[Federal Register Volume 65, Number 29 (Friday, February 11, 2000)]
[Proposed Rules]
[Pages 6929-6936]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-2867]


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SOCIAL SECURITY ADMINISTRATION

20 CFR Parts 404 and 416

RIN 0960-AE99


Technical Revisions to Medical Criteria for Determinations of 
Disability

AGENCY: Social Security Administration (SSA).

ACTION: Proposed rules.

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SUMMARY: We are proposing to make a number of technical revisions to 
the Listing of Impairments (the listings). We use the listings to 
adjudicate claims for disability under titles II and XVI of the Social 
Security Act (the Act) when we evaluate claims of individuals at steps 
3 of our sequential evaluation processes for adults and children. The 
proposed changes reflect advances in medical knowledge, treatment, and 
terminology, clarify certain listing criteria, remove listings that we 
rarely use or that are redundant, and add new listings consistent with 
current medical practice.
    These proposed revisions are technical changes that are intended to 
clarify or modify current language to improve understanding and 
usability. They are not intended to be a comprehensive update of the 
listings.

DATES: To be sure that your comments are considered, we must receive 
them no later than April 11, 2000.

ADDRESSES: Comments should be submitted in writing to the Commissioner 
of Social Security, P.O. Box 17703, Baltimore, MD 21235-7703, sent by 
telefax to (410) 966-2830, sent by e-mail to ``[email protected]'', 
or delivered to the Office of Process and Innovation Management, Social 
Security Administration, L2109 West Low Rise Building, 6401 Security 
Boulevard, Baltimore, MD 21235-6401, between 8:00 a.m. and 4:30 p.m. on 
regular business days. Comments may be inspected during these hours by 
making arrangements with the contact person shown below.

FOR FURTHER INFORMATION CONTACT: Carolyn Kiefer, Social Insurance 
Specialist, Office of Disability, Social Security Administration, 3-B-9 
Operations Building, 6401 Security Boulevard, Baltimore, Maryland 
21235-6401, (410) 965-9104 or TTY (410) 966-5609.

SUPPLEMENTARY INFORMATION:

Background

    Title II of the Act provides for the payment of disability 
insurance benefits to workers insured under the Act. Title II also 
provides, under certain circumstances, for the payment of child's 
insurance benefits for persons who become disabled before age 22 and 
widow's and widower's insurance benefits based on disability for 
widows, widowers, and surviving divorced spouses of insured 
individuals. In addition, title XVI of the Act provides for 
Supplemental Security Income (SSI) payments to persons who are aged, 
blind, or disabled and who have limited income and resources.
    For adults under both the title II and title XVI programs and for 
persons claiming child's insurance benefits based on disability under 
the title II program, ``disability'' means that an impairment(s) 
results in an inability to engage in any substantial gainful activity. 
For an individual under age 18 claiming SSI benefits based on 
disability, ``disability'' means that an impairment(s) results in 
``marked and severe functional limitations.'' Under both title II and 
title XVI, disability must be the result of any medically determinable 
physical or mental impairment(s) that can be expected to result in 
death or that has lasted or can be expected to last for a continuous 
period of at least 12 months.
    The process for determining whether an individual (except for an 
individual under age 18 claiming SSI benefits based on disability) is 
disabled based on the statutory definition is set forth in our 
longstanding regulations at Secs. 404.1520 and 416.920. These 
regulations provide for a sequential evaluation process for evaluating 
disability. There is a separate sequential evaluation process described 
in regulations at Sec. 416.924 for individuals under age 18 claiming 
SSI benefits based on disability. At step 3 of both sequential 
evaluation processes we ask the same question: Whether an individual 
who is not engaging in substantial gainful activity and who has an 
impairment(s) that is severe, has an impairment(s) that meets or equals 
in severity the criteria of an impairment listed in appendix 1 of 
subpart P of part 404, the listings. The listings describe, for each of 
the major body systems, impairments that are considered severe enough 
to prevent a person from doing any gainful activity (or in the case of 
a child under age 18 claiming SSI benefits based on disability, to 
cause marked and severe functional limitations). Although the listings 
are contained only in part 404, they are referenced by subpart I of 
part 416.
    The listings are divided into Part A and Part B. The criteria in 
Part A are applied in evaluating impairments of persons age 18 or over. 
The criteria in Part A may also be used to evaluate impairments in 
persons under age 18 if the disease processes have a similar effect on 
adults and children. In evaluating disability for a person under age 
18, we first use the criteria in Part B and, if the criteria in Part B 
do not apply, we use the criteria in Part A (see Secs. 404.1525 and 
416.925).
    These changes are not intended to be a comprehensive update and 
revision of the listings. We continue to review each of the body system 
listings to determine appropriate revisions and updates of a more 
substantive nature. If we determine that more substantive revisions are 
necessary, we will publish a notice in the Federal Register describing 
those proposed revisions and requesting public comments. Therefore, we 
are now requesting comments only on the specific technical changes we 
are

[[Page 6930]]

proposing in this notice of proposed rulemaking.
    The following is a detailed summary of the proposed revisions and 
our reasons for proposing these changes.

Explanation of Proposed Revisions

    We propose to revise the language throughout all listings regarding 
references to ``X-ray(s),'' roentgenograms (which is another word for 
X-rays), and radiographic studies (which is another process similar to 
roentgenography), to include ``other appropriate medically acceptable 
imaging'' as satisfactory medical evidence. The proposed changes occur 
in the following sections and/or listings:
    Sections 1.00A, 1.00B and 1.00C of the preface to the 
musculoskeletal body system and Listings 1.03, 1.04, 1.05, 1.08, 1.09, 
and 1.11;
    Section 2.00B2 of the preface to the special senses and speech body 
system;
    Section 4.00C3 of the preface to the cardiovascular system;
    Section 5.00C of the preface to the digestive system and Listings 
5.03, 5.04, and 5.05;
    Listing 6.02C1 of the genito-urinary system;
    Listing 7.16A of the hemic and lymphatic system;
    Listing 9.03A of the endocrine system;
    Listing 14.08M6 of the immune system;
    Section 100.00B of the preface to growth impairments;
    Listings 101.02A3 and 101.08 of the musculoskeletal system;
    Listing 103.04B3 of the respiratory system;
    Section 104.00E of the preface to the cardiovascular system;
    Section 105.00B of the preface to the digestive system and Listings 
105.05A and 105.05C;
    Section 113.00B of the preface to the neoplastic diseases; and,
    Listing 114.08N6 of the immune system.
    We are proposing these changes to recognize that there have been 
significant advances in medical imaging, such as (but not limited to) 
computerized axial tomography (CAT scan) and magnetic resonance imaging 
(MRI), and to increase the types of evidence that can be used to meet 
the listings. Under Secs. 404.1525 and 416.925 of our regulations, an 
individual's impairment ``meets'' the criteria of a given listing only 
by showing the same findings that are required in the listing. Because 
of this, an individual who has all of the findings required by a 
listing except X-ray evidence but who has the same or better 
information from a CAT scan, MRI, or other medically acceptable modern 
imaging technique than can be gotten from X-ray cannot meet the 
listing; instead, we must find that the individual's impairment 
medically equals the listing. The proposed changes would allow us to 
find that such individuals have impairments that meet these listings. 
We also made the proposed phrase nonspecific to allow for flexibility 
in the use of the use of the listings should new medically appropriate 
imaging techniques be developed in the future.
    We are also proposing to add a brief explanation in the prefaces of 
the musculoskeletal adult and childhood listings (in paragraphs 1.00B 
and 101.00B, respectively) to explain what we mean by appropriate 
medically acceptable imaging techniques, and to explain that we will 
not purchase such expensive tests as CAT scans or MRIs in the course of 
obtaining documentation, but we will consider the results of these 
tests if they are available.
1.01 and 101.01  Category of Impairments, Musculoskeletal
    We are making a correction to Listing 1.09 to move the word ``of'' 
to its proper placement following the parenthetical text that describes 
what we mean by ``Amputation or anatomical deformity.'' The ``of'' is 
currently incorrectly placed after the word ``deformity,'' and before 
the explanatory parenthetical language.
    We are proposing to amend childhood Listing 101.08, Chronic 
osteomyelitis, to make it consistent with the language and criteria of 
adult Listing 1.08, which addresses osteomyelitis or septic arthritis. 
Since the adult listing is more complete and comprehensive, we are 
amending the childhood listing to be consistent with the adult listing.
2.00 and 102.00  Special Senses and Speech
    We propose to revise the heading of 2.00A to read ``Disorders of 
Vision'' because the term currently used, ``Ophthalmology,'' is most 
commonly used to define the branch of medicine that deals with the 
anatomy, physiology, and pathology of the eye, whereas these listings, 
in fact, address visual disorders.
    We propose to remove the word ``central'' in referring to vision 
and visual acuity throughout 2.00 and 102.00 because it is redundant. 
``Central vision'' is medically synonymous with ``visual acuity.'' We 
propose to revise 2.00A1 to explain that diseases or injury of the eyes 
may result in loss of visual acuity or loss of the peripheral field. It 
is the loss of visual acuity that results in inability to distinguish 
detail and prevents reading and fine work, while the loss of the 
peripheral field restricts the ability of an individual to move about 
freely. We propose to clarify this section by stating that the extent 
of impairment of sight should be determined by visual acuity and 
peripheral field testing. Likewise, in 2.00A2, with the removal of the 
word ``central,'' we also propose to revise the opening sentence to 
clarify that loss of visual acuity may result in impaired distant and/
or near vision (not ``caused by'' impaired vision).
    Thus, we are proposing to remove the word ``central'' from the 
following: 2.00A1, 2.00A2, 2.00A5, 2.00A6, 2.02, Table No. 1 and its 
footnotes 2 and 3, 102.00A, and 102.02.
    Also, we propose to further revise Table No. 1 by adding the word 
``acuity'' to the first line of the chart, ``Percent visual acuity 
efficiency,'' and also to the title, ``Percentage of Visual Acuity 
Efficiency Corresponding to Visual Acuity Notations * * *''.
    Additionally, we propose clarifying the language of Listing 2.04 by 
replacing the phrase ``central visual efficiency'' with the phrase 
``visual acuity efficiency.''
    We propose to revise 2.00B3 by removing the word ``organic'' from 
its title, removing the first sentence of the section, and amending the 
second sentence to clarify that the ability to produce speech by any 
means includes the use of mechanical or electronic devices that improve 
voice or articulation. Also in this section, we propose to correct the 
reference to ``neurologic'' disorders by appropriately calling them 
``neurological'' disorders.
    We propose to remove Listing 2.05, Complete homonymous hemianopsia 
(with or without macular sparing) because the language of 2.05 now 
directs that this disorder should be evaluated under Listing 2.04. 
Since we are not proposing to change Listing 2.04 in any substantive 
way, we will still use this listing to evaluate complete homonymous 
hemianopsia and there is no need to retain the separate listing.
    We propose to revise Listing 2.09, Organic loss of speech, to 
remove the word ``organic'' because we believe that the cause of loss 
of speech (i.e., whether it is or is not ``organic'') should be 
immaterial for purpose of applying this listing. We also propose to 
change the word ``and'' to ``or'' to clarify that the inability to 
produce speech that can be heard, understood, or sustained will meet 
the listing, instead of the requirement under the current language that 
all three of these factors be present. We believe that any one of these 
factors is sufficient to establish that an

[[Page 6931]]

individual has a listing-level impairment.
3.00 and 103.00  Respiratory System
    In the listing preface, we propose to revise some of the technical 
language dealing with the requirements for spirometry calibration and 
testing for diffusing capacity of the lungs for carbon monoxide (DLCO) 
to comply with the standards of current medical practice.
    In 3.00E and 103.00B, Documentation of pulmonary function testing, 
we propose to revise the last sentence of the third paragraph of each 
section to explain that the testing device must have a daily recorded 
calibration of volume units performed sometime prior to the pulmonary 
function study. This revises the current requirement for separate 
calibration tracings to be performed at the time each pulmonary 
function test is performed. We believe a single daily calibration of 
the testing device is sufficient to provide accurate pulmonary 
measurements for purposes of our listings.
    In 3.00F1, Diffusing capacity of the lungs for carbon monoxide 
(DLCO), fifth paragraph, fourth and fifth sentences, we are proposing 
the deletion of the reference to the algorithm used to calculate test 
results and the language regarding ``independent calculation of 
results.'' We believe this algorithm no longer needs to be provided in 
the documentation of DLCO since adjudicators are not expected to 
recompute the test results. Rather, we are asking that the file include 
documentation of the source of the predicted equation to permit 
adjudicators to verify that the test was performed adequately.
3.01 and 103.01  Category of Impairments, Respiratory System
    We propose to add a new listing addressing lung transplants for 
both adults and children. Listing 3.11 for adults and Listing 103.05 
for children, Lung transplant, is proposed to be consistent with other 
organ transplant listings and to provide that an individual undergoing 
a lung transplant will be considered under a disability for 12 months 
following the date of surgery with evaluation of any residual 
impairment thereafter.
4.00 and 104.00  Cardiovascular System
    In 4.00A, Introduction, fourth paragraph, second sentence, and 
104.00A, Introduction, sixth paragraph, second sentence, we propose to 
revise the language to change the word ``make'' to the word 
``consider'' in the clause referring to making a medical equivalence 
determination in the case of an adult, and for children, a medical or 
functional equivalence determination. The current language could be 
misinterpreted to mean that, when an individual has a medically 
determinable impairment that is not listed, or a combination of 
impairments no one of which meets a listing, we will find that his or 
her impairment is medically equivalent to a listing, or for children, 
medically or functionally equivalent to a listing. Our intent has 
always been to indicate only that we will consider whether the 
impairment or combination of impairments is medically equivalent (or 
for children medically or functionally equivalent) to a listing. This 
is only a clarification of what we have always intended by the language 
in these sections.
5.00 and 105.00  Digestive System
    As discussed above, we are proposing to amend Listings 5.05A and 
105.05C to allow for documentation of esophageal varices by X-rays, 
endoscopy, or other appropriate medically acceptable imaging. This will 
allow for changes in medical technology over time and will eliminate 
the current unnecessary language differences in the parenthetical 
portion of these listings.
    We propose to add a new listing to both the adult and childhood 
listings for the digestive system to address liver transplantation in 
keeping with our other organ transplantation listings. For adults, the 
new listing will be 5.09, Liver transplant; for children, it will be 
105.09, Liver transplant.
    Also, we are correcting a typographical error in 5.00C.
7.00 and 107.00  Hemic and Lymphatic System
    We propose to add T-cell lymphoblastic lymphoma to the discussion 
of acute leukemia in sections 7.00E and 107.00C as well as in Listings 
7.11 and 107.11. This disorder follows the same course and requires the 
same treatment as acute leukemia and is just as serious. By including 
this disorder in the preface and as a listed impairment in both the 
adult and childhood listings, we believe evaluation will be simplified 
by specifically directing adjudicators to the criteria for evaluating 
this disease.
    We propose to amend the reference to bone marrow transplantation in 
Listing 7.17, Aplastic anemias or hematologic malignancies (excluding 
acute leukemia), to ``bone marrow or stem cell transplantation'' to add 
the new medical technique of stem cell transplantation which is 
comparable to bone marrow transplantation.
8.01  Category of Impairments, Skin
    We are correcting a spelling error in Listing 8.06. The correct 
name of this impairment is Hidradenitis suppurative, acne conglobata.
9.01  Category of Impairments, Endocrine System
    We propose to revise Listing 9.02, Thyroid Disorders, to remove 
paragraph A, which refers to ``Progressive exophthalmos as measured by 
exophthalmometry,'' because this complication now rarely occurs due to 
advances in treatment for thyroid disease.
11.00 and 111.00  Neurological
    We are proposing changes in the language that we currently use for 
epilepsy and its treatment throughout these listings to make our 
listing language consistent with current medical terminology. For 
example, we propose changing the term ``convulsive disorders'' in 
11.00A to ``epilepsy,'' and changing the references to 
``anticonvulsive'' treatment and drugs to ``antiepileptic'' treatment 
and drugs to reflect current medical terminology. In keeping with these 
changes in terminology, we are also proposing changing the descriptions 
of the categories of epilepsy under Listings 11.02 and 11.03 in Part A, 
and Listings 111.02 and 111.03 in Part B. In place of the term major 
motor seizures (11.02 and 111.02) we are proposing ``convulsive 
epilepsy,'' and for the term minor motor seizures (11.03 and 111.03), 
we are proposing ``nonconvulsive epilepsy.'' These terms are in keeping 
with current medical terminology.
    We also propose to remove the requirement for electroencephalogram 
(EEG) evidence to support the existence of epilepsy throughout the 
neurological listings with the exception of cases involving 
nonconvulsive epilepsy in children. This is the only category of 
epilepsy in which an EEG is the definitive diagnostic tool; in all 
other situations of epilepsy, it is rare for an EEG to confirm the 
presence of a seizure disorder.
    We propose to amend the language of Listing 111.02B3 by changing it 
from ``significant emotional disorder'' to ``significant mental 
disorder.'' This clarifies the nature of the impairment identified, 
i.e., a defined mental impairment, and is consistent with other listing 
terminology.
    We propose to remove Listing 11.15, Tabes dorsalis, because the 
availability of effective screening tests and treatment have markedly 
reduced the

[[Page 6932]]

incidence of this disorder. With the capability to do early 
identification and treatment in cases of syphilis, the disease that 
leads to Tabes dorsalis, we believe this listing is no longer needed.
    With the proposal to remove Listing 11.15, we are also proposing to 
remove the reference to 11.15B currently in Listing 11.17A, which deals 
with disorganization of motor function in degenerative diseases such as 
Huntington's chorea and Friedreich's ataxia. The disorganization of 
motor function described in Listing 11.04B includes disturbances of 
gait as described in 11.15B, so we believe that the reference to 11.04B 
is sufficient to address the manifestations of the degenerative 
diseases covered by Listing 11.17.
12.01 and 112.01  Category of Impairments, Mental
    We are proposing to highlight a portion of the language in the 
capsule definition of Listing 12.05 by italicizing it. Listing 12.05 
deals with mental retardation and autism. Mental retardation is defined 
as a significantly subaverage general intellectual functioning with 
deficits in adaptive behavior initially manifested during the 
developmental period (before age 22). To draw the user's attention to 
the portion dealing with the time period for the manifestations of 
these deficits, we propose to italicize the text initially manifested 
during the developmental period (before age 22).
    We are proposing to correct an error in Listing 112.05F1 and 
112.05F2. The word ``limitations'' should be ``limitation.'' This is 
consistent with the wording of the adult Listing 12.05C, ``imposing 
additional and significant work-related limitation of function.''
13.01  Category of Impairments, Neoplastic Diseases--Malignant
    We propose to amend Listing 13.08, Thyroid gland, adding another 
criterion, ``Anaplastic carcinoma of the thyroid.'' This would be 
designated as 13.08B, and the current listing language would become 
13.08A. Anaplastic carcinoma of the thyroid is a distinct type of 
carcinoma that can be specified as part of this listing because it is 
of the same level of severity as the current listing and has a poor 
prognosis. We believe that identifying it separately will assist 
adjudicators in evaluating thyroid neoplasms.

Clarity of These Proposed Rules

    Executive Order 12866 and the President's memorandum of June 1, 
1998, (63 F.R. 31885), require each agency to write all rules in plain 
language. In addition to your substantive comments on these proposed 
rules, we invite your comments on how to make these proposed rules 
easier to understand.
    For example:
     Have we organized the material to suit your needs?
     Are the requirements in these rules clearly stated?
     Do the rules contain technical language or jargon that 
isn't clear?
     Would a different format (grouping and order of sections, 
use of headings, paragraphing) make these rules easier to understand?
     Would more (but shorter) sections be better?
     Could we improve clarity by adding tables, lists, or 
diagrams?
     What else could we do to make these rules easier to 
understand?

Electronic Versions

    The electronic file of this document is available on the internet 
at http://www.access.gpo.gov/su__docs/aces/aces140.html. It is also 
available on the internet site for SSA (i.e., ``SSA Online'') at http://www.ssa.gov/.

Regulatory Procedures

Executive Order 12866

    We have consulted with the Office of Management and Budget (OMB) 
and determined that these proposed regulations do not meet the criteria 
for a significant regulatory action under Executive Order 12866. Thus, 
they were not subject to OMB review.

Regulatory Flexibility Act

    We certify that these proposed regulations will not have a 
significant economic impact on a substantial number of small entities 
because they affect only individuals. Thus, a regulatory flexibility 
analysis as provided in the Regulatory Flexibility Act, as amended, is 
not required.

Paperwork Reduction Act

    These proposed regulations will impose no additional reporting or 
recordkeeping requirements requiring OMB clearance.

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

List of Subjects

20 CFR Part 404

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

20 CFR Part 416

    Administrative practice and procedure, Aged, Blind, Disability 
benefits, Public assistance programs, Reporting and recordkeeping 
requirements, Supplemental Security Income.

    Dated: January 28, 2000.
Kenneth S. Apfel,
Commissioner of Social Security.

    For the reasons set forth in the preamble, we are proposing to 
amend part 404, subpart P, and part 416, subpart I of chapter III of 
title 20 of the Code of Federal Regulations as follows:

PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE 
(1950-  )

Subpart P [Amended]

    1. The authority citation for subpart P of part 404 continues to 
read as follows:

    Authority:  Secs. 202, 205(a), (b), and (d)-(h), 216(i), 221(a) 
and (i), 222(c), 223, 225, and 702(a)(5) of the Social Security Act 
(42 U.S.C. 402, 405(a), (b), and (d)-(h), 416(i), 421(a) and (i), 
422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193, 110 
Stat. 2105, 2189.

Appendix 1 to Subpart P of Part 404--[Amended]

    2. Appendix 1 to subpart P of part 404 is amended as follows:
    a. Section 1.00 in part A of appendix 1 is amended:
    (1) By revising the last sentence of paragraph A;
    (2) By revising the first sentence in the second paragraph of 
paragraph B;
    (3) By adding a new eighth paragraph to paragraph B; and,
    (4) By revising paragraph C;
    b. Section 1.03 in part A of appendix 1, paragraph A is revised.
    c. Section 1.04 in part A of appendix 1 is amended by revising the 
introductory text.
    d. Section 1.05 in part A of appendix 1 is amended by revising the 
introductory text in paragraphs A and B.
    e. Section 1.08 in part A of appendix 1 is amended by revising the 
heading.
    f. Section 1.09 in part A of appendix 1 is amended by revising the 
heading.
    g. Section 1.11 in part A of appendix 1 is revised.
    h. Section 2.00 in part A of appendix 1 is amended:
    (1) By revising the heading of paragraph A;
    (2) By revising paragraph A1, the first two sentences of paragraph 
A2, and paragraph A5;
    (3) By amending paragraph A6 to remove the word ``central'' in the 
first, fourth, fifth, and sixth sentences;

[[Page 6933]]

    (4) By revising the last sentence in the third paragraph of 
paragraph B2;
    (5) By revising paragraph B3;
    (6) By amending Table No. 1 by revising the heading to read, 
``Percentage of visual acuity efficiency corresponding to visual acuity 
notations for distance in the phakic and aphakic eye (better eye)'' by 
revising the heading of the right column on the first line of the table 
to read, ``Percent visual acuity efficiency''; and by amending 
footnotes 2 and 3 to Table No. 1 by removing the word ``central.''
    i. Section 2.02 in part A of appendix 1 is amended by removing the 
word ``central'' in the heading.
    j. Section 2.04 in part A of appendix 1 is revised.
    k. Section 2.05 in part A of appendix 1 is removed and reserved.
    l. Section 2.09 in part A of appendix 1 is revised.
    m. Section 3.00 in part A of appendix 1 is amended by revising the 
last sentence in the third paragraph of paragraph E, and by amending 
paragraph F1 by revising the fourth and fifth sentences of the fifth 
paragraph.
    n. Section 3.11 in part A of appendix 1 is added.
    o. Section 4.00, paragraph A, in part A of appendix 1 is amended in 
the second sentence of the fourth paragraph by revising ``make'' to 
read ``consider'', and in paragraph C3 by amending the third sentence 
of the first paragraph.
    p. Section 5.00, paragraph C, in part A of appendix 1 is amended in 
the fourth sentence by revising ``roentgenograms'' to read ``X-rays or 
other appropriate medically acceptable imaging,'' and by revising 
``impairmentich'' to read ``impairment which.''
    q. Section 5.03 in part A of appendix 1 is revised.
    r. Section 5.04 in part A of appendix 1 is amended by revising the 
heading and by revising paragraph C.
    s. Section 5.05 in part A of appendix 1 is amended by revising the 
first sentence in paragraph A.
    t. Section 5.09 in part A of appendix 1 is added.
    u. Section 6.02 in part A of appendix 1 is amended by revising 
paragraph C1.
    v. Section 7.00 in part A of appendix 1 is amended by revising the 
heading and the first sentence of the first paragraph of paragraph E.
    w. Section 7.11 in part A of appendix 1 is amended by revising the 
heading.
    x. Section 7.16 in part A of appendix 1 is amended by revising 
paragraph A.
    y. Section 7.17 in part A of appendix 1 is amended by revising the 
first sentence.
    z. Section 8.06 in part A of appendix 1, the heading is amended by 
revising ``Hydradenitis'' to read ``Hidradenitis.''
    aa. In section 9.02 in part A of appendix 1, the word ``With:'' 
following the heading and paragraph A are removed and the paragraph 
designation ``B'' is removed from paragraph B.
    bb. Section 9.03, paragraph A, in part A of appendix 1 is revised.
    cc. Section 11.00, paragraph A, in part A of appendix 1 is amended 
by revising the heading, by revising the first sentence in the first 
paragraph, by removing the second paragraph, by redesignation the third 
paragraph as the second paragraph and by amending the first, second and 
third sentences in the redesignating second paragraph to revise the 
word ``anticonvulsive'' to read ``antiepileptic.''
    dd. Section 11.02 in part A of appendix 1 is amended by revising 
the heading.
    ee. Section 11.03 in part A of appendix 1 is amended by revising 
the heading.
    ff. Section 11.15 in part A of appendix 1 is removed and reserved.
    gg. Section 11.17, paragraph A, in part A of appendix 1 is amended 
by removing the words ``or 11.15B''.
    hh. Section 12.05 in part A of appendix 1 is amended by revising 
the first sentence of the introductory text.
    ii. Section 13.08 in part A of appendix 1 is revised.
    jj. Section 14.08 in part A of appendix 1 is amended by revising 
paragraph M6.
    kk. Section 100.00, paragraph B, in part B of appendix 1 is 
revised.
    ll. Section 101.00, paragraph B, in part B of appendix 1 is amended 
by adding a second paragraph.
    mm. Section 101.02, paragraph A3, in part B of appendix 1 is 
revised.
    nn. Section 101.08 in part B of appendix 1 is revised.
    oo. Section 102.00 in part B of appendix 1, is amended by removing 
the word ``central'' from the first and second sentences of paragraph 
A.
    pp. Section 102.02 in part B of appendix 1 is amended by removing 
the word ``central'' from the heading.
    qq. Section 103.00, paragraph B, in part B of appendix 1 is amended 
by revising last sentence of the third paragraph.
    rr. Section 103.04, paragraph B3, in part B of appendix 1 is 
revised.
    ss. Section 103.05 in part B of appendix 1 is added after Table 
III.
    tt. Section 104.00, paragraph A, in part B of appendix 1 is amended 
in the last sentence of the sixth paragraph by revising ``make a 
determination'' to read ``consider,'' and paragraph E is amended by 
revising the first sentence of the third paragraph.
    uu. Section 105.00 in part B of appendix 1, is amended to revise 
the first sentence in paragraph B.
    vv. Section 105.05, paragraphs A and C, in part B of appendix 1 are 
revised.
    ww. Section 105.09 in part B of appendix 1 is added.
    xx. Section 107.00, paragraph C, in part B of appendix 1 is amended 
by revising the heading and by revising the first sentence of the first 
paragraph.
    yy. Section 107.11 in part B of appendix 1 is amended by revising 
the heading.
    zz. Section 111.00 in part B of appendix 1, paragraph A is revised 
and paragraph B is amended by revising the heading, and by removing the 
second sentence.
    aaa. Section 111.02 in part B of appendix 1 is amended by revising 
the headings of paragraphs A and B; by revising the first sentence of 
the introductory text of paragraphs A and B; and by revising paragraph 
B3.
    bbb. Section 111.03 in part B of appendix 1 is amended by revising 
the heading.
    ccc. Section 112.05, paragraphs F1 and F2, in part B of appendix 1 
are amended by revising ``limitations'' to read ``limitation.''
    ddd. Section 113.00 in part B of appendix 1, is amended by revising 
the third sentence in paragraph B.
    eee. Section 114.08, paragraph N6, in part B of appendix 1, 
paragraph N6 is revised.
    The added and revised text is as follows:

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

* * * * *

1.00  Musculoskeletal System

    A. * * * Evaluations of musculoskeletal impairments should be 
supported where applicable by detailed descriptions of the joints, 
including ranges of motion, condition of the musculature, sensory or 
reflex changes, circulatory deficits, and abnormalities as shown by 
X-ray or other appropriate medically acceptable imaging.
    B. * * *
    Evaluation of the impairment caused by disorders of the spine 
requires that a clinical diagnosis of the entity to be evaluated 
first must be established on the basis of adequate history, physical 
examination, and roentgenograms or other appropriate medically 
acceptable imaging. * * *
* * * * *
    Medically acceptable imaging includes, but is not limited to, X-
ray imaging, computerized axial tomography (CAT scan), magnetic 
resonance imaging (MRI), with or without contrast material, and 
radionuclear bone scans. While any appropriate medically

[[Page 6934]]

acceptable imaging is useful in establishing the diagnosis of 
musculoskeletal impairments, some tests, such as CAT scans and MRIs 
are quite expensive and some, such as myelograms, are invasive and 
may involve significant risk. If the results of these tests are 
available from the claimant or other sources at no or minimal cost 
to the agency, they will be considered in the evaluation of the 
claim. However, expensive tests and tests that may involve 
significant risk to the claimant, such as myelograms, will not be 
ordered.
    C. After maximum benefit from surgical therapy has been achieved 
in situations involving fractures of an upper extremity (see 1.12) 
or soft tissue injuries of a lower or upper extremity (see 1.13), 
i.e., there have been no significant changes in physical findings or 
findings as shown by x-rays or other appropriate medically 
acceptable imaging techniques for any 6-month period after the last 
definitive surgical procedure, evaluation should be made on the 
basis of demonstrable residuals.
* * * * *
    1.03  Arthritis of a major weight-bearing joint (due to any 
cause):
* * * * *
    A. Gross anatomical deformity of hip or knee (e.g., subluxation, 
contracture, bony or fibrous ankylosis, instability) supported by x-
ray or other appropriate medically acceptable imaging evidence 
showing either significant joint space narrowing or significant bony 
destruction, and markedly limiting ability to walk or stand; or,
* * * * *
    1.04  Arthritis of one major joint in each of the upper 
extremities (due to any cause):
    With history of persistent joint pain and stiffness, signs of 
marked limitation of motion of the affected joints on current 
physical examination, and X-ray or other appropriate medically 
acceptable imaging evidence of either significant joint space 
narrowing or significant bony destruction. With:
* * * * *
    1.05  Disorders of the spine: 
    A. Arthritis manifested by ankylosis or fixation of the cervical 
or dorsolumbar spine at 30 deg. or more of flexion measured from the 
neutral position, with X-ray or other appropriate medically 
acceptable imaging evidence of:
* * * * *
    B. Osteoporosis, generalized (established by X-ray or other 
appropriate medically acceptable imaging) manifested by pain and 
limitation of back motion and paravertebral muscle spasm with X-ray 
or other appropriate medically acceptable imaging evidence of 
either:
* * * * *
    1.08  Osteomyelitis or septic arthritis (established by X-ray or 
other appropriate medically acceptable imaging):
* * * * *
    1.09  Amputation or anatomical deformity (i.e., loss of major 
function due to degenerative changes associated with vascular or 
neurological deficits, traumatic loss of muscle mass or tendons and 
X-ray or other appropriate medically acceptable imaging evidence of 
bony ankylosis at an unfavorable angle, joint subluxation or 
instability) of:
* * * * *
    1.11  Fracture of the femur, tibia, tarsal bone or pelvis with 
solid union not evident on X-ray or other appropriate medically 
acceptable imaging, and not clinically solid, when such 
determination is feasible, and return to full weight-bearing status 
did not occur or is not expected to occur within 12 months of onset.
* * * * *

2.00  Special Senses and Speech

A. Disorders of Vision

    1. Causes of impairment. Diseases or injury of the eyes may 
produce loss of visual acuity or loss of the peripheral field. Loss 
of visual acuity results in inability to distinguish detail and 
prevents reading and fine work. Loss of the peripheral field 
restricts the ability of an individual to move about freely. The 
extent of impairment of sight should be determined by visual acuity 
and peripheral field testing.
    2. Visual acuity. Loss of visual acuity may result in impaired 
distant and/or near vision. However, for an individual to meet the 
level of severity described in 2.02 and 2.04, only the remaining 
visual acuity for distance of the better eye with best correction 
based on the Snellen test chart measurement may be used. * * *
* * * * *
    5. Visual efficiency. Loss of visual efficiency may be caused by 
disease or injury resulting in reduction of visual acuity or visual 
field. The visual efficiency of one eye is the product of the 
percentage of visual acuity efficiency and the percentage of visual 
field efficiency. (See tables no. 1 and 2, following 2.09.)
* * * * *
    B. * * *
    2. * * *
* * * * *
    * * * When polytomograms, contrast radiography, or other special 
tests have been performed, copies of the reports of these tests 
should be obtained in addition to reports of skull and temporal bone 
X-rays or other appropriate medically acceptable imaging.
    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. Impairment of 
speech due to neurological disorders should be evaluated under 
11.00--11.19.
* * * * *
    2.04  Loss of visual efficiency. Visual efficiency of better eye 
after best correction 20 percent or less. (The percent of remaining 
visual efficiency = the product of the percent of remaining visual 
acuity efficiency and the percent of remaining visual field 
efficiency.)
    2.05  [Removed and reserved]
* * * * *
    2.09  Loss of speech due to any cause with inability to produce 
by any means speech which can be heard, understood, or sustained.
* * * * *

3.00  Respiratory System

* * * * *
    E. Documentation of pulmonary function testing. 
* * * * *
    * * * 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.
* * * * *
    F. Documentation of chronic impairment of gas exchange. 
    1. * * *
* * * * *
    * * * 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 and/or carboxyhemoglobin were made 
appropriately.
* * * * *
    3.11  Lung transplant. Consider under a disability for 12 months 
following surgery; thereafter, evaluate the residual impairment.

4.00  Cardiovascular System

* * * * *
    C. * * *
    3. * * * In selected cases, these tests may be purchased after a 
medical history and physical examination, report of chest x-rays or 
other appropriate medically acceptable imaging, ECGs, and other 
appropriate tests have been evaluated, preferably by a program 
physician with experience in the care of patients with 
cardiovascular disease. * * *
    5.03  Stricture, stenosis, or obstruction of the esophagus 
(demonstrated by X-ray, endoscopy, or other appropriate medically 
acceptable imaging) with weight loss as described under listing 
5.08.
    5.04  Peptic ulcer disease (demonstrated by X-ray, endoscopy, or 
other appropriate medically acceptable imaging). With:
* * * * *
    C. Recurrent obstruction demonstrated by X-ray, endoscopy, or 
other appropriate medically acceptable imaging; or,
* * * * *
    5.05  Chronic liver disease (e.g., portal, postnecrotic, or 
biliary cirrhosis; chronic active hepatitis; Wilson's disease). * * 
*
    A. Esophageal varices (demonstrated by X-ray, endoscopy, or 
other appropriate medically acceptable imaging) with a documented 
history of massive hemorrhage attributable to these varices. * * *
* * * * *
    5.09  Liver transplant. Consider under a disability for 12 
months following surgery; thereafter, evaluate the residual 
impairment.
* * * * *

6.02

* * * * *
    C. * * *
    1. Renal osteodystrophy manifested by severe bone pain and 
abnormalities shown by

[[Page 6935]]

appropriate radiographic or other medically acceptable imaging 
(e.g., osteitis fibrosa, marked osteoporosis, pathologic fractures); 
or
* * * * *

7.00  Hemic and Lymphatic System

* * * * *
    E. Acute leukemia or T-cell lymphoblastic lymphoma. Initial 
diagnosis of acute leukemia or T-cell lymphoblastic lymphoma must be 
based upon definitive bone marrow pathologic evidence. * * *
* * * * *
    7.11  Acute leukemia or T-cell lymphoblastic lymphoma.
* * * * *
    7.16  Myeloma (confirmed by appropriate serum or urine protein 
electrophoresis and bone marrow findings). With:
    A. Radiologic or other appropriate medically acceptable imaging 
evidence of bony involvement with intractable bone pain; or
* * * * *
    7.17  Aplastic anemias or hematologic malignancies (excluding 
acute leukemia): With bone marrow or stem cell transplantation. * * 
*
* * * * *
    9.03  Hyperparathyroidism. With:
    A. Generalized decalcification of bone on X-ray or other 
appropriate medically acceptable imaging study and elevation of 
plasma calcium to 11 mg. per deciliter (100 ml.) or greater; or
* * * * *

11.00  Neurological

    A. Epilepsy. In epilepsy, regardless of etiology degree of 
impairment will be determined according to type, frequency, 
duration, and sequelae of seizures. * * *
* * * * *
    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 weekly in spite of at least 3 months of prescribed treatment.
* * * * *
    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.
* * * * *
    12.05  Mental Retardation and Autism: Mental retardation refers 
to a significantly subaverage general intellectual functioning with 
deficits in adaptive behavior initially manifested during the 
developmental period (before age 22). * * *
* * * * *
    13.08  Thyroid gland:
    A. Carcinoma with metastases beyond the regional lymph nodes, 
not controlled by prescribed therapy; or
    B. Anaplastic carcinoma of the thyroid.
* * * * *
    14.08  Human immunodeficiency virus (HIV) infection.
* * * * *
    M. * * *
    6. Sinusitis documented by radiography or other appropriate 
medically acceptable imaging.
* * * * *

100.00  Growth Impairment

* * * * *
    B. Bone age determinations should include a full descriptive 
report of roentgenograms or other medically acceptable imaging 
specifically obtained to determine bone age and must cite the 
standardization method used. Where roentgenograms or other 
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, roentgenograms or 
other 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.
* * * * *

101.00  Musculoskeletal System

* * * * *
    B. * * *
    Medically acceptable imaging includes, but is not limited to, X-
ray imaging, computerized axial tomography (CAT scan), magnetic 
resonance imaging (MRI), with or without contrast material, and 
radionuclear bone scans. While any appropriate medically acceptable 
imaging is useful in establishing the diagnosis of musculoskeletal 
impairments, many tests, such as CAT scans and MRIs are quite 
expensive and some, such as myelograms, are invasive and may involve 
significant risk. If the results of these tests are available from 
the claimant or other sources at no or minimal cost to the agency, 
they will be considered in the evaluation of the claim. However, 
expensive tests and tests that may involve significant risk to the 
claimant, such as myelograms, will not be ordered.
* * * * *
    101.02  Juvenile rheumatoid arthritis.
* * * * *
    A. * * *
    3. Radiographic or other appropriate medically acceptable 
imaging evidence showing joint narrowing, erosion, or subluxation; 
or
* * * * *
    101.08  Osteomyelitis or septic arthritis (established by X-ray 
or other appropriate medically acceptable imaging):
    A. Located in the pelvis, vertebra, femur, tibia, or a major 
joint of an upper or lower extremity, with persistent activity or 
occurrence of at least two episodes of acute activity within a 5-
month period prior to adjudication, manifested by local inflammatory 
and systemic signs and laboratory findings (e.g., heat, redness, 
swelling, leucocytosis, or increased sedimentation rate) and 
expected to last at least 12 months despite prescribed therapy; or
    B. Multiple localizations and systemic manifestations as in A. 
above.
* * * * *

103.00  Respiratory System

* * * * *
    B. * * *
* * * * *
    * * * 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.
* * * * *
    103.04  Cystic fibrosis.
* * * * *
    B. * * *
    3. Radiographic or other appropriate medically acceptable 
imaging evidence of extensive disease, such as thickening of the 
proximal bronchial airways or persistence of bilateral peribronchial 
infiltrates; or
* * * * *
    103.05  Lung transplant. Consider under a disability for 12 
months following surgery; thereafter, evaluate the residual 
impairment.
* * * * *

104.00  Cardiovascular System

* * * * *
    E. * * *
    Findings of cardiomegaly shown by chest x-ray or other 
appropriate medically acceptable imaging evidence must be 
accompanied by other evidence of chronic heart failure or 
ventricular dysfunction. * * *
* * * * *

105.00  Digestive System

* * * * *
    B. Documentation of gastrointestinal impairments should include 
pertinent operative findings, radiographic or other appropriate 
medically acceptable imaging studies, endoscopy, and biopsy reports. 
* * *
* * * * *
    105.05  Chronic liver disease. * * *
    A. Inoperable billiary atresia demonstrated by X-ray or other 
appropriate medically acceptable imaging or surgery; or
* * * * *
    C. Esophageal varices (demonstrated by X-rays, endoscopy, or 
other appropriate medically acceptable imaging); or
* * * * *
    105.09  Liver transplant. Consider under a disability for 12 
months following surgery; thereafter, evaluate the residual 
impairment.
* * * * *

107.00  Hemic and Lymphatic System

* * * * *
    C. Acute leukemia or T-cell lymphoblastic lymphoma. Initial 
diagnosis of acute leukemia or T-cell lymphoblastic lymphoma must be 
based upon definitive bone marrow pathologic evidence. * * *
* * * * *
    107.11  Acute leukemia or T-cell lymphoblastic lymphoma. * * *
* * * * *

[[Page 6936]]

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. * * *
* * * * *
    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. * * *
* * * * *
    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. * * *
* * * * *
    3. Significant mental disorder; or
* * * * *
    111.03  Nonconvulsive epilepsy. * * *
* * * * *

113.00  Neoplastic Diseases, Malignant

* * * * *
    B. Documentation. * * * If an operative procedure has been 
performed, the evidence should include a copy of the operative note 
and the report of the gross and microscopic examination of the 
surgical specimen, along with all pertinent laboratory and X-ray 
reports or reports from other appropriate medically acceptable 
imaging.* * *
* * * * *
    114.08  Human immunodeficiency virus (HIV) infection.
* * * * *
    N. * * *
    6. Sinusitis documented by radiography or other appropriate 
medically acceptable imaging.
* * * * *

PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND 
DISABLED

Subpart I--[Amended]

    3. The authority citation for subpart I of part 416 continues to 
read as follows:

    Authority: Secs. 702(a)(5), 1611, 1614, 1619, 1631(a), (c) and 
(d)(1), and 1633 of the Social Security Act (42 U.S.C. 902 (a)(5), 
1382, 1382c, 1382h, 1383(a), (c), and (d)(1), and 1383b); secs. 4(c) 
and 5, 6(c)-(e), 14(a) and 15, Pub. L. 98-460, 98 Stat. 1794, 1801, 
1802, and 1808 (42 U.S.C. 421 note, 423 note, 1382h note).


Sec. 416.926  [Amended]

    4. Section 416.926a is amended by removing paragraphs (d) (8) and 
(9), and redesignating paragraph (d) (10), (11), and (12) as paragraphs 
(d) (8), (9), and (10).

[FR Doc. 00-2867 Filed 2-10-00; 8:45 am]
BILLING CODE 4191-02-P