[Federal Register Volume 80, Number 74 (Friday, April 17, 2015)]
[Rules and Regulations]
[Pages 21159-21169]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-08849]


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SOCIAL SECURITY ADMINISTRATION

20 CFR Part 404

[Docket No. SSA-2010-0055]
RIN 0960-AF88


Revised Medical Criteria for Evaluating Hematological Disorders

AGENCY: Social Security Administration.

ACTION: Final rules.

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SUMMARY: We are revising the criteria in the Listing of Impairments 
(listings) that we use to evaluate cases involving hematological 
disorders in adults and children under titles II and XVI of the Social 
Security Act (Act). These revisions reflect our adjudicative 
experience, advances in medical knowledge, diagnosis, and treatment, 
and public comments we received in response to a Notice of Proposed 
Rulemaking (NPRM).

DATES: These rules are effective May 18, 2015.

[[Page 21160]]


FOR FURTHER INFORMATION CONTACT: Cheryl Williams, Office of Medical 
Policy, Social Security Administration, 6401 Security Boulevard, 
Baltimore, Maryland 21235-6401, (410) 965-1020. 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.socialsecurity.gov.

SUPPLEMENTARY INFORMATION: 

Background

    We are revising and making final the rules for evaluating 
hematological disorders that we proposed in an NPRM published in the 
Federal Register on November 19, 2013 at 78 FR 69324. Even though these 
rules will not go into effect until 30 days after publication of this 
document, for clarity, we refer to them in this preamble as the 
``final'' rules. We refer to the rules in effect prior to that time as 
the ``prior'' rules.
    In the preamble to the NPRM, we discussed the revisions we proposed 
for the hematological disorders body system. Since we are mostly 
adopting those revisions as we proposed them, we are not repeating that 
information here. Interested readers may refer to the preamble to the 
NPRM for this information, available at http://www.regulations.gov.
    We are making several changes in these final rules from the NPRM 
based upon some of the public comments we received. We explain these 
changes below in the ``Summary of Public Comments on the NPRM'' section 
of this preamble.

Why are we revising the listings for hematological disorders?

    We developed these final rules as part of our ongoing review of the 
listings. When we last comprehensively revised the listings for the 
hematological disorders body system in final rules published on 
December 6, 1985, we indicated in the preamble to those rules that we 
would carefully monitor these listings to ensure that they continue to 
meet program purposes, and that we would update them if warranted.\1\
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    \1\ See 50 FR 50068. We published some revisions to the 
hematological body system on April 24, 2002, and November 15, 2004. 
See 67 FR 20018 and 69 FR 67017 (corrected at 70 FR 15227). These 
revisions were not comprehensive; they addressed only specific 
listings.
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Summary of Public Comments on the NPRM

    In the NPRM, we provided the public with a 60-day comment period 
that ended on January 21, 2014. We received 32 comments. The commenters 
included advocacy groups, a national group representing disability 
examiners in the State agencies that make disability determinations for 
us, State agencies, groups representing medical practitioners, and 
individual members of the public. A number of the letters provided 
identical comments and recommendations.
    We carefully considered all of the significant comments relevant to 
this rulemaking. We condensed and summarized the comments below. We 
presented the commenters' concerns and suggestions and responded to all 
significant issues that were within the scope of these rules. We 
provide our reasons for adopting or not adopting the recommendations in 
our responses below.

General Comments

    Comment: One commenter recommended that we review the medical 
criteria in the listings for evaluating hematological disorders every 
five years to ensure they reflect the latest advances in treatment and 
clinical practice. The commenter thought it especially important that 
we review ongoing clinical trials and published reports regarding 
advances in genetic testing and the clinical use of new blood 
derivatives and biologics.
    Response: While we agree with the commenter that it is important to 
keep abreast of advances in treatment and clinical practice for 
hematological disorders, we have not made any changes to our proposed 
listings as a result of this comment. As mentioned above, we will 
monitor the final rules to ensure they still meet our program purposes. 
While doing this, we will consider whether we need to revise the rules 
to reflect advances in medical knowledge and clinical practice.\2\
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    \2\ We have made it a priority to ensure that we keep the 
listings up to date and to report our progress. For example, see 
SSA's Annual Performance Plan for Fiscal Year 2015, Revised 
Performance Plan for Fiscal Year 2014, and Annual Performance Report 
for Fiscal Year 2013 available at http://www.ssa.gov/agency/performance/2015/FY2015-APP-APR.pdf.
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    Comment: Several commenters expressed concern that people with 
hematological disorders may be disabled but their impairments do not 
satisfy the specific medical criteria in the listings. The commenters 
said these people may have periods of relative functional ability 
punctuated by unpredictable and episodic complications that result in 
an inability to work. They believed such complications do not 
necessarily have to be prolonged or frequent to be disabling and to 
result in loss of employment, failure in school, or other major 
disruptions in the person's life.
    Response: We agree that many of these final listings have specific 
medical criteria. Some people with hematological disorders may have 
complications that do not occur with the severity or frequency that 
these listings require. We believe the functional criteria in our final 
rules address commenters' concerns by providing criteria that may 
permit a finding of disability at the listing step of the sequential 
evaluation process in people who suffer repeated complications of their 
impairments, but who may not be continually restricted in their 
functioning between complications. For example, our intent in new 
functional listing 7.18 for adults, and in our functional equivalence 
rules for children, is to evaluate impairments that are difficult to 
assess in strict medical terms. We can use the functional criteria in 
listing 7.18, as well as our functional equivalence rules in claims for 
childhood disability under the Supplemental Security Income (SSI) 
program, to evaluate claims filed by people who become ill and improve, 
but become ill again, either with the same complications of their 
hematological disorders or with different ones.
    Comment: One commenter recommended we add a criterion in these 
final rules requiring compliance with prescribed therapy.
    Response: We did not adopt the commenter's recommendation because 
we believe our adjudicators can establish the relevance of a person's 
noncompliance under our current rules and current operating 
instructions regarding failure to follow prescribed treatment.\3\ Under 
our policy, we must assess a person's noncompliance on an individual 
basis because the person may have good cause for not following 
prescribed treatment. Good cause may include concern about the cost or 
adverse effects of treatment, lack of access to treatment, religious 
beliefs, or other situations. We also provide information to our 
adjudicators in final sections 7.00H and 107.00G on how to consider 
whether a person is receiving or following treatment.
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    \3\ See 20 CFR 404.1530 and 416.930; also see Social Security 
Ruling 82-59: Titles II and XVI: Failure to Follow Prescribed 
Treatment available at: http://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR82-59-di-02.html); and also see DI 23010 Failure to 
Follow Prescribed Treatment--Procedures, Program Operations Manual 
System (POMS), available at: https://secure.ssa.gov/apps10/poms.nsf/lnx/0423010000.
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    Comment: Another commenter recommended that the final listings 
consider the cost of medication for

[[Page 21161]]

treating hematological disorders before denying children's disability 
claims.
    Response: We did not adopt the comment because, as just indicated, 
we will consider on an individual case basis whether a person, 
including a child, can afford, or has access to, medically necessary 
treatments.
    Comment: Some commenters objected to our use of hospitalization as 
a criterion in several final listings for determining listing-level 
severity of a person's hematological disorder. These listings require 
hospitalization at least three times within a 12-month period, with 
each hospitalization occurring at least 30 days apart. The commenters 
believed health insurers and hospitals are actively trying to reduce 
hospital admissions, which may prevent some disabled people from 
receiving benefits. One commenter thought that discrimination and a 
lack of uniformity of treatment protocols among communities and 
hospitals could also affect decisions regarding hospitalization. The 
commenters recommended we delete the hospitalization requirement or 
require fewer than three hospitalizations in a 12-month period. Some 
commenters also recommended we consider the frequency of outpatient 
visits as a measure of listing-level severity.
    Response: We decided to retain the hospitalization criterion 
because our intent in these final listings is to reflect criteria that 
result in an inability to perform any gainful activity, which can be 
demonstrated by a need for a level of care beyond more conventional 
treatments for hematological disorders. We believe the hospitalization 
criterion is an advantage to people who apply for disability benefits 
because it provides another way for us to find them disabled at the 
listing step.
    We want to assure the commenters that we are able to evaluate 
hematological disorders resulting in fewer than three hospitalizations 
in a consecutive 12-month period under the criteria in final listing 
7.18 for adults, the functional equivalence rules for children, or at 
other steps in our sequential evaluation process. For example, the 
criteria in listing 7.18 evaluate the functional impact of the person's 
impairment in the broad areas of activities of daily living, social 
functioning, and concentration, persistence, or pace, including the 
functional impact of treatment such as repeated outpatient visits for 
complications. We are also able to evaluate hematological disorders 
that are ``severe'' but do not meet or equal any listing under the 
final steps of the sequential evaluation process.
    Comment: One commenter expressed concern that people with 
hematological disorders may have complications and co-occurring 
conditions for years, but their impairments never result in 
hospitalization. This commenter was also concerned that our 
adjudicators may not know about many of the hematological disorders, 
their effects, and how to recognize them.
    Response: As previously discussed, we believe the functional 
criteria in listing 7.18 and our childhood functional equivalence 
criteria under the SSI program will help us determine disability 
appropriately for people whose hematological disorders result in fewer 
than three hospitalizations in a 12-month period. These criteria also 
cover people who have never been hospitalized.
    With regard to the commenter's concerns about adjudicators' 
knowledge of hematological disorders, the introductory text and 
listings provide common examples of hematological disorders and 
describe their complications. However, we do not think it is practical 
or necessary to list all hematological disorders and their 
complications. Instead, as we do with respect to other changes in our 
listings, we plan to provide instructions and training to our 
adjudicators. These instructions and the training will help our 
adjudicators recognize less common examples of hematological disorders 
and their associated complications and functional limitations.
    Comment: One commenter believed the requirement that the 
hospitalization must last at least 48 hours seems to be ``arbitrary'' 
and not based on scientific or medical standards. The commenter thought 
it would be just as appropriate for us to require the hospitalization 
to last at least 24 hours, as listings in some other body systems 
require.
    Response: We disagree with the commenter that we should require 
hospital stays of at least 24 hours. As we noted in the preamble of the 
NPRM, the 48-hour criterion more clearly defines our intent in prior 
listing 7.05B for an ``extended hospitalization.'' \4\ This criterion 
is more detailed than in the prior listing, but it is not stricter. We 
believe the scientific and medical literature shows that many people 
hospitalized for serious complications of hematological disorders are 
included in the 48-hour criterion, and that this criterion can help 
identify an impairment of listing-level severity.
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    \4\ 78 FR at 69328.
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    In sickle cell disease, for instance, a 2008 study found 63 percent 
of children hospitalized for pain crises had hospital stays of at least 
4 days, not counting time in the emergency department.\5\ Similarly, a 
2004 study of children hospitalized for sickle cell disease 
complications other than strokes reported a median hospital stay of 3 
days \6\; children with strokes had a median hospital stay of 6 days. A 
2010 study of adults and children with sickle cell complications 
reported an average initial hospital stay of 5.6 days.\7\ Children in 
the 2008 study with long hospital stays tended to have high pain 
scores, pain in multiple body sites, co-occurring complications, and a 
need for extensive treatment.
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    \5\ Rogovik, A., et al., Admission and length of stay due to 
painful vasoocclusive crisis in children, The American Journal of 
Emergency Medicine, Sep;27(7), 797-801 (2008).
    \6\ Fullerton, H., et al., Declining stroke rates in California 
children with sickle cell disease, Blood, Jul;104(2), 336-339 
(2004).
    \7\ Brousseau, D., et al., Acute care utilization and 
rehospitalizations for sickle cell disease, Journal of the American 
Medical Association, Apr;303(13), 1288-1294 (2010).
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    In hemophilia, a study published in 2011 of Texas patients with 
bleeding episodes reported a median hospital stay of 4 days.\8\ A 2005 
study of patients with potentially life-threatening bleeds in the 
iliopsoas muscle reported a median hospital stay of 4.8 days.\9\ 
Hospital stays may be longer for iliopsoas bleeds in hemophiliacs with 
``inhibitors'' (replacement factor alloantibodies).\10\ Generally, 
hemophiliacs with inhibitors may require more extensive treatment than 
those without inhibitors because their bleeding episodes often are 
resistant to standard treatments.\11\
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    \8\ Mirchandani, G.G., et al., Surveillance of bleeding 
disorders, Texas, 2007, American Journal of Preventive Medicine, 
Dec;41(6 Suppl 4), S354-359 (2011).
    \9\ Balkan, C., et al., Iliopsoas haemorrhage in patients with 
haemophilia: Results of one centre, Haemophilia, Sep:11(5), 463-467 
(2005).
    \10\ Ashrani, A.A., et al., Iliopsoas haemorrhage in patients 
with bleeding disorders--experience from one centre, Haemophilia, 
Nov;9(6), 721-726 (2003).
    \11\ Soucie, J.M., et al., Home-based factor infusion therapy 
and hospitalization for bleeding complications among males with 
haemophilia, Mar;7(2), 198-206 (2001).
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    The study findings described above are consistent with our 
adjudicative experience that many claimants with listing-level 
hematological disorders satisfy the 48-hour criterion because their 
complications are difficult to treat and recoveries are prolonged.\12\ 
On the other hand, we believe requiring the hospitalization to last at 
least 24 hours would not be an accurate predictor of impairment 
severity because this criterion would include people who

[[Page 21162]]

recover relatively quickly and satisfactorily with standard treatments. 
These hospitalizations include people hospitalized only overnight, for 
example, to receive extra fluids after treatment in the emergency 
department, and those kept for observation after surgery. In this 
regard, a 24-hour criterion would not reflect our intent that the 
listing be used to evaluate impairments at the listing level, which 
require treatment beyond the usual course of treatment for the 
hematological disorder.
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    \12\ The study findings only expand on, and confirm, the data in 
the studies we cited in the NPRM. They do not change either the 
methodology in the listing or any substantive criteria in it.
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    Comment: One commenter questioned our use of the term ``disorders 
of hemostasis'' in the introductory text and the listings. The 
commenter noted that the medical community usually refers to the 
grouping of clotting and bleeding disorders as ``disorders of 
thrombosis and hemostasis.''
    Response: We adopted the comment and modified the listings 
accordingly.
    Comment: Some commenters suggested minor editorial changes in the 
introductory text, such as a comment asking us to indicate that the 
examples of complications of hematological disorders in section 7.00C, 
section 7.00D, and other final sections are not all-inclusive.
    Response: We made these minor editorial changes for clarity and 
consistency; none were substantive.

Sections 7.00B and 107.00B--What evidence do we need to document that 
you have a hematological disorder?

    Comment: Some commenters expressed concern over the requirement in 
proposed sections 7.00B and 107.00B that laboratory reports of 
definitive tests establishing hematological disorders have a 
physician's signature. These commenters thought this requirement too 
difficult or burdensome for some claimants because it may require them 
to obtain additional medical evidence. These commenters said it is not 
the usual practice for the overseeing physician in a laboratory to sign 
laboratory reports of definitive tests. They recommended we accept 
reports signed by treating physicians or other physicians if these 
reports state that the definitive hematological evidence is present in 
the medical records. They also believed we should accept a physician's 
statement that a person has a hematological disorder, even if the 
definitive hematological evidence is not present in the medical 
records.
    Response: We did not adopt the comments. Under our policy, evidence 
establishing a medically determinable impairment (MDI) must be 
appropriately developed. To develop this evidence appropriately, it 
must come from acceptable medical sources, that is, medical or 
osteopathic doctors.\13\ A doctor's signature on a definitive 
laboratory test establishing that the person has a hematological 
disorder confirms the evidence came from an acceptable medical source, 
and we do not need to develop the evidence further to establish an MDI. 
In situations in which a doctor did not sign the definitive laboratory 
test, we will continue to develop the evidence. Final sections 7.00B 
and 107.00B provide examples of additional evidence we may obtain from 
doctors to establish the MDI, and we believe these examples are 
comparable to what the commenters recommended. Consequently, final 
sections 7.00B and 107.00B clarify how we develop evidence establishing 
the MDI; they do not add new requirements.
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    \13\ See 20 CFR 404.1513(a) and 416.913(a).
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Sections 7.00C and 107.00C--What are hemolytic anemias, and how do we 
evaluate them under 7.05 and 107.05?

    Comment: One commenter pointed out that hemolytic anemias are 
sometimes acquired conditions.
    Response: We adopted this comment and revised final sections 7.00C1 
and 107.00C1 to provide examples of acquired hemolytic anemias. We made 
similar changes in final sections 7.00D1, 107.00D1, 7.00E1, and 
107.00E1. We also provided examples of acquired disorders of thrombosis 
and hemostasis, as well as disorders of bone marrow failure.
    Comment: A commenter recommended that we add hereditary 
spherocytosis to the list of common examples of hemolytic anemias in 
adults. The commenter also suggested that we add paroxysmal nocturnal 
hemoglobinuria to the list of examples.
    Response: We adopted this recommendation and added hereditary 
spherocytosis to the list in 7.00C1. We also added hereditary 
spherocytosis to the list of common examples of hemolytic anemias in 
children in 107.00C1 to make the child listings consistent with the 
adult listings.
    We did not adopt the commenter's recommendation that we add 
paroxysmal nocturnal hemoglobinuria to the list of examples. Although 
we evaluate paroxysmal nocturnal hemoglobinuria under the hematological 
disorders listings, it is a very rare disorder. We provide only 
examples of common hemolytic anemias in the listings because we do not 
believe it is practical or necessary to name all of the hematological 
disorders we evaluate under this body system. We plan to provide 
information to our adjudicators about less common examples of 
hematological disorders, such as paroxysmal nocturnal hemoglobinuria, 
through training and operating instructions.
    Comment: We received many comments expressing concern over our 
exclusion in proposed sections 7.00C4 and 107.00C4 of prophylactic red 
blood cell (RBC) transfusions to prevent stroke in people with sickle 
cell disease. Some of these commenters recommended that we delete the 
statement in proposed section 7.00C4 that we do not consider 
prophylactic RBC transfusions for sickle cell disease to be of equal 
medical significance to transfusion-dependent thalassemia.\14\ They 
said people with sickle cell disease who require prophylactic RBC 
transfusions are usually chronically ill, and they cited articles in 
the current medical literature to support their views. Another 
commenter believed final sections 7.00C4 and 107.00C4 needed more 
information to help adjudicators determine whether the need for RBC 
transfusions will be life-long.
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    \14\ 78 FR at 69333.
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    The commenters also believe people with sickle cell disease who 
receive prophylactic RBC transfusion to prevent stroke may be more 
severely impaired than people with transfusion-dependent beta 
thalassemia major because they have a far greater burden of 
cerebrovascular disease and intellectual and physical impairment. 
Additionally, a comment from a national advocacy group for physicians 
in pediatric hematology and oncology said its membership now considers 
sickle cell disease with stroke to be a transfusion-dependent disorder 
like thalassemia because of the risk of recurrent strokes if 
prophylactic RBC transfusion stops.
    Response: We do not agree that treatment with prophylactic RBC 
transfusions alone should reflect a listing-level impairment in sickle 
cell disease and have not adopted the commenters' recommendations. 
Under the Act, we cannot find that a person is disabled based on the 
risk of a complication occurring in the future, as, for example, when 
transfusion therapy is effective and the person has not experienced a 
stroke.
    However, we agree that people with sickle cell disease are 
chronically sick. We added language to final sections 7.00C4 and 
107.00C4 that directs evaluation under listings 11.00, 111.00, 12.00, 
and 112.00 if a claimant has had a stroke. We also added language in 
final sections 7.00C4 and 107.00C4 explaining that we will consider 
functional limitations associated with

[[Page 21163]]

chronic RBC transfusions under final listing 7.18 for adults, the 
functional equivalence rules for children, as well as the listings for 
any affected body systems. The additional language also addresses 
complications resulting from chronic RBC transfusion, such as iron 
overload.
    We also deleted the term ``transfusion-dependent'' in the final 
sections 7.00C4, 107.00C4, 7.00E3, and 107.00E3 because comments 
demonstrated to us that this term may confuse adjudicators. We made a 
corresponding change in final listings 7.05D, 107.05D, 7.10B, and 
107.10B. Instead, we use the phrase, ``requiring RBC transfusions at 
least once every 6 weeks to maintain life.'' We believe this phrase is 
more descriptive of our intent in these final rules, which is that 
listing-level severity for hematological disorders requires treatment 
with RBC transfusions that are life-saving in nature and life-long in 
need. Moreover, we are confident our adjudicators will understand the 
requirement that the RBC transfusions must be ``life-long,'' as 
reflected in the ultimately fatal nature of beta thalassemia major and 
myelodysplastic syndrome if this treatment is withdrawn.

Sections 7.00D and 107.00D--What are disorders of thrombosis and 
hemostasis, and how do we evaluate them under 7.08 and 107.08?

    Comment: A commenter noted that the future development of new 
treatments for hemophilia may make the term ``factor infusions'' less 
relevant.
    Response: We adopted the comment and use the term ``clotting-factor 
proteins'' in final sections 7.00D2 and 107.00D2, instead of the term 
``factor infusions.''
    Comment: A commenter stated that the language in proposed sections 
7.00D2 and 107.00D2 was vague and did not make it clear that these 
sections included any surgery.
    Response: We revised final sections 7.00D2 and 107.00D2 to state 
explicitly that we consider all surgeries in people with disorders of 
thrombosis or hemostasis to be complications of their disorders if they 
needed treatment with clotting-factor proteins or anticoagulant 
medications to control bleeding or coagulation in connection with the 
surgery.

Sections 7.00I and 107.00H--How do we evaluate episodic events in 
hematological disorders?

    Comment: Some commenters thought proposed sections 7.00I and 
107.00I could imply that the consecutive 12-month period required for 
episodic events could not include the months before a person files a 
disability claim, or the months before the person's alleged onset date 
of disability.
    Response: In response to these comments, we added language to 
clarify the guidance in final sections 7.00I and 107.00I.

Listings 7.05 and 107.05--Hemolytic Anemias, Including Sickle Cell 
Disease, Thalassemia, and Their Variants

    Comment: Several commenters expressed concern about the criterion 
in proposed listings 7.05A and 107.05A requiring at least six pain 
crises treated with parenteral narcotic medications within a 12-month 
period and occurring at least 30 days apart. These commenters believed 
this criterion is too restrictive, particularly for evaluating sickle 
cell disease. They believed that recent scientific and medical 
literature points to three pain crises requiring parenteral narcotic 
medication within a 12-month period as a more appropriate standard.
    Some commenters also noted that pain crises treated with only oral 
narcotic medications may be severe enough to disrupt a person's life 
for days or weeks. These commenters believed such pain crises greatly 
impair a person's mobility, self-care, and mental capacity, and they 
noted that there can be long-term, cumulative tissue and organ damage 
associated with the crises. A national advocacy group for persons with 
hematological disorders recommended we consider the daily use of oral 
opioids as a criterion for listing-level severity. The group provided a 
suggested revision to final listing 7.05A that considered a person 
disabled if he or she required daily oral opioids for chronic pain for 
a period of at least 30 consecutive days, at least three times within a 
12-month period.
    Response: We did not adopt these comments because we believe final 
listings 7.05A and 107.05A provide objective criteria that are more 
descriptive of our intent and more specific to listing-level 
determinations than the prior listings. In addition, as we noted 
previously, final listing 7.18 provides criteria to evaluate claims 
from individuals whose impairments do not satisfy the medical criteria 
in final listing 7.05A, but whose impairments result in functional 
limitations that meet the criteria of listing 7.18. These effects may 
include chronic pain and other complications, as well as a frequent 
need for oral narcotic medication or other treatments that may cause 
negative side effects. Some people with sickle cell disease or other 
hemolytic anemia may have impairments that are less than listing-level 
severity, but may still be disabling. We can evaluate these impairments 
through the steps of our sequential evaluation process after the 
listing step.
    Comment: One commenter noted that a person hospitalized for pain 
crises may receive treatments other than parenteral narcotic 
medication, such as local or regional anesthetic blocks. The commenter 
believed pain crises requiring such treatments also result in 
functional impairments and are indicative of pain severity, but were 
not reflected in proposed listings 7.05A and 107.05A.
    Response: While it is true final listings 7.05A and 107.05A do not 
specify these other treatments, we did not adopt this comment because 
we are able to evaluate hospitalizations for pain crises treated with 
other treatments under final listings 7.05B and 107.05B, or we can 
evaluate the functional impairments described by the commenter under 
final listing 7.18, or the functional equivalence rules for childhood 
disability claims under the SSI program.
    Comment: One commenter agreed with the requirement in listings 
7.05B and 107.05B that a hospitalization should last at least 48 hours, 
but recommended that this criterion not include hours spent in the 
hospital emergency department immediately before the hospitalization. 
The commenter said hospitals may not always document patients' arrival 
times in their emergency departments and times of discharge to 
inpatient units.
    Response: We did not adopt the commenter's recommendation because 
our adjudicative experience shows that hospitals document these times 
in the great majority of cases.
    Comment: A commenter suggested we count the hours a person receives 
treatment in a comprehensive sickle cell disease center under our 
requirement in final listings 7.05B and 107.05B that hospitalizations 
for complications of hemolytic anemias last at least 48 hours. We 
received a similar comment regarding comprehensive hemophilia treatment 
centers.
    Response: We adopted these comments. We explain in final sections 
7.00C2 and 107.00C2 that we will count the hours the person receives 
treatment in a comprehensive sickle cell disease center if the 
treatment is comparable to the treatment provided in a hospital 
emergency department. We also revised final listings 7.08 and 107.08 
and final sections 7.00D2 and 107.00D2 in response to the comment 
regarding comprehensive hemophilia treatment centers.

[[Page 21164]]

    Comment: One commenter believed the requirement in proposed 
listings 7.05B and 107.05B for three hospitalizations within a 12-month 
period is too restrictive because it applies only to a subset of people 
with sickle cell disease who the commenter described as ``high-risk'' 
patients. The commenter believed we should consider a person with 
sickle cell disease to be disabled if he or she has any of the 
complications described in final sections 7.00C2 and 107.00C2 because 
this person needs continual follow-up and monitoring regardless of 
hospitalization.
    Response: While we appreciate the commenter's concerns--and we 
agree that people with sickle cell disease have serious impairments if 
they have any of the complications described in final sections 7.00C2 
and 107.00C2--we did not adopt the comment. We can evaluate these 
claimants' impairments under any appropriate listing in the affected 
body system, or at the steps of our sequential evaluation process after 
the listing step, if they do not meet or medically equal the criteria 
in listings 7.05B and 107.05B.
    Comment: We received a comment recommending we add guidance to the 
listings that explains to adjudicators they can use hematocrit readings 
under final listings 7.05C and 107.05C if a person's case record does 
not include hemoglobin measurements. The commenter was concerned 
adjudicators might misinterpret the listings to mean they cannot use 
hematocrit readings under any circumstances.
    Response: We did not adopt this recommendation. These final 
listings require hemoglobin measurements at 7.0 grams per deciliter (g/
dL) or less, occurring at least three times within a 12-month period 
with at least 30 days between measurements. In the great majority of 
cases, our adjudicative experience shows a person's case record 
provides both hemoglobin measurements and hematocrit readings. 
Moreover, we are confident that our adjudicators understand they can 
use comparable hematocrit levels to medically equal the listings if 
hemoglobin measurements are not available. The final listings do not 
provide substantive instructions to our adjudicators for determining 
such equivalence because we can better provide this information through 
operating instructions and training.
    Comment: Two commenters questioned whether we should use hemoglobin 
measurements at all. One commenter said the science and the medical 
communities have not established a critical threshold for hemoglobin 
for determining disability. The other commenter said disability depends 
on factors besides hemoglobin level, such as the duration of anemia, 
the bone marrow's response, and associated cardiovascular or other 
organ dysfunction. For children, this commenter said we should also 
consider amount of fatigue, inability to concentrate, problems with 
executive function, and memory deficiencies.
    Response: We did not adopt these comments because we believe this 
criterion is reasonable for quickly identifying people whose hemolytic 
anemias are clearly disabling, and whose claims should be allowed at 
the listing step. Hemoglobin at 7.0 g/dL or less can result in an 
abnormal heartbeat, shortness of breath with mild exertion, significant 
fatigue, and other very serious complications. Given these 
complications, we believe the criteria in the final listings reflect a 
persistence of very low hemoglobin that can prevent an adult from 
working, or prevent a child from functioning independently, 
appropriately, and effectively in an age-appropriate manner.
    Comment: A commenter noted that people with sickle cell disease and 
a history of frequent pain crises or acute chest syndrome may be 
receiving prophylactic RBC transfusions to alleviate these 
complications and are not likely to have hemoglobin measurements of 7.0 
g/dL. The commenter recommended that listings 7.05C and 107.05C allow 
for a finding of disability for people who receive prophylactic RBC 
transfusions for these complications.
    Response: We did not adopt the comment because the intent of the 
hemoglobin finding in final listings 7.05C and 107.05C is to provide a 
faster way for us to determine listing-level disability without needing 
to consider a person's specific complications.
    Comment: The same commenter also thought that adjudicators will 
have difficulty identifying hemoglobin measurements of 7.0 g/dL among 
potentially hundreds of measurements in a person's case record.
    Response: We did not adopt this comment. We agree that a person's 
case record may provide many hemoglobin measurements; however, our 
adjudicators are accustomed to evaluating such evidence.

Listing 7.18--Repeated Complications of Hematological Disorders

    Comment: One commenter suggested that we add ``chronic skin 
ulcers'' to the examples of complications in final listing 7.18.
    Response: We did not adopt this comment. Both the proposed rules 
and these final rules include skin ulcers as a possible complication 
that we will evaluate under listing 7.18. However, skin ulcers and 
other complications we evaluate under the listing do not have to be 
chronic. We explain in final section 7.00G2 that a person's 
complications do not have to be the same each time, but can vary. A 
person could have skin ulcers once and may satisfy this criterion in 
the listing if he or she also has other complications during the period 
we are considering in connection with the application.
    Comment: A commenter suggested we include chronic, non-vascular 
necrosis-related low back pain in final listing 7.18 as a complication 
of a hematological disorder. The commenter also suggested that listing 
7.18 take into consideration pain resulting from prolonged periods of 
standing or physical activity in people who have chronic pain from a 
hematological disorder such as sickle cell disease.
    Response: We did not believe it was necessary to adopt the 
commenter's suggestions. The pain resulting from repeated complications 
of hematological disorders that listing 7.18 requires can include the 
chronic pain the commenter describes.
    Comment: One commenter believed that it is important for 
adjudicators to give appropriate weight to evaluations by nurses, 
social workers, and physical therapists when determining a person's 
functional limitations under final listing 7.18.
    Response: We agree that such sources can provide important 
information to show the severity of a person's impairment and how it 
affects his or her ability to work, and we currently provide guidance 
to our adjudicators in our regulations for considering this evidence 
and who may provide it.\15\
---------------------------------------------------------------------------

    \15\ See 20 CFR 404.1513(d), 20 CFR 416.913(d), and Social 
Security Ruling 06-03p: Titles II and XVI: Considering Opinions and 
Other Evidence from Sources Who Are Not ``Acceptable Medical 
Sources'' in Disability Claims, 71 FR 45593 (2006) (also available 
at: http://www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03-di-01.html).
---------------------------------------------------------------------------

Listing 107.08--Disorders of Hemostasis, Including Hemophilia and 
Thrombocytopenia

    Comment: A commenter believed proposed listing 107.08 did not 
recognize the developmental and functional impact that disability has 
on children and should reflect a need for frequent medical 
intervention, not only hospitalizations. The commenter stated that 
repeated hospitalizations and frequent outpatient medical treatment

[[Page 21165]]

affect children much more profoundly than adults.
    Response: We did not adopt the commenter's recommendation because 
we can evaluate the functional and developmental impact of a child's 
frequent medical treatment under our functional equivalence rules. 
Under these rules, we evaluate how independently, appropriately, and 
effectively the child functions compared to children of the same age 
who do not have a hematological disorder. This evaluation includes 
assessing what activities the child cannot do, has difficulty doing, or 
is restricted from doing because of the interactive and cumulative 
effects of his or her disorder and medical care.

Listing 107.10--Disorders of Bone Marrow Failure, Including 
Myelodysplastic Syndromes, Aplastic Anemia, Granulocytopenia, and 
Myelofibrosis

    Comment: A commenter stated that the requirement in 107.10A for 
three hospitalizations within a 12-month period may be too restrictive 
for children because ``impairment can be severe in a child'' following 
a single hospitalization.
    Response: We did not modify the proposed listing as a result of 
this comment. We believe the hospitalization criterion for disorders of 
bone marrow failure is an advantage to children and adults who apply 
for disability benefits because it provides another way we may find 
them disabled at the listing step. Additionally, the child functional 
equivalence rules help us evaluate SSI claims filed by children whose 
hematological disorders result in fewer than three hospitalizations in 
a 12-month period.

What is our authority to make rules and set procedures for determining 
whether a person is disabled under the statutory definition?

    Under the Act, we have authority to make rules and regulations and 
to establish necessary and appropriate procedures to carry out such 
provisions.\16\
---------------------------------------------------------------------------

    \16\ See sections 205(a), 702(a)(5), and 1631(d)(1).
---------------------------------------------------------------------------

How long will these final rules be in effect?

    These final rules will be in effect for 5 years after their 
effective date, unless we extend them. We will continue to monitor 
these rules to ensure that they continue to meet program purposes, and 
may revise them before the end of the 5-year period if warranted.

Regulatory Procedures

Executive Order 12866, as Supplemented by Executive Order 13563

    We consulted with the Office of Management and Budget (OMB) and 
determined that these final rules meet the requirements for a 
significant regulatory action under Executive Order 12866, as 
supplemented by Executive Order 13563 and was reviewed by OMB.

Regulatory Flexibility Act

    We certify that these final rules will not have a significant 
economic impact on a substantial number of small entities because they 
affect only individuals. Therefore, the Regulatory Flexibility Act, as 
amended, does not require us to prepare a regulatory flexibility 
analysis.

Paperwork Reduction Act

    These final rules do not impose new or affect any existing 
reporting or recordkeeping requirements and are not subject to OMB 
clearance.

(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; and 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: April 10, 2015.
Carolyn W. Colvin,
Acting Commissioner of Social Security.
    For the reasons set out in the preamble, we are amending 20 CFR 
part 404, subpart P as set forth below:

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

Subpart P--[Amended]

0
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), 
(i), and (j), 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), (i), and 
(j), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193, 
110 Stat. 2105, 2189; sec. 202, Pub. L. 108-203, 118 Stat. 509 (42 
U.S.C. 902 note).

0
2. Amend appendix 1 to subpart P of part 404 by revising:
0
a. Item 8 of the introductory text before part A;
0
b. Section 7.00 of part A;
0
c. Section 13.00K2c(ii) of part A;
0
d. Second sentence of section 13.00K3 of part A; and
0
e. Section 107.00 of part B.
    The revisions read as follows:

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

* * * * *
    8. Hematological Disorders (7.00 and 107.00): May 18, 2020.
* * * * *

Part A

* * * * *

7.00 HEMATOLOGICAL DISORDERS

A. What hematological disorders do we evaluate under these 
listings?

    1. We evaluate non-malignant (non-cancerous) hematological 
disorders, such as hemolytic anemias (7.05), disorders of thrombosis 
and hemostasis (7.08), and disorders of bone marrow failure (7.10). 
These disorders disrupt the normal development and function of white 
blood cells, red blood cells, platelets, and clotting-factor 
proteins (factors).
    2. We evaluate malignant (cancerous) hematological disorders, 
such as lymphoma, leukemia, and multiple myeloma, under the 
appropriate listings in 13.00, except for lymphoma associated with 
human immunodeficiency virus (HIV) infection, which we evaluate 
under 14.08E.

 B. What evidence do we need to document that you have a 
hematological disorder?

    We need the following evidence to document that you have a 
hematological disorder:
    1. A laboratory report of a definitive test that establishes a 
hematological disorder, signed by a physician; or
    2. A laboratory report of a definitive test that establishes a 
hematological disorder that is not signed by a physician and a 
report from a physician that states you have the disorder; or
    3. When we do not have a laboratory report of a definitive test, 
a persuasive report from a physician that a diagnosis of your 
hematological disorder was confirmed by appropriate laboratory 
analysis or other diagnostic method(s). To be persuasive, this 
report must state that you had the appropriate definitive laboratory 
test or tests for diagnosing your disorder and provide the results, 
or explain how your diagnosis was established by other diagnostic 
method(s) consistent with the prevailing state of medical knowledge 
and clinical practice.
    4. We will make every reasonable effort to obtain the results of 
appropriate laboratory testing you have had. We will not purchase 
complex, costly, or invasive tests, such as tests of clotting-factor 
proteins, and bone marrow aspirations.

C. What are hemolytic anemias, and how do we evaluate them under 
7.05?

    1. Hemolytic anemias, both congenital and acquired, are 
disorders that result in premature destruction of red blood cells 
(RBCs). Hemolytic disorders include abnormalities of hemoglobin 
structure

[[Page 21166]]

(hemoglobinopathies), abnormal RBC enzyme content and function, and 
RBC membrane (envelope) defects that are congenital or acquired. The 
diagnosis of hemolytic anemia is based on hemoglobin electrophoresis 
or analysis of the contents of the RBC (enzymes) and membrane. 
Examples of congenital hemolytic anemias include sickle cell 
disease, thalassemia and their variants, and hereditary 
spherocytosis. Acquired hemolytic anemias may result from autoimmune 
disease (for example, systemic lupus erythematosus) or mechanical 
devices (for example, heart valves, intravascular patches).
    2. The hospitalizations in 7.05B do not all have to be for the 
same complication of the hemolytic anemia. They may be for three 
different complications of the disorder. Examples of complications 
of hemolytic anemia that may result in hospitalization include 
osteomyelitis, painful (vaso-occlusive) crisis, pulmonary infections 
or infarctions, acute chest syndrome, pulmonary hypertension, 
chronic heart failure, gallbladder disease, hepatic (liver) failure, 
renal (kidney) failure, nephrotic syndrome, aplastic crisis, and 
stroke. We will count the hours you receive emergency treatment in a 
comprehensive sickle cell disease center immediately before the 
hospitalization if this treatment is comparable to the treatment 
provided in a hospital emergency department.
    3. For 7.05C, we do not require hemoglobin to be measured during 
a period in which you are free of pain or other symptoms of your 
disorder. We will accept hemoglobin measurements made while you are 
experiencing complications of your hemolytic anemia.
    4. 7.05D refers to the most serious type of beta thalassemia 
major in which the bone marrow cannot produce sufficient numbers of 
normal RBCs to maintain life. The only available treatments for beta 
thalassemia major are life-long RBC transfusions (sometimes called 
hypertransfusion) or bone marrow transplantation. For purposes of 
7.05D, we do not consider prophylactic RBC transfusions to prevent 
strokes or other complications in sickle cell disease and its 
variants to be of equal significance to life-saving RBC transfusions 
for beta thalassemia major. However, we will consider the functional 
limitations associated with prophylactic RBC transfusions and any 
associated side effects (for example, iron overload) under 7.18 and 
any affected body system(s). We will also evaluate strokes and 
resulting complications under 11.00 and 12.00.

D. What are disorders of thrombosis and hemostasis, and how do we 
evaluate them under 7.08?

    1. Disorders of thrombosis and hemostasis include both clotting 
and bleeding disorders, and may be congenital or acquired. These 
disorders are characterized by abnormalities in blood clotting that 
result in hypercoagulation (excessive blood clotting) or 
hypocoagulation (inadequate blood clotting). The diagnosis of a 
thrombosis or hemostasis disorder is based on evaluation of plasma 
clotting-factor proteins (factors) and platelets. Protein C or 
protein S deficiency and Factor V Leiden are examples of 
hypercoagulation disorders. Hemophilia, von Willebrand disease, and 
thrombocytopenia are examples of hypocoagulation disorders. Acquired 
excessive blood clotting may result from blood protein defects and 
acquired inadequate blood clotting (for example, acquired hemophilia 
A) may be associated with inhibitor autoantibodies.
    2. The hospitalizations in 7.08 do not all have to be for the 
same complication of a disorder of thrombosis and hemostasis. They 
may be for three different complications of the disorder. Examples 
of complications that may result in hospitalization include anemias, 
thromboses, embolisms, and uncontrolled bleeding requiring multiple 
factor concentrate infusions or platelet transfusions. We will also 
consider any surgery that you have, even if it is not related to 
your hematological disorder, to be a complication of your disorder 
of thrombosis and hemostasis if you require treatment with clotting-
factor proteins (for example, factor VIII or factor IX) or 
anticoagulant medication to control bleeding or coagulation in 
connection with your surgery. We will count the hours you receive 
emergency treatment in a comprehensive hemophilia treatment center 
immediately before the hospitalization if this treatment is 
comparable to the treatment provided in a hospital emergency 
department.

E. What are disorders of bone marrow failure, and how do we 
evaluate them under 7.10?

    1. Disorders of bone marrow failure may be congenital or 
acquired, characterized by bone marrow that does not make enough 
healthy RBCs, platelets, or granulocytes (specialized types of white 
blood cells); there may also be a combined failure of these bone 
marrow-produced cells. The diagnosis is based on peripheral blood 
smears and bone marrow aspiration or bone marrow biopsy, but not 
peripheral blood smears alone. Examples of these disorders are 
myelodysplastic syndromes, aplastic anemia, granulocytopenia, and 
myelofibrosis. Acquired disorders of bone marrow failure may result 
from viral infections, chemical exposure, or immunologic disorders.
    2. The hospitalizations in 7.10A do not all have to be for the 
same complication of bone marrow failure. They may be for three 
different complications of the disorder. Examples of complications 
that may result in hospitalization include uncontrolled bleeding, 
anemia, and systemic bacterial, viral, or fungal infections.
    3. For 7.10B, the requirement of life-long RBC transfusions to 
maintain life in myelodysplastic syndromes or aplastic anemias has 
the same meaning as it does for beta thalassemia major. (See 
7.00C4.)

F. How do we evaluate bone marrow or stem cell transplantation 
under 7.17?

    We will consider you to be disabled for 12 months from the date 
of bone marrow or stem cell transplantation, or we may consider you 
to be disabled for a longer period if you are experiencing any 
serious post-transplantation complications, such as graft-versus-
host (GVH) disease, frequent infections after immunosuppressive 
therapy, or significant deterioration of organ systems. We do not 
restrict our determination of the onset of disability to the date of 
the transplantation in 7.17. We may establish an earlier onset date 
of disability due to your transplantation if evidence in your case 
record supports such a finding.

G. How do we use the functional criteria in 7.18?

    1. When we use the functional criteria in 7.18, we consider all 
relevant information in your case record to determine the impact of 
your hematological disorder on your ability to function 
independently, appropriately, effectively, and on a sustained basis 
in a work setting. Factors we will consider when we evaluate your 
functioning under 7.18 include, but are not limited to: Your 
symptoms, the frequency and duration of complications of your 
hematological disorder, periods of exacerbation and remission, and 
the functional impact of your treatment, including the side effects 
of your medication.
    2. Repeated complications means that the complications occur on 
an average of three times a year, or once every 4 months, each 
lasting 2 weeks or more; or the complications do not last for 2 
weeks but occur substantially more frequently than three times in a 
year or once every 4 months; or they occur less frequently than an 
average of three times a year or once every 4 months but last 
substantially longer than 2 weeks. Your impairment will satisfy this 
criterion regardless of whether you have the same kind of 
complication repeatedly, all different complications, or any other 
combination of complications; for example, two of the same kind of 
complication and a different one. You must have the required number 
of complications with the frequency and duration required in this 
section. Additionally, the complications must occur within the 
period we are considering in connection with your application or 
continuing disability review.
    3. To satisfy the functional criteria in 7.18, your 
hematological disorder must result in a ``marked'' level of 
limitation in one of three general areas of functioning: Activities 
of daily living, social functioning, or difficulties in completing 
tasks due to deficiencies in concentration, persistence, or pace. 
Functional limitations may result from the impact of the disease 
process itself on your mental functioning, physical functioning, or 
both your mental and physical functioning. This limitation could 
result from persistent or intermittent symptoms, such as pain, 
severe fatigue, or malaise, resulting in a limitation of your 
ability to do a task, to concentrate, to persevere at a task, or to 
perform the task at an acceptable rate of speed. (Severe fatigue 
means a frequent sense of exhaustion that results in significant 
reduced physical activity or mental function. Malaise means frequent 
feelings of illness, bodily discomfort, or lack of well-being that 
result in significantly reduced physical activity or mental 
function.) You may also have limitations because of your treatment 
and its side effects.
    4. Marked limitation means that the symptoms and signs of your 
hematological

[[Page 21167]]

disorder interfere seriously with your ability to function. Although 
we do not require the use of such a scale, ``marked'' would be the 
fourth point on a five-point scale consisting of no limitation, mild 
limitation, moderate limitation, marked limitation, and extreme 
limitation. We do not define ``marked'' by a specific number of 
different activities of daily living or different behaviors in which 
your social functioning is impaired, or a specific number of tasks 
that you are able to complete, but by the nature and overall degree 
of interference with your functioning. You may have a marked 
limitation when several activities or functions are impaired, or 
even when only one is impaired. Additionally, you need not be 
totally precluded from performing an activity to have a marked 
limitation, as long as the degree of limitation interferes seriously 
with your ability to function independently, appropriately, and 
effectively. The term ``marked'' does not imply that you must be 
confined to bed, hospitalized, or in a nursing home.
    5. Activities of daily living include, but are not limited to, 
such activities as doing household chores, grooming and hygiene, 
using a post office, taking public transportation, or paying bills. 
We will find that you have a ``marked'' limitation in activities of 
daily living if you have a serious limitation in your ability to 
maintain a household or take public transportation because of 
symptoms such as pain, severe fatigue, anxiety, or difficulty 
concentrating, caused by your hematological disorder (including 
complications of the disorder) or its treatment, even if you are 
able to perform some self-care activities.
    6. Social functioning includes the capacity to interact with 
others independently, appropriately, effectively, and on a sustained 
basis. It includes the ability to communicate effectively with 
others. We will find that you have a ``marked'' limitation in 
maintaining social functioning if you have a serious limitation in 
social interaction on a sustained basis because of symptoms such as 
pain, severe fatigue, anxiety, or difficulty concentrating, or a 
pattern of exacerbation and remission, caused by your hematological 
disorder (including complications of the disorder) or its treatment, 
even if you are able to communicate with close friends or relatives.
    7. Completing tasks in a timely manner involves the ability to 
sustain concentration, persistence, or pace to permit timely 
completion of tasks commonly found in work settings. We will find 
that you have a ``marked'' limitation in completing tasks if you 
have a serious limitation in your ability to sustain concentration 
or pace adequate to complete work-related tasks because of symptoms, 
such as pain, severe fatigue, anxiety, or difficulty concentrating 
caused by your hematological disorder (including complications of 
the disorder) or its treatment, even if you are able to do some 
routine activities of daily living.

H. How do we consider your symptoms, including your pain, severe 
fatigue, and malaise?

    Your symptoms, including pain, severe fatigue, and malaise, may 
be important factors in our determination whether your hematological 
disorder(s) meets or medically equals a listing, or in our 
determination whether you are otherwise able to work. We cannot 
consider your symptoms unless you have medical signs or laboratory 
findings showing the existence of a medically determinable 
impairment(s) that could reasonably be expected to produce the 
symptoms. If you have such an impairment(s), we will evaluate the 
intensity, persistence, and functional effects of your symptoms 
using the rules throughout 7.00 and in our other regulations. (See 
sections 404.1528, 404.1529, 416.928, and 416.929 of this chapter.) 
Additionally, when we assess the credibility of your complaints 
about your symptoms and their functional effects, we will not draw 
any inferences from the fact that you do not receive treatment or 
that you are not following treatment without considering all of the 
relevant evidence in your case record, including any explanations 
you provide that may explain why you are not receiving or following 
treatment.

I. How do we evaluate episodic events in hematological disorders?

    Some of the listings in this body system require a specific 
number of events within a consecutive 12-month period. (See 7.05, 
7.08, and 7.10A.) When we use such criteria, a consecutive 12-month 
period means a period of 12 consecutive months, all or part of which 
must occur within the period we are considering in connection with 
your application or continuing disability review. These events must 
occur at least 30 days apart to ensure that we are evaluating 
separate events.

J. How do we evaluate hematological disorders that do not meet one 
of these listings?

    1. These listings are only common examples of hematological 
disorders that we consider severe enough to prevent a person from 
doing any gainful activity. If your disorder does not meet the 
criteria of any of these listings, we must consider whether you have 
a disorder that satisfies the criteria of a listing in another body 
system. For example, we will evaluate hemophilic joint deformity or 
bone or joint pain from myelofibrosis under 1.00; polycythemia vera 
under 3.00, 4.00, or 11.00; chronic iron overload resulting from 
repeated RBC transfusion (transfusion hemosiderosis) under 3.00, 
4.00, or 5.00; and the effects of intracranial bleeding or stroke 
under 11.00 or 12.00.
    2. If you have a severe medically determinable impairment(s) 
that does not meet a listing, we will determine whether your 
impairment(s) medically equals a listing. (See sections 404.1526 and 
416.926 of this chapter.) Hematological disorders may be associated 
with disorders in other body systems, and we consider the combined 
effects of multiple impairments when we determine whether they 
medically equal a listing. If your impairment(s) does not medically 
equal a listing, you may or may not have the residual functional 
capacity to engage in substantial gainful activity. We proceed to 
the fourth, and, if necessary, the fifth steps of the sequential 
evaluation process in sections 404.1520 and 416.920. We use the 
rules in sections 404.1594, 416.994, and 416.994a of this chapter, 
as appropriate, when we decide whether you continue to be disabled.
    7.01 Category of Impairments, Hematological Disorders
    7.05 Hemolytic anemias, including sickle cell disease, 
thalassemia, and their variants (see 7.00C), with:
    A. Documented painful (vaso-occlusive) crises requiring 
parenteral (intravenous or intramuscular) narcotic medication, 
occurring at least six times within a 12-month period with at least 
30 days between crises.
    OR
    B. Complications of hemolytic anemia requiring at least three 
hospitalizations within a 12-month period and occurring at least 30 
days apart. Each hospitalization must last at least 48 hours, which 
can include hours in a hospital emergency department or 
comprehensive sickle cell disease center immediately before the 
hospitalization (see 7.00C2).
    OR
    C. Hemoglobin measurements of 7.0 grams per deciliter (g/dL) or 
less, occurring at least three times within a 12-month period with 
at least 30 days between measurements.
    OR
    D. Beta thalassemia major requiring life-long RBC transfusions 
at least once every 6 weeks to maintain life (see 7.00C4).
    7.08 Disorders of thrombosis and hemostasis, including 
hemophilia and thrombocytopenia (see 7.00D), with complications 
requiring at least three hospitalizations within a 12-month period 
and occurring at least 30 days apart. Each hospitalization must last 
at least 48 hours, which can include hours in a hospital emergency 
department or comprehensive hemophilia treatment center immediately 
before the hospitalization (see 7.00D2).
    7.10 Disorders of bone marrow failure, including myelodysplastic 
syndromes, aplastic anemia, granulocytopenia, and myelofibrosis (see 
7.00E), with:
    A. Complications of bone marrow failure requiring at least three 
hospitalizations within a 12-month period and occurring at least 30 
days apart. Each hospitalization must last at least 48 hours, which 
can include hours in a hospital emergency department immediately 
before the hospitalization (see 7.00E2).
    OR
    B. Myelodysplastic syndromes or aplastic anemias requiring life-
long RBC transfusions at least once every 6 weeks to maintain life 
(see 7.00E3).
    7.17 Hematological disorders treated by bone marrow or stem cell 
transplantation (see 7.00F). Consider under a disability for at 
least 12 consecutive months from the date of transplantation. After 
that, evaluate any residual impairment(s) under the criteria for the 
affected body system.
    7.18 Repeated complications of hematological disorders (see 
7.00G2), including those complications listed in 7.05, 7.08, and 
7.10 but without the requisite findings for those listings, or other

[[Page 21168]]

complications (for example, anemia, osteonecrosis, retinopathy, skin 
ulcers, silent central nervous system infarction, cognitive or other 
mental limitation, or limitation of joint movement), resulting in 
significant, documented symptoms or signs (for example, pain, severe 
fatigue, malaise, fever, night sweats, headaches, joint or muscle 
swelling, or shortness of breath), and one of the following at the 
marked level (see 7.00G4):
    A. Limitation of activities of daily living (see 7.00G5).
    B. Limitation in maintaining social functioning (see 7.00G6).
    C. Limitation in completing tasks in a timely manner due to 
deficiencies in concentration, persistence, or pace (see 7.00G7).
* * * * *

13.00 MALIGNANT NEOPLASTIC DISEASES

* * * * *

K. How do we evaluate specific malignant neoplastic diseases?

* * * * *
    2. Leukemia.
* * * * *
    c. Chronic lymphocytic leukemia.
* * * * *
    ii. We evaluate the complications and residual impairment(s) 
from chronic lymphocytic leukemia (CLL) under the appropriate 
listings, such as 13.05A2 or an appropriate listing in 7.00.
* * * * *
    3. Macroglobulinemia or heavy chain disease. * * * We evaluate 
the resulting impairment(s) under the criteria of 7.00 or any other 
affected body system.
* * * * *

Part B

* * * * *

107.00 HEMATOLOGICAL DISORDERS

A. What hematological disorders do we evaluate under these 
listings?

    1. We evaluate non-malignant (non-cancerous) hematological 
disorders, such as hemolytic anemias (107.05), disorders of 
thrombosis and hemostasis (107.08), and disorders of bone marrow 
failure (107.10). These disorders disrupt the normal development and 
function of white blood cells, red blood cells, platelets, and 
clotting-factor proteins (factors).
    2. We evaluate malignant (cancerous) hematological disorders, 
such as lymphoma, leukemia, and multiple myeloma under the 
appropriate listings in 113.00, except for lymphoma associated with 
human immunodeficiency virus (HIV) infection, which we evaluate 
under 114.08E.

 B. What evidence do we need to document that you have a 
hematological disorder?

    We need the following evidence to document that you have a 
hematological disorder:
    1. A laboratory report of a definitive test that establishes a 
hematological disorder, signed by a physician; or
    2. A laboratory report of a definitive test that establishes a 
hematological disorder that is not signed by a physician and a 
report from a physician that states you have the disorder; or
    3. When we do not have a laboratory report of a definitive test, 
a persuasive report from a physician that a diagnosis of your 
hematological disorder was confirmed by appropriate laboratory 
analysis or other diagnostic method(s). To be persuasive, this 
report must state that you had the appropriate definitive laboratory 
test or tests for diagnosing your disorder and provide the results, 
or explain how your diagnosis was established by other diagnostic 
method(s) consistent with the prevailing state of medical knowledge 
and clinical practice.
    4. We will make every reasonable effort to obtain the results of 
appropriate laboratory testing you have had. We will not purchase 
complex, costly, or invasive tests, such as tests of clotting-factor 
proteins, and bone marrow aspirations.

C. What are hemolytic anemias, and how do we evaluate them under 
107.05?

    1. Hemolytic anemias, both congenital and acquired, are 
disorders that result in premature destruction of red blood cells 
(RBCs). Hemolytic anemias include abnormalities of hemoglobin 
structure (hemoglobinopathies), abnormal RBC enzyme content and 
function, and RBC membrane (envelope) defects that are congenital or 
acquired. The diagnosis of hemolytic anemia is based on hemoglobin 
electrophoresis or analysis of the contents of the RBC (enzymes) and 
membrane. Examples of congenital hemolytic anemias include sickle 
cell disease, thalassemia, and their variants, and hereditary 
spherocytosis. Acquired hemolytic anemias may result from autoimmune 
disease (for example, systemic lupus erythematosus) or mechanical 
devices (for example, heart valves, intravascular patches).
    2. The hospitalizations in 107.05B do not all have to be for the 
same complication of the hemolytic anemia. They may be for three 
different complications of the disorder. Examples of complications 
of hemolytic anemia that may result in hospitalization include 
dactylitis, osteomyelitis, painful (vaso-occlusive) crisis, 
pulmonary infections or infarctions, acute chest syndrome, pulmonary 
hypertension, chronic heart failure, gallbladder disease, hepatic 
(liver) failure, renal (kidney) failure, nephrotic syndrome, 
aplastic crisis, and strokes. We will count the hours you receive 
emergency treatment in a comprehensive sickle cell disease center 
immediately before the hospitalization if this treatment is 
comparable to the treatment provided in a hospital emergency 
department.
    3. For 107.05C, we do not require hemoglobin to be measured 
during a period in which you are free of pain or other symptoms of 
your disorder. We will accept hemoglobin measurements made while you 
are experiencing complications of your hemolytic anemia.
    4. 107.05D refers to the most serious type of beta thalassemia 
major in which the bone marrow cannot produce sufficient numbers of 
normal RBCs to maintain life. The only available treatments for beta 
thalassemia major are life-long RBC transfusions (sometimes called 
hypertransfusion) or bone marrow transplantation. For purposes of 
107.05D, we do not consider prophylactic RBC transfusions to prevent 
strokes or other complications in sickle cell disease and its 
variants to be of equal significance to life-saving RBC transfusions 
for beta thalassemia major. However, we will consider the functional 
limitations associated with prophylactic RBC transfusions and any 
associated side effects (for example, iron overload) under 
functional equivalence and any affected body system(s). We will also 
evaluate strokes and resulting complications under 111.00 and 
112.00.

D. What are disorders of thrombosis and hemostasis, and how do we 
evaluate them under 107.08?

    1. Disorders of thrombosis and hemostasis include both clotting 
and bleeding disorders, and may be congenital or acquired. These 
disorders are characterized by abnormalities in blood clotting that 
result in hypercoagulation (excessive blood clotting) or 
hypocoagulation (inadequate blood clotting). The diagnosis of a 
thrombosis or hemostasis disorder is based on evaluation of plasma 
clotting-factor proteins (factors) and platelets. Protein C or 
protein S deficiency and Factor V Leiden are examples of 
hypercoagulation disorders. Hemophilia, von Willebrand disease, and 
thrombocytopenia are examples of hypocoagulation disorders. Acquired 
excessive blood clotting may result from blood protein defects and 
acquired inadequate blood clotting (for example, acquired hemophilia 
A) may be associated with inhibitor autoantibodies.
    2. The hospitalizations in 107.08 do not all have to be for the 
same complication of a disorder of thrombosis and hemostasis. They 
may be for three different complications of the disorder. Examples 
of complications that may result in hospitalization include anemias, 
thromboses, embolisms, and uncontrolled bleeding requiring multiple 
factor concentrate infusions or platelet transfusions. We will also 
consider any surgery that you have, even if it is not related to 
your hematological disorder, to be a complication of your disorder 
of thrombosis and hemostasis if you require treatment with clotting-
factor proteins (for example, factor VIII or IX) or anticoagulant 
medication to control bleeding or coagulation in connection with 
your surgery. We will count the hours you receive emergency 
treatment in a comprehensive hemophilia treatment center immediately 
before the hospitalization if this treatment is comparable to the 
treatment provided in a hospital emergency department.

E. What are disorders of bone marrow failure, and how do we 
evaluate them under 107.10?

    1. Disorders of bone marrow failure may be congenital or 
acquired, characterized by bone marrow that does not make enough 
healthy RBCs, platelets, or granulocytes (specialized types of white 
blood cells); there may also be a combined failure of these bone 
marrow-producing cells. The diagnosis is based on peripheral blood 
smears and bone marrow

[[Page 21169]]

aspiration or bone marrow biopsy, but not peripheral blood smears 
alone. Examples of these disorders are myelodysplastic syndromes, 
aplastic anemia, granulocytopenia, and myelofibrosis. Acquired 
disorders of bone marrow failure may result from viral infections, 
chemical exposure, or immunologic disorders.
    2. The hospitalizations in 107.10A do not all have to be for the 
same complication of bone marrow failure. They may be for three 
different complications of the disorder. Examples of complications 
that may result in hospitalization include uncontrolled bleeding, 
anemia, and systemic bacterial, viral, or fungal infections.
    3. For 107.10B, the requirement of life-long RBC transfusions to 
maintain life in myelodysplastic syndromes or aplastic anemias has 
the same meaning as it does for beta thalassemia major. (See 
107.00C4.)

F. How do we evaluate bone marrow or stem cell transplantation 
under 107.17?

    We will consider you to be disabled for 12 months from the date 
of bone marrow or stem cell transplantation, or we may consider you 
to be disabled for a longer period if you are experiencing any 
serious post-transplantation complications, such as graft-versus-
host (GVH) disease, frequent infections after immunosuppressive 
therapy, or significant deterioration of organ systems. We do not 
restrict our determination of the onset of disability to the date of 
the transplantation in 107.17. We may establish an earlier onset of 
disability due to your transplantation if evidence in your case 
record supports such a finding.

G. How do we consider your symptoms, including your pain, severe 
fatigue, and malaise?

    Your symptoms, including pain, severe fatigue, and malaise, may 
be important factors in our determination whether your hematological 
disorder meets or medically equals a listing, or in our 
determination whether you otherwise have marked and severe 
functional limitations. We cannot consider your symptoms unless you 
have medical signs or laboratory findings showing the existence of a 
medically determinable impairment(s) that could reasonably be 
expected to produce the symptoms. If you have such an impairment(s), 
we will evaluate the intensity, persistence, and functional effects 
of your symptoms using the rules throughout 107.00 and in our other 
regulations. (See sections 416.928 and 416.929 of this chapter.) 
Additionally, when we assess the credibility of your complaints 
about your symptoms and their functional effects, we will not draw 
any inferences from the fact that you do not receive treatment or 
that you are not following treatment without considering all of the 
relevant evidence in your case record, including any explanations 
you provide on why you are not receiving or following treatment.

H. How do we evaluate episodic events in hematological disorders?

    Some of the listings in this body system require a specific 
number of events within a consecutive 12-month period. (See 107.05, 
107.08, and 107.10A.) When we use such criteria, a consecutive 12-
month period means a period of 12 consecutive months, all or part of 
which must occur within the period we are considering in connection 
with your application or continuing disability review. These events 
must occur at least 30 days apart to ensure that we are evaluating 
separate events.

I. How do we evaluate hematological disorders that do not meet one 
of these listings?

    1. These listings are only common examples of hematological 
disorders that we consider severe enough to result in marked and 
severe functional limitations. If your disorder does not meet the 
criteria of any of these listings, we must consider whether you have 
a disorder that satisfies the criteria of a listing in another body 
system. For example, we will evaluate hemophilic joint deformity 
under 101.00; polycythemia vera under 103.00, 104.00, or 111.00; 
chronic iron overload resulting from repeated RBC transfusion 
(transfusion hemosiderosis) under 103.00, 104.00, or 105.00; and the 
effects of intracranial bleeding or stroke under 111.00 or 112.00.
    2. If you have a severe medically determinable impairment(s) 
that does not meet a listing, we will determine whether your 
impairment(s) medically equals a listing. (See section 416.926 of 
this chapter.) Hematological disorders may be associated with 
disorders in other body systems, and we consider the combined 
effects of multiple impairments when we determine whether they 
medically equal a listing. If your impairment(s) does not medically 
equal a listing, we will also consider whether it functionally 
equals the listings. (See section 416.926a of this chapter.) We use 
the rules in Sec.  416.994a of this chapter when we decide whether 
you continue to be disabled.
    107.01 Category of Impairments, Hematological Disorders
    107.05 Hemolytic anemias, including sickle cell disease, 
thalassemia, and their variants (see 107.00C), with:
    A. Documented painful (vaso-occlusive) crises requiring 
parenteral (intravenous or intramuscular) narcotic medication, 
occurring at least six times within a 12-month period with at least 
30 days between crises.
    OR
    B. Complications of hemolytic anemia requiring at least three 
hospitalizations within a 12-month period and occurring at least 30 
days apart. Each hospitalization must last at least 48 hours, which 
can include hours in a hospital emergency department or 
comprehensive sickle cell disease center immediately before the 
hospitalization (see 107.00C2).
    OR
    C. Hemoglobin measurements of 7.0 grams per deciliter (g/dL) or 
less, occurring at least three times within a 12-month period with 
at least 30 days between measurements.
    OR
    D. Beta thalassemia major requiring life-long RBC transfusions 
at least once every 6 weeks to maintain life (see 107.00C4).
    107.08 Disorders of thrombosis and hemostasis, including 
hemophilia and thrombocytopenia (see 107.00D), with complications 
requiring at least three hospitalizations within a 12-month period 
and occurring at least 30 days apart. Each hospitalization must last 
at least 48 hours, which can include hours in a hospital emergency 
department or comprehensive hemophilia treatment center immediately 
before the hospitalization (see 107.00D2).
    107.10 Disorders of bone marrow failure, including 
myelodysplastic syndromes, aplastic anemia, granulocytopenia, and 
myelofibrosis (see 107.00E), with:
    A. Complications of bone marrow failure requiring at least three 
hospitalizations within a 12-month period and occurring at least 30 
days apart. Each hospitalization must last at least 48 hours, which 
can include hours in a hospital emergency department immediately 
before the hospitalization (see 107.00E2).
    OR
    B. Myelodysplastic syndromes or aplastic anemias requiring life-
long RBC transfusions at least once every 6 weeks to maintain life 
(see 107.00E3).
    107.17 Hematological disorders treated by bone marrow or stem 
cell transplantation (see 107.00F). Consider under a disability for 
at least 12 consecutive months from the date of transplantation. 
After that, evaluate any residual impairment(s) under the criteria 
for the affected body system.
* * * * *
[FR Doc. 2015-08849 Filed 4-16-15; 8:45 am]
 BILLING CODE 4191-02-P