More On Listings

Suzanne [email protected]://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

NOSSCR October 2009San Francisco, CA

• 1955 First list of disabling diseases• 1968 Listings published in CFR• 1977 Children published in CFR• 1985 revised mental• 1997 Children revised (interim final rules)• 2001 Children revised (final rules)• 2002 revised musculoskeletal• 2004 revised skin, cancer• 2005 revised genitourinary• 2006 revised medical equivalence

standard, revised cardiac• 2007 revised digestive, special senses & speech• 2008 revised immune system

Alan L. Cowles, M.D., Ph.D. The History of the Disability Listings, March 2, 2005 http://www.ssa.gov/history/pdf/Listings_History.pdf

[email protected] http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

2009 Malignant Neoplastic

Diseases 2010

Growth Impairment Respiratory System Hematological

Disorders Endocrine System Neurological Mental Disorders

2011 Musculoskeletal System Cardiovascular System

2012 Digestive System Skin Disorders

2013 Genitourinary

Impairments Impairments That Affect

Multiple Body Systems 2015

Special Senses and Speech

2016 Immune System


• SOURCE: Annual Statistical Report on the Social Security Disability Insurance Program, 2003, Table 36.

• NOTES: Unknown diagnoses are excluded from the series. There was a change in the data series in 1995. Before 1995, the diagnostic data for awards at the appeals level were estimated from the diagnoses of cases allowed at the initial level. Beginning in 1995, all levels of decisions were included in the diagnostic data.


1.05C BEFORE 11/19/01

(e.g., herniated nucleus pulposus, spinal stenosis) with the following persisting for at least 3 months despite prescribed therapy and expected to last 12 months. With Pain, muscle spasm, and significant limitation of motion in

the spine, and appropriate radicular distribution

of significant motor loss with muscle weakness, and

sensory, and reflex loss.

1.04A AFTER 11/19/01

(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 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)[email protected] http://www.linkedin.com/pub/suzanne-villalon-

hinojosa/9/199/786

• We no longer require anatomic or radicular distribution of both sensory and reflex abnormalities…but require only that one or the other be present.

• This is because sensory and reflex abnormalities are not concurrent in all cases of nerve root compression that would nonetheless be disabling at the listing level.

• Depending on the level of the compression, both sensory and reflex abnormalities may not occur anatomically.

• The listing does require a “neuro-anatomic distribution” of pain to make clear that the nerve root compression would have to be reasonably expected to cause the pain. – 66 Fed Reg. 58018

AHCPR Archived Quick Reference Guide http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.34420#34422


Bechterew Sign

Bonnets Phenomena

Bragard’s Sign

Drop Test Ely’s Sign Fajersztajn

Test Flip Test Gaenslen

Test Goldthwait’

s Test Kernig Sign

Lasegue Sign

Linder Sign Nachlas Test Neri Bowing

Sign Ober Sign Patrick Test Sicards Sign Smith

Peterson Test

Spurlings Sign

Yeomans Test AHCPR Archived Quick Reference Guide

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.34420#34422

Straight and Bent Leg Raising Tests, Jesse N. Borden, M.D., FACS, Diplomate American Board of Orthopedic Surgery


The straight leg raising (SLR) test can detect tension on the L5 and/or S1 nerve root. SLR may reproduce leg pain by stretching nerve roots irritated by a disc herniation.

Pain below the knee at less than 70 degrees of straight leg raising, aggravated by dorsiflexion of the ankle and relieved by ankle plantar flexion or external limb rotation, is most suggestive of tension on the L5 or S1 nerve root related to disc herniation. Reproducing back pain alone with SLR testing does not indicate significant nerve root tension.

Crossover pain occurs when straight raising of the patient's well limb elicits pain in the leg with sciatica. Crossover pain is a stronger indication of nerve root compression than pain elicited from raising the straight painful limb.

Sitting knee extension can also test sciatic tension. The patient with significant nerve root irritation tends to complain or lean backward to reduce tension on the nerve.


http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.34313

SSA will not re-contact the clinician and will accept the positive test unless: SLR is positive in one position but negative in the

other position The pain elicited is not in the appropriate neuro-

anatomical distribution The positive SLR findings are not consistently

reproducible (that does not mean present at every exam), or

Back pain is noted as a positive SLR test (not a true positive result).


• Number of deaths for leading causes of death:– Heart disease: 631,636 – Cancer: 559,888 – Stroke (cerebrovascular diseases):

137,119 – Chronic lower respiratory diseases:

124,583 – Accidents (unintentional injuries):

121,599 – Diabetes: 72,449 – Alzheimer's disease: 72,432 – Influenza and Pneumonia: 56,326 – Nephritis, nephrotic syndrome, and

nephrosis: 45,344 – Septicemia: 34,234

• Source: Deaths: Final Data for 2006, Tables B, D, 7, [email protected] http://www.linkedin.com/pub/suzanne-villalon-

hinojosa/9/199/786

9.08 BEFORE 11/19/01 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

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. Amputation at, or above, the tarsal region Due to diabetic necrosis or peripheral

arterial disease; or D. Retinitis proliferans;

Evaluate the visual impairment under the criteria in 2.02, 2.03, or 2.04

9.08 AFTER 11/19/01

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

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


1.05B 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.

Engineering advances have produced prosthetic devices which minimize and distribute stress so that some individuals wearing artificial limbs after amputation above the tarsal level for any reason (including diabetes mellitus, and vascular and arterial disease ) are able to work.

66 Fed. Reg. [email protected] http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

• 4 out of 5 patients undergoing an amputation will do well. But diabetics who have had one lower limb amputated• have a 50 percent mortality rate in the

five years following the amputation, and a• 50 percent risk of developing a serious

lesion in the second limb within two years.

http://www.reversegangrene.com/foot_gangrene_bk_amputation_home.htm


…we recognize that individuals with the type of lower extremity amputation described in final listing 1.05B, will have an inability to ambulate effectively, as defined in 1.00B2b, when they are not using a prosthesis.

This would be true whether they do not use a prosthesis because: they cannot afford one, a prosthesis has not been

prescribed for them, or for other reasons.

▪ 66 Fed.Reg. 58015

An individual’s inability to afford treatment and/or inaccessibility in the local community is a justifiable cause for failing to follow treatment.SSR 82-59


• Meet a listing

– All the criteria of the listing is found in the evidence

– Any relevant criteria in the introduction is also found in the evidence, and

– The duration requirement is met.• 20 CFR §§ 404.1525(c)(3) and

415.925(c)(3)

• Equal a listing– You have a listed impairment

without the requisite findings (or you have them all but one is not severe enough) but you also have other findings that are of equal medical significance to the required criteria.

– You have an unlisted impairment but you also have findings closely analogous to listed impairments.

– You have a combination of impairments which don’t meet a listing but you also have findings which are of at least equal medical significance to the required criteria.• 20 CFR §§ 404.1526 and


20 CFR § 404.1528 Symptoms are outside the medical evidence of

record. SSR 96-3p

Symptoms cannot be the basis of severity if not supported by “objective medical evidence.”

SSR 96-7p Symptoms cannot be the basis of a finding of

disability unless medical signs & lab findings establish the impairment which could reasonably be expected to produce the symptoms.

Symptoms are not enough to equal a listing


All evidence (except vocational factors) is relevant to a determination of equivalence. 404.1526(c) Symptoms are considered when consistent with

impairments. 404.1529(b) Evaluate symptoms by comparing objective evidence to

other evidence. Other evidence includes statements from you, treating, non-

treating sources about: what may precipitate or aggravate your symptoms, treatments or other methods you use to alleviate them, and how the

symptoms may affect your pattern of daily living) 404.1529(c)(3)

If the symptoms, signs, and laboratory findings of your impairment(s) are equivalent in severity to those of a listed impairment, we will find you disabled. 404.1529(d)(3)

Evidentiary Requirements for Making Findings About Medical Equivalence , 71 Fed. Reg. 10424, March 1, 2006

But equivalence “happens” when: other findings=listed

findings


A dysthymic disorder (an unlisted impairment) that medically equals listing 12.04A1, major depressive disorder is by definition as medically severe as a major depressive disorder.

▪ 71 Fed. Reg. [email protected] http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

However, a different functional limitation could substitute for a required finding if equally severe. 1 extreme=2 marked

(mental impairments) 2 moderates=1

marked (immune system disorders)

20 CFR § 404.1529(d)(3)


In conditions which are episodic in character, c0nsideration should be given to frequency and duration of exacerbations, length of remissions, and permanent residuals. 11.00D

Episodic nature acknowledged and frequency specified in the listing: seizures, asthma, recurrent arrhythmias, sickle cell crises,

ischemic heart disease, mental impairments, autoimmune disorders

Episodic nature acknowledged and frequency not specified meniere’s, multiple sclerosis, myasthenia gravis, skin

Episodic nature not acknowledged nor frequency specified: diabetes

Unlisted but episodic: migraines, narcolepsy, pancreatitis


• An individual’s migraine headaches (an unlisted impairment) are medically equivalent in severity to listing 11.03, a seizure disorder listing that is the most closely analogous listing we have for comparison.

–71 Fed. Reg. [email protected] http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

Arachnoiditis is chronic inflammation inside the dura, whereas epidural fibrosis is scarring outside the dural sac.

Many doctors appear to regard epidural fibrosis as less clinically significant than arachnoiditis, but in essence the nerve root compression arising from epidural fibrosis may cause similar clinical problems in terms of lower limb pain, sensory disturbance and weakness.

In cases of arachnoiditis, there is often associated epidural fibrosis, but the reverse is not generally acknowledged, so that patients may be left with a diagnosis of epidural fibrosis and are unable to get a diagnosis of arachnoiditis even when the clinical picture fits.

Arachnoiditis is an underdiagnosed condition.

The Adhesive Arachnoiditis Syndrome, Dr. Sara Smith, http://www.arachnoiditis.info/content/

the_adhesive_arachnoiditis_syndrome/the_adhesive_arachnoiditis_syndrome_3.html [email protected] http://www.linkedin.com/pub/suzanne-villalon-

hinojosa/9/199/786

• RSD – http://rsdrx.com/what_is_rsd.htm

• Kidney disease– http://www.emedicinehealth.com/chronic_kidney_disease/

article_em.htm• Liver disease

– http://www.liverfoundation.org/education/info/progression/• Cardiac

– http://www.americanheart.org/presenter.jhtml?identifier=4569• Cancer

– http://www.cancer.gov/cancertopics/factsheet/Detection/staging• Multiple Sclerosis

– http://www.mssociety.org.uk/about_ms/types_of_ms/index.html• Gout

– http://www.niams.nih.gov/Health_Info/Gout/[email protected] http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

longstanding policy requires that the judgment of a physician (or psychologist) designated by the Commissioner on the issue of equivalence on the evidence before the administrative law judge or the Appeals Council must be received into the record as expert opinion evidence and given appropriate weight.


Old 404.1526: medical evidence only

We will also consider the medical opinion given by one or more medical or psychological consultants designated by the Commissioner in deciding medical equivalence

New 404.1526: all evidence We also consider the opinion

given by one or more medical or psychological consultants designated by the Commissioner.


Administrative law judges may also ask for and consider opinions from medical experts on whether your impairment(s) equals the requirements of any impairment listed in appendix 1 to this subpart. 404.1527(f)(2)(iii)

Although we consider opinions from medical sources on issues such as whether your impairment(s) meets or equals the requirements of any impairment(s) in the Listing of Impairments, your residual functional capacity…the final responsibility for deciding these issues is reserved to the Commissioner. 404.1527(e)(2)

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