[Federal Register Volume 67, Number 214 (Tuesday, November 5, 2002)]
[Notices]
[Pages 67436-67439]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-28057]


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SOCIAL SECURITY ADMINISTRATION


Social Security Ruling, SSR 02-2p; Titles II and XVI: Evaluation 
of Interstitial Cystitis

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling.

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SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of 
Social Security gives notice of Social Security Ruling, SSR 02-2p. This 
Ruling clarifies the policies of the Social Security Administration for 
developing and evaluating title II and title XVI claims for disability 
on the basis of Interstitial Cystitis (IC). IC is a complex, chronic 
bladder disorder characterized by urinary frequency, urinary urgency, 
and pelvic pain.

EFFECTIVE DATE: November 5, 2002.

FOR FURTHER INFORMATION CONTACT: Carolyn Kiefer, Office of Disability, 
Social Security Administration, 6401 Security Boulevard, Baltimore, MD 
21235-6401, (410) 965-9104. For information on eligibility or filing 
for benefits, call our national toll-free number 1-800-772-1213 or TTY 
1-800-325-0778, or visit our Internet web site, Social Security Online, 
at http://www.ssa.gov.

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    If this Social Security Ruling is later superseded, modified, or 
rescinded, we will publish a notice in the Federal Register to that 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

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

    Dated: October 25, 2002.
Jo Anne B. Barnhart,
Commissioner of Social Security.

Policy Interpretation Ruling

Titles II and XVI: Evaluation of Interstitial Cystitis

    Purpose: To provide guidance on SSA policy concerning the 
development and evaluation of interstitial cystitis (IC) in disability 
claims filed under titles II and XVI of the Social Security Act (the 
Act).
    Citations: Sections 216(i), 223(d), 223(f), 1614(a), and 1614(c) of 
the Act, as amended; Regulations No. 4, subpart P, sections 404.1502, 
404.1505, 404.1508, 404.1509, 404.1511, 404.1512, 404.1513, 404.1520, 
404.1520a, 404.1521, 404.1523, 404.1525, 404.1526, 404.1528, 404.1529, 
404.1530, 404.1545, 404.1546, 404.1561, 404.1594, and appendix 1; and 
Regulations No. 16, subpart I, sections 416.902, 416.905, 416.906, 
416.908, 416.909, 416.911, 416.912, 416.913, 416.920, 416.920a, 
416.921, 416.923, 416.924, 416.925, 416.926, 416.926a, 416.928, 
416.929, 416.930, 416.945, 416.946, 416.961, 416.994, and 416.994a.
    Introduction: The Act and our implementing regulations require that 
an individual establish disability based on the existence of a 
medically determinable impairment; that is, one that can be shown by 
medical evidence, consisting of symptoms, signs, and laboratory 
findings. Disability may not be established on the basis of an 
individual's statement of symptoms alone.
    This Ruling explains that IC (a complex, chronic bladder disorder), 
when accompanied by appropriate symptoms, signs, and laboratory 
findings, is a medically determinable impairment that can be the basis 
for a finding of ``disability.'' It also provides guidance for the 
evaluation of claims involving IC.

Policy Interpretation

General

1. What Is IC?
    IC is a complex, chronic bladder disorder characterized by urinary 
frequency, urinary urgency, and pelvic pain. IC occurs most frequently 
in women (about 10 times more often than in men), and sometimes prior 
to age 18. IC may be associated with other disorders, such as 
fibromyalgia, chronic fatigue syndrome, allergies, irritable bowel 
syndrome, inflammatory bowel

[[Page 67437]]

disease, endometriosis, and vulvodynia (vulvar/vaginal pain). IC also 
may be associated with systemic lupus erythematosus.
    The symptoms of IC may vary in incidence, duration, and severity. 
The causes of IC are currently unknown, and treatments are directed 
towards relief of symptoms. While no treatment is uniformly effective 
for everyone, there are many treatments available, and individuals may 
obtain some measure of relief. However, response to treatment is 
variable, and some individuals may have symptoms that are intractable 
to the current treatments available. Treatment may include bladder 
distention; bladder instillation; oral drugs, such as the prescription 
drug Elmiron, antidepressants, antihistamines, and narcotic analgesics; 
and the use of transcutaneous electrical nerve stimulation.
2. How Is IC Diagnosed?
    The diagnosis is one of exclusion. A physician must rule out other 
conditions before making a diagnosis of IC because there is currently 
no definitive test to identify IC. The symptoms of IC are similar to 
those of other disorders, such as acute urinary tract or vaginal 
infections, post-radiation bladder inflammation or infection, bladder 
cancer, kidney stones, endometriosis, neurological disorders, sexually 
transmitted diseases, and, in men, chronic bacterial and nonbacterial 
prostatitis.
    Symptoms of IC vary both in kind and in intensity from individual 
to individual, and even in the same individual. The three most common 
symptoms are an urgent need to urinate (urgency), a frequent need to 
urinate (frequency), and pain in the bladder and surrounding pelvic 
region. These symptoms may occur either singly or in combination. The 
pain may range from mild discomfort to extreme distress. The intensity 
of the pain may increase as the bladder fills, and decrease as it 
empties. In addition, many patients experience vaginal, testicular or 
penile pain, or low back and thigh pain. A woman's symptoms may worsen 
around the time of menstruation.
    A diagnosis of IC is based on the presence of some or all of the 
following:
    [sbull] Presence of urinary urgency or frequency (day and/or 
night), either singly or in combination;
    [sbull] Pain in the bladder and surrounding pelvic region;
    [sbull] Suprapubic tenderness on physical examination;
    [sbull] Glomerulations (pinpoint bleeding caused by recurrent 
irritation) on the bladder wall after hydrodistention on cystoscopy;
    [sbull] Hunner's ulcers on the bladder wall after hydrodistention 
on cystoscopy; and,
    [sbull] Absence of other disorders that could cause the symptoms.
    Diagnostic tests used to identify or exclude other disorders 
include urinalysis, urine culture, urine cytology, cystoscopy, biopsy 
of the bladder wall, and, in men, culture of prostate secretions.
    The standard test currently used to aid in the diagnosis of IC is a 
cystoscopy with hydrodistention of the bladder (performed under 
anesthesia). It can be used to reveal glomerulations or Hunner's 
ulcers. A biopsy of the bladder wall can be taken to rule out diseases 
such as bladder cancer. Cystoscopy with hydrodistention also makes it 
possible to estimate bladder capacity, which is an important guide to 
treatment. The hydrodistention of the bladder itself also sometimes 
provides a therapeutic benefit, with a reduction in pain and urinary 
frequency for a limited time period. A report on the results of a 
cystoscopy, if done, should be part of the medical record. An absence 
of glomerulations or Hunner's ulcers on cystoscopy does not exclude a 
diagnosis of IC; a minority of individuals with IC (10%) will not have 
either of these medical signs. Cystoscopy should not be purchased to 
establish a diagnosis of IC because it is an invasive procedure.
    While the medical findings discussed above are the principal 
symptoms, signs, and laboratory findings currently used to establish a 
diagnosis of IC, and, consequently, the existence of a medically 
determinable impairment, they are not all-inclusive. As progress is 
made in medical research into IC, additional signs and laboratory 
findings may be identified and new diagnostic techniques may be 
developed that also would establish a diagnosis of IC. The existence of 
IC may be documented with medical signs or laboratory findings other 
than those listed above, provided that such documentation is consistent 
with medically accepted clinical practice and is consistent with the 
other evidence in the case record.
3. What Is a Medically Determinable Impairment?
    Sections 216(i) and 1614(a)(3) of the Act define ``disability'' \1\ 
as the inability to engage in any substantial gainful activity by 
reason of any medically determinable physical or mental impairment (or 
combination of impairments) which can be expected to result in death or 
which has lasted or can be expected to last for a continuous period of 
not less than 12 months.\2\
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    \1\ Except for statutory blindness.
    \2\ For a child under age 18 claiming benefits under title XVI, 
disability will be established if the child is suffering from a 
medically determinable physical or mental impairment (or combination 
of impairments) that results in ``marked and severe functional 
limitations.'' See section 1614(a)(3)(C) of the Act and 20 CFR 
416.906. However, for clarity, the following discussions refer only 
to claims of individuals claiming disability benefits under title II 
and individuals age 18 or older claiming disability benefits under 
title XVI. The concepts in this ruling, however, are also intended 
to apply in determining disability based on IC for individuals under 
age 18 under title XVI.
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    Sections 223(d)(3) and 1614(a)(3)(D) of the Act and 20 CFR 404.1508 
and 416.908 require that an impairment result from anatomical, 
physiological, or psychological abnormalities that can be shown by 
medically acceptable clinical and laboratory diagnostic techniques. The 
Act and regulations further require that an impairment be established 
by medical evidence that consists of symptoms, signs, and laboratory 
findings, and not only by an individual's statement of symptoms.
4. How Is IC Identified as a Medically Determinable Impairment?
    We \3\ generally will rely on the judgment of a physician who has 
made the diagnosis after a review of the claimant's medical history, a 
physical examination of the claimant, and any pertinent testing to 
establish the existence of IC. In the absence of evidence to the 
contrary in the case record, we will find a medically determinable 
impairment is established if the evidence contains the appropriate 
symptoms, signs, and laboratory findings, as discussed under question 2 
above. However, if there is evidence that indicates that the diagnosis 
is questionable, and the evidence is inadequate to determine whether or 
not the individual is disabled, we will contact the treating source for 
clarification, using the guidelines in 20 CFR 404.1512(e) and 
416.912(e).
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    \3\ The terms we and us in this Social Security Ruling have the 
same meaning as in 20 CFR 404.1502 and 416.902. We or us refers to 
either the Social Security Administration or the State agency making 
the disability or blindness determination; i.e., our adjudicators at 
all levels of the administrative review process and our quality 
reviewers.
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5. How Do We Consider IC in the Sequential Evaluation Process? \4\
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    \4\ For ease of reading, we refer in this Ruling only to the 
steps of the sequential evaluation processes for initial adult 
claims, 20 CFR 404.1520 and 416.920. We use separate sequential 
evaluation processes when we do continuing disability reviews; i.e., 
reviews to determine whether individuals who are receiving 
disability benefits are still disabled, or when we determine whether 
an individual has a ``closed period of disability.'' These rules are 
set out in 20 CFR 404.1594 and 416.994, and the guidance in this 
Ruling applies to all of the appropriate steps in those regulations 
as well.
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    Once we determine that the individual has the medically

[[Page 67438]]

determinable impairment IC, we will consider it in determining whether:
    [sbull] The individual's impairment(s) is severe.
    [sbull] The individual's impairment(s) meets or equals the 
requirements of a listed impairment in the listings.
    [sbull] The individual's impairment(s) prevents him or her from 
doing past relevant work and other work that exists in significant 
numbers in the national economy.
6. Can We Find an Individual Disabled Based on IC Alone?
    If an individual has the medically determinable impairment IC that 
is ``severe'' as described in question 7 below, we may find that the IC 
medically equals a listing, if appropriate. (See 20 CFR 404.1525 and 
416.925.) (In the case of a child seeking benefits under title XVI, we 
also may find that it functionally equals the listings (20 CFR 
416.926a).) We also may find in a title II claim, or an adult claim 
under title XVI, that the IC results in a finding that the individual 
is disabled based on his or her residual functional capacity (RFC), 
age, education, and past work experience.
    An individual with IC also may report symptoms suggestive of a 
mental impairment (for example, the individual may say that he or she 
is anxious or depressed, having difficulties with memory and 
concentration, etc.). If the evidence supports a possible discrete 
mental impairment or symptoms such as anxiety or depression resulting 
from the individual's IC or the side effects of medication, we will 
develop the possible mental impairment. If the evidence does not 
establish a medically determinable mental impairment, but does 
establish the presence of symptoms such as anxiety or depression 
resulting from the individual's IC or side effects of medication, we 
will determine whether there are any work-related functional 
limitations resulting from the symptoms. We will address any work-
related functional limitations at steps 4 and 5 of the sequential 
evaluation process.

Sequential Evaluation: Step 2, Severe Impairment

7. When Is IC a ``Severe'' Impairment?
    As with any other medical condition, we will find that IC is a 
``severe'' impairment when, alone or in combination with another 
medically determinable physical or mental impairment(s), it 
significantly limits an individual's physical or mental ability to do 
basic work activities. (For children applying for disability under 
title XVI, we will find that IC is a ``severe'' impairment when it 
causes more than minimal functional limitations.) We also will consider 
the effects of any symptoms (such as pain or fatigue) that could limit 
functioning. (See SSR 85-28, ``Titles II and XVI: Medical Impairments 
That Are Not Severe'' and SSR 96-3p, ``Titles II and XVI: Considering 
Allegations of Pain and Other Symptoms In Determining Whether a 
Medically Determinable Impairment Is Severe.'') Therefore, we will find 
that an impairment(s) is ``not severe'' only if it is a slight 
abnormality (or a combination of slight abnormalities) that has no more 
than a minimal effect on the individual's ability to do basic work 
activities (or, for a child applying under title XVI, if it causes no 
more than minimal functional limitations).

Sequential Evaluation: Step 3, the Listings

8. How Do We Evaluate IC at Step 3 of Sequential Evaluation, the 
Listings?
    IC may be a factor in both ``meets'' and ``equals'' determinations.
    Because there is no listing for IC, we will find that an individual 
with IC ``meets'' the requirements of a listing if he or she has 
another impairment that, by itself, meets the requirements of a 
listing. We also will find that a listing is met if there is an 
impairment that, in combination with IC, meets the requirements of a 
listing. For example, IC may increase the severity of coexisting or 
related impairments, including mental disorders, to the extent that the 
combination of impairments meets the requirements of a listing. This 
also may be true in the reverse; coexisting or related impairments may 
increase the severity of IC.
    We also may find that IC, by itself, is medically equivalent to a 
listed impairment (or, in the case of a child applying under title XVI, 
also functionally equivalent to the listings).
    We also will find equivalence if an individual has multiple 
impairments, including IC, no one of which meets or equals the 
requirements of a listing, but the combination of impairments is 
equivalent in severity to a listed impairment.
    However, we will not make assumptions about the severity or 
functional effects of IC combined with other impairments. IC in 
combination with another impairment may or may not increase the 
severity or functional limitations of the other impairment. We will 
evaluate each case based on the information in the case record.
    Further, we will never deny an individual's claim because the 
individual's IC does not meet or medically equal a listing. If an 
individual with IC has a severe impairment that does not meet or 
medically equal a listing, we may still find the individual disabled 
based on other rules in the ``sequential evaluation process'' that we 
use to evaluate all disability claims.

Sequential Evaluation: Steps 4 and 5, Assessing Functioning in Adults; 
Step 3, Assessing Functional Equivalence in Children

9. How Do We Evaluate IC in Assessing Residual Functional Capacity 
(RFC) in Adults and Functional Equivalence in Children?
    IC can cause limitation of function. The functions likely to be 
limited depend on many factors, including urinary frequency and pain. 
An individual may have limitations in any of the exertional functions 
such as sitting, standing, walking, lifting, carrying, pushing, and 
pulling. It also may affect ability to do postural functions, such as 
climbing, balancing, stooping, and crouching. The ability to tolerate 
extreme heat, humidity, or hazards also may be affected.
    The effects of IC may not be obvious. For example, many people with 
IC have chronic pelvic pain, which can affect the ability to focus and 
sustain attention on the task at hand. Nocturia (nighttime urinary 
frequency) may disrupt sleeping patterns. This can lead to drowsiness 
and lack of mental clarity during the day. IC also may affect an 
individual's social functioning. The presence of urinary frequency 
alone can necessitate trips to the bathroom as often as every 10 to 15 
minutes, day and night. Consequently, some individuals with IC 
essentially may confine themselves to their homes. In assessing RFC, we 
must consider all of the individual's symptoms in deciding how such 
symptoms may affect functional capacities.
    An assessment also should be made of the effect IC has upon the 
individual's ability to perform routine movement and necessary physical 
activity within the work environment. Individuals with IC may have 
problems with the ability to sustain a function over time.

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    As explained in SSR 96-8p (``Titles II and XVI: Assessing Residual 
Functional Capacity in Initial Claims''), our RFC assessments must 
consider an individual's maximum remaining ability to do sustained work 
activities in an ordinary work setting on a regular and continuing 
basis. A ``regular and continuing basis'' means 8 hours a day, for 5 
days a week, or an equivalent work schedule.\5\ In cases involving IC, 
fatigue may affect the individual's physical and mental ability to 
sustain work activity. This may be particularly true in cases involving 
urinary frequency.
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    \5\ However, see footnote 2 of SSR 96-8p. That footnote explains 
that the ability to work 8 hours a day for 5 days a week is not 
always required for a finding at step 4 of the sequential evaluation 
process for adults when an individual can do past relevant work that 
was part-time work, if that work was substantial gainful activity, 
performed within the applicable period, and lasted long enough for 
the person to learn to do it.
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    For a child applying for benefits under title XVI, we will evaluate 
the functional consequences of IC (either alone or in combination with 
other impairments) to decide if the child's impairment(s) functionally 
equals the listings. For example, the functional limitations imposed by 
IC, by itself or in combination with another impairment(s), may 
establish an extreme limitation in one broad area of functioning (e.g., 
attending and completing tasks) or marked limitations in two broad 
areas of functioning (e.g., attending and completing tasks, and 
interacting and relating with others).
    As with any other impairment, we will explain how we reached our 
conclusions on whether IC caused any physical or mental limitations.

Effective Date: This Ruling is effective November 5, 2002.
    Cross-References: SSR 85-28, ``Titles II and XVI: Medical 
Impairments That Are Not Severe''; SSR 96-2p, ``Titles II and XVI: 
Giving Controlling Weight to Treating Source Medical Opinions''; SSR 
96-3p, ``Titles II and XVI: Considering Allegations of Pain and Other 
Symptoms in Determining Whether a Medically Determinable Impairment is 
Severe''; SSR 96-4p, ``Titles II and XVI: Symptoms, Medically 
Determinable Physical and Mental Impairments, and Exertional and 
Nonexertional Limitations''; SSR 96-5p, ``Titles II and XVI: Medical 
Source Opinions on Issues Reserved to the Commissioner''; SSR 96-6p, 
``Titles II and XVI: Consideration of Administrative Findings of Fact 
by State Agency Medical and Psychological Consultants and Other Program 
Physicians and Psychologists at the Administrative Law Judge and 
Appeals Council Levels of Administrative Review; Medical Equivalence''; 
SSR 96-7p, ``Titles II and XVI: Evaluation of Symptoms in Disability 
Claims: Assessing the Credibility of an Individual's Statements''; SSR 
96-8p, ``Titles II and XVI: Assessing Residual Functional Capacity in 
Initial Claims''; and SSR 96-9p, ``Titles II and XVI: Determining 
Capability to Do Other Work--Implications of a Residual Functional 
Capacity for Less Than a Full Range of Sedentary Work.''

[FR Doc. 02-28057 Filed 11-4-02; 8:45 am]
BILLING CODE 4191-02-P