[Federal Register Volume 64, Number 83 (Friday, April 30, 1999)]
[Notices]
[Pages 23380-23384]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-10840]


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SOCIAL SECURITY ADMINISTRATION


Social Security Ruling, SSR 99-2p.; Titles II and XVI: Evaluating 
Cases Involving Chronic Fatigue Syndrome (CFS)

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling.

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SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of 
Social Security gives notice of Social Security Ruling, SSR 99-2p. This 
Ruling clarifies disability policy for the evaluation and adjudication 
of disability claims invo1ving Chronic Fatigue Syndrome (CFS). This 
Ruling explains that, when it is accompanied by appropriate medical 
signs or laboratory findings, CFS is a medically determinable 
impairment that can be the basis for a finding of ``disability.'' This 
Ruling ensures that all adjudicators will use the same policies and 
procedures in evaluating disability claims involving CFS, and provides 
a consolidated statement of these policies and procedures.

EFFECTIVE DATE: April 30, 1999.

FOR FURTHER INFORMATION CONTACT: Carolyn Kiefer, Office of Disability, 
Division of Medical and Vocational Policy, Social Security 
Administration, 6401 Security Boulevard, Baltimore, MD 21235-6401, 
(410) 965-9104.

SUPPLEMENTARY INFORMATION: Although we are not required to do so 
pursuant to 5 U.S.C. 552(a)(1) and (a)(2), we are publishing this 
Social Security Ruling in accordance with 20 CFR 402.35(b)(1).
    Social Security Rulings make available to the public precedential 
decisions relating to the Federal old-age, survivors, disability, 
supplemental security income, and black lung benefits programs. Social 
Security Rulings may be based on case decisions made at all 
administrative levels of adjudication, Federal court decisions, 
Commissioner's decisions, opinions of the Office of the General 
Counsel, and policy interpretations of the law and regulations.
    Although Social Security Rulings do not have the same force and 
effect as the statute or regulations, they are binding on all 
components of the Social Security Administration, in accordance with 20 
CFR 402.35(b)(1), and are to be relied upon as precedents in 
adjudicating cases.
    If this Social Security Ruling is later superseded, modified, or 
rescinded, we will publish a notice in the Federal Register to that 
effect.

(Catalog of Federal Domestic Assistance, Programs 96.001 Social 
Security--Disability Insurance; 96.006 Supplemental Security Income)

    Dated: April 23, 1999.
Kenneth S. Apfel,
Commissioner of Social Security.

Policy Interpretation Ruling Titles II and XVI: Evaluating Cases 
Involving Chronic Fatigue Syndrome (CFS)

Purpose

    To restate and clarify the policies of the Social Security 
Administration for developing and evaluating title II and title XVI 
claims for disability on the basis of Chronic Fatigue Syndrome (CFS), 
also frequently known as Chronic Fatigue and Immune Dysfunction 
Syndrome.

Citations (Authority)

    Sections 216(i), 223(d), 223(f), 1614(a)(3) and 1614(a)(4) of the 
Social Security Act, as amended; Regulations No. 4, subpart P, sections 
404.1505, 40404.1508-404.1513, 404.1520, 404.1520a, 404.1521, 404.1523, 
404.1526-404.1529, 404.1560-404.1569a and 404.1593-404.1594;

[[Page 23381]]

and Regulations No. 16, subpart I, sections 416.905, 416.906, 416.908-
416.913, 416.920, 416.920a, 416.921, 416.923, 416.924, 416.924b, 
416.924c, 416.926, 416.926a, 416.927-416.929, 416.960-416.969a, 
416.987, 416.993, 416.994, and 416.994a.

Introduction

    CFS is a systemic disorder consisting of a complex of symptoms that 
may vary in incidence, duration, and severity. The current case 
criteria for CFS, developed by an international group convened by the 
Centers for Disease Control and Prevention (CDC) as an identification 
tool and research definition, include a requirement for four or more of 
a specified list of symptoms. These constitute a patient's complaints 
as reported to a provider of treatment.
    However, the Social Security Act (the Act) and our implementing 
regulations require that an individual establish disability based on 
the existence of a medically determinable impairment; i.e., one that 
can be shown by medical evidence, consisting of medical signs, symptoms 
and laboratory findings. Disability may not be established on the basis 
of an individual's statement of symptoms alone.
    This Ruling explains that CFS, when accompanied by appropriate 
medical signs or laboratory findings, is a medically determinable 
impairment that can be the basis for a finding of ``disability.'' It 
also provides guidance for the evaluation of claims involving CFS.

Policy Interpretation

    CFS constitutes a medically determinable impairment when it is 
accompanied by medical signs or laboratory findings, as discussed 
below. CFS may be a disabling impairment.

Definition of CFS

    CFS is a systemic disorder consisting of a complex of symptoms that 
may vary in incidence, duration, and severity. It is characterized in 
part by prolonged fatigue that lasts 6 months or more and that results 
in substantial reduction in previous levels of occupational, 
educational, social, or personal activities. In accordance with 
criteria established by the CDC, a physician should make a diagnosis of 
CFS ``only after alternative medical and psychiatric causes of chronic 
fatiguing illness have been excluded'' (Annals of Internal Medicine, 
121:953-9, 1994). CFS has been diagnosed in children, particularly 
adolescents, as well as in adults.
    Under the CDC definition, the hallmark of CFS is the presence of 
clinically evaluated, persistent or relapsing chronic fatigue that is 
of new or definite onset (i.e., has not been lifelong), cannot be 
explained by another physical or mental disorder, is not the result of 
ongoing exertion, is not substantially alleviated by rest, and results 
in substantial reduction in previous levels of occupational, 
educational, social, or personal activities. Additionally, the current 
CDC definition of CFS requires the concurrence of 4 or more of the 
following symptoms, all of which must have persisted or recurred during 
6 or more consecutive months of illness and must not have pre-dated the 
fatigue:

     Self-reported impairment in short-term memory or 
concentration severe enough to cause substantial reduction in 
previous levels of occupational, educational, social, or personal 
activities;
     Sore throat;
     Tender cervical or axillary lymph nodes;
     Muscle pain;
     Multi-joint pain without joint swelling or redness;
     Headaches of a new type, pattern, or severity;
     Unrefreshing sleep; and
     Postexertional malaise lasting more than 24 hours.

    Within these parameters, an individual with CFS can also exhibit a 
wide range of other manifestations, such as muscle weakness, swollen 
underarm (axillary) glands, sleep disturbances, visual difficulties 
(trouble focusing or severe photosensitivity), orthostatic intolerance 
(e.g., lightheadedness or increased fatigue with prolonged standing), 
other neurocognitive problems (e.g., difficulty comprehending and 
processing information), fainting, dizziness, and mental problems 
(e.g., depression, irritability, anxiety).
Requirement for a Medically Determinable Impairment
    Sections 216(i) and 1614(a)(3) of the Act define ``disability'' 
1 as the inability to engage in any substantial gainful 
activity (SGA) by reason of any medically determinable physical or 
mental impairment (or combination of impairments) which can be expected 
to result in death or which has lasted or can be expected to last for a 
continuous period of not less than 12 months.2 Sections 
223(d)(3) and 1614(a)(3)(D) of the Act, and 20 CFR 404.1508 and 416.908 
require that an impairment result from anatomical, physiological, or 
psychological abnormalities that can be shown by medically acceptable 
clinical and laboratory diagnostic techniques. The Act and regulations 
further require that an impairment be established by medical evidence 
that consists of signs, symptoms, and laboratory findings, and not only 
by an individual's statement of symptoms.
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    \1\ Except for statutory blindness.
    \2\ For individuals under age 18 claiming benefits under title 
XVI, disability will be established if the individual is suffering 
from a medically determinable physical or mental impairment (or 
combination of impairments) that results in ``marked and severe 
functional limitations.'' See section 1614(a)(3)(C) of the Act and 
20 CFR 416.906. However, for clarity, the following discussions 
refer only to claims of individuals claiming disability benefits 
under title II and individuals age 18 or older claiming disability 
benefits under title XVI. The concepts in this ruling, however, are 
also intended to apply in determining disability based on CFS for 
individuals under age 18 under title XVI.
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    Under the CDC definition, the diagnosis of CFS can be made based on 
an individual's reported symptoms alone once other possible causes for 
the symptoms have been ruled out. However, the foregoing statutory and 
regulatory provisions require that, for evaluation of claims of 
disability under the Act, there must also be medical signs or 
laboratory findings before the existence of a medically determinable 
impairment may be established.
Establishing the Existence of a Medically Determinable Impairment
    The following medical signs and laboratory findings establish the 
existence of a medically determinable impairment in individuals who 
have CFS. Although no specific etiology or pathology has yet been 
established for CFS, many research initiatives continue, and some 
progress has been made in ameliorating symptoms in selected 
individuals. With continuing scientific research, new medical evidence 
may emerge that will further clarify the nature of CFS and provide 
greater specificity regarding the clinical and laboratory diagnostic 
techniques that should be used to document this disorder.
    Because of this, the medical criteria discussed below are only 
examples of signs and laboratory findings that will establish the 
existence of a medically determinable impairment; they are not all-
inclusive. As progress is made in medical research into CFS, additional 
signs and laboratory findings may also be found that can be used to 
establish that individuals with CFS have a medically determinable 
impairment. The existence of CFS may be documented with medical signs 
or laboratory findings other than those listed below, provided that 
such documentation is consistent with medically accepted clinical 
practice and is consistent with the other evidence in the case record.

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Examples of Medical Signs That Establish the Existence of a Medically 
Determinable Impairment
    For purposes of Social Security disability evaluation, one or more 
of the following medical signs clinically documented over a period of 
at least 6 consecutive months establishes the existence of a medically 
determinable impairment for individuals with CFS:

     Palpably swollen or tender lymph nodes on physical 
examination;
     Nonexudative pharyngitis;
     Persistent, reproducible muscle tenderness on repeated 
examinations, including the presence of positive tender points; 
3 or,
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    \3\ There is considerable overlap of symptoms between CFS and 
Fibromyalgia Syndrome (FMS), but individuals with CFS who have 
tender points have a medically determinable impairment. Individuals 
with impairments that fulfill the American College of Rheumatology 
criteria for FMS (which includes a minimum number of tender points) 
may also fulfill the criteria for CFS. However, individuals with CFS 
who do not have the specified number of tender points to establish 
FMS, will still be found to have a medically determinable 
impairment.
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     Any other medical signs that are consistent with 
medically accepted clinical practice and are consistent with the 
other evidence in the case record.
Examples of Laboratory Findings That Establish the Existence of a 
Medically Determinable Impairment
    At this time, there are no specific laboratory findings that are 
widely accepted as being associated with CFS. However, the absence of a 
definitive test does not preclude reliance upon certain laboratory 
findings to establish the existence of a medically determinable 
impairment in persons with CFS. Therefore, the following laboratory 
findings establish the existence of a medically determinable impairment 
in individuals with CFS: 4

    \4\ It should be noted that standard laboratory test results in 
the ``normal'' range are characteristic for many individuals with 
CFS, and should not be relied upon to the exclusion of all other 
clinical evidence in decisions regarding the presence and severity 
of a medically determinable impairment.
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     An elevated antibody titer to Epstein-Barr virus (EBV) 
capsid antigen equal to or greater than 1:5120, or early antigen 
equal to or greater than 1:640;
     An abnormal magnetic resonance imaging (MRI) brain 
scan;
     Neurally mediated hypotension as shown by tilt table 
testing or another clinically accepted form of testing; or,
     Any other laboratory findings that are consistent with 
medically accepted clinical practice and are consistent with the 
other evidence in the case record; for example, an abnormal exercise 
stress test or abnormal sleep studies, appropriately evaluated and 
consistent with the other evidence in the case record.
Mental Findings That Establish the Existence of a Medically 
Determinable Impairment
    Some individuals with CFS report ongoing problems with short-term 
memory, information processing, visual-spatial difficulties, 
comprehension, concentration, speech, word-finding, calculation, and 
other symptoms suggesting persistent neurocognitive impairment. When 
ongoing deficits in these areas have been documented by mental status 
examination or psychological testing, such findings constitute medical 
signs or (in the case of psychological testing) laboratory findings 
that establish the presence of a medically determinable impairment.
    Individuals with CFS may also exhibit medical signs, such as 
anxiety or depression, indicative of the existence of a mental 
disorder. When such medical signs are present and appropriately 
documented, the existence of a medically determinable impairment is 
established.
Evaluation
    1. General. Claims involving CFS are adjudicated using the 
sequential evaluation process, just as for any other impairment. Once a 
medically determinable impairment has been found to exist (see 
discussion above), the severity of the impairment(s) must be 
established. The severity of an individual's impairment(s) is 
determined based on the totality of medical signs, symptoms, and 
laboratory findings, and the effects of the impairment(s), including 
any related symptoms, on the individual's ability to function.
    Also, several other disorders (including, but not limited to, FMS, 
multiple chemical sensitivity, and Gulf War Syndrome, as well as 
various forms of depression, and some neurological and psychological 
disorders) may share characteristics similar to those of CFS. When 
there is evidence of the potential presence of another disorder that 
may adequately explain the individual's symptoms, it may be necessary 
to pursue additional medical or other development.
    2. Step 2. When an adjudicator finds that an individual with CFS 
has a medically determinable impairment, he or she must consider that 
the individual has an impairment that could reasonably be expected to 
produce the individual's symptoms associated with CFS, as required in 
20 CFR 404.1529(b) and 416.929(b), and proceed to evaluate the 
intensity and persistence of the symptoms. Thus, if an adjudicator 
concludes that an individual has a medically determinable impairment, 
and the individual alleges fatigue, pain, symptoms of neurocognitive 
problems, or other symptoms consistent with CFS, these symptoms must be 
considered in deciding whether the individual's impairment is 
``severe'' at step 2 of the sequential evaluation process and at any 
later steps reached in the sequential evaluation process. If fatigue, 
pain, neurocognitive symptoms, or other symptoms are found to cause a 
limitation or restriction having more than a minimal effect on an 
individual's ability to perform basic work activities, the adjudicator 
must find that the individual has a ``severe'' impairment. See SSR 96-
3p, ``Titles II and XVI: Considering Allegations of Pain and Other 
Symptoms in Determining Whether a Medically Determinable Impairment is 
Severe.''
    3. Step 3. When an individual is found to have a severe impairment, 
the adjudicator must proceed with the sequential evaluation process and 
must next consider whether the individual's impairment is of the 
severity contemplated by the Listing of Impairments contained in 
appendix 1, subpart P of 20 CFR 404. Inasmuch as CFS is not a listed 
impairment, an individual with CFS alone cannot be found to have an 
impairment that meets the requirements of a listed impairment; however, 
the specific findings in each case should be compared to any pertinent 
listing to determine whether medical equivalence may exist.5
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    \5\ In evaluating title XVI claims for disability benefits for 
individuals under age 18, consideration must also be given to the 
possibility of functional equivalence. See 20 CFR 416.926a.
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    Further, in cases in which individuals with CFS have psychological 
manifestations related to CFS, consideration should always be given to 
whether the individual's impairment meets or equals the severity of any 
impairment in the mental disorders listings in 20 CFR, part 404, 
subpart P, appendix 1, sections 12.00 ff. or 112.00 ff.
    4. Steps 4 and 5. For those impairments that do not meet or equal 
the severity of a listing, an assessment of residual functional 
capacity (RFC) must be made, and adjudication must proceed to the 
fourth and, if necessary, the fifth step of the sequential evaluation 
process.6 In assessing RFC, all of the individual's symptoms 
must be considered in deciding how such symptoms may affect functional 
capacities. See SSR 96-7p, ``Titles II and

[[Page 23383]]

XVI: Evaluation of Symptoms in Disability Claims: Assessing the 
Credibility of an Individual's Statements'' and SSR 96-8p, ``Titles II 
and XVI: Assessing Residual Functional Capacity in Initial Claims.''
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    \6\ These steps of the sequential evaluation process are not 
applicable to claims for benefits under title XVI for individuals 
under age 18. See 20 CFR 416.924.
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    If it is determined that the individual's impairment(s) precludes 
the performance of past relevant work (or if there was no past relevant 
work), a finding must be made about the individual's ability to perform 
other work. The usual vocational considerations (see 20 CFR 404.1560-
404.1569a and 416.960-416.969a) must be applied in determining the 
individual's ability to perform other work.
    Many individuals with CFS are ``younger individuals,'' ages 18 
through 49 (see 20 CFR 404.1563 and 416.963). Age, education, and work 
experience are not usually considered to limit significantly the 
ability of individuals under age 50 to make an adjustment to other 
work, including unskilled sedentary work.7 However, a 
finding of ``disabled'' is not precluded for those individuals under 
age 50 who do not meet all of the criteria of a specific rule and who 
do not have the ability to perform a full range of sedentary work. The 
conclusion about whether such individuals are disabled will depend 
primarily on the nature and extent of their functional limitations or 
restrictions. Thus, if it is found that an individual is able to do 
less than the full range of sedentary work, refer to SSR 96-9p, 
``Titles II and XVI: Determining Capability to Do Other Work--
Implications of a Residual Functional Capacity for Less Than a Full 
Range of Sedentary Work.'' As explained in that Ruling, whether the 
individual will be able to make an adjustment to other work requires 
adjudicative judgment regarding factors such as the type and extent of 
the individual's limitations or restrictions and the extent of the 
erosion of the occupational base for sedentary work.
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    \7\ However, ``younger individuals'' ages 45-49 who are 
illiterate in English or unable to communicate in English, whose 
past work was unskilled (or who had no past relevant work), or who 
have no transferable skills, and who are limited to a full range of 
sedentary work, must be found disabled under rule 201.17 in Table 
No. 1 of appendix 2 of the Medical-Vocational Guidelines in 20 CFR 
part 404.
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    5. Duration. The medical signs and symptoms of CFS fluctuate in 
frequency and severity and often continue over a period of many months 
or years. Thus, appropriate documentation should include a longitudinal 
clinical record of at least 12 months prior to the date of application, 
unless the alleged onset of CFS occurred less than 12 months in the 
past, or unless a fully favorable determination or decision can be made 
without additional documentation. The record should contain detailed 
medical observations, treatment, the individual's response to 
treatment, and a detailed description of how the impairment limits the 
individual's ability to function over time.
    When the alleged onset of disability secondary to CFS occurred less 
than 12 months before adjudication, the adjudicator must evaluate the 
medical evidence and project the degree of impairment severity that is 
likely to exist at the end of 12 months.8 Information about 
treatment and response to treatment as well as any medical source 
opinions about the individual's prognosis at the end of 12 months are 
helpful in deciding whether the medically determinable impairment(s) is 
expected to be of disabling severity for at least 12 consecutive 
months.
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    \8\ To meet the statutory requirement for ``disability,'' an 
individual must have been unable to engage in any SGA by reason of 
any medically determinable physical or mental impairment which is 
expected to result in death or which has lasted or can be expected 
to last for a continuous period of not less than 12 months. Thus, 
the existence of an impairment for 12 continuous months is not 
controlling; rather, it is the existence of a disabling impairment 
which has lasted or can be expected to last for at least 12 months 
that meets the duration requirement of the Act.
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    6. Continuing Disability Reviews. In those cases in which an 
individual is found to have a disability based on CFS but medical 
improvement is anticipated, an appropriate continuing disability review 
should be scheduled based on the probability of cessation under the 
Medical Improvement Review Standard. This standard takes into account 
relevant individual case facts such as the combined severity of other 
chronic or static impairments and the individual's vocational factors.
Documentation
    1. General. As with all claims for disability under both title II 
and title XVI, documentation of medical signs or laboratory findings in 
cases involving CFS is critical to establishing the presence of a 
medically determinable impairment. In cases in which CFS is alleged, 
longitudinal clinical records reflecting ongoing medical evaluation and 
treatment from the individual's medical sources, especially treating 
sources, are extremely helpful in documenting the presence of any 
medical signs or laboratory findings, as well as the individual's 
functional status over time. Every reasonable effort should be made to 
secure all available, relevant evidence in cases involving CFS to 
ensure appropriate and thorough evaluation.
    Generally, evidence for the 12-month period preceding the month of 
application should be requested unless there is reason to believe that 
development of an earlier period is necessary, or unless the alleged 
onset of disability is less than 12 months before the date of the 
application.
    2. Recontacting Medical Sources/Consultative Examinations. If the 
adjudicator finds that the evidence is inadequate to determine whether 
the individual is disabled, he or she must first recontact the 
individual's treating or other medical source(s) to determine whether 
the additional information needed is readily available, in accordance 
with 20 CFR 404.1512 and 416.912.9 Only after the 
adjudicator determines that the information needed is not readily 
available from the individual's health care provider(s), or that the 
necessary information or clarification cannot be sought from the 
individual's health care provider(s), should the adjudicator proceed to 
arrange for a consultative examination(s) in accordance with 20 CFR 
404.1519a and 416.919a. The type of consultative examination(s) 
purchased will depend on the nature of the individual's symptoms and 
the extent of the evidence already in the case record.
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    \9\ We may not seek additional evidence or clarification from a 
medical source when we know from past experience that the source 
either cannot or will not provide the necessary findings.
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    3. Resolution of Conflicts. It should be noted that conflicting 
evidence in the medical record is not unusual in cases of CFS due to 
the complicated diagnostic process involved in these cases. 
Clarification of any such conflicts in the medical evidence should be 
sought first from the individual's treating or other medical sources.
    Medical opinions from treating sources about the nature and 
severity of an individual's impairment(s) are entitled to deference and 
may be entitled to controlling weight. If we find that a treating 
source's medical opinion on the issue(s) of the nature and severity of 
an individual's impairment(s) is well-supported by medically acceptable 
clinical and laboratory diagnostic techniques and is not inconsistent 
with the other substantial evidence in the case record, the adjudicator 
will give it controlling weight. (See SSR 96-2p, ``Titles II and XVI: 
Giving Controlling Weight to Treating Source Medical Opinions,'' and 
SSR 96-5p, ``Titles II and XVI: Medical Source Opinions on

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Issues Reserved to the Commissioner.'') 10
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    \10\ A medical source opinion that an individual is ``disabled'' 
or ``unable to work,'' has an impairment(s) that meets or is 
equivalent in severity to the requirements of a listing, has a 
particular residual functional capacity (RFC), that concerns whether 
an individual's RFC prevents him or her from doing past relevant 
work, or that concerns the application of vocational factors, is an 
opinion on an issue reserved to the Commissioner. Every such opinion 
must still be considered in adjudicating a disability claim; 
however, the adjudicator will not give any special significance to 
such an opinion because of its source. See SSR 96-5p, ``Titles II 
and XVI: Medical Source Opinions on Issues Reserved to the 
Commissioner.''
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    4. Assessing Credibility. In accordance with SSR 96-7p, if the 
existence of a medically determinable impairment that could reasonably 
be expected to produce the symptoms has been established, as outlined 
above, but an individual's statements about the intensity, persistence, 
or functionally limiting effects of symptoms are not substantiated by 
objective medical evidence, the adjudicator must consider all of the 
evidence in the case record, including any statements by the individual 
and other persons concerning the individual's symptoms. The adjudicator 
must then make a finding on the credibility of the individual's 
statements about symptoms and their functional effects. When additional 
information is needed to assess the credibility of the individual's 
statements about symptoms and their effects, the adjudicator must make 
every reasonable effort to obtain available information that could shed 
light on the credibility of the individual's statements.
    Treating and other medical sources. In evaluating credibility, the 
adjudicator should ask the treating or other medical source(s) to 
provide information about the extent and duration of an individual's 
impairment(s), including observations and opinions about how well the 
individual is able to function, the effects of any treatment, including 
side effects, and how long the impairment(s) is expected to limit the 
individual's ability to function. Opinions from an individual's medical 
sources, especially treating sources, concerning the effects of CFS on 
the individual's ability to function in a sustained manner in 
performing work activities or in performing activities of daily living 
are important in enabling adjudicators to draw conclusions about the 
severity of the impairment(s) and the individual's RFC. In this regard, 
any information a medical source is able to provide contrasting the 
individual's impairment(s) and functional capacities since the alleged 
onset of CFS with the individual's status prior to the onset of CFS 
will be helpful in evaluating the individual's impairment(s) and its 
functional consequences.
    Third-party information, including evidence from medical sources 
who are not ``acceptable medical sources'' for the purpose of 
establishing the existence of a medically determinable impairment, but 
who have provided services to the individual, may be very useful in 
deciding the individual's credibility. Information other than an 
individual's allegations and reports from the individual's treating 
sources helps to assess an individual's ability to function on a day-
to-day basis and to depict the individual's capacities over a period of 
time. Such evidence includes, but is not limited to:

     Information from neighbors, friends, relatives, or 
clergy;
     Statements from such individuals as past employers, 
rehabilitation counselors, or school teachers about the individual's 
impairment(s) and the effects of the impairment(s) on the 
individual's functioning in the work place, rehabilitation facility, 
or educational institution;
     Statements from other practitioners with knowledge of 
the individual, e.g., nurse-practitioners, physicians' assistants, 
naturopaths, therapists, social workers, and chiropractors;
     Statements from other sources with knowledge of the 
individual's ability to function in daily activities; and
     The individual's own record (such as a diary, journal, 
or notes) of his or her own impairment(s) and its impact on function 
over time.

    The adjudicator should carefully consider this information when 
making findings about the credibility of the individual's allegations 
regarding functional limitations or restrictions.

EFFECTIVE DATE: This Ruling is effective on April 30, 1999.

CROSS-REFERENCES: SSR 96-2p, ``Titles II and XVI: Giving Controlling 
Weight to Treating Source Medical Opinions,'' SSR 96-3p, ``Titles II 
and XVI: Considering Allegations of Pain and Other Symptoms in 
Determining Whether a Medically Determinable Impairment is Severe,'' 
SSR 96-4p, ``Titles II and XVI: Symptoms, Medically Determinable 
Physical and Mental Impairments, and Exertional and Nonexertional 
Limitations,'' SSR 96-5p, ``Titles II and XVI: Medical Source Opinions 
on Issues Reserved to the Commissioner,'' SSR 96-7p, ``Titles II and 
XVI: Evaluation of Symptoms in Disability Claims: Assessing the 
Credibility of an Individual's Statements,'' SSR 96-8p, ``Titles II and 
XVI: Assessing Residual Functional Capacity in Initial Claims,'' and 
SSR 96-9p, ``Titles II and XVI: Determining Capability to Do Other 
Work--Implications of a Residual Functional Capacity for Less Than a 
Full Range of Sedentary Work.''

[FR Doc. 99-10840 Filed 4-29-99; 8:45 am]
BILLING CODE 4190-29-P