulmonary pneumocystis carinii infection; or
3. Strongyloidiasis, extra-intestinal; or
4. Toxoplasmosis of an organ other than the liver, spleen, or lymph nodes.

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or
D. Viral infections:
1. Cytomegalovirus disease (documented as described in 114.00D4b) at a site other than the
liver, spleen, or lymph nodes; or
2. Herpes simplex virus causing:
a. Mucocutaneous infection (e.g., oral, genital, perianal) lasting for 1 month or longer; or
b. Infection at a site other than the skin or mucous membranes (e.g., bronchitis, pneumonitis,
esophagitis, or encephalitis); or
c. Disseminated infection; or
3. Herpes zoster, either disseminated or with multidermatomal eruptions that are resistant to
treatment; or
4. Progressive multifocal leukoencephalopathy; or
5. Hepatitis, as described under the criteria of 105.05.
or
E. Malignant neoplasms:
1. Carcinoma of the cervix, invasive, FIGO stage II and beyond; or
2. Karposi's sarcoma with:
a. Extensive oral lesions; or
b. Involvement of the gastrointestinal tract, lungs, or other visceral organs; or
c. Involvement of the skin or mucous membranes as described under the criteria of 114.08F;
or
3. Lymphoma (e.g., primary lymphoma of the brain, Burkitt's lymphoma, immunoblastic
sarcoma, other Non-Hodgkin's lymphoma, Hodgkin's disease); or
4. Squamous cell carcinoma of the anus.
or
F. Conditions of the skin or mucous membranes (other than described in B2, D2, or D3 above)
with extensive fungating or ulcerating lesions not responding to treatment (e.g., dermatological
conditions such as eczema or psoriasis, vulvovaginal or other mucosal candida, condyloma
caused by human papillomavirus, genital ulcerative disease), or evaluate under the criteria in

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8.00ff.
or
G. Hematologic abnormalities:
1. Anemia, as described under the criteria in 7.02; or
2. Granulocytopenia, as described under the criteria in 7.15; or
3. Thrombocytopenia, as described under the criteria of 107.06 or 7.06.
or
H. Neurological manifestations of HIV infection (e.g., HIV encephalopathy, peripheral
neuropathy), as described under the criteria in 111.00ff, or resulting in one or more of the
following:
1. Loss of previously acquired, or marked delay in achieving, developmental milestones or
intellectual ability (including the sudden acquisition of a new learning disability); or
2. Impaired brain growth (acquired microcephaly or brain atrophy—see 114.00D5); or
3. Progressive motor dysfunction affecting gait and station or fine and gross motor skills.
or
I. Growth disturbance, with:
1. An involuntary weight loss (or failure to gain weight at an appropriate rate for age) resulting
in a fall of 15 percentiles from established growth curve (on standard growth charts) that
persists for 2 months or longer; or
2. An involuntary weight loss (or failure to gain weight at an appropriate rate for age) resulting
in a fall to below the third percentile from established growth curve (on standard growth charts)
that persists for 2 months or longer; or
3. Involuntary weight loss greater than 10 percent of baseline that persists for 2 months or
longer; or
4. Growth impairment as described under the criteria in 100.00ff.
or
J. Diarrhea, lasting for 1 month or longer, resistant to treatment, and requiring intravenous
hydration, intravenous alimentation, or tube feeding.
or

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K. Cardiomyopathy, as described under the criteria in 104.00ff or 11.04.
or
L. Lymphoid interstitial pneumonia/pulmonary lymphoid hyperplasia (LIP/PLH complex), with
respiratory symptoms that significantly interfere with age-appropriate activities, and that cannot
be controlled by prescribed treatment.
or
M. Nephropathy, as described under the criteria in 106.00.
or
N. One or more of the following infections (other than described in A-M, above), resistant to
treatment or requiring hospitalization or intravenous treatment 3 or more times in 1 year (or
evaluate sequelae under the criteria for the affected body system):
1. Sepsis;
2. Meningitis; or
3. Pneumonia; or
4. Septic arthritis; or
5. Endocarditis; or
6. Sinusitis documented by appropriate medically acceptable imaging.
or
O. Any other manifestation(s) of HIV infection (including any listed in 114.08A-N, but without
the requisite findings, e.g., oral candidiasis not meeting the criteria in 114.08F, diarrhea not
meeting the criteria in 114.08J, or any other manifestation(s), e.g., oral hairy leukoplakia,
hepatomegaly), resulting in one of the following:
1. For children from birth to attainment of age 1, at least one of the criteria in paragraphs A-E
of 112.12; or
2. For children age 1 to attainment of age 3, at least one of the appropriate age-group criteria
in paragraph B1 of 112.02; or
3. For children age 3 to attainment of age 18, at least two of the appropriate age-group criteria
in paragraph B2 of 112.02.
114.09 Inflammatory arthritis. Documented as described in 114.00E, with one of the following:
A. History of joint pain, swelling, and tenderness, and signs on current physical examination of

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Appendix 1 to Subpart P

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joint inflammation or deformity in two or more major joints resulting in inability to ambulate
effectively or inability to perform fine and gross movements effectively, as defined in 114.00E3
and 101.00B2b and B2c;
or
B. Ankylosing spondylitis or other spondyloarthropathy, with diagnosis established by findings
of unilateral or bilateral sacroiliitis (e.g., erosions or fusions), shown by appropriate medically
acceptable imaging, with both:
1. History of back pain, tenderness, and stiffness, and
2. Findings on physical examination of ankylosis (fixation) of the dorsolumbar or cervical spine
at 45° or more of flexion measured from the vertical position (zero degrees);
or
C. An impairment as described under the criteria in 114.02A.
or
D. Inflammatory arthritis, with signs of peripheral joint inflammation on current examination, but
with lesser joint involvement than in A and lesser extra-articular features than in C, and:
1. Significant, documented constitutional symptoms and signs (e.g., fatigue, fever, malaise,
weight loss), and
2. Involvement of two or more organs/body systems (see 114.00E5). At least one of the
organs/body systems must be involved to at least a moderate level of severity.
or
E. Inflammatory spondylitis or other inflammatory spondyloarthropathies, with lesser deformity
than in B and lesser extra-articular features than in C, with signs of unilateral or bilateral
sacroiliitis on appropriate medically acceptable imaging; and with the extra-articular features
described in 114.09D.
[50 FR 35066, Aug. 28, 1985]
For FEDERAL REGISTER citations affecting appendix 1 to subpart P of part 404,
see the List of CFR Sections Affected, which appears in the Finding Aids section of the printed
volume and on GPO Access.
EDITORIAL NOTE:

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