[Federal Register Volume 67, Number 79 (Wednesday, April 24, 2002)]
[Rules and Regulations]
[Pages 20018-20028]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-9737]


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SOCIAL SECURITY ADMINISTRATION

20 CFR Part 404

[Regulations No. 4 and 16]
RIN 0960-AE99


Technical Revisions to Medical Criteria for Determinations of 
Disability

AGENCY: Social Security Administration (SSA).

ACTION: Final rules.

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SUMMARY: These final rules make a number of technical revisions to the 
Listing of Impairments (the listings). We use the listings when you 
claim benefits based on disability under titles II and XVI of the 
Social Security Act (the Act). We are making these revisions to reflect 
advances in medical knowledge, treatment and terminology, to clarify 
certain criteria in the listings, to remove listings that we rarely 
use, and to add new listings consistent with current medical practice. 
We are making these individual technical revisions in order to improve 
our medical listings and make them easier to understand and use.

DATES: These final regulations are effective May 24, 2002.

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 1-800-966-5609 for information about 
these rules. For information on eligibility, filing for benefits, or 
coverage of earnings, call our national toll-free number, 1-800-772-
1213 or TTY (410) 966-5609, or visit our Internet web site, Social 
Security Online, at http://www.sss.gov.

SUPPLEMENTARY INFORMATION: We are revising and making final the rules 
we proposed in the Notice of Proposed Rulemaking (NPRM) published in 
the Federal Register on February 11, 2000 (65 FR 6932).

Background

    Under title II of the Act, we provide for the payment of disability 
benefits if you are disabled and belong to one of the following three 
groups:
     Workers insured under the Act;
     Children of insured workers; and
     Widows, widowers, and surviving divorced spouses (see 20 
CFR 404.336) of insured workers.
    Under title XVI of the Act, we provide for Supplemental Security 
Income (SSI) payments on the basis of disability if you have limited 
income and resources.
    Under both title II and title XVI programs, disability must be the 
result of any medically determinable physical or mental impairment or 
combination of impairments 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.
    Our definitions of disability are shown in the following table:

------------------------------------------------------------------------
                                                    Disability means you
                                                      have a medically
                                                        determinable
 If you file a claim under * *  And you are * * *    impairment(s) that
               *                                    meets the statutory
                                                    duration requirement
                                                    and results in * * *
------------------------------------------------------------------------
Title II......................  An adult or a      The inability to do
                                 child.             any substantial
                                                    gainful activity
                                                    (SGA).
Title XVI.....................  An adult.........  The inability to do
                                                    any SGA.
Title XVI.....................  A child..........  Marked and severe
                                                    functional
                                                    limitations.
------------------------------------------------------------------------

    We use a sequential evaluation process, set out in Secs. 404.1520 
and 416.920 of our regulations, when we evaluate a claim for disability 
benefits if you are an adult. We use a separate sequential evaluation 
process described in Sec. 416.924 of our regulations if you are a child 
claiming SSI payments based on disability. At step three of both 
sequential evaluation processes, we determine whether you have an 
impairment(s) that meets or medically equals the listings. If you are a 
child applying for SSI payments based on disability, we also determine 
if your impairment(s) functionally equals the listings.
    The listings describe, for each of the major body systems, 
impairments that we consider severe enough to prevent you from doing 
any gainful activity. In the case of a child applying for SSI payments 
based on disability, the listings describe impairments that we consider 
severe enough to result in marked and severe functional limitations.
    The listings are divided into Part A and Part B. We apply the 
medical criteria in Part A when we assess your claim if you are an 
adult (i.e., a person age 18 or over). If you are a child, we first use 
the criteria in Part B. If the criteria in Part B do not apply, and the 
specific disease process(es) has a similar effect on adults and 
children, we then use the criteria in Part A (see Secs. 404.1525, 
404.1526, 416.925, and 416.926).
    The changes we are making in these final rules 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 
substantive revisions and updates. If we determine that more 
substantive revisions are necessary, we will publish notices of 
proposed rulemaking in the Federal Register describing those proposed 
revisions and requesting public comments.

[[Page 20019]]

Explanation of Revisions

    We are revising language throughout the listings to incorporate 
imaging techniques other than x-rays alone. This revised language was 
incorporated in the following listing sections: 2.00B2; 5.03; 5.04; 
5.05; 6.02(C)(1); 7.16; and 9.03. This is being done by adding language 
allowing for ``appropriate medically acceptable imaging'' to be used 
when imaging evidence is called for as part of the medical 
documentation. Since x-rays are incorporated in the phrase 
``appropriate medically acceptable imaging,'' we have removed the 
specific mention of ``x-rays'' when we refer to appropriate medically 
acceptable imaging throughout the listings addressed in this 
rulemaking.
    We made a revision to our proposed rulemaking language in the 
prefaces of the listings for the body systems affected by this change. 
We added language to explain that appropriate medically acceptable 
imaging includes, but is not limited to, x-ray imaging, computerized 
axial tomography (CAT scan) or magnetic resonance imaging (MRI), with 
or without contrast material, myelography, and radionuclear bone scans. 
To further clarify what we mean by ``appropriate,'' we added a sentence 
to these prefaces that states ``Appropriate means that the technique 
used is the proper one to support the evaluation and diagnosis of the 
impairment.''
    We made a number of revisions to the listings for the Special 
Senses and Speech body systems, 2.00 and 102.00. We substituted the 
heading ``Disorders of Vision'' in 2.00A for ``Ophthalmology'' to make 
clear that these listings deal with visual disorders, rather than the 
branch of medicine dealing with the anatomy, physiology, and pathology 
of the eye. We also removed the word ``central'' when referring to 
visual acuity in the preface sections 2.00A1, 2.00A2, 2.00A5, 2.00A6, 
102.00A, listings 2.02 and 102.02, and in Table No. 1, because the word 
is redundant. It is the loss of visual acuity in itself (be it central 
or peripheral) that results in the inability to distinguish detail, and 
thereby prevents reading and fine work. We further clarify this in a 
revision to section 2.00A2 which states that ``Loss of visual acuity 
may result in impaired distant vision or near vision, or both.'' We 
also clarified listing 2.04 by replacing the phrase ``central visual 
efficiency'' with the phrase ``visual acuity efficiency.'' We removed 
listing 2.05, Complete homonymous hemianopsia, as a separate listing 
since it merely directs evaluation to listing 2.04, which we are not 
substantively changing. Listing 2.04 will permit evaluation of this 
disorder.
    We also removed the word ``organic'' in section 2.00B3 and in 
listing 2.09 because the cause of the loss of speech is not material to 
its evaluation under this body system. We also clarified listing 2.09 
to make it clear that the inability to produce by any means speech that 
can be heard, understood, or sustained is sufficient to meet this 
listing; all three of these factors do not need to be present to meet 
the listing.
    For the respiratory system listings for adults and children, 3.00 
and 103.00, we changed some of the technical testing requirements to be 
simpler and to be consistent with standard laboratory practices. If the 
spirogram is generated by any means other than direct pen linkage to a 
mechanical displacement-type spirometer, we will no longer require 
separate calibration tracings to be performed at the time each 
pulmonary function test is performed. Rather, a single daily 
calibration of the testing device will suffice. For direct pen linkage 
spirometry equipment, the tracing is directly generated and inherently 
accurate so that no mechanically generated calibrations are required. 
We also revised listing section 3.00F so that we no longer require that 
the algorithm used to calculate the test for diffusing capacity of the 
lungs for carbon monoxide be provided as part of the documentation for 
this test. Rather, the source of the predicted equation should be 
provided. This information is sufficient to verify that the test was 
performed adequately.
    We added a new listing for both adults and children to cover lung 
transplants, listings 3.11 and 103.05, respectively. These listings 
provide that we will consider an individual to be disabled for 12 
months following the date of surgery. After that time, we will evaluate 
any residual impairment.
    In order to correct a possible misinterpretation in our intent, we 
revised listing sections 4.00A and 104.00A. We now state that we will 
``consider'' (rather than ``make'') a medical equivalence finding for 
an adult, and a medical or functional equivalence finding for a child 
seeking SSI payments, in situations where the individual has either a 
medically determinable impairment that is not listed, or has a 
combination of impairments, no one of which meets a listing. We have 
always intended that we consider whether the impairment or combination 
of impairments medically equals a listing (or, as appropriate, 
medically or functionally equals a listing). The use of the word 
``make'' may have given the erroneous impression that we would 
automatically find medical equivalence in all cases where the 
impairment(s) was severe but did not meet the exact requirements of a 
listing.
    For the digestive body systems listings for adults and children, 
5.00 and 105.00, we added new listings to address liver 
transplantation, listings 5.09 and 105.09, respectively. Under these 
listings, we will consider the individual to be disabled for 12 months 
following the date of the liver transplant surgery. After that period, 
we will evaluate any residual impairment.
    For the hemic and lymphatic body system listings, for adults and 
children, we added T-cell lymphoblastic lymphoma to listings 7.11 and 
107.11, respectively. These listings currently address acute leukemia 
only. We also included a discussion of T-cell lymphoblastic lymphoma in 
the sections 7.00E and 107.00C of the preface to the listings. Because 
T-cell lymphoblastic lymphoma follows the same course and requires the 
same treatment as acute leukemia, we believe it will simplify 
adjudication by naming this particular lymphoma in the listings. We 
also added stem cell transplantation as a new medical technique 
comparable to bone marrow transplantation in listing 7.17.
    In the skin body system listing, we corrected a spelling error in 
listing 8.06.
    In the endocrine body system listing for adults, we removed 
paragraph A of listing 9.02. This listing, which addresses progressive 
exophthalmos as measured by exophthalmometry, is a rare complication in 
light of today's medical treatments for thyroid disease.
    In the neurological body system listings for adults and children, 
11.00 and 111.00, we made a number of changes to reflect current 
medical terminology (convulsive and nonconvulsive epilepsy), and to 
modify the documentation requirement for an electroencephalogram (EEG). 
With the exception of nonconvulsive epilepsy in children, we will no 
longer require that an EEG be part of the documentation needed to 
support the presence of epilepsy. An EEG is a definitive diagnostic 
tool in cases of nonconvulsive epilepsy in children, but it is rare for 
an EEG to confirm epilepsy in its other forms for either adults or 
children. In listings 11.02 and 11.03, we changed the terminology to 
reflect convulsive and nonconvulsive epilepsy, and we made comparable 
changes to the childhood epilepsy listings. We also changed references 
to ``anticonvulsive''

[[Page 20020]]

treatment to ``antiepileptic'' treatment and ``antiepileptic'' drugs. 
These changes are consistent with current medical usage.
    We changed listing 111.02B3 to refer to a ``Significant mental 
disorder'' for consistency with other listing terminology, for example, 
that of listings 111.07B3 and 4, and to clarify that we require a 
defined mental impairment in order to fulfill this listing criteria for 
convulsive epilepsy.
    We eliminated current listing 11.15 for tabes dorsalis because this 
disease is rarely seen today, given the availability of effective 
medical screening and treatment for syphilis. With this deletion, we 
also amended listing 11.17 by removing the reference to listing 11.15B 
currently in listing 11.17A. The current reference to listing 11.04B 
contained in listing 11.17 adequately addresses the disorganization of 
motor function that is needed to evaluate the effects of these 
degenerative diseases on an individual's gait.
    In the neoplastic diseases body system listings for adults, 13.00, 
we amended listing 13.08 to add the criterion, ``Anaplastic 
(undifferentiated) carcinoma of the thyroid,'' and designated it as 
listing 13.08A. This is a distinct type of thyroid carcinoma with a 
poor prognosis, and it is of the same level of severity as the current 
thyroid listing. By identifying this type of carcinoma specifically, we 
believe we will simplify adjudication for these types of cases.
    For clarity, we refer to the changes we are making here as the 
``final'' rules and to the rules that will be changed by these final 
rules as the ``current'' rules. However, these final rules do not go 
into effect until 30 days after the date of this publication. 
Therefore, the ``current'' rules will still be in effect until that 
date.

Public Comments

    On February 11, 2000, we published a notice of proposed rulemaking 
(NPRM) in the Federal Register (65 FR 6929) proposing to make a number 
of technical revisions to our listings. We gave interested persons 60 
days within which to submit written comments on the proposed rules; the 
comment period closed on April 11, 2000. We received 90 comments from 
the public. Most of the comments came from disabled individuals. Other 
comments came from State agencies that make disability determinations 
for us, advocacy organizations, and professional organizations whose 
members have interests and responsibilities that require them to have 
some expertise in the evaluation of disability claims.
    Several commenters simply expressed agreement with the proposed 
changes, believed that they would be beneficial, and stated that the 
language was improved so that it was easier to understand. Along this 
line, some of these commenters specifically supported our proposal to 
update the language in our listings concerning imaging techniques to 
include other appropriate medically acceptable imaging techniques in 
addition to x-rays. These commenters believed this was an improvement 
that would be beneficial for both claimants and adjudicators.
    A few commenters, however, stated that the proposed revisions to 
the listings were difficult to read and understand. These commenters 
recommended that the listings be written to be understandable to lay 
people, rather than to doctors. Since the listings summarize required 
medical signs, laboratory findings, and symptoms, we often find it 
necessary to retain appropriate medical terms and language in the 
listings. To the extent possible, we write our regulations in plain 
language. We intend to incorporate as much plain language as possible 
as we review and revise each individual body system listing, and we 
wrote these proposed revisions as simply as possible within the context 
of the listing being revised.
    The following are summaries of comments that directly related to 
the proposed rules, or related to areas that were discussed in the 
proposed rules, along with our responses. Because some of the comments 
were lengthy, we have condensed, summarized and paraphrased them. We 
have tried, however, to summarize the commenters' views accurately, and 
to respond to all of the significant issues raised by the commenters 
that were within the scope of these rules. Many of the comments, 
however, pertained to matters that were not within the scope of these 
proposed rules. We referred those comments to the appropriate 
components of the Social Security Administration and do not address 
them in this preamble.

Musculoskeletal Body System

    Comment: Two commenters requested that we make additional changes 
to the listings on the evaluation of osteomyelitis (listings 1.08 and 
101.08). One commenter recommended that we include the spinal 
manifestations of the disorder in the listings. The other commenter 
suggested that we clarify the reference to a ``major joint of an upper 
or lower extremity'' in listing 1.08, since osteomyelitis involves 
bones, not joints. The first commenter also expressed concern that 
chronic osteomyelitis was not listed because she knew of situations in 
which treatment did not eliminate the infection.
    Response: We have not adopted these comments. We have not included 
any technical revisions to the musculoskeletal body system listings in 
these final rules. On November 19, 2001, we published final rules in 
the Federal Register revising the medical criteria we use for 
evaluating musculoskeletal impairments in adults and children. In those 
final rules, we noted that we removed listings 1.08 and 101.08, 
osteomyelitis or septic arthitis, because fundamental advances in 
antibiotic therapy has meant that, when they do occur, these conditions 
are not usually expected to last for one year. Therefore, we will 
evaluate claims involving these impairments on a case-by-case basis to 
determine whether they medically equal (or, as appropriate, 
functionally equal) the listings (66 FR 58010).
    Comment: One commenter suggested that we make an additional change 
to listing 1.11, fracture of the femur, tibia, tarsal bone, or pelvis, 
to include the non-union of the distal fibula.
    Response: This listing, which is now listing 1.06 as a result of 
the final rules that we published on November 19, 2001, addresses the 
major bones of the lower extremities that are usually involved in 
weight bearing. While we did not specifically include reference to 
situations involving non-union of the distal fibula, a case of this 
type that fulfilled the overall severity requirements of listing 1.06 
could be found to medically equal this listing.

Special Senses and Speech

    Comment: One commenter recommended that we make changes to listing 
2.09 in addition to the ones we proposed. This commenter first 
suggested that we clarify the term ``sustained'' in listing 2.09. This 
commenter also expressed concern that, if the term ``organic'' was 
deleted from listing 2.09, the rules should also clarify whether all 
known means to produce speech must have been tried and failed. Finally, 
the commenter recommended that we include language from the preamble to 
the NPRM in the final rules, either in listing 2.09 or in the 
introductory section of the listing, section 2.00B3. The commenter 
stated that we should include in the regulatory text the statement 
that, ``We believe that any one of these factors is sufficient to 
establish that an individual has a listing-level impairment.''
    Response: We have not adopted these comments. Revised listing 2.09 
makes

[[Page 20021]]

clear that the inability to produce speech linked to any of the three 
factors (can be heard, can be understood, or can be sustained) will 
satisfy the requirements of the listing. We do not believe that adding 
the sentence from the preamble to the proposed rules, as the commenter 
suggested, clarifies the rule any further. The other issues raised by 
this commenter will require more extensive revisions to the special 
senses and speech listings than were intended under this rulemaking 
proceeding. We will consider more detailed clarifications as part of 
our review of the special senses and speech body system listings.
    Comment: Some commenters expressed concern about the changes we 
proposed to listing section 2.00, on the evaluation of vision 
disorders. One commenter recommended that section 2.00A1 not be revised 
to remove the word ``central'' when referring to vision and visual 
acuity because the terms ``central vision'' and ``visual acuity'' are 
not medically synonymous. The commenter noted that it is possible to 
have a small island of usable vision in the center of a dense central 
field loss. This could result in measurable but unusable central visual 
acuity. This could potentially occur in cases involving impairments 
such as macular degeneration, diabetic retinopathy, end-stage glaucoma, 
end-stage retinitis pigmentosa, and ischemic vision loss. The commenter 
also stated that the term ``peripheral fields'' was unclear. The second 
commenter, an ophthalmologist, expressed similar concerns. He commented 
that we were not using accurate terminology when we proposed to use the 
terms ``visual acuity'' and ``peripheral fields.''
    Response: We have not adopted these comments. While we understand 
the commenters' concerns, our use of the terms we proposed in this 
section of the preface is consistent with common definitions which 
satisfy our needs for purposes of disability adjudication. We agree 
that vision physiologists might prefer to use more sophisticated 
terminology in accordance with their professional needs to discern 
complex distinctions. However, for purposes of disability adjudication, 
our use of the terms ``visual acuity'' and ``peripheral fields'' are 
familiar and defined concepts. We believe, based on our program 
experience, that they adequately satisfy our needs in evaluating 
disability claims of individuals with visual impairments. However, we 
will consider these comments when we review and revise the special 
senses and speech body system listings.
    Comment: One commenter recommended that we continue to use the term 
``Ophthalmology'' instead of our proposed revision, ``Disorders of 
Vision,'' for the heading of listing section 2.00A. Similarly, another 
commenter thought we should use the term ``Visual Impairment'' rather 
than ``Disorders of Vision.'' This commenter stated that this was 
consistent with terminology used by schools and most rehabilitation 
facilities.
    Response: We have not adopted these comments. As we noted above, we 
believe our use of more common terminology is suitable for our 
purposes. We also believe that changing our heading of listing section 
2.00A to ``Disorders of Vision'' is appropriate to convey our 
identification of the material in this section of the listings.
    Comment: One commenter stated that we should revise our measurement 
assessment tools for the peripheral field and for central visual 
function, and eliminate the use of the Goldmann perimeter and the 
Snellen visual acuity tests. Another commenter agreed that we should 
revise our rules on the use of the Goldmann perimeter in light of our 
emphasis on changes in the listings to reflect advances in medical 
knowledge.
    Response: We have not adopted these comments. These comments raise 
issues that are outside the scope of this rulemaking proceeding. We 
will consider the concerns the commenters expressed as we consider more 
substantive revisions to the special senses and speech body system 
listings.

Digestive System

    Comment: One commenter suggested that we include other diagnostic 
techniques, such as a CAT scan or ultrasound, as acceptable 
confirmation of liver disease, in addition to a liver biopsy, under 
listing 5.05F.
    Response: We have not adopted this comment because it is beyond the 
scope of this rulemaking proceeding. We will, however, consider the 
comment as part of our comprehensive review of the digestive system 
listings.

Neurological

    Comment: One commenter recommended that we revise the preface to 
the listing to reflect the deletion of listing 11.15, for tabes 
dorsalis.
    Response: We have not adopted this comment. Listing 11.15 is not 
discussed in the preface to the current neurological listings, and we 
see no need to add a discussion regarding its deletion. Tabes dorsalis 
is rarely seen in modern medicine. If we had to evaluate this 
condition, it would be appropriate to consider whether the condition 
medically equaled other neurological listings. For example, sensory 
deficits associated with tabes dorsalis could be evaluated under 
listing 11.04A, or visual limitations associated with this condition 
could be evaluated using listing 11.09B.
    Comment: One commenter, from an advocacy organization on behalf of 
individuals with epilepsy, commended the proposed change of wording to 
use ``antiepileptic'' in place of ``anticonvulsant.'' Another 
commenter, however, stated that the change would limit the listing, 
because convulsive disorders other than epilepsy would no longer fall 
under this listing section. The first commenter also supported the 
elimination of the requirement for an electroencephalogram (EEG) in all 
diagnoses of epilepsy. However, this commenter also expressed concern 
that we did not change some other outdated terminology contained in the 
epilepsy listings, and recommended that we make additional changes to 
the listings.
    Response: We agree with the commenter about the need to make 
additional revisions to the listings for epilepsy in order to further 
update them. We are in the process of reviewing and revising the 
neurological body system listings and expect to issue proposed rules as 
part of that revision. We expect that any future revisions will address 
the commenter's concerns. Because the changes the commmenter suggested 
are more detailed and substantive, we do not believe that these 
suggested changes are within the scope of this rulemaking proceeding. 
In regard to the concern that these proposed changes would limit the 
usefulness of the seizure listings, the primary disorder being 
addressed here is in fact epilepsy. Other convulsive disorders or 
similarly disruptive disorders can still be evaluated under these 
epilepsy listings by using medical equivalence, as has been done in the 
past with such disorders as narcolepsy and pseudoseizures.
    Comment: One commenter stated that we should use the terms 
``partial'' seizures and ``generalized'' seizures in the listings, 
rather than ``convulsive epilepsy'' (listing 11.02) and ``nonconvulsive 
epilepsy'' (listing 11.03).
    Response: As noted above, we are currently reviewing the entire 
neurological body system to identify further appropriate revisions. As 
part of this process, we anticipate some restructuring of listings 
using broader impairment categories, as well as additional changes in 
the listings dealing with epilepsy and terminology related to epilepsy. 
We will consider the

[[Page 20022]]

commenter's recommendations during the review of the entire 
neurological body system listings.
    Comment: One commenter expressed concern that we were removing 
myasthenia gravis from the listings as a listed impairment.
    Response: We did not propose removing this impairment as a listed 
impairment in our regulations. Myasthenia gravis is evaluated under 
listing 11.12.
    Comment: One commenter questioned when we would recognize post-
polio syndrome as a disabling impairment, since the neuromuscular 
effects result in additional functional loss and are usually permanent 
and slowly progressive.
    Response: The late effects of polio, also referred to as post-polio 
syndrome or sequelae, are recognized as a potentially disabling 
impairment and are evaluated under our current listing 11.11, Anterior 
poliomyelitis. Under listing 11.11, we evaluate your overall motor 
function. If the impairment is not found to meet or equal a listed 
impairment, we consider the impact of the impairment and any related 
symptoms in determining your residual functional capacity and we 
proceed to evaluate your impairment under our sequential evaluation 
procedures in accordance with Sec. 404.1545.

Mental

    Comment: One commenter recommended that we use the definition of 
mental retardation (MR) found in the Diagnostic and Statistical Manual 
of Mental Disorders (4th ed. 1994) (DSM-IV), published by the American 
Psychiatric Association, as the definition of MR in listing 12.05 and 
112.05.
    Response: We did not adopt the comment. The definition of MR we use 
in our listings is consistent with, if not identical to, the 
definitions of MR used by the leading professional organizations. The 
four major professional organizations in the United States that deal 
with MR have each established their own definition of MR. While all the 
definitions require significant deficits in intellectual functioning, 
as evidenced by IQ scores of approximately 70 or below, age of onset 
and the method of measuring the required deficits in adaptive 
functioning differ among the organizations.
    For example, the definition of MR used in the DSM-IV is 
predominantly based on (but not identical to) the revised definition of 
MR promulgated by the American Association on Mental Retardation (AAMR) 
in 1993. The DSM-IV states: ``The essential feature of mental 
retardation is significantly subaverage general intellectual 
functioning (further defined as an IQ standard score of approximately 
70 or below), that is accompanied by significant limitations in at 
least two of the following skill areas: communication, self-care, home 
living, social/interpersonal skills, use of community resources, self-
direction, functional academic skills, work, leisure, health, and 
safety. The onset must occur before age 18 years.''
    Following publication of this new definition of MR by the AAMR, the 
American Psychological Association published its own ``Manual of 
Diagnosis and Professional Practice in Mental Retardation, 1996.'' It 
states: ``Mental retardation refers to (a) significant limitations in 
general intellectual functioning; (b) significant limitations in 
adaptive functioning, which exist concurrently; and (c) onset of 
intellectual and adaptive limitations before the age of 22 years.'' In 
its definition, (a) is defined as ``* * * an IQ or comparable normed 
score that is two or more standard deviations below the population mean 
for the measure;'' and for (b), ``* * * the criterion of significance 
is a summary index score that is two or more standard deviations below 
the mean * * *.''
    The definition of MR used by SSA in the listings is not restricted 
to diagnostic uses alone, nor does it seek to endorse the methodology 
of one professional organization over another. While capturing the 
essence of the definitions used by the professional organizations, it 
also is used to determine eligibility for disability benefits. SSA's 
definition establishes the necessary elements, while allowing use of 
any of the measurement methods recognized and endorsed by the 
professional organizations.

Neoplastic Diseases--Malignant

    Comment: One commenter requested that we add ``undifferentiated'' 
carcinoma of the thyroid to the listing 13.08. The commenter noted that 
this would be the same as the proposed anaplastic carcinoma of the 
thyroid, but the inclusion of both terms would better clarify the 
rules.
    Response: We have adopted this comment and have made the change in 
listing 13.08.

General

    Comment: A professional organization representing disability 
adjudicators at the state level generally agreed with the proposed 
revisions. However, the comments expressed concern about the proposed 
deletion of listing 2.05 for complete homonymous hemianopsia and 
listing 11.15 for tabes dorsalis, and the removal of the reference in 
listing 9.02 to ``progressive exophthalmos as measured by 
exophthalmometry.'' The commenter agreed that these conditions were 
rarely seen, but remained concerned that their removal may lead to 
these conditions being overlooked. The commenter recommended that any 
revisions to these listings be done as we revise individual body system 
listings.
    Response: We have not adopted these comments. We believe it is 
appropriate to delete listings 2.05 and 11.15 and to remove the 
reference to progressive exophthalmos in listing 9.02 as part of these 
final rules. All of these conditions are extremely rare and are 
amenable to treatment, given modern medical practices. The listings are 
intended to identify commonly occurring and frequently seen impairments 
that are considered severe enough to preclude any gainful activity in 
adults (or that result in ``marked and severe functional limitations'' 
in children). We do not believe there is any benefit in waiting to 
delete these listings until we revise the specific body system 
listings.
    Comment: A number of commenters requested that other specific 
impairments be included in the listings. The commenters suggested that 
we add a number of impairments that are not now included in the 
listings, such as Lyme disease, trigeminal neuralgia, chronic fatigue 
syndrome (CFS), fibromyalgia, systemic mastocytosis, migraines, 
vestibular disorders, reflex sympathetic dystrophy syndrome, 
narcolepsy, arachnoiditis, porphyria, and hepatitis A, B, and C. The 
commenters believe that these impairments are medically severe and 
result in substantial functional loss due to the illnesses themselves 
as well as the associated symptoms and side effects from various 
treatments. They requested that specific listing criteria be included 
in our listings so that individuals with these disorders could be found 
disabled as appropriate and would not be overlooked solely due to the 
fact that their specific impairments were not named in the listings.
    Response: We did not adopt these comments, which are outside the 
scope of this rulemaking proceeding. In proposing these revisions, we 
intended primarily to address existing listings and to update or 
clarify the medical terminology used in some listings. We explained in 
the NPRM that more substantive changes to the listings would be 
addressed when we reviewed the listing criteria for each individual 
body system (65 FR 6929). We will consider including new criteria for

[[Page 20023]]

specific impairments, such as those mentioned above, as we review the 
appropriate respective body systems.
    However, we emphasize that if you have an impairment(s) that is not 
included in the listings, you may still be found disabled at the third 
step of the sequential evaluation processes for adults and children if 
your impairment(s) medically equals a listing. This longstanding policy 
is explained in Secs. 404.1526 and 416.926 of our regulations. If you 
are a child under age 18, we may also find that an impairment or 
combination of impairments functionally equals the listings, as 
explained in Sec. 416.926a of our regulations. In addition, if you are 
an adult, we can find you disabled at a later step in the sequential 
evaluation process, as explained in Secs. 404.1545-404.1568 and 
416.945-416.968 of our regulations. With respect to the specific 
impairments noted by the commenters, a Social Security Ruling (SSR), 
SSR 99-2p (64 FR 23380), provides detailed guidance on how we evaluate 
claims involving CFS.
    Comment: Several commenters suggested that we make specific changes 
to listings that we did not propose changing in the proposed rules.
    Response: We did not adopt these comments, which are also outside 
the scope of this rulemaking proceeding. However, we will consider the 
commenters' proposed changes as we revise individual body system 
listings.
    Comment: A few commenters were concerned that individuals would 
lose their benefits based on the proposed technical changes to the 
listings.
    Response: No individual's disability benefits will be ceased solely 
on the basis of these technical revisions to the listings. We conduct 
periodic reviews of individuals receiving benefits to determine whether 
they are still disabled. These reviews are known as continuing 
disability reviews (CDRs). However, when we conduct CDRs, we do not 
find that your disability has ended based on a change in a listing. In 
most cases, we must show that your impairment(s) has medically improved 
and that this improvement is ``related to the ability to work.'' If 
your impairment(s) has not medically improved, we will generally find 
that you are still disabled. Even if the impairment(s) has medically 
improved, our regulations provide that the improvement is not ``related 
to the ability to work'' if the impairment(s) continues to meet or 
equal the ``same listing section used to make our most recent favorable 
decision.'' This is true even if we have deleted or revised the listing 
section that we used to make the most recent favorable decision. See 
Secs. 404.1594(c)(3)(i) and 416.994(b)(2)(iv)(A) of our regulations. A 
similar provision for CDRs for children eligible for SSI based on 
disability appears in Sec. 416.994a(b)(2) of our regulations.
    As we noted in the effective date section of this preamble, these 
final rules will be effective on May 24, 2002. Our current rules will 
continue to apply until the effective date of these final rules. When 
these final rules become effective, we will apply them to new 
applications filed on or after the effective date of the rules. We will 
also apply them to the entire period at issue for claims that are 
pending at any stage of our administrative review process, including 
claims that are pending administrative review after remand from a 
Federal court.
    With respect to claims in which we have made a final decision, and 
that are pending judicial review in Federal court, we expect that the 
court's review of the Commissioner's final decision would be made in 
accordance with the rules in effect at the time of the final decision. 
If the court determines that the Commissioner's final decision is not 
supported by substantial evidence, or contains an error of law, we 
would expect that the court would reverse the final decision, and 
remand the case for further administrative proceedings pursuant to the 
fourth sentence of section 205(g) of the Act, except in those few 
instances where the court determines that it is appropriate to reverse 
the final decision and award benefits, without remanding the case for 
further administrative proceedings. In those cases decided by a court 
after the effective date of the rules, where the court reverses the 
Commissioner's final decision and remands the case for further 
administrative proceedings, on remand, we will apply the provisions of 
these final rules to the entire period at issue in the claim.
    Comment: One commenter felt that these proposed revisions were 
structured to take disability benefits away from individuals who were 
stabilized by medications. This individual felt that medications had 
masked the severity of his liver disease and this had adversely 
affected his ability to receive a transplant.
    Response: These proposed revisions are not in any way intended to 
change the way we evaluate the impairment(s) of individuals who benefit 
from prescribed medication(s). In evaluating any medical impairment, we 
must consider the impact of any treatments and medications that you are 
taking, both from the standpoint of how they benefit you as well as any 
adverse side effects you may experience. We evaluate your impairment in 
light of the medications or treatments that you have been provided by 
your medical sources. We do not judge the appropriateness of such 
medications or treatments.

Other Changes

    We proposed several changes to the listings that we are not making 
in these final rules. The NPRM contained a drafting error in reference 
to section 11.02 addressing epilepsy. We proposed to revise the heading 
to be more consistent with current medical technology, but we had not 
intended to change the frequency criterion for the number of seizures 
required to meet this listing. The proposed rules incorrectly stated 
the frequency as ``occurring more frequently than once weekly.'' (65 FR 
6935). We did not intend to change the existing frequency criterion, 
which continues to read, ``occurring more frequently than once a 
month.'' We have revised the final rules consistent with our original 
intent.
    Second, the NPRM proposed revising Sec. 416.926a(d) to remove 
subparagraphs (8) and (9) of this section and revise the numbering 
accordingly. On June 14, 2000, we published a notice of intent to issue 
regulations and request for comments that asked experts in growth 
impairments in children, and other interested members of the public, 
for comments on how we should revise the childhood growth impairment 
listings (65 FR 37321). We will consider whether and how we should 
revise these examples of growth impairments, which we consider to 
functionally equal the listings, in the context of that rulemaking 
proceeding. As a result, we are not making any changes to Sec. 416.926a 
in these final rules. Former Sec. 416.926a(d)(8) and (9) were 
redesignated as Sec. 416.926a(m)(7) and (m)(8), respectively, in the 
final childhood disability rules that we published on September 11, 
2000 (65 FR 54747). Those final rules were effective on January 2, 
2001.
    Third, we have not included the technical revisions involving the 
adult mental disorders body system listings (section 12.00) in these 
final rules. On August 21, 2000, we published final rules revising the 
medical criteria we use for evaluating mental disorders and traumatic 
brain injury in adults (65 FR 50746). In those final rules, we made 
several revisions to listing 12.05, including a revision to the capsule 
definition to the listing. Consequently, there is no need to include 
any additional changes to that listing in these final rules.

[[Page 20024]]

    Fourth, we did not include the technical revisions involving the 
musculoskeletal body system listings (section 1.00 and 101.00) for 
adults and children in these final rules. On November 19, 2001, we 
published final rules revising the medical criteria we use for 
evaluating musculoskeletal disorders in adults and children (66 FR 
58010). In those final rules, we made the revisions we had proposed in 
this rulemaking proceeding.
    However, the language we used in the final rules revising the 
musculoskeletal listings to describe what we mean by appropriate 
medically acceptable imaging techniques should also be included in the 
preface of other body systems that refer to imaging techniques. 
Accordingly, we added this language to the prefaces of those body 
systems that we address in this rulemaking proceeding as part of these 
final rules. We will also add it as needed to other body system 
listings as we revise them in the future. The addition of this language 
allows us to delete the specific references to ``x-rays'' in listing 
sections 2.00B2 and 113.00A, and to delete the phrase ``x-ray imaging'' 
previously included in listings 5.03, 5.04, 5.05, and 105.05.
    Aside from those changes noted above, we are not making any other 
changes to the proposed revisions.

Regulatory Procedures

Executive Order 12866

    The Office of Management and Budget (OMB) has reviewed these final 
rules in accordance with Executive Order (E.O.) 12866, as amended by 
E.O. 13258. We have also determined that these rules meet the plain 
language requirements of E.O. 12866.

Regulatory Flexibility Act

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

Paperwork Reduction Act

    These final rules contain reporting requirements at: 2.00B; 3.00F; 
11.02; 11.03; 14.00B; 14.08M; 100.00B; 102.00A; 104.00E; 105.00B; 
111.00A; and 113.00B; 114.00B; and 114.08N. The public reporting burden 
is accounted for in the Information Collection Requests for the various 
forms that the public uses to submit the information to SSA. 
Consequently, a 1-hour placeholder burden is being assigned to the 
specific reporting requirement(s) contained in these rules. We are 
seeking clearance of the burdens referenced in these rules because 
these rules were not considered during the clearance of the forms. An 
Information Collection Request has been submitted to OMB. While these 
rules will be effective 30 days from publication, these burdens will 
not be effective until cleared by OMB. We are soliciting comments on 
the burden estimate; the need for the information; its practical 
utility; ways to enhance its quality, utility and clarity; and on ways 
to minimize the burden on respondents, including the use of automated 
collection techniques or other forms of information technology. We will 
publish a notice in the Federal Register upon OMB approval of the 
information collection requirements. Comments should be submitted to 
the OMB desk officer for SSA within 30 days of publication of this 
final rule at the following address: Office of Management and Budget, 
Attn: Desk Officer for SSA, New Executive Office Building, Room 10235, 
725 17th St., NW, Washington, DC 20503.

(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social 
Security-Disability Insurance; 96.002, Social Security-Retirement 
Insurance; 96.004, Social Security-Survivors Insurance; 96.006, 
Supplemental Security Income)

List of Subjects in 20 CFR Part 404

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

    Dated: February 12, 2002.
Jo Anne B. Barnhart,
Commissioner of Social Security.


    For the reasons set forth in the preamble, part 404, subpart P of 
chapter III of title 20 of the Code of Federal Regulations is amended 
as follows:

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

Subpart P--Determining Disability and Blindness

    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. In part A:
    1. Section 2.00 is amended:
    a. By revising the heading of paragraph A;
    b. By revising paragraph A1, the first two sentences of paragraph 
A2, and paragraph A5;
    c. By amending the first, fourth, fifth, and sixth sentences of 
paragraph A6 to remove the word ``central'';
    d. By revising the last sentence in the second undesignated 
paragraph of paragraph B2 and by amending the second undesignated 
paragraph of paragraph B2 to add two new sentences at the end of the 
paragraph;
    e. By revising paragraph B3;
    2. Section 2.02 is amended by removing the word ``central'' in the 
heading.
    3. Section 2.04 is revised.
    4. Section 2.05 is removed and reserved.
    5. Section 2.09 is revised.
    6. Table No. 1 following section 2.09 is amended 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.''
    7. Section 3.00 is amended by revising the last sentence in the 
second undesignated paragraph of paragraph E, and by amending paragraph 
F1 by revising the fourth and fifth sentences of the fourth 
undesignated paragraph.
    8. Section 3.11 is added.
    9. Section 4.00, paragraph A, is amended by revising the second 
sentence of the third undesignated paragraph, and paragraph C3 is 
amended by revising the third sentence of the paragraph and adding two 
new sentences.
    10. Section 5.00, paragraph C, is amended by revising the fourth 
sentence and by adding two new sentences.
    11. Section 5.03 is revised.
    12. Section 5.04 is amended by revising the heading and by revising 
paragraph C.
    13. Section 5.05 is amended by revising the first sentence in 
paragraph A.
    14. Section 5.09 is added after the tables.
    15. Section 6.00 is amended by adding two new sentences to 
paragraph A.

[[Page 20025]]

    16. Section 6.02 is amended by revising paragraph C1.
    17. Section 7.00 is amended by adding two new sentences to 
paragraph B.
    18. Section 7.00 is amended by revising the first sentence of the 
first paragraph of paragraph E.
    19. Section 7.11 is amended by revising the heading.
    20. Section 7.16 is amended by revising the heading and by revising 
paragraph A.
    21. Section 7.17 is amended by revising the heading and by revising 
the first sentence.
    22. Section 8.06 is amended by revising the heading.
    23. Section 9.00, the first paragraph, is amended by adding two new 
sentences.
    24. In section 9.02, the word ``With:'' following the heading and 
paragraph A are removed and the paragraph designation ``B'' is removed 
from paragraph B.
    25. Section 9.03, paragraph A, is revised.
    26. Section 11.00 is amended in paragraph A:
    a. By revising the heading;
    b. By revising the first sentence in paragraph 11.00A;
    c. By removing the first undesignated paragraph; and
    d. By revising the first, second and third sentences in the second 
undesignated paragraph.
    27. Section 11.02 is amended by revising the heading.
    28. Section 11.03 is amended by revising the heading.
    29. Section 11.15 is removed and reserved.
    30. Section 11.17 is amended by revising paragraph A.
    31. Section 13.08 is revised.
    32. Section 14.00 is amended by revising the first sentence of the 
first undesignated paragraph of paragraph B and by adding two new 
sentences following this sentence.
    33. Section 14.08 is amended by revising paragraph M6.
    B. In part B:
    1. Section 100.00, paragraph B, is revised.
    2. Section 102.00 is amended by revising the first and second 
sentences of paragraph A.
    3. Section 102.02 is amended by revising the heading.
    4. Section 103.00, paragraph B, is amended by revising the last 
sentence of the second undesignated paragraph.
    5. Section 103.00, paragraph D, is amended by adding a new first 
undesignated paragraph.
    6. Section 103.00, paragraph E, is amended by revising the second 
sentence.
    7. Section 103.04, paragraph B3, is revised.
    8. Section 103.05 is added after Table III.
    9. Section 104.00, paragraph A, is amended by revising the last 
sentence of the fifth undesignated paragraph, and paragraph E is 
amended by revising the first sentence of the second undesignated 
paragraph and adding a new sentence to the second undesignated 
paragraph.
    10. Section 105.00 is amended by revising the first sentence in 
paragraph B and adding two new sentences.
    11. Section 105.05 is amended by revising paragraphs A and C.
    12. Section 105.09 is added.
    13. Section 107.00, paragraph C, is amended by revising the heading 
and by revising the first sentence.
    14. Section 107.11 is amended by revising the heading.
    15. Section 111.00 paragraph A is revised and paragraph B is 
amended by revising the heading, and by removing the second sentence.
    16. Section 111.02 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.
    17. Section 111.03 is amended by revising the heading.
    18. Section 113.00 is amended by revising the third sentence in 
paragraph B and by adding two new sentences to paragraph B.
    19. Section 114.00 is amended by revising the first sentence of the 
second undesignated paragraph of paragraph B and by adding two new 
sentences following this sentence.
    20. Section 114.08 is amended by revising paragraph N6.
    The added and revised text is as follows:

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

* * * * *

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 vision or near vision, or both. However, for you 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 appropriate medically 
acceptable imaging reports of the skull and temporal bone. Medically 
acceptable imaging includes, but is not limited to, x-ray imaging, 
computerized axial tomography (CAT scan) or magnetic resonance 
imaging (MRI), with or without contrast material, myelography, and 
radionuclear bone scans. ``Appropriate'' means that the technique 
used is the proper one to support the evaluation and diagnosis of 
the impairment.
    3. Loss of speech. In evaluating the loss of speech, the ability 
to produce speech by any means includes the use of mechanical or 
electronic devices that improve voice or articulation. Impairments 
of speech may also be evaluated under the body system for the 
underlying disorder, such as neurological disorders, 11.00ff.
* * * * *
    2.04  Loss of visual efficiency. The visual efficiency of the 
better eye after best correction is 20 percent or less. (The percent 
of remaining visual efficiency is equal to the product of the 
percent of remaining visual acuity efficiency and the percent of 
remaining visual field efficiency.)
    2.05  [Reserved.]
* * * * *
    2.09  Loss of speech due to any cause, with inability to produce 
by any means speech that 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. * * *
* * * * *

[[Page 20026]]

     * * * The percentage concentrations of inspired O2 
and inspired and expired CO and He for each of the maneuvers should 
be provided. Sufficient data must be provided, including 
documentation of the source of the predicted equation, to permit 
verification that the test was performed adequately, and that, if 
necessary, corrections for anemia or carboxyhemoglobin were made 
appropriately.
* * * * *
    3.11  Lung transplant. Consider under a disability for 12 months 
following the date of surgery; thereafter, evaluate the residual 
impairment.

4.00  Cardiovascular System

    A.* * *
    * * * Therefore, in any case in which you have a medically 
determinable impairment that is not listed, or a combination of 
impairments no one of which meets a listing, we will consider a 
medical equivalence determination. * * *
* * * * *
    C. * * *
    3. * * * In selected cases, these tests may be purchased after a 
medical history and physical examination, report of 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. Medically 
acceptable imaging includes, but is not limited to, x-ray imaging, 
computerized axial tomography (CAT scan) or magnetic resonance 
imaging (MRI), with or without contrast material, myelography, and 
radionuclear bone scans. ``Appropriate'' means that the technique 
used is the proper one to support the evaluation and diagnosis of 
the impairment. * * *
* * * * *

5.00  Digestive System

* * * * *
    C. * * * To be considered a severe impairment which will last 
for at least 12 months, a recurrent ulcer after definitive surgery 
must be demonstrated, despite therapy, by repeated appropriate 
medically acceptable imaging of the upper gastrointestinal tract or 
by gastroscopic examinations. Medically acceptable imaging includes, 
but is not limited to, x-ray imaging, computerized axial tomography 
(CAT scan) or magnetic resonance imaging (MRI), with or without 
contrast material, myelography, and radionuclear bone scans. 
``Appropriate'' means that the technique used is the proper one to 
support the evaluation and diagnosis of the impairment. * * *
* * * * *
    5.03  Stricture, stenosis, or obstruction of the esophagus 
(demonstrated by endoscopy or other appropriate medically acceptable 
imaging) with weight loss as described under listing 5.08.
    5.04  Peptic ulcer disease (demonstrated by endoscopy or other 
appropriate medically acceptable imaging).
* * * * *
    C. Recurrent obstruction demonstrated by 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). 
With:
    A. Esophageal varices (demonstrated by 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 the date of surgery; thereafter, evaluate the 
residual impairment(s).

6.00  Genito-Urinary System

    A. * * * Medically acceptable imaging includes, but is not 
limited to, x-ray imaging, computerized axial tomography (CAT scan) 
or magnetic resonance imaging (MRI), with or without contrast 
material, myelography, and radionuclear bone scans. ``Appropriate'' 
means that the technique used is the proper one to support the 
evaluation and diagnosis of the impairment.
* * * * *
    6.02   * * *
* * * * *
    C. * * *
    1. Renal osteodystrophy manifested by severe bone pain and 
abnormalities shown by appropriate medically acceptable imaging 
(e.g., osteitis fibrosa, marked osteoporosis, pathologic fractures); 
or
* * * * *

7.00  Hemic and Lymphatic System

* * * * *
    B. * * * Medically acceptable imaging includes, but is not 
limited to, x-ray imaging, computerized axial tomography (CAT scan) 
or magnetic resonance imaging (MRI), with or without contrast 
material, myelography, and radionuclear bone scans. ``Appropriate'' 
means that the technique used is the proper one to support the 
evaluation and diagnosis of the impairment.
* * * * *
    E. Acute leukemia (including 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 (including T-cell lymphoblastic lymphoma).
* * * * *
    7.16  Multiple myeloma (confirmed by appropriate serum or urine 
protein electrophoresis and bone marrow findings). With:
    A. Appropriate medically acceptable imaging evidence of bony 
involvement with intractable bone pain; or
* * * * *
    7.17  Aplastic anemias or hematologic malignancies (excluding 
acute leukemia and T-cell lymphoblastic lymphoma): With bone marrow 
or stem cell transplantation. * * *
* * * * *
    8.06  Hidradenitis suppurativa, acne conglobata.
* * * * *

9.00  Endocrine System

     * * * Medically acceptable imaging includes, but is not limited 
to, x-ray imaging, computerized axial tomography (CAT scan) or 
magnetic resonance imaging (MRI), with or without contrast material, 
myelography, and radionuclear bone scans. ``Appropriate'' means that 
the technique used is the proper one to support the evaluation and 
diagnosis of the impairment.
* * * * *
    9.03  Hyperparathyroidism. With:
    A. Generalized decalcification of bone on appropriate medically 
acceptable imaging study and elevation of plasma calcium to 11 mg. 
per deciliter (100 ml.) or greater; or
* * * * *
    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. * * *
    Under 11.02 and 11.03, the criteria can be applied only if the 
impairment persists despite the fact that the individual is 
following prescribed antiepileptic treatment. Adherence to 
prescribed antiepileptic therapy can ordinarily be determined from 
objective clinical findings in the report of the physician currently 
providing treatment for epilepsy. Determination of blood levels of 
phenytoin sodium or other antiepileptic drugs may serve to indicate 
whether the prescribed medication is being taken. * * *
* * * * *
    11.02  Epilepsy--convulsive epilepsy, (grand mal or 
psychomotor), documented by detailed description of a typical 
seizure pattern, including all associated phenomena; occurring more 
frequently than once a month in spite of at least 3 months of 
prescribed treatment.
* * * * *
    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.
* * * * *
    11.15  [Reserved.]
* * * * *
    11.17  Degenerative disease not listed elsewhere, such as 
Huntington's chorea, Friedreich's ataxia, and spino-cerebellar 
degeneration. With:
    A. Disorganization of motor function as described in 11.04B; or 
* * *
* * * * *
    13.08  Thyroid gland:
    A. Anaplastic (undifferentiated) carcinoma of the thyroid; or
    B. Carcinoma with metastases beyond the regional lymph nodes, 
not controlled by prescribed therapy.
* * * * *

14.00  Immune System

* * * * *

[[Page 20027]]

    B. * * *
    The documentation needed to establish the existence of a 
connective tissue disorder is medical history, physical examination, 
selected laboratory studies, appropriate medically acceptable 
imaging, and, in some instances, tissue biopsy. Medically acceptable 
imaging includes, but is not limited to, x-ray imaging, computerized 
axial tomography (CAT scan) or magnetic resonance imaging (MRI), 
with or without contrast material, myelography, and radionuclear 
bone scans. ``Appropriate'' means that the technique used is the 
proper one to support the evaluation and diagnosis of the 
impairment. * * *
* * * * *
    14.08  Human immunodeficiency virus (HIV) infection.
* * * * *
    M. * * *
    6. Sinusitis documented by appropriate medically acceptable 
imaging.
* * * * *

100.00  Growth Impairment

* * * * *
    B. Bone age determinations should include a full descriptive 
report of medically acceptable imaging specifically obtained to 
determine bone age and must cite the standardization method used. 
Where appropriate medically acceptable imaging must be obtained 
currently as a basis for adjudication under 100.03, views or scans 
of the left hand and wrist should be ordered. In addition 
appropriate medically acceptable imaging of the knee and ankle 
should be obtained when cessation of growth is being evaluated in an 
older child at, or past, puberty. Medically acceptable imaging 
includes, but is not limited to, x-ray imaging, computerized axial 
tomography (CAT scan) or magnetic resonance imaging (MRI), with or 
without contrast material, myeolgraphy, and radionuclear bone scans. 
``Appropriate'' means that the technique used is the proper one to 
support the evaluation and diagnosis of the impairment.
* * * * *

102.00  Special Senses and Speech

    A. Visual impairments in children. Impairment of visual acuity 
should be determined with use of the standard Snellen test chart. 
Where this cannot be used, as in very young children, a complete 
description of the findings should be provided, using other 
appropriate methods of examination, along with a description of the 
techniques used for determining the visual acuity for distance. * * 
*
* * * * *
    102.02 Impairments of visual acuity.
* * * * *

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.
* * * * *
    D. * * *
    Medically acceptable imaging includes, but is not limited to, x-
ray imaging, computerized axial tomography (CAT scan) or magnetic 
resonance imaging (MRI), with or without contrast material, 
myelography, and radionuclear bone scans. ``Appropriate'' means that 
the technique used is the proper one to support the evaluation and 
diagnosis of the impairment.
    E. * * *
    The diagnosis is established by the requirement for continuous 
or nocturnal supplemental oxygen for more than 30 days, in 
association with characteristic changes on medically acceptable 
imaging and clinical signs of respiratory dysfunction, including 
retractions, rales, wheezing, and tachypnea.
* * * * *
    103.04  Cystic fibrosis.
* * * * *
    B. * * *
    3. Appropriate medically acceptable imaging evidence of 
extensive disease, such as thickening of the proximal bronchial 
airways or persistence of bilateral peribronchial infiltrates;
* * * * *
    103.05  Lung transplant. Consider under a disability for 12 
months following the date of surgery; thereafter, evaluate the 
residual impairment(s).

104.00  Cardiovascular System

    A. * * *
    When you have a medically determinable impairment that is not 
listed, an impairment that does not meet the requirements of a 
listing, or a combination of impairments no one of which meets the 
requirements of a listing, we will consider a determination whether 
your impairment(s) medically equals or, as appropriate, functionally 
equals the listings. (See Secs. 404.1526, 416.926, and 416.926a.)
* * * * *
    E. * * *
    Findings of cardiomegaly shown by appropriate medically 
acceptable imaging evidence must be accompanied by other evidence of 
chronic heart failure or ventricular dysfunction. ``Appropriate'' 
means that the imaging technique used is the proper one to support 
the evaluation and diagnosis of the impairment. * * *
* * * * *

105.00  Digestive System

* * * * *
    B. Documentation of gastrointestinal impairments should include 
pertinent operative findings, appropriate medically acceptable 
imaging studies, endoscopy, and biopsy reports. Medically acceptable 
imaging includes, but is not limited to, x-ray imaging, computerized 
axial tomography (CAT scan) or magnetic resonance imaging (MRI), 
with or without contrast material, myelography, and radionuclear 
bone scans. ``Appropriate'' means that the technique used is the 
proper one to support the evaluation and diagnosis of the 
impairment. * * *
* * * * *
    105.05  Chronic liver disease. * * *
    A. Inoperable biliary atresia demonstrated by appropriate 
medically acceptable imaging or surgery; or
* * * * *
    C. Esophageal varices (demonstrated by endoscopy or other 
appropriate medically acceptable imaging); or
* * * * *
    105.09  Liver transplant. Consider under a disability for 12 
months following the date of surgery; thereafter, evaluate the 
residual impairment.
* * * * *

107.00  Hemic and Lymphatic System

* * * * *
    C. Acute leukemia (including 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 (including T-cell lymphoblastic 
lymphoma).
* * * * *

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
* * * * *

[[Page 20028]]

    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 reports or 
reports from appropriate medically acceptable imaging. Medically 
acceptable imaging includes, but is not limited to, x-ray imaging, 
computerized axial tomography (CAT scan) or magnetic resonance 
imaging (MRI), with or without contrast material, myelography, and 
radionuclear bone scans. ``Appropriate'' means that the technique 
used is the proper one to support the evaluation and diagnosis of 
the impairment. * * *
* * * * *

114.00  Immune System

* * * * *
    B. * * *
* * * * *
    The documentation needed to establish the existence of a 
connective tissue disorder is medical history, physical examination, 
selected laboratory studies, appropriate medically acceptable 
imaging, and, in some instances, tissue biopsy. Medically acceptable 
imaging includes, but is not limited to, x-ray imaging, computerized 
axial tomography (CAT scan) or magnetic resonance imaging (MRI), 
with or without contrast material, myelography, and radionuclear 
bone scans. ``Appropriate'' means that the technique used is the 
proper one to support the evaluation and diagnosis of the 
impairment. * * *
* * * * *
    114.08  Human immunodeficiency virus (HIV) infection.
* * * * *
    N. * * *
    6. Sinusitis documented by appropriate medically acceptable 
imaging.
* * * * *

[FR Doc. 02-9737 Filed 4-23-02; 8:45 am]
BILLING CODE 4191-02-P