[Federal Register Volume 83, Number 88 (Monday, May 7, 2018)]
[Proposed Rules]
[Pages 20646-20673]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-08889]



[[Page 20645]]

Vol. 83

Monday,

No. 88

May 7, 2018

Part III





Social Security Administration





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20 CFR Parts 404 and 416





Revised Medical Criteria for Evaluating Musculoskeletal Disorders; 
Proposed Rule

  Federal Register / Vol. 83, No. 88 / Monday, May 7, 2018 / Proposed 
Rules  

[[Page 20646]]


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SOCIAL SECURITY ADMINISTRATION

20 CFR Parts 404 and 416

[Docket No. SSA-2006-0112]
RIN 0960-AG38


Revised Medical Criteria for Evaluating Musculoskeletal Disorders

AGENCY: Social Security Administration.

ACTION: Notice of proposed rulemaking.

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SUMMARY: We propose to revise the criteria in the Listing of 
Impairments (listings) that we use to evaluate claims involving 
musculoskeletal disorders in adults and children under titles II and 
XVI of the Social Security Act (Act). These proposed revisions reflect 
our adjudicative experience, advances in medical knowledge and 
treatment of musculoskeletal disorders, and recommendations from 
medical experts.

DATES: To ensure that your comments are considered, we must receive 
them no later than July 6, 2018.

ADDRESSES: You may submit comments by one of three methods--internet, 
fax, or mail. Do not submit the same comments multiple times or by more 
than one method. Regardless of which method you choose, please state 
that your comments refer to Docket No. SSA-2006-0112 so that we may 
associate your comments with the correct regulation.
    Caution: You should be careful to include in your comments only 
information that you wish to make publicly available. We strongly urge 
you not to include in your comments any personal information, such as 
Social Security numbers or medical information.
    1. Internet: We strongly recommend that you submit your comments 
via the internet. Please visit the Federal eRulemaking portal at http://www.regulations.gov. Use the Search function to find docket number 
SSA-2006-0112. The system will issue you a tracking number to confirm 
your submission. You will not be able to view your comment immediately 
because we must post each comment manually. It may take up to a week 
for your comment to be viewable.
    2. Fax: Fax comments to (410) 966-2830.
    3. Mail: Address your comments to the Office of Regulations and 
Reports Clearance, Social Security Administration, 107 Altmeyer 
Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401.
    Comments are available for public viewing on the Federal 
eRulemaking portal at http://www.regulations.gov or in person, during 
regular business hours, by arranging with the contact person identified 
below.

FOR FURTHER INFORMATION CONTACT: Cheryl A. Williams, Office of 
Disability 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 site, Social Security Online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION: This notice of proposed rulemaking (NPRM) is 
divided into several parts. First, we provide the supplementary 
information, which is often referred to as the preamble. In the 
preamble, we explain why we propose to revise the listings for the 
musculoskeletal body system and how we developed the proposed rules. We 
also offer a narrative of the changes we are proposing. The preamble 
tells the story behind the proposed rule changes, but if we decide to 
proceed with a final rule, the preamble will not become part of the 
Code of Federal Regulations.
    The next section is the proposed revisions to the listing of 
impairments, located in Appendix 1 to Subpart P of 20 CFR part 404. For 
each body system affected by these proposed rules (e.g., 1.00 
Musculoskeletal Disorders), we first provide proposed changes to the 
introductory text (e.g., 1.00A, B, C, etc.). If we decide to proceed 
with a final rule, the introductory text will become part of the Code 
of Federal Regulations. The introductory text details which disorders 
we evaluate and what evidence we need to conduct this evaluation. It 
also defines certain terms, and provides valuable background 
information. Individuals often refer to the introductory text for 
additional details related to a specific listing under which a 
medically determinable impairment (MDI) is being evaluated. After the 
introductory text, we provide specific listing text and criteria (e.g., 
1.15 and 1.16). The listings themselves provide specific criteria that 
an MDI must meet (or medically equal) in order for an individual to be 
found disabled under the listings.

I. Why are we proposing to revise the listings for the musculoskeletal 
body system?

    We last published final rules that revised the musculoskeletal body 
system on November 19, 2001.\1\ We are now proposing to update the 
introductory text and criteria in the current listings to reflect our 
adjudicative experience, advances in medical knowledge and treatment of 
musculoskeletal disorders, and comments and recommendations from 
medical experts.
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    \1\ 66 FR 58010. We also made a conforming change to the rules 
for musculoskeletal disorders when we published final rules revising 
the rules for immune system disorders on March 18, 2006 (73 FR 
14570).
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    While we believe our proposed revisions reflect advances in medical 
knowledge and treatment of musculoskeletal disorders, we are interested 
in receiving public comments on the following issues:
     Are there any musculoskeletal disorders that will meet one 
of the proposed listings, but are generally expected to medically 
improve after a certain amount of time to the point at which the 
disorders will no longer be of listing-level severity? If you believe 
there are musculoskeletal disorders that fit into this category, please 
tell us by submitting your comments and any supporting research or 
data. We will use your comments on this issue to inform our policy on 
the timing of continuing disability reviews.\2\
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    \2\ See Sec. Sec.  404.1590 and 416.990 of this chapter for our 
policy on when we will conduct a continuing disability review.
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     Are the proposed functional criteria appropriate and 
sufficient for assessing listing level severity? If you believe the 
proposed functional criteria are either insufficient for documenting an 
impairment that meets a listing-level severity, or you believe these 
criteria will exclude eligible individuals with an impairment of 
listing-level severity, please tell us by submitting your comments and 
any supporting research or data.
     Did we remove or omit any valuable information that should 
be included in the introductory text? We intend for this text to ease 
administrative burdens for adjudicators, claimants, claimant 
representatives, and the public by clarifying terms, removing 
extraneous language, and providing guidance in an orderly fashion. If 
you believe we removed or omitted any valuable information, please tell 
us by submitting your comments and any supporting research or data.
     Should any of the proposed listings for musculoskeletal 
disorders be combined into one listing or divided into multiple 
listings for adjudicative ease and capture individuals with impairments 
that meet a listing-level severity? If you believe our listing 
categories create unnecessary administrative barriers for impairments 
that meet listing level severity, please

[[Page 20647]]

tell us by submitting your comments and any supporting research or 
data.
     Did we appropriately define ``close proximity of time'' in 
section 1.00C7 as meaning that all of the relevant criteria have to 
appear in the medical record within a period not to exceed 4 months of 
one another for musculoskeletal disorders? The 4-month threshold 
represents a period in which an individual receiving treatment for a 
chronic severe musculoskeletal impairment will undergo multiple 
examinations or treatments from their medical source(s). Individuals 
with chronic severe musculoskeletal impairments typically undergo 
multiple examinations or treatments. Therefore, we believe a 4-month 
threshold provides individuals with adequate time to receive multiple 
medical treatments documenting the existence of listing level criteria, 
should the relevant criteria exist. If you believe the ``close 
proximity of time'' should be defined by a different measure than 4 
months, please tell us by submitting your comments and any supporting 
research or data.
     Based on advances in medical surgical, recuperative, and 
functionally restorative treatment of musculoskeletal disorders, would 
the proposed listing criteria allow us to adequately assess whether an 
individual has achieved ``maximum benefit from therapy'' or whether an 
individual is ``under continuing surgical management''? It is important 
that we do not encourage or incentivize individuals to increase their 
medical treatment to maintain or access disability benefits, 
particularly medical treatments that would likely be ineffective, or 
that may even be harmful, for the individual? If you believe ``the 
maximum therapeutic benefits'' criterion should be revised and 
evaluated by a different measure, please tell us by submitting your 
comments and any supporting research or data.

II. How did we develop these proposed rules?

    As medicine and medical treatment are continuously evolving, we 
utilized well-known references such as the Guides to the Evaluation of 
Permanent Impairment from the American Medical Association, Harrison's 
Principles of Internal Medicine, Current Diagnosis & Treatment in 
Orthopedics, and Nelson Textbook of Pediatrics as a starting point to 
develop the proposed changes to these rules.\3\ We also requested 
extensive input from our medical consultants (physicians employed by or 
who contract with us) who have years of experience practicing in 
relevant fields of medicine and who have intimate knowledge of our 
disability programs to develop our proposed changes to the 
musculoskeletal disorders listings. We rely on our medical consultants 
and their professional opinions based on their clinical experience and 
research to help us develop what criteria correspond with listing-level 
severity.
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    \3\ Full citations are available in X. References below.
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    In developing our proposed rule changes, we used the resources 
above, our programmatic knowledge, our adjudicative experience, and the 
medical literature, such as Archives of Physical Medicine and 
Rehabilitation, Journal of the American Academy of Orthopaedic 
Surgeons, and Hand Clinics. These resources informed us of the most 
recent best practices and medical advancements and either support, or 
are consistent with, our proposed rule changes.
    In addition to these distinguished medical sources and our medical 
consultants, in proposing these changes to the musculoskeletal 
disorders listings, we used information from:
     People who make and review disability determinations and 
decisions for us in State agencies, in our Office of Quality Review, 
and in our Office of Hearing Operations;
     Comments we received regarding the 2001 ``Final rules with 
request for comment,'' \4\ which we used as a starting point for 
identifying areas needing further research; and
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    \4\ The final rules with request for comments are available at 
http://www.gpo.gov/fdsys/pkg/FR-2001-11-19/pdf/01-28456.pdf. 
Comments on the final rules may be found at http://www.regulations.gov/ gov/, and search for ``SSA-2006-0112''.
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     Additional published sources we list in the References 
section at the end of this preamble, including the National Academies 
of Sciences, Engineering, and Medicine, Health and Medicine Division 
(formerly the Institute of Medicine).

III. What major revisions are we proposing?

    We propose to revise both the content and the structure of the 
adult and childhood musculoskeletal disorders listings and introductory 
texts as follows:
     Provide uniform and specific severity criteria for 
evaluating the effects of a musculoskeletal disorder on a person's 
functioning;
     Revise the introductory texts in 1.00 Musculoskeletal 
Disorders and 101.00 Musculoskeletal Disorders to provide guidance on 
the specific severity criteria;
     Add specific sections in the introductory texts in 1.00 
Musculoskeletal Disorders and 101.00 Musculoskeletal Disorders to 
provide guidance on each listing;
     Revise the content and structure of the current listings 
to incorporate the new severity criteria into each listing;
     Add listings for evaluating pathologic fractures due to 
any cause (1.19 Pathologic fractures due to any cause for adults and 
101.19 Pathologic fractures due to any cause for children);
     Add a child listing for evaluating musculoskeletal 
disorders of infants and toddlers, from birth to attainment of age 3, 
with developmental motor delay (101.24 Musculoskeletal disorders of 
infants and toddlers, from birth to attainment of age 3, with 
developmental motor delay);
     Use the same general structure in most adult and child 
listings, consisting of symptoms, signs, laboratory findings, and 
applicable functional criteria, in that order;
     Remove current 1.02 and 101.02 Major dysfunction of a 
joint(s) (due to any cause) and incorporate the provisions in proposed 
1.18 and 101.18 Abnormality of a major joint(s) in any extremity;
     Remove current 1.04 Disorders of the spine and 1.04A 
``Evidence of nerve root compression,'' and incorporate the provisions 
of 1.04A in proposed 1.15 Disorders of the skeletal spine resulting in 
compromise of a nerve root(s);
     Remove current 1.04B ``Spinal arachnoiditis'' because it 
is a secondary effect, rather than a primary skeletal spine disorder, 
which can be evaluated under proposed 1.16 Lumbar spinal stenosis 
resulting in compromise of the cauda equina;
     Remove current 1.04C ``Lumbar spinal stenosis,'' and 
incorporate its provisions in proposed 1.16 Lumbar spinal stenosis 
resulting in compromise of the cauda equina;
     Remove current 101.04 Disorders of the spine and 
incorporate the provisions in proposed 101.15 Disorders of the skeletal 
spine resulting in compromise of a nerve root(s) and 101.16 Lumbar 
spinal stenosis resulting in compromise of the cauda equina;
     Remove current 1.05 and 101.05 Amputation (due to any 
cause), and incorporate its provisions in proposed 1.20 and 101.20 
Amputation due to any cause;
     Remove current 1.06 and 101.06 Fracture of the femur, 
tibia, pelvis, or one or more of the tarsal bones; and incorporate the 
provisions of those listings in proposed 1.22 and 101.22 Non-healing or 
complex fracture of the

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femur, tibia, pelvis, or one or more of the tarsal bones;
     Remove current 1.07 and 101.07 Fracture of an upper 
extremity; and incorporate the provisions of those listings in proposed 
1.23 and 101.23 Non-healing or complex fracture of an upper extremity; 
and
     Remove current 1.08 and 101.08 Soft tissue injury (e.g., 
burns), and incorporate the provisions in proposed 1.21 and 101.21 Soft 
tissue injury or abnormality under continuing surgical management.

IV. What changes are we proposing to the introductory text of the 
musculoskeletal disorders listings for adults?

    We propose to adopt a question-and-answer framework to make the 
guidance contained in the introduction easier for adjudicators, 
claimants, claimant representatives, and the public to locate, and to 
make the introductory text consistent with the format used in other 
body systems.
    We propose to remove the phrases ``loss of function'' and 
``functional loss'' and replace the content of current 1.00B1 General, 
101.00B1 General, 1.00B2 How we define loss of function in these 
listings, and 101.00B2 How We Define Loss of Function in These 
Listings. We are replacing the content of 1.00B1 General and 101.00B1 
General because it may be read to imply that we require an absence of 
function in order to evaluate an impairment under these listings. 
Except in the case of amputation, the proposed listings do not require 
a complete absence of function. In 1.00B2 How We Define Loss of 
Function in These Listings and 101.00B2 How We Define Loss of Function 
in These Listings, we are removing the descriptive phrases, ``inability 
to ambulate effectively,'' ``extreme limitation of the ability to 
walk,'' ``interferes very seriously with the individual's ability to 
independently initiate, sustain, or complete activities,'' 
``ineffective ambulation,'' and ``independent ambulation,'' along with 
the corresponding examples in that paragraph. We are replacing these 
descriptors with uniform and specific severity criteria, which we 
believe will provide clearer guidance for adjudicators and the public.
    We propose to provide new uniform and specific functional criteria, 
which we describe in the introductory text for each listing, for 
evaluating the severity of limitations caused by musculoskeletal 
disorders. We chose these particular functional criteria because they 
clearly illustrate the level of dysfunction for upper and lower 
extremities that would cause an adult to be unable to work, or that 
would cause a child to be unable to perform age-appropriate activities. 
The effects of a particular disorder on musculoskeletal functioning, 
and the treatment needed, direct which of these criteria are 
appropriate for each of the listings. The functional criteria for 
adults are as follows:
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches;
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving fine 
and gross movements, and a documented medical need for a one-handed 
assistive device that requires the use of the other upper extremity; or
    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements.
    In developing this uniform and specific severity criteria, we 
utilized medical resources, such as ``Ambulatory Assistive Devices in 
Orthopaedics: Uses and Modifications,'' \5\ the professional experience 
of our medical consultants, information related to workplace 
functioning from the Bureau of Labor Statistics, and our adjudicative 
experience. Each of these criteria illustrate restrictions of multiple 
extremities and thus, significant limitations.
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    \5\ Full citation is available in X. References, below.
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    We propose to explain each proposed listing in separate sections of 
the introduction.
    The following chart shows the headings of the current and proposed 
sections of the adult introductory text:

------------------------------------------------------------------------
       Current introductory text            Proposed introductory text
------------------------------------------------------------------------
A. Disorders of the musculoskeletal      A. Which disorders do we
 system.                                  evaluate under these listings?
B. Loss of function....................  B. Which related disorders do
                                          we evaluate under other
                                          listings?
C. Diagnosis and Evaluation............  C. What evidence do we need to
                                          evaluate your musculoskeletal
                                          disorder under these listings?
D. The physical examination............  D. How do we consider symptoms,
                                          including pain, under these
                                          listings?
E. Examination of the Spine............  E. How do we use the functional
                                          criteria under these listings?
F. Major joints........................  F. What do we consider when we
                                          evaluate disorders of the
                                          skeletal spine resulting in
                                          compromise of a nerve root(s)
                                          (1.15)?
G. Measurements of joint motion........  G. What do we consider when we
                                          evaluate lumbar spinal
                                          stenosis resulting in
                                          compromise of the cauda equina
                                          (1.16)?
H. Documentation.......................  H. What do we consider when we
                                          evaluate reconstructive
                                          surgery or surgical
                                          arthrodesis of a major weight-
                                          bearing joint (1.17)?
I. Effects of Treatment................  I. What do we consider when we
                                          evaluate abnormality of a
                                          major joint(s) in any
                                          extremity (1.18)?
J. Orthotic, Prosthetic, or Assistive    J. What do we consider when we
 Devices.                                 evaluate pathologic fractures
                                          due to any cause (1.19)?
K. Disorders of the spine..............  K. What do we consider when we
                                          evaluate amputation due to any
                                          cause (1.20)?
L. Abnormal curvatures of the spine....  L. What do we consider when we
                                          evaluate soft tissue injury or
                                          abnormality under continuing
                                          surgical management (1.21)?
M. Under continuing surgical management  M. What do we consider when we
                                          evaluate non-healing or
                                          complex fractures of the
                                          femur, tibia, pelvis, or one
                                          or more of the tarsal bones
                                          (1.22)?
N. After maximum benefit from therapy    N. What do we consider when we
 has been achieved.                       evaluate non-healing or
                                          complex fractures of an upper
                                          extremity (1.23)?

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O. Major function of the face and head.  O. How do we determine when
                                          your soft tissue injury or
                                          abnormality, or your upper
                                          extremity fracture, is no
                                          longer under continuing
                                          surgical management or you
                                          have received maximum
                                          therapeutic benefit?
P. When surgical procedures have been    P. How do we evaluate the
 performed.                               severity and duration of your
                                          established musculoskeletal
                                          disorder when there is no
                                          record of ongoing treatment?
Q. Effects of obesity..................  Q. How do we evaluate substance
                                          use disorders that co-exist
                                          with musculoskeletal
                                          disorders?
                                         R. How do we evaluate disorders
                                          that do not meet one of the
                                          musculoskeletal listings?
------------------------------------------------------------------------

Proposed 1.00--Introduction

    The following is a detailed description of the changes we propose 
to the introductory text.
Proposed 1.00A--Which disorders do we evaluate under these listings?
    We propose to revise current 1.00A Disorders of the musculoskeletal 
system to explain that we evaluate musculoskeletal disorders that 
result in dysfunction of the skeletal spine or of the upper or lower 
extremities,\6\ fractures, and soft tissue \7\ abnormalities or 
injuries that are under continuing surgical management.
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    \6\ Impairments involving the shoulders will typically affect 
upper extremities while the impairments involving the pelvis, hips, 
and ribs typically affect lower extremities. When assessing 
dysfunction, the resultant incapacity or limitation is key to 
assessing the impairment under the applicable medical listing.
    \7\ Soft tissue refers to non-skeletal tissues that make up a 
large percentage of the body, such as the tendons, ligaments, fascia 
and muscles.
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    We begin with listings for disorders affecting functioning of the 
skeletal spine, because our adjudicative experience shows that these 
are the most frequently used listings in this body system.
Proposed 1.00B--Which related disorders do we evaluate under other 
listings?
    We propose to replace the content of current 1.00B Loss of function 
with improved guidance for disorders that affect musculoskeletal 
functioning, which we evaluate under other listings. We explain that we 
evaluate injuries of the skeletal spine resulting in dysfunction of the 
spinal cord under 11.00 Neurological Disorders, and we evaluate 
inflammatory arthritis under 14.00 Immune System Disorders. We state 
that we evaluate abnormal curvatures of the spine that adversely affect 
functioning in other body systems under the appropriate listing in the 
affected body system. We have removed the guidance from current 1.00L 
that states ``Abnormal curvatures of the spine (specifically, 
scoliosis, kyphosis and kyphoscoliosis) can result in impaired 
ambulation, but may also adversely affect functioning in body systems 
other than the musculoskeletal system.'' Instead, we propose to 
evaluate spinal curvatures that affect musculoskeletal functioning 
under proposed 1.15 Disorders of the skeletal spine resulting in 
compromise of a nerve root(s), depending on the area of dysfunction 
created by the curvature. We also state that we can evaluate a 
curvature of the spine that is under continuing surgical management 
under proposed 1.21 Soft tissue injury or abnormality under continuing 
surgical management.
Proposed 1.00C--What evidence do we need to evaluate your 
musculoskeletal disorder under these listings?
    We propose to replace current 1.00C Diagnosis and Evaluation with a 
comprehensive explanation of the information and evidence we need to 
evaluate musculoskeletal disorders. Once we establish the disorder, we 
evaluate evidence from medical and non-medical sources to assess 
severity and duration under the musculoskeletal listings. We describe 
the elements needed in a physical examination report. We discuss 
laboratory and other test findings and their usefulness and 
limitations, and we explain our policy concerning evaluation of imaging 
and other diagnostic tests. We discuss our need for operative reports 
and what we will accept in the absence of such reports, incorporating 
the guidance from current introductory section 1.00P When surgical 
procedures have been performed. We identify the evidence we need 
concerning a person's treatment and response to it.
    In section 1.00C6 Assistive devices, we clarify what we mean by a 
prosthesis(es) and an orthosis(es). We discuss the evidence we need 
when a person with a musculoskeletal disorder uses an assistive 
device(s), including a cane(s), crutch(es), walker, prosthesis(es), or 
orthosis(es).
    In section 1.00C7 Longitudinal evidence, we explain the importance 
of a longitudinal medical record in determining whether a 
musculoskeletal disorder satisfies the duration requirement. We explain 
that, for all listings except 1.19 Pathologic fractures due to any 
cause, 1.20A ``Amputation of both upper extremities'' 1.20B 
``Hemipelvectomy or hip disarticulation'', and 1.21 Soft tissue injury 
or abnormality under continuing surgical management, all listing 
criteria must be present simultaneously, or within a close proximity of 
time; and must have lasted, or be expected to last, for a continuous 
period of at least 12 months for a disorder to meet a listing.
    In section 1.00C What evidence do we need to evaluate your 
musculoskeletal disorder under these listings?, we clarify that, when 
the listing criteria are linked by the word ``and'' (whether in small 
case or capital case), the requirements must be simultaneously present, 
or present within a ``close proximity of time,'' which we define in 
section 1.00C7 as meaning that all of the relevant criteria have to 
appear in the medical record within a period not to exceed 4 months of 
one another. Consistent with the standard of care and common industry 
practice, according to our medical consultants, literature review, and 
external medical experts, such as those from the Health and Medicine 
Division at the National Academies of Science Engineering and Medicine, 
an individual receiving treatment for a chronic severe musculoskeletal 
impairment will typically receive treatment or undergo examination at 
least once every 3 months. Should an individual meet an applicable 
listing, the listing criteria is likely to be documented every third 
month. The 4-month threshold provides leeway in cases where a physical 
examination might not be performed or symptoms are not documented at a 
given appointment. The 4-month threshold represents a period in which 
individuals receiving treatment for a chronic severe musculoskeletal 
impairment will undergo multiple examinations or treatments from their 
medical source(s), providing a window encompassing multiple medical

[[Page 20650]]

appointments over which applicable listing criteria can be adequately 
documented. The 4-month threshold does not apply to imaging.
    We propose to add this clarification to address a holding in 
Radford v. Colvin, 734 F.3d 288 (4th Cir. 2013) with respect to current 
1.04A Disorders of the spine, ``Evidence of nerve root compression.'' 
The Radford Court held that ``[a] claimant need not show that each 
symptom was present at precisely the same time--i.e., simultaneously--
in order to establish the chronic nature of his condition. Nor need a 
claimant show that the symptoms were present in the claimant in 
particularly close proximity.'' \8\
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    \8\ 734 F.3d at 294.
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    Because this holding of the Radford Court differed from our 
interpretation of the listing requirement, we issued Acquiescence 
Ruling (AR) 15-1(4) to implement the Court of Appeals holding within 
the States in the Fourth Circuit.\9\ We now propose to clarify our 
longstanding interpretation of the regulations in response to the 
Radford decision. We also propose to clarify that this policy applies 
to other listings that have similar requirements.
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    \9\ 80 FR 57418 (2015). Available at: https://www.ssa.gov/OP_Home/rulings/ar/04/AR2015-01-ar-04.html.
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    The issuance of a new regulation to address a holding of a Court of 
Appeals that conflicts with our policy is consistent with the process 
described in our regulations for issuing and rescinding Acquiescence 
Rulings. Our regulations specifically contemplate that we may 
``subsequently publish a new regulation(s) addressing an issue(s) not 
previously included in our regulations when that issue(s) was the 
subject of a circuit court holding that conflicted with our 
interpretation of the Social Security Act or regulations and that 
holding was not compelled by the statute or Constitution.'' 20 CFR 
404.985(e)(4), 416.1485(e)(4). After we have considered the public 
comments in response to these proposed rules and issued any final 
rules, we will decide whether we need to rescind the Radford AR.
    Section 1.00C8 Surgical treatment, discusses how we evaluate 
surgical treatment. We explain when and why we may wait to receive 
additional evidence before making a determination of disability.
Proposed 1.00D--How do we consider symptoms, including pain, under 
these listings?
    We propose to replace current 1.00D The physical examination with 
guidance about how we consider symptoms of musculoskeletal impairments, 
particularly pain. We explain that your pain must be supported by 
medical signs and laboratory findings, established by medically 
acceptable clinical, laboratory, or diagnostic techniques, showing the 
existence of a medical impairment(s) which results from anatomical, 
physiological, or psychological abnormalities.
Proposed 1.00E--How do we use the functional criteria under these 
listings?
    We propose to replace current 1.00E Examination of the Spine with 
new guidance about how we use the functional criteria to evaluate 
musculoskeletal disorders under these listings. We explain what we mean 
by functional criteria, we list the criteria, and we explain why 
listings 1.20A `Amputation of both upper extremities'', 1.20B 
``Hemipelvectomy or hip disarticulation'' and 1.21 Soft tissue injury 
or abnormality under continuing surgical management do not include the 
functional criteria. We also explain that we will evaluate a person's 
functioning with respect to the work environment, rather than the home 
environment, because the ability to walk independently about one's home 
without the use of assistive devices does not, in and of itself, 
indicate an ability to walk without an assistive device in a work 
environment. We explain that in order to be disabling, a 
musculoskeletal disorder must satisfy the medical criteria as well as 
the 12-month duration requirement and, where applicable, must include 
at least one of the functional criteria of a listing.
Proposed 1.00F--What do we consider when we evaluate disorders of the 
skeletal spine resulting in compromise of a nerve root(s) (1.15)?
    We propose to replace the content of current 1.00F Major joints 
with guidance regarding how we evaluate disorders of the skeletal spine 
under proposed 1.15 Disorders of the skeletal spine resulting in 
compromise of a nerve root(s). In proposed 1.00F, we list the various 
spinal disorders that result in compromise of nerve roots; we explain 
the symptoms and signs associated with those disorders; and we explain 
how a medical source evaluates those symptoms and signs in clinical 
examinations.
Proposed 1.00G--What do we consider when we evaluate lumbar spinal 
stenosis resulting in compromise of the cauda equina (1.16)?
    We propose to replace the content of current 1.00G Measurements of 
joint motion with guidance about how we evaluate the effects of 
compromise of the cauda equina due to lumbar spinal stenosis under 
proposed 1.16 Lumbar spinal stenosis resulting in compromise of the 
cauda equina. We explain how lumbar spinal stenosis can compromise the 
cauda equina; we provide a more detailed discussion of the cauda equina 
and associated symptoms and signs; and we explain how the disorder 
affects functioning. We also explain the difference between pain caused 
by compromise of the cauda equina (neurogenic claudication or 
pseudoclaudication) and pain caused by peripheral arterial disease 
(vascular claudication).
Proposed 1.00I--What do we consider when we evaluate abnormality of a 
major joint(s) in any extremity (1.18)?
    We propose to replace the content of current 1.00I Effects of 
Treatment with guidance about how we evaluate abnormality in a major 
joint(s) under proposed 1.18 Abnormality of a major joint(s) in any 
extremity. We explain how we define abnormalities of the joints, and 
give specific examples of the types of diseases, injuries, and other 
conditions that may contribute to joint dysfunction. We also explain 
how these disorders interfere with functions of the extremities.
Proposed 1.00J--What do we consider when we evaluate pathologic 
fractures due to any cause (1.19)?
    We propose to replace the content of current 1.00J Orthotic, 
Prosthetic, or Assistive Devices with guidance regarding how we 
evaluate pathologic fractures under proposed new 1.19 Pathologic 
fractures due to any cause. We explain what we mean by ``pathologic 
fractures;'' we state that these types of fractures can affect the 
skeletal spine, extremities, or other parts of the skeletal system; we 
give examples of disorders that can cause pathologic fractures; and we 
explain how we evaluate their occurrence and recurrence.
Proposed 1.00K--What do we consider when we evaluate amputation due to 
any cause (1.20)?
    We propose to replace the content of current 1.00K Disorders of the 
spine with guidance about how we evaluate amputation due to any cause 
under proposed 1.20 Amputation due to any

[[Page 20651]]

cause. We explain that we evaluate amputations involving upper or lower 
extremities and combinations of those extremities, as well as 
hemipelvectomies and hip disarticulations. We explain that when a 
person has amputations of one upper extremity at any level above the 
wrist and one lower extremity at or above the ankle, we consider 
whether the person has a documented medical need for a one-handed 
assistive device. We also explain how we consider amputation of one or 
both lower extremities at or above the ankle (tarsal joint). We state 
that we use this listing when a person has residual limb complications 
that have lasted, or are expected to last, for at least 12 months, and 
the person is not currently undergoing surgical management.
Proposed 1.00L--What do we consider when we evaluate soft tissue injury 
or abnormality under continuing surgical management (1.21)?
    We propose to replace the content of current 1.00L Abnormal 
curvatures of the spine with guidance about how we evaluate soft tissue 
abnormality or injury of any part of the body that is under continuing 
surgical management. We also incorporate the provisions of current 
sections 1.00M Under continuing surgical management, 1.00N After 
maximum benefit from therapy has been achieved, 1.00O Major function of 
the face and head, and 1.00P When surgical procedures have been 
performed. We explain that we use proposed 1.21 Soft tissue injury or 
abnormality under continuing surgical management to evaluate any soft 
tissue abnormality or injury, whether congenital or acquired, including 
malformations, third- and fourth-degree burns, craniofacial injuries, 
avulsive injuries, amputations with complications of the residual 
limb(s), and complications of non-healing or complex traumatic 
fractures. We explain that a person must have a documented medical need 
for a continuing series of ongoing surgical procedures and associated 
medical treatments, directed toward saving, reconstructing, or 
replacing the affected part of the body. We further explain that these 
treatments must have been, or must be expected to be, ongoing for a 
continuous period of least 12 months. We list the clinical evidence we 
need to determine whether a disorder meets this listing. We explain how 
we evaluate third- and fourth-degree burns and craniofacial injuries. 
We also explain how we evaluate when maximum therapeutic benefit has 
occurred and how we evaluate residual impairment.
Proposed 1.00M--What do we consider when we evaluate non-healing or 
complex fractures of the femur, tibia, pelvis, or one or more of the 
tarsal bones (1.22)?
    We propose to replace the content of current 1.00M Under continuing 
surgical management with guidance about how we evaluate non-healing or 
complex fractures involving bones in the lower extremity. We also 
provide definitions for ``non-healing fracture'' and ``complex 
fracture.''
Proposed 1.00N--What do we consider when we evaluate non-healing or 
complex fractures of an upper extremity (1.23)?
    We propose to replace the content of current 1.00N After maximum 
benefit from therapy with guidance about how we evaluate non-healing or 
complex fractures involving bone in the upper extremity. We also 
provide definitions for ``non-healing fracture'' and ``complex 
fracture.''
Proposed 1.00O--How do we determine your soft tissue injury or 
abnormality or your upper extremity fracture is no longer under 
continuing surgical management or you have received maximum therapeutic 
benefit?
    We propose to replace the content of current 1.00O Major function 
of the face and head with guidance about determining when a soft tissue 
injury or abnormality or upper extremity fracture is no longer under 
continuing surgical management. We also incorporate the provisions of 
current sections 1.00M Under continuing surgical management, 1.00N 
After maximum benefit from therapy has been achieved, and 1.00P When 
surgical procedures have been performed.
Proposed 1.00P--How do we evaluate the severity and duration of your 
established musculoskeletal disorder when there is no record of ongoing 
treatment?
    We propose to replace the content of current 1.00P When surgical 
procedures have been performed with guidance about how we assess 
impairments when there is no longitudinal medical record. We explain 
that when the individual has not received ongoing treatment or has just 
begun treatment, we may ask the individual to attend a consultative 
examination. We also explain that we may be able to assess the severity 
and duration of the individual's impairment based on the medical record 
and current evidence alone. In this section, we incorporate guidance 
from current section 1.00H3 When there is no record of ongoing 
treatment.
Proposed 1.00R--How do we evaluate disorders that do not meet one of 
the musculoskeletal listings?
    We propose to add a new section 1.00R with guidance explaining that 
if a person's disorder does not meet or medically equal the criteria of 
any of these listings, we will consider whether it meets or medically 
equals the criteria for a listing in another body system. We explain 
that if an impairment does not meet or medically equal any listing, we 
will assess the person's residual functional capacity (RFC) and 
determine whether the person is capable of performing past work or 
adjusting to other work in the national economy. We also cite the rules 
we use when we determine whether a person continues to be disabled. In 
this section, we incorporate guidance from current section 1.00H4 
Evaluation when the criteria of a musculoskeletal listing are not met.

V. What changes are we proposing to the musculoskeletal listings for 
adults?

    We propose to revise the name of the body system from 
``Musculoskeletal System'' to ``Musculoskeletal Disorders.''
    We propose to rename the headings of the listings and to renumber 
the listings in a more logical order, beginning with disorders of the 
spine, as those are the most frequently used; moving outward physically 
to the extremities; and then to skeletal or soft tissue injuries. When 
these rules become final, renumbering the listings should make it 
easier for us to keep track of data trends for specific types of 
impairments over time. It should also help to prevent confusion in 
identifying or referring to prior listings after we publish a final 
rule.
    We propose to present the overall structure of the listings in an 
outline form to make the rules more readily accessible to the reader. 
The following chart provides a comparison of the current and the 
proposed adult listings:

[[Page 20652]]



------------------------------------------------------------------------
            Current listing                      Proposed listing
------------------------------------------------------------------------
1.02 Major dysfunction of a joint(s)     1.02 Removed without
 (due to any cause).                      replacement.
1.03 Reconstructive surgery or surgical  1.03 Removed without
 arthrodesis of a major weight-bearing    replacement.
 joint.
1.04 Disorders of the spine............  1.04 Removed without
                                          replacement.
1.05 Amputation (due to any cause).....  1.05 Removed without
                                          replacement.
1.06 Fracture of the femur, tibia,       1.06 Removed without
 pelvis, or one or more of the tarsal     replacement.
 bones.
1.07 Fracture of an upper extremity....  1.07 Removed without
                                          replacement.
1.08 Soft tissue injury (e.g., burns)..  1.08 Removed without
                                          replacement.
                                         1.15 Disorders of the skeletal
                                          spine resulting in compromise
                                          of a nerve root(s).
                                         1.16 Lumbar spinal stenosis
                                          resulting in compromise of the
                                          cauda equina.
                                         1.17 Reconstructive surgery or
                                          surgical arthrodesis of a
                                          major weight-bearing joint.
                                         1.18 Abnormality of a major
                                          joint(s) in any extremity.
                                         1.19 Pathologic fractures due
                                          to any cause.
                                         1.20 Amputation due to any
                                          cause.
                                         1.21 Soft tissue injury or
                                          abnormality under continuing
                                          surgical management.
                                         1.22 Non-healing or complex
                                          fracture of the femur, tibia,
                                          pelvis, or one or more of the
                                          tarsal bones
                                         1.23 Non-healing or complex
                                          fracture of an upper
                                          extremity.
------------------------------------------------------------------------

    All of the proposed musculoskeletal listings contain multiple 
criteria. We distinguish whether all of the criteria must be met in 
order to meet that specific listing or just one of the criteria must be 
met in order to meet that specific listing by using a capital ``AND'' 
or ``OR,'' respectively. The ``AND'' or ``OR'' sit on a line 
independently on the left margin. We also distinguish whether all sub-
criteria must be met or just one of the sub-criteria must be met in 
order to satisfy the relevant criteria by using a lowercase ``and'' or 
``or,'' respectively.

1.15 Disorders of the Skeletal Spine Resulting in Compromise of a Nerve 
Root(s)

    Proposed 1.15 Disorders of the skeletal spine resulting in 
compromise of a nerve root(s) incorporates and clarifies the provisions 
of current 1.04A for evidence of nerve root compression. In proposed 
1.15 we have removed references to the particular disorders associated 
with compromise of a nerve root(s) and discussion of the tests used to 
demonstrate them. We have incorporated the references to specific 
disorders in the introductory text because they are examples of 
possible causative agents, whereas the listing addresses the effects of 
those agents on the nerve root(s). We have also removed the sign of 
atrophy from the listing because medical research and our experience 
does not show atrophy necessarily correlates with any given level of 
functioning. We have provided for consideration of limitation of motion 
by evaluating the physical limitation of musculoskeletal functioning it 
causes using the new functional criteria. Under proposed criterion 
1.15B for radicular neurological signs, we have included muscle 
weakness and sensory changes. We have also added the requirement for 
``[d]ecreased deep tendon reflexes'' to the criterion because it is a 
manifestation of the disorder and illustrates our intentions for this 
listing. A criterion for imaging, which is not explicitly required in 
current 1.04A, has been added as proposed 1.15C ``Findings on imaging 
consistent with compromise of a nerve root(s)'' because it is a 
component necessary to establishing the disorder.

1.16 Lumbar Spinal Stenosis Resulting in Compromise of the Cauda Equina

    Proposed 1.16 Lumbar spinal stenosis resulting in compromise of the 
cauda equina incorporates and clarifies the provisions of current 1.04C 
for lumbar spinal stenosis resulting in pseudoclaudication. We 
incorporate each of the requirements in current 1.04C into sections A-D 
of the proposed listing and clarify the current requirements with 
specific information in sections A-C. We have made a separate listing 
for compromise of the cauda equina due to the effects of lumbar spinal 
stenosis, because the symptoms and signs of this disorder differ from 
those of other nerve root(s) disorders and are not typically associated 
with a specific nerve root(s).

1.17 Reconstructive Surgery or Surgical Arthrodesis of a Major Weight-
Bearing Joint

    Proposed 1.17 Reconstructive surgery or surgical arthrodesis of a 
major weight-bearing joint incorporates and clarifies the provisions of 
current listing 1.03 Reconstructive surgery or surgical arthrodesis of 
a major weight-bearing joint.

1.18 Abnormality of a Major Joint(s) in Any Extremity

    Proposed 1.18 Abnormality of a major joint(s) in any extremity 
incorporates and clarifies the provisions of current listings 1.02 
Major dysfunction of a joint(s) (due to any cause). It includes the 
criteria from current 1.02 for evaluating dysfunction of any of the 
major joints in either the upper or lower extremities, or both, whether 
due to anatomical deformity, pain, or abnormal motion. We removed the 
terms ``peripheral'' and ``weight-bearing,'' which are in the current 
listing for major joint disorders (1.02 Major dysfunction of a joint(s) 
(due to any cause)), because proposed 1.18 covers all major joints in 
any extremity, making those distinctions unnecessary.

1.19 Pathologic Fractures Due to Any Cause

    Proposed 1.19 Pathologic fractures due to any cause is a new 
listing that covers pathologic fractures of any part of the 
musculoskeletal system. Medical treatment and recovery expectations for 
fractures differ, depending on whether the condition is due to an 
underlying pathology (such as osteoporosis), or to a traumatic event. 
For this reason, we propose a separate listing for fractures caused by 
an underlying pathology in order to provide specific criteria related 
to their evaluation and adjudication. We propose to evaluate complex or 
non-

[[Page 20653]]

healing traumatic fractures under proposed 1.22 Non-healing or complex 
fracture of the femur, tibia, pelvis, or one or more of the tarsal 
bones or 1.23 Non-healing or complex fracture of an upper extremity.

1.20 Amputation Due to Any Cause

    Proposed 1.20 Amputation due to any cause incorporates and 
clarifies the provisions of current 1.05 Amputation (due to any cause). 
Proposed 1.20B for hemipelvectomy or hip disarticulation corresponds to 
current 1.05D for hemipelvectomy or hip disarticulation. In proposed 
1.20A for amputation of both upper extremities and 1.20B for 
hemipelvectomy or hip disarticulation, we do not include any functional 
criteria, because we presume that a person with a disorder under either 
proposed 1.20A or 1.20B has limitations that satisfy one or more of the 
functional criteria in 1.00E2 and meet the duration requirement.

1.21 Soft Tissue Injury or Abnormality Under Continuing Surgical 
Management

    Proposed 1.21 Soft tissue injury or abnormality under continuing 
surgical management revises current listing 1.08 Soft tissue injury 
(e.g., burns). This proposed listing is consistent with our long-
standing recognition that extensive, prolonged treatment in order to 
re-establish or improve function of the affected body part(s) may 
contribute to an inability to perform work-related activity.
    It encompasses any abnormality of, or injury (including burns) to 
soft tissue that is under continuing surgical management directed 
toward saving, reconstructing, or replacing the affected part of the 
body. In proposed 1.21, we do not include any functional criteria 
because the prescribed surgical procedures treatments typically require 
a series of documented interventions over extended periods, which 
render the person unable to perform work-related activity on a 
sustained basis.

1.22 Non-Healing or Complex Fracture of the Femur, Tibia, Pelvis, or 
One or More of the Tarsal Bones

    Proposed 1.22 Non-healing or complex fracture of the femur, tibia, 
pelvis, or one or more of the tarsal bones incorporates and clarifies 
the provisions of current listing 1.06 Fracture of the femur, tibia, 
pelvis, or one or more of the tarsal bones.

1.23 Non-Healing or Complex Fracture of an Upper Extremity

    Proposed 1.23 Non-healing or complex fracture of an upper extremity 
incorporates and clarifies the provisions of current listing 1.07 
Fracture of an upper extremity.

VI. What changes are we proposing to the introductory text of the 
musculoskeletal disorders listings for children?

    The same basic rules for evaluating musculoskeletal disorders in 
adults apply to the evaluation of such disorders in children. Except 
for changes in the introductory text specific to children, we propose 
to repeat most of the introductory text of proposed 1.00 
Musculoskeletal Disorders in the introductory text of proposed 101.00 
Musculoskeletal Disorders. Since we have already described these 
proposed revisions in the introductory text of proposed 1.00, we 
describe here only those sections of the proposed 101.00 rules that are 
unique to children or that require further explanation.
    The following chart shows the headings of the current and proposed 
sections of the childhood introductory text:

------------------------------------------------------------------------
       Current introductory text            Proposed introductory text
------------------------------------------------------------------------
A. Disorders of the musculoskeletal      A. Which disorders do we
 system.                                  evaluate under these listings?
B. Loss of Function....................  B. Which related disorders do
                                          we evaluate under other
                                          listings?
C. Diagnosis and Evaluation............  C. What evidence do we need to
                                          evaluate your musculoskeletal
                                          disorder under these listings?
D. The physical examination............  D. How do we consider symptoms,
                                          including pain, under these
                                          listings?
E. Examination of the Spine............  E. How do we use the functional
                                          criteria under these listings?
F. Major joints........................  F. What do we consider when we
                                          evaluate disorders of the
                                          skeletal spine resulting in
                                          compromise of a nerve root(s)
                                          (101.15)?
G. Measurements of joint motion........  G. What do we consider when we
                                          evaluate lumbar spinal
                                          stenosis resulting in
                                          compromise of the cauda equina
                                          (101.16)?
H. Documentation.......................  H. What do we consider when we
                                          evaluate reconstructive
                                          surgery or surgical
                                          arthrodesis of a major weight-
                                          bearing joint (101.17)?
I. Effects of Treatment................  I. What do we consider when we
                                          evaluate abnormality of a
                                          major joint(s) in any
                                          extremity (101.18)?
J. Orthotic, Prosthetic, or Assistive    J.What do we consider when we
 Devices.                                 evaluate pathologic fractures
                                          due to any cause (101.19)?
K. Disorders of the spine..............  K. What do we consider when we
                                          evaluate amputation due to any
                                          cause (101.20)?
L. Abnormal curvatures of the spine....  L. What do we consider when we
                                          evaluate soft tissue injury or
                                          abnormality under continuing
                                          surgical management (101.21)?
M. Under continuing surgical management  M. What do we consider when we
                                          evaluate non-healing or
                                          complex fractures of the
                                          femur, tibia, pelvis, or one
                                          or more of the tarsal bones
                                          (101.22)?
N. After maximum benefit from therapy    N. What do we consider when we
 has been achieved.                       evaluate non-healing or
                                          complex fractures of an upper
                                          extremity (101.23)?
O. Major function of the face and head.  O. What do we consider when we
                                          evaluate musculoskeletal
                                          disorders of infants and
                                          toddlers from birth to
                                          attainment of age 3 with
                                          developmental motor delay
                                          (101.24)?
P. When surgical procedures have been    P. How do we determine when
 performed.                               your soft tissue injury or
                                          abnormality, or your upper
                                          extremity fracture, is no
                                          longer under continuing
                                          surgical management or you
                                          have received maximum
                                          therapeutic benefit?
                                         Q. How do we evaluate the
                                          severity and duration of your
                                          established musculoskeletal
                                          disorder when there is no
                                          record of ongoing treatment?
                                         R. How do we evaluate disorders
                                          that do not meet one of the
                                          musculoskeletal listings?
------------------------------------------------------------------------


[[Page 20654]]

VII. What changes are we proposing to the musculoskeletal disorders 
listings for children?

    We propose to revise the name of the body system from 
``Musculoskeletal System'' to ``Musculoskeletal Disorders.''
    We propose to add 101.24 Musculoskeletal disorders of infants and 
toddlers, from birth to attainment of age 3, with developmental motor 
delay. This listing evaluates developmental motor delay due to a 
musculoskeletal medically determinable impairment as a functional 
criterion for infants and toddlers. We propose to move the requirement 
of developmental motor skills that are no greater than one-half of the 
expected age performance from current 101.00B2c(2) How we assess 
inability to perform fine and gross movements in very young children 
into proposed 101.24. Proposed 101.24 does not have an adult 
counterpart.
    We propose to use functional criteria for children that are the 
same as the criteria for adults.
    The following chart provides a comparison of the current childhood 
listings and the proposed childhood listings:

------------------------------------------------------------------------
       Current childhood listings          Proposed childhood listings
------------------------------------------------------------------------
101.02 Major dysfunction of a joint(s)   101.02 Removed without
 (due to any cause).                      replacement.
101.03 Reconstructive surgery or         101.03 Removed without
 surgical arthrodesis of a major weight-  replacement.
 bearing joint.
101.04 Disorders of the spine..........  101.04 Removed without
                                          replacement.
101.05 Amputation (due to any cause)...  101.05 Removed without
                                          replacement.
101.06 Fracture of the femur, tibia,     101.06 Removed without
 pelvis, or one or more of the tarsal     replacement.
 bones.
101.07 Fracture of an upper extremity..  101.07 Removed without
                                          replacement.
101.08 Soft tissue injury (e.g., burns)  101.08 Removed without
                                          replacement.
                                         101.15 Disorders of the
                                          skeletal spine resulting in
                                          compromise of a nerve root(s).
                                         101.16 Lumbar spinal stenosis
                                          resulting in compromise of the
                                          cauda equina.
                                         101.17 Reconstructive surgery
                                          or surgical arthrodesis of a
                                          major weight-bearing joint.
                                         101.18 Abnormality of a major
                                          joint(s) in any extremity.
                                         101.19 Pathologic fractures due
                                          to any cause.
                                         101.20 Amputation due to any
                                          cause.
                                         101.21 Soft tissue injury or
                                          abnormality under continuing
                                          surgical management.
                                         101.22 Non-healing or complex
                                          fracture of the femur, tibia,
                                          pelvis, or one or more of the
                                          tarsal bones.
                                         101.23 Non-healing or complex
                                          fracture of an upper
                                          extremity.
                                         101.24 Musculoskeletal
                                          disorders of infants and
                                          toddlers, from birth to
                                          attainment of age 3, with
                                          developmental motor delay.
------------------------------------------------------------------------

    As is the case with adults, for children, all of the proposed 
musculoskeletal listings contain multiple criteria. We distinguish 
whether all of the criteria must be met in order to meet that specific 
listing or just one of the criteria must be met in order to meet that 
specific listing by using a capital ``AND'' or ``OR,'' respectively. 
The ``AND'' or ``OR'' sit on a line independently on the left margin. 
We also distinguish whether all sub-criteria must be met or just one of 
the sub-criteria must be met in order to satisfy the relevant criteria 
by using a lowercase ``and'' or ``or,'' respectively.

VIII. Other Changes

    We propose to make conforming changes to current sections 4.00G4 
What is lymphedema and how will we evaluate it? and 104.00F9 What is 
lymphedema and how will we evaluate it? of the cardiovascular system 
listings to indicate that we may evaluate whether lymphedema medically 
equals proposed listings 1.18 and 101.18 Abnormality of a major 
joint(s) in any extremity.
    We propose to make conforming changes to the introductory text and 
listing criteria for immune system disorders. Many disorders of the 
immune system affect the musculoskeletal system; therefore, we are 
making these revisions to reflect this relationship and ensure 
consistency in our evaluation of musculoskeletal functioning. In 14.00C 
Definitions and 114.00C Definitions, we propose to provide explanations 
of terms for evaluating immune system disorders consistent with those 
we propose for evaluating musculoskeletal disorders. We propose to add 
definitions for ``assistive device(s),'' ``documented medical need,'' 
``fine and gross movements,'' and ``hand-held assistive device.'' We 
also propose to replace ``major peripheral joints'' with ``major joint 
of an upper or lower extremity,'' to revise the explanation of that 
term, and to remove the terms ``inability to ambulate effectively'' and 
``inability to perform fine and gross movements effectively'' for 
consistency with the proposed musculoskeletal disorders listings.
    We propose to revise the information in current sections 14.00D4 
Polymyositis and dermatomyositis (14.05) and 114.00D4 ``Polymyositis 
and dermatomyositis (114.05)'' describing how we evaluate polymyositis 
and dermatomyositis in motor skills of newborns, younger infants, 
children, and adults. We propose to revise these sections for 
consistency with the proposal to remove the term ``unable to ambulate 
effectively.'' We propose to replace ``ambulate effectively'' with 
``walk without physical or mechanical assistance.''
    We propose to make editorial changes to current sections 14.00D6 
Inflammatory arthritis (14.09) and 114.00D6 Inflammatory arthritis 
(114.09). We propose to replace ``major peripheral joints'' with 
``major joints in an upper or lower extremity,'' ``ambulation or fine 
and gross movements'' with ``walking or performing fine and gross 
movements,'' and ``ambulation or the performance of fine and gross 
movements'' with ``walking or performing fine and gross movements.''

[[Page 20655]]

    We propose to make conforming changes to describe listing-level 
severity in proposed listing criteria 14.09A and 114.09A ``Persistent 
inflammation or persistent deformity'' as follows: we propose to 
replace ``an impairment that results in an `extreme' (very serious) 
limitation'' with ``the presence of an impairment-related, significant 
limitation cited in the criteria of these listings.'' We propose to 
replace ``one major peripheral weight-bearing joint resulting in the 
inability to ambulate effectively'' with ``one major joint in a lower 
extremity resulting in a documented medical need for a walker, 
bilateral canes, or bilateral crutches.'' We propose to replace ``one 
major peripheral joint in each upper extremity resulting in the 
inability to perform fine and gross movements effectively'' with ``one 
major joint in each upper extremity resulting in an impairment-related, 
significant limitation in the ability to perform fine and gross 
movements.''
    To describe listing-level severity in current listing criteria 
14.09C and 114.09 C ``Ankylosing spondylitis or other 
spondyloarthropathies'' we propose to replace ``extreme limitation'' 
with ``impairment-related significant limitation'' and ``inability to 
ambulate effectively'' with ``a documented medical need for a walker, 
bilateral canes, or bilateral crutches.''
    To describe listing-level severity in current listing criteria 
14.09B, C, and D and 114.09B and C for impairments due to inflammatory 
arthritis, we also propose to replace ``major peripheral joints'' with 
``major joints in an upper or lower extremity.''
    We propose to revise current section 114.00J2b ``Musculoskeletal 
involvement, such as surgical reconstruction of a joint, under 101.00'' 
to indicate that we may evaluate immune system disorders in children 
involving developmental motor delay under 101.00 Musculoskeletal 
Disorders.
    We propose conforming changes to current immune system disorders 
listings 14.04 Systemic sclerosis (scleroderma), 14.05 Polymyositis and 
dermatomyositis, 14.09 Inflammatory arthritis, 114.04 Systemic 
sclerosis (scleroderma), 114.05 Polymyositis and dermatomyositis and 
114.09 Inflammatory arthritis. In proposed 14.04 Systemic sclerosis 
(scleroderma), 14.05 Polymyositis and dermatomyositis, and 14.09 
Inflammatory arthritis for adults, we would replace ``inability to 
ambulate effectively'' with the requirement of one of the following:
     A documented medical need for a walker, bilateral canes, 
or bilateral crutches; or
     An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving fine 
and gross movements, and a documented medical need for a one-handed 
assistive device that requires the use of the other upper extremity.
    In proposed 114.04 Systemic sclerosis (scleroderma), 114.05 
Polymyositis and dermatomyositis, and 114.09 Inflammatory arthritis for 
children, we would replace ``inability to ambulate effectively'' with 
the requirement of one of the following:
     A documented medical need for a walker, bilateral canes, 
or bilateral crutches; or
     An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity.
    In proposed 14.04 Systemic sclerosis (scleroderma), 14.05 
Polymyositis and dermatomyositis, and 14.09 Inflammatory arthritis for 
adults, we would replace ``inability to perform fine and gross 
movements effectively'' with ``inability to use both upper extremities 
to the extent that neither can be used to independently initiate, 
sustain, and complete work-related activities involving fine and gross 
movements.''
    In proposed 114.04 Systemic sclerosis (scleroderma), 114.05 
Polymyositis and dermatomyositis, and 114.09 Inflammatory arthritis for 
children, we would replace ``inability to perform fine and gross 
movements effectively'' with ``inability to use both upper extremities 
to the extent that neither can be used to independently initiate, 
sustain, and complete age-appropriate activities involving fine and 
gross movements.''
    In proposed 14.09 Inflammatory arthritis and 114.09 Inflammatory 
arthritis, we would replace ``major peripheral weight-bearing joints'' 
with ``major joints in a lower extremity(ies).'' In proposed 14.09 
Inflammatory arthritis and 114.09 Inflammatory arthritis, we would 
replace ``major peripheral joints'' with ``major joints'' or ``major 
joints of an upper or lower extremity(ies),'' as appropriate for the 
affected extremity(-ies).
    We propose to remove the first and second examples in Sec.  
416.926a(m) of this chapter, Examples of impairments that functionally 
equal the listings. The first example is ``[a]ny condition that is 
disabling at the time of onset, requiring continuing surgical 
management within 12 months after onset as a life-saving measure or for 
salvage or restoration of function, and such major function is not 
restored or is not expected to be restored within 12 months after onset 
of this condition.'' (See Sec.  416.926a(m)(1) of this chapter.) We are 
removing this example because, at the time it was written, there were 
no specific criteria that considered the need for ongoing surgical 
management in the listings. The second example is ``[e]ffective 
ambulation possible only with obligatory bilateral upper limb 
assistance.'' (See Sec.  416.926a(m)(2) of this chapter.) We are 
removing this example because several of the proposed childhood 
listings include a criterion considering ``. . . a documented medical 
need for a walker, bilateral canes, or bilateral crutches'' (that is, 
``obligatory bilateral upper limb assistance.'') With the inclusion of 
the proposed childhood listings, it will no longer be necessary to have 
these examples in the regulations.

IX. Administrative Matters

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

    The Social Security Act authorizes us to make rules and regulations 
and to establish necessary and appropriate procedures to implement 
them.\10\
---------------------------------------------------------------------------

    \10\ Sections 205(a), 702(a)(5), and 1631(d)(1).
---------------------------------------------------------------------------

How long would these proposed rules be effective?

    If we publish these proposed rules as final rules, they will remain 
in effect for 5 years after the date they become effective, unless we 
extend them, or revise and issue them again.

Clarity of These Proposed Rules

    Executive Order 12866, as supplemented by Executive Order 13563, 
requires each agency to write all rules in plain language. In addition 
to your substantive comments on these proposed rules, we invite your 
comments on how to make them easier to understand.
    For example:
     Would more, but shorter, sections be better?
     Are the requirements in the rules clearly stated?
     Have we organized the material to suit your needs?
     Could we improve clarity by adding tables, lists, or 
diagrams?
     What else could we do to make the rules easier to 
understand?
     Do the rules contain technical language or jargon that is 
not clear?

[[Page 20656]]

     Would a different format make the rules easier to 
understand, e.g., grouping and order of sections, use of headings, 
paragraphing?

Anticipated Economic Impact of the Proposed Rules

Financial Classification of SSA's Regulations

    Based on criteria established by OMB Circular A-4 and Executive 
Order 13771, we classify this rule as a ``transfer rule.'' Transfer 
rules do not create or impose novel costs; rather, they regulate the 
transfer of monetary payments from one group to another without 
affecting the total resources available to society.
    Under our Old-Age, Survivors, and Disability Insurance program 
(OASDI), SSA's regulations govern the transfer of benefits payments to 
qualified workers primarily from revenues collected from payroll taxes 
(FICA) and self-employment taxes (SECA). Under the Supplemental 
Security Income (SSI) program, funded by general tax revenues, SSA 
makes payments to individuals with limited income and resources who are 
aged, blind, or disabled.
    This proposed rule establishes eligibility criteria for 
transferring disability payments to those persons who qualify for such 
payments based on the presence of a musculoskeletal body system 
disorder.

Anticipated Accounting Costs of These Proposed Rules

Anticipated Costs to Our Programs

    For fiscal years (FY) 2018-2022, our Office of the Chief Actuary 
estimates that this proposed rule, once finalized, may result in a 
reduction of $57,000,000 to our OASDI program costs, and an increase of 
$11,000,000 to our SSI program costs. It is important to note that due 
to the roughly offsetting estimated effects of changes from allowance 
to denial and from denial to allowance, the true net effect for either 
program, OASDI or SSI, could potentially be either a small cost or a 
small saving.

Anticipated Administrative Costs to the Social Security Administration

    In calculating whether the implementation of this proposed rule, 
once finalized, may result in administrative costs or savings to the 
agency, we examine two sources: (1) Work-years and (2) direct financial 
administrative costs.
    We define work-years as a measure of the SSA employee work time a 
proposed rule will cost or save during implementation of its policies. 
We calculate one work-year as 2,080 hours of labor, which represents 
the amount of hours one SSA employee works per year based on a standard 
40-hour workweek.
    We estimate the direct financial administrative costs of a proposed 
rule by examining requirements stemming from new regulations, including 
systems start-up and maintenance costs, operational costs resulting 
from new workloads, and internal training costs for relevant agency 
staff and adjudicators. To assess savings resulting from a proposed 
rule, we examine Systems and operational workload changes.
    Based on the above factors, our Office of Budget, Finance, and 
Management estimates that implementation of these proposed rules, upon 
finalization, will result in overall administrative savings for SSA of 
fewer than 15 work-years and less than $2 million annually for the 
period of FY 2018-2022.

When will we start to use these rules?

    We will not use these rules until we evaluate public comments and 
publish final rules in the Federal Register. All final rules we issue 
include an effective date. We will continue to use our current rules 
until that date. If we publish final rules, we will include a summary 
of those relevant comments we received along with responses and an 
explanation of how we will apply the new rules.

Regulatory Procedures

Executive Order 12866, as Supplemented by Executive Order 13563

    We consulted with the Office of Management and Budget (OMB) and 
determined that this notice of proposed rulemaking (NPRM) meets the 
criteria for a significant regulatory action under Executive Order 
12866, as supplemented by Executive Order 13563. Therefore, OMB 
reviewed it.

Regulatory Flexibility Act

    We certify that this NPRM will not have a significant economic 
impact on a substantial number of small entities because it affects 
individuals only. Therefore, a regulatory flexibility analysis is not 
required under the Regulatory Flexibility Act, as amended.

Paperwork Reduction Act

    These proposed rules do not create any new or affect any existing 
collections and, therefore, do not require OMB approval under the 
Paperwork Reduction Act.

X. References

    We consulted the following references when we developed these 
proposed rules:

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    We included these references in the rulemaking record for these 
proposed rules and will make them available for inspection by 
interested individuals who make arrangements with the contact person 
identified above.

(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

20 CFR Part 404

    Administrative practice and procedure; Blind, Disability benefits; 
Old-Age, survivors, and disability insurance; Reporting and 
recordkeeping requirements; Social Security.

20 CFR Part 416

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

Nancy A. Berryhill,
Acting Commissioner of Social Security.

    For the reasons set out in the preamble, we propose to amend 20 
CFR, chapter III, 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) 
and (h)-(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) and (h)-
(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 as follows:
0
a. Revise item 2 of the introductory text before part A;
0
b. Amend part A by revising the body system name for section 1.00 in 
the table of contents;
0
c. Revise section 1.00 of part A;
0
d. Revise the second sentence of paragraph 4.00G4b of part A;
0
e. Redesignate current 14.00C2 through 14.00C12 of part A as follows:

------------------------------------------------------------------------
            Old section                          New section
------------------------------------------------------------------------
                   14.00C2                              14.00C3
                   14.00C3                              14.00C4
                   14.00C4                              14.00C6
                   14.00C5                              14.00C7
                   14.00C6                              14.00C8
                   14.00C7                              14.00C9
                   14.00C8                              14.00C10
                   14.00C9                              14.00C11
                   14.00C10                             14.00C12
                   14.00C11                             14.00C13
                   14.00C12                             14.00C14
------------------------------------------------------------------------

0
f. Add new paragraphs 14.00C2 and 14.00C5 to part A;
0
g. Revise 14.00C8 through 14.00C10;
0
h. Revise the first sentence of paragraph 14.00D4c(i) of part A;
0
i. Revise the second and third sentences of paragraph 14.00D6a of part 
A;
0
j. Revise paragraph 14.00D6e(i) and the first sentence of 14.00D6e(ii) 
of part A;
0
k. Revise 14.04B, 14.04C2, and 14.05A of part A;
0
l. Revise 14.09A and the first sentence of 14.09B of part A;
0
m. Amend part B by revising the body system name for section 101.00 in 
the table of contents;
0
n. Revise section 101.00 of part B;
0
o. Revise the second sentence of paragraph 104.00F9b of part B;
0
p. Redesignate current 114.00C2 through 114.00C12 of part B as follows:

------------------------------------------------------------------------
                       Old section                          New section
------------------------------------------------------------------------
114.00C2................................................        114.00C3
114.00C3................................................        114.00C4
114.00C4................................................        114.00C6
114.00C5................................................        114.00C7
114.00C6................................................        114.00C8
114.00C7................................................        114.00C9
114.00C8................................................       114.00C10
114.00C9................................................       114.00C11
114.00C10...............................................       114.00C12
114.00C11...............................................       114.00C13
114.00C12...............................................       114.00C14
------------------------------------------------------------------------

0
q. Add new paragraphs 114.00C2 and 114.00C5 to part B;

[[Page 20659]]

0
r. Revise 114.00C8 through 114.00C10;
0
s. Revise the first sentence of paragraph 114.00D4c(ii) of part B;
0
t. Revise the second and third sentences of paragraph 114.00D6a of part 
B;
0
u. Revise paragraph 114.00D6e(i) and the first sentence of 
114.00D6e(ii) of part B;
0
v. Revise listings 114.04B, 114.04C2, and 114.05A of part B; and
0
w. Revise 114.09A and the heading of 114.09B of part B.
    The revisions read as follows:

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

* * * * *
    2. Musculoskeletal Disorders (1.00 and 101.00): [THIS EXPIRES 5 
YEARS FROM THE EFFECTIVE DATE OF THE FINAL RULES].
* * * * *

Part A

* * * * *

1.00 Musculoskeletal Disorders.

* * * * *

1.00 Musculoskeletal Disorders

    A. Which disorders do we evaluate under these listings?
    1. We evaluate disorders of the skeletal spine (vertebral 
column) or of the upper or lower extremities that affect 
musculoskeletal functioning in the musculoskeletal body system 
listings. We use the term ``skeletal'' when we are referring to the 
structure of the bony skeleton. The skeletal spine refers to the 
bony structures, ligaments, and discs making up the spine. We refer 
to the ``skeletal'' spine in some musculoskeletal listings to 
differentiate it from the neurological spine (see 1.00B1). Disorders 
may be congenital or acquired, and may include deformities, 
amputations, or other musculoskeletal abnormalities. These disorders 
may involve the bones or major joints; or the tendons, ligaments, 
muscles, or other soft tissues.
    2. We also evaluate soft tissue abnormalities or injuries 
(including burns) that are under continuing surgical management (see 
1.00L1). The abnormalities or injuries may affect any part of the 
body, including the face and skull.
    B. Which related disorders do we evaluate under other listings?
    1. We evaluate a disorder or injury of the skeletal spine that 
results in damage to, and neurological dysfunction of, the spinal 
cord and its associated nerves (for example, paraplegia or 
quadriplegia) under the criteria in 11.00 Neurological Disorders.
    2. We evaluate inflammatory arthritis (for example, rheumatoid 
arthritis) under the criteria in 14.00 Immune System Disorders.
    3. We evaluate curvatures of the skeletal spine under these 
musculoskeletal disorders listings and other listings as appropriate 
for the affected body system. Curvatures of the skeletal spine that 
affect musculoskeletal functioning are evaluated under 1.15 
Disorders of the skeletal spine resulting in compromise of a nerve 
root(s). If a curvature of the skeletal spine is under continuing 
surgical management, we can evaluate it for medical equivalence to 
1.21 Soft tissue injury or abnormality under continuing surgical 
management. Curvatures of the skeletal spine may also adversely 
affect functioning in body systems other than the musculoskeletal 
system. For example, the curvature may interfere with your ability 
to breathe (see 3.00 Respiratory Disorders); there may be impaired 
myocardial function (see 4.00 Cardiovascular System); or there may 
be disfigurement resulting in social withdrawal or depression (see 
12.00 Mental Disorders).
    4. We evaluate non-healing or pathological fractures due to 
cancer, whether it is a primary site or metastases, under the 
criteria in 13.00 Cancer (Malignant Neoplastic Diseases).
    5. We evaluate the leg pain associated with peripheral vascular 
claudication, as well as diabetic foot ulcers, under the criteria in 
4.00 Cardiovascular System.
    6. We evaluate burns that do not require continuing surgical 
management under the criteria in 8.00 Skin Disorders.
    C. What evidence do we need to evaluate your musculoskeletal 
disorder under these listings?
    1. General. To establish the presence of a musculoskeletal 
disorder as a medically determinable impairment, we need objective 
medical evidence from an acceptable medical source who has examined 
you for the disorder. To assess the severity and duration of your 
disorder, we evaluate evidence from both medical and nonmedical 
sources who can describe how you function. If there is no record of 
ongoing medical treatment for your disorder, we will follow the 
guidelines in 1.00P How do we evaluate the severity and duration of 
your established musculoskeletal disorder when there is no record of 
ongoing treatment? We will determine the extent and kinds of 
evidence we need from medical and non-medical sources based on the 
individual facts about your disorder. For our basic rules on 
evidence, see Sec. Sec.  404.1502, 404.1512, 404.1513, 404.1513a, 
404.1520b, 416.902, 416.912, 416.913, 416.913a, and 416.920b of this 
chapter. For our rules on evidence about your symptoms, see 
Sec. Sec.  404.1529 and 416.929 of this chapter.
    2. Physical examination report(s). In the report(s) of your 
physical examination, we need a detailed description of the 
orthopedic, neurologic, or other objective clinical findings 
appropriate to your specific musculoskeletal disorder. We require 
objective clinical findings from the medical source's direct 
observations during your physical examination, not simply his or her 
report of your statements about your symptoms and limitations. When 
the medical source reports that a clinical test sign(s) is positive, 
unless we have evidence to the contrary, we will assume that he or 
she performed the test properly. For instance, we will assume a 
straight-leg raising test was conducted properly, i.e., in a sitting 
and supine position, even if the medical source does not specify the 
positions in which the test was performed. In the absence of 
evidence to the contrary, we will accept the medical source's 
interpretation of the test. If you use an assistive device (see 
1.00C6), the report must support the medical need for the device. If 
reduction in muscle strength is a factor, we require medical 
documentation of measurement of the strength of the muscle(s) in 
question, generally based on a grading system of 0 to 5. Zero (0) 
indicates complete loss of strength and 5 indicates maximum 
strength, consistent with Table 1 below. The documentation should 
also include measurements of grip and pinch strength, if there is 
evidence of involvement of one or both hands.

                                 Table 1
------------------------------------------------------------------------
 
------------------------------------------------------------------------
                Grading Scale of Muscle Function: 0 to 5
------------------------------------------------------------------------
0.............................  None.............  No visible or
                                                    palpable
                                                    contraction.
1.............................  Trace............  Visible or palpable
                                                    contraction with no
                                                    motion.
2.............................  Poor.............  Active range of
                                                    motion (ROM) with
                                                    gravity eliminated.
3.............................  Fair.............  Active ROM against
                                                    gravity only,
                                                    without resistance.
4.............................  Good.............  Active ROM against
                                                    gravity, moderate
                                                    resistance.
5.............................  Normal...........  Active ROM against
                                                    gravity, maximum
                                                    resistance.
------------------------------------------------------------------------

    3. Laboratory findings: Imaging and other diagnostic tests
    a. Imaging refers to medical imaging techniques, such as x-ray, 
computed tomography (CT), magnetic resonance imaging (MRI), and 
radionuclide scanning. For the purpose of these listings, the 
imaging technique(s) must be consistent with the generally accepted 
standards of medical knowledge and clinical practice.
    b. Findings on imaging must have lasted, or must be expected to 
last, for a continuous period of at least 12 months.
    c. Imaging and other diagnostic tests can provide evidence of 
physical abnormalities; however, they may correlate poorly with

[[Page 20660]]

your symptoms, including pain, or with your musculoskeletal 
functioning. Accordingly, we cannot use such tests as a substitute 
for physical examination findings about your ability to function, 
nor can we infer severity or functional limitations based solely on 
such tests.
    d. For our policies about when we will purchase imaging and 
other diagnostic tests, see Sec. Sec.  404.1519k, 404.1519m, 
416.919k, and 416.919m of this chapter.
    4. Operative reports. If you have had a surgical procedure(s), 
we need either the operative reports, including details of the 
findings at surgery and information about any medical complications 
that may have occurred, or confirmatory evidence of the surgical 
procedure(s) from a medical source (for example, detailed follow-up 
reports or notations in the medical records concerning your past 
medical history).
    5. Effects of treatment
    a. General. Treatments for musculoskeletal disorders may have 
beneficial or adverse effects, and responses to treatment vary from 
person to person. We will evaluate all of the effects of treatment 
(including surgical treatment, medications, and therapy) on the 
symptoms, signs, and laboratory findings of your musculoskeletal 
disorder, and on your musculoskeletal functioning.
    b. Response to treatment. To evaluate your musculoskeletal 
functioning in response to treatment, we need specific information 
related to your impairment, including the following: A description 
of your medications, including frequency of administration; the type 
and frequency of therapy you receive; and a description of your 
response to treatment and any complications you experience related 
to your impairment. The effects of treatment may be temporary or 
long-term. We need information over a sufficient period to determine 
the effect of treatment on your current musculoskeletal functioning 
and to permit reasonable projections about your future functioning. 
In some cases, we will need additional evidence to make an 
assessment about your response to treatment. Depending upon the 
timing of this treatment in relation to the alleged onset date of 
disability, we may need to defer evaluation of the impairment for a 
period of up to 3 months from the date treatment began to permit 
consideration of treatment effects, unless we can make a 
determination or decision using the evidence we have.
    6. Assistive devices
    a. General. An assistive device, for the purposes of these 
listings, is any device that is used to improve stability, 
dexterity, or mobility. An assistive device can be worn (see 1.00C6b 
and c), or hand-held (see 1.00C6d). If you use any type of assistive 
device(s), we need evidence from a medical source regarding the 
documented medical need for the device(s). When we use the term 
``documented medical need,'' we mean that there is evidence from a 
medical source(s) in the medical record that supports your need for 
an assistive device (see Sec. Sec.  404.1513 and 416.913 of this 
chapter). The evidence must include documentation from a medical 
source(s) describing any limitation(s) in your upper or lower 
extremity functioning that supports your need for the assistive 
device(s), and the circumstances for which you need it. The evidence 
does not have to include a specific prescription for the device(s).
    b. Prosthesis(es). A prosthesis is a wearable device, such as an 
artificial limb, that takes the place of an absent body part. We 
need evidence from a medical source documenting your ability to 
walk, or to perform fine and gross movements (see 1.00E3), with the 
prosthesis(es) in place. When amputation(s) involves a lower 
extremity or extremities, it is not necessary to evaluate your 
ability to walk without the prosthesis(es) in place. If you cannot 
use your prosthesis(es) due to complications affecting your residual 
limb(s), we need documentation from a medical source regarding the 
condition of your residual limb(s) and the medical basis for your 
inability to use the prosthesis(es).
    c. Orthosis(es). An orthosis is a wearable device that prevents 
or corrects a dysfunction or deformity by aligning or supporting the 
affected body part. An orthosis may also be referred to as a 
``brace.'' If you have an orthosis(es), we need evidence from a 
medical source documenting your ability to walk, or to perform fine 
and gross movements, with the orthosis(es) in place. If you cannot 
use your orthosis(es), we need evidence from a medical source 
documenting the medical basis for your inability to use the 
device(s).
    d. Hand-held assistive devices. Hand-held assistive devices 
include canes, crutches, or walkers, and are carried in your hand(s) 
to support or aid you in walking. When you require a one-handed 
assistive device for ambulation, such as a cane or single crutch, 
and your other upper extremity has limitations preventing its use 
for fine or gross movement(s) (see 1.00E3), the need for the 
assistive device limits the use of both upper extremities. If you 
use a hand-held assistive device, we need evidence from a medical 
source documenting your need for the device(s) and describing how 
you walk with the device(s).
    7. Longitudinal evidence
    a. We generally need a longitudinal medical record to assess the 
duration of your musculoskeletal disorder, because symptoms, signs, 
and laboratory findings related to most musculoskeletal disorders 
may wax and wane, may improve over time, or may respond to 
treatment. By providing evidence over an extended period, the 
medical record will show whether your musculoskeletal functioning is 
improving, worsening, or unchanging.
    b. For 1.19 Pathologic fractures due to any cause and 1.21 Soft 
tissue injury or abnormality under continuing surgical management, 
the required 12-month duration period is stated in the listing 
itself. For 1.20A (amputation of both upper extremities) or 1.20B 
(hemipelvectomy or hip disarticulation), we presume satisfaction of 
the duration requirement.
    c. For all listings not referenced in 1.00C7b above, all of the 
required criteria must be present simultaneously, or within a close 
proximity of time, to satisfy the level of severity needed to meet 
the listing. When we use the term ``close proximity of time,'' we 
mean that all of the relevant criteria have to appear in the medical 
record within a period not to exceed 4 months of one another. When 
the criterion in question is imaging, we mean those findings on 
imaging that we could reasonably expect to have been present at the 
date of impairment or date of onset. To meet a listing that uses the 
word ``and'' or ``AND'' to link the elements of the required 
criteria, the medical record must establish the simultaneous 
presence, or presence within a close proximity of time, of all the 
required medical criteria. Once this level of severity is 
established, the medical record must also show that this level of 
severity has continued, or is expected to continue, for a continuous 
period of at least 12 months.
    8. Surgical treatment
    For some musculoskeletal disorders, a medical source may 
recommend surgery. If you have not yet had the recommended surgery, 
we will not deny your claim based on an assumption that surgery will 
resolve or improve your disorder. We will assess each case on an 
individual basis. Depending on your response to treatment, or 
depending on your medical sources' treatment plans, we may defer our 
findings regarding the effect of surgical intervention until a 
sufficient period has passed to permit proper consideration or 
judgment about your future functioning. See 1.00C5b Response to 
treatment.
    D. How do we consider symptoms, including pain, under these 
listings?
    1. Individuals with musculoskeletal disorders may experience 
pain or other symptoms; however, statements alone about your pain or 
other symptoms cannot establish that you are disabled. Further, an 
alleged or reported increase in the intensity of a symptom, such as 
pain, no matter how severe, cannot be substituted for a medical sign 
or diagnostic finding present in the listing criteria. Pain is 
included as just one consideration in paragraph A in listings 1.15, 
1.16, and 1.18, but is not required to satisfy the criteria in these 
listings. Examples of other findings that will satisfy the criteria 
in paragraph A include muscle fatigue, nonradicular distribution of 
sensory loss in one or both extremities, and joint stiffness.
    2. To consider your pain, we require objective medical evidence 
from an acceptable medical source showing the existence of a 
medically determinable impairment(s) (MDI) that could reasonably be 
expected to produce the pain. When your musculoskeletal MDI could 
reasonably be expected to produce the pain or other symptoms 
alleged, we consider all your symptoms, including pain, and the 
extent to which your symptoms can reasonably be accepted as 
consistent with all of the objective medical evidence, including 
medical signs and laboratory or diagnostic findings. See Sec. Sec.  
404.1529 and 416.929 of this chapter for information on how we 
evaluate pain or other symptoms related to a musculoskeletal 
impairment.
    E. How do we use the functional criteria under these listings?
    1. General. We will determine that your musculoskeletal disorder 
meets a listing if it satisfies the medical criteria; includes at 
least one of the functional criteria, if included in the listing; 
and satisfies the 12-month duration requirement. We will use the 
relevant evidence that we have to evaluate

[[Page 20661]]

your musculoskeletal functioning with respect to the work 
environment rather than the home environment. For example, an 
ability to walk independently at home without an assistive device 
does not, in and of itself, indicate an ability to walk without an 
assistive device in a work environment.
    2. Functional criteria. The functional criteria are based on 
impairment-related physical limitations in your ability to use both 
upper extremities, one or both lower extremities, or a combination 
of one upper and one lower extremity. A musculoskeletal disorder 
satisfies the functional criteria of a listing when the medical 
documentation shows the presence of at least one of the impairment-
related limitations cited in the listing. The required impairment-
related physical limitation of musculoskeletal functioning must have 
lasted, or be expected to last, for a continuous period of at least 
12 months, medically documented by one of the following:
    a. A documented medical need (see 1.00C6a) for a walker, 
bilateral canes, or bilateral crutches (see 1.00C6d);
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements (see 1.00E3), and a documented medical need 
(see 1.00C6a) for a one-handed assistive device (see 1.00C6d) that 
requires the use of your other upper extremity;
    c. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements (see 
1.00E3).
    3. Fine and gross movements. Fine movements, for the purposes of 
these listings, involve use of your wrists, hands, and fingers; such 
movements include picking, pinching, manipulating, and fingering. 
Gross movements involve use of your shoulders, upper arms, forearms, 
and hands; such movements include handling, gripping, grasping, 
holding, turning, and reaching. Gross movements also include 
exertional abilities such as lifting, carrying, pushing, and 
pulling. Examples of inability to perform fine and gross movements 
include, but are not limited to, the inability to take care of 
personal hygiene, the inability to sort and handle papers or files, 
and the inability to place files in a file cabinet at or above waist 
level.
    4. When we do not use the functional criteria. We do not use the 
functional criteria to evaluate amputation of both upper extremities 
under 1.20A, hemipelvectomy or hip disarticulation under 1.20B, and 
soft tissue injuries or abnormalities under continuing surgical 
management under 1.21.
    F. What do we consider when we evaluate disorders of the 
skeletal spine resulting in compromise of a nerve root(s) (1.15)?
    1. General. We consider musculoskeletal disorders such as 
herniated nucleus pulposus, spinal osteoarthritis (spondylosis), 
vertebral slippage (spondylolisthesis), degenerative disc disease, 
facet arthritis, and vertebral fracture or dislocation. Spinal 
disorders may cause cervical or lumbar spine dysfunction when 
abnormalities of the skeletal spine compromise nerve roots of the 
cervical spine, a nerve root of the lumbar spine, or a nerve root of 
both cervical and lumbar spines.
    2. Compromise of a nerve root(s). Compromise of a nerve root(s), 
sometimes referred to as ``nerve root impingement,'' is a term used 
when a physical object is seen pushing on the nerve root in an 
imaging study or during surgery. Objects such as tumors, herniated 
discs, foreign bodies, or arthritic spurs may cause compromise of a 
nerve root. It can occur when a musculoskeletal disorder produces 
irritation, inflammation, or compression of the nerve root(s) as it 
exits the skeletal spine between the vertebrae. Related symptoms 
must be associated with, or follow the path of, the specific nerve 
root(s), thereby presenting a neuro-anatomic (usually referred to as 
``radicular'') distribution of symptoms and signs, including pain, 
paresthesia (for example, burning, prickling, or tingling), sensory 
loss, and usually muscle weakness specific to the affected nerve 
root(s).
    a. Compromise of unilateral nerve root of the cervical spine. 
Compromise of a nerve root as it exits the cervical spine between 
the vertebrae may affect the functioning of the associated upper 
extremity. The clinical examination reproduces the related symptoms 
based on radicular signs and clinical tests (for example, a positive 
Spurling's test) appropriate to the specific cervical nerve root.
    b. Compromise of bilateral nerve roots of the cervical spine. 
Although uncommon, if compromise of a nerve root occurs on both 
sides of the cervical spinal column, functioning of both upper 
extremities may be limited.
    c. Compromise of a nerve root(s) of the lumbar spine. Compromise 
of a nerve root as it exits the lumbar spine between the vertebrae 
may limit the functioning of the associated lower extremity. The 
clinical examination reproduces the related symptoms based on 
radicular signs and clinical tests. When a nerve root of the lumbar 
spine is compromised, we require a positive straight-leg raising 
test (also known as a Lasegue test) in both supine and sitting 
positions appropriate to the specific lumbar nerve root that is 
compromised. (See 1.00C2 for guidance on interpreting information 
from a physical examination report.)
    G. What do we consider when we evaluate lumbar spinal stenosis 
resulting in compromise of the cauda equina (1.16)?
    1. We consider the limiting effects of pain, sensory changes, 
and muscle weakness caused by compromise of the cauda equina due to 
lumbar spinal stenosis. The cauda equina is a bundle of nerve roots 
that descends from the lower part of the spinal cord. Lumbar spinal 
stenosis can compress the nerves of the cauda equina, causing 
sensory changes and muscle weakness that may affect your ability to 
stand or walk. Pain related to compromise of the cauda equina is 
``nonradicular,'' because it is not typically associated with a 
specific nerve root (as is radicular pain in the cervical or lumbar 
spine).
    2. Compromise of the cauda equina due to spinal stenosis can 
affect your ability to walk because of neurogenic claudication (also 
known as pseudoclaudication), a disorder usually causing non-
radicular pain that starts in the low back and radiates bilaterally 
(or less commonly, unilaterally) into the buttocks and lower 
extremities (or extremity). Extension of the lumbar spine, as when 
walking or merely standing, provokes the pain of neurogenic 
claudication. It is relieved by forward flexion of the lumbar spine 
or by sitting. In contrast, the leg pain associated with peripheral 
vascular claudication results from inadequate arterial blood flow to 
a lower extremity. It occurs repeatedly and consistently when a 
person walks a certain distance and is relieved when the person 
rests.
    H. What do we consider when we evaluate reconstructive surgery 
or surgical arthrodesis of a major weight-bearing joint (1.17)?
    1. We consider reconstructive surgery or surgical arthrodesis 
when an acceptable medical source(s) documents the surgical 
procedure(s) and associated medical treatments to restore function 
of the affected body part(s). The reconstructive surgery may be a 
single event or it may be a series of procedures directed toward the 
salvage or restoration of functional use of the affected joint.
    2. Major weight-bearing joints. The major weight-bearing joints 
are the hip, knee, and ankle-foot. The ankle and foot are considered 
together as one major joint.
    3. Surgical arthrodesis. Surgical arthrodesis is the artificial 
fusion of the bones that form a joint, essentially eliminating the 
joint.
    I. What do we consider when we evaluate abnormality of a major 
joint(s) in any extremity (1.18)?
    1. General. We consider musculoskeletal disorders that produce 
anatomical abnormalities of major joints of the extremities, 
resulting in functional abnormalities in the upper or lower 
extremities (for example, osteoarthritis and chronic infections of 
bones and joints, surgical arthrodesis of a joint). Major joint of 
an upper extremity refers to the shoulder, elbow, and wrist-hand. We 
consider the wrist and hand together as one major joint. Major joint 
of a lower extremity refers to the hip, knee, and ankle-foot. We 
consider the ankle and hindfoot together as one major joint, because 
it is necessary for walking. Abnormalities affecting the joints may 
include ligamentous laxity or rupture, soft tissue contracture, or 
tendon rupture, and can cause muscle weakness of the affected body 
part.
    2. How do we define abnormality in the extremities? An 
anatomical abnormality in any extremity(ies) is one that is readily 
observable by a medical source during a physical examination (for 
example, subluxation or contracture), or is present on imaging (for 
example, ankylosis, bony destruction, joint space narrowing, or 
deformity). A functional abnormality is abnormal motion or 
instability of the affected part(s), including limitation of motion, 
excessive motion (hypermobility), movement outside the normal plane 
of motion for the joint (for example, lateral deviation), or 
fixation of the affected parts.
    J. What do we consider when we evaluate pathologic fractures due 
to any cause (1.19)?

[[Page 20662]]

We consider pathologic fractures of the bones in the skeletal spine, 
extremities, or other parts of the skeletal system. Pathologic 
fractures result from disorders that weaken the bones, making them 
vulnerable to breakage. For non-healing or complex traumatic 
fractures without accompanying pathology, see 1.22 Non-healing or 
complex fracture of the femur, tibia, pelvis, or one or more of the 
tarsal bones or 1.23 Non-healing or complex fracture of an upper 
extremity. Pathologic fractures may occur with osteoporosis, 
osteogenesis imperfecta or any other skeletal dysplasias, side 
effects of medications, and disorders of the endocrine or other body 
systems. They must occur on separate, distinct occasions, rather 
than multiple fractures occurring at the same time, but they may 
affect the same bone(s) multiple times. There is no required period 
between the incidents of fracture(s), but they must all occur within 
a 12-month period; for example, separate incidents may occur within 
hours or days of each other. However, the associated limitation(s) 
of function must last, or be expected to last, at least 12 months.
    K. What do we consider when we evaluate amputation due to any 
cause (1.20)?
    1. General. We consider amputation (the full or partial loss or 
absence of any extremity) due to any cause, including trauma, 
congenital abnormality or absence, surgery for treatment of 
conditions such as cancer or infection, or complications of 
peripheral vascular disease or diabetes mellitus.
    2. Amputation of both upper extremities (1.20A). Upper extremity 
amputations, for the purposes of this listing, may occur at any 
level above the wrists (carpal joints), up to and including 
disarticulation of the shoulder (glenohumeral) joint. We do not 
evaluate amputations below the wrists under this listing, because 
the resulting limitation of function of the thumb(s), finger(s), or 
hand(s) will vary, depending on the extent of loss and corresponding 
effect on fine and gross movements (see 1.00E3). For amputations 
below the wrist, we will follow the remaining steps of the 
sequential evaluation process (see Sec. Sec.  404.1520 and 416.920 
of this chapter).
    3. Hemipelvectomy or hip disarticulation (1.20B). Hemipelvectomy 
involves amputation of an entire lower extremity through the 
sacroiliac joint. Hip disarticulation involves amputation of an 
entire lower extremity through the hip joint capsule and closure of 
the remaining musculature over the exposed acetabular bone.
    4. Amputation of one upper extremity at any level above the 
wrist and one lower extremity at or above the ankle (1.20C). We 
evaluate the absence of one upper extremity and one lower extremity 
with regard to whether you have a documented medical need (see 
1.00C6a) for a one-handed assistive device (see 1.00C6d), such as a 
cane or crutch. In this situation, you may wear a prosthesis (see 
1.00C6b) on your lower extremity, but nevertheless have a documented 
medical need for a one-handed assistive device. If you do, you would 
need to use your other upper extremity to hold the assistive device, 
making the extremity unavailable to perform other fine and gross 
movements (see 1.00E3) such as carrying. In such a case, your 
disorder would meet this listing.
    5. Amputation of one or both lower extremities at or above the 
ankle (tarsal joint) (1.20D). When we evaluate amputations of one or 
both lower extremities:
    a. We consider the condition of your residual limb(s), and 
whether you can wear a prosthesis(es) (see 1.00C6b). When you have a 
prosthesis(es), we will examine your residual limb with the 
prosthesis(es) in place. If you are unable to use a prosthesis(es) 
because of residual limb complications that have lasted, or are 
expected to last, for at least 12 months, and you are not currently 
undergoing surgical management (see 1.00L) of your condition, we 
evaluate your disorder under this listing.
    b. Under 1.20D ``Amputation of one or both lower extremities at 
or above the ankle (tarsal joint),'' we consider whether you have a 
documented medical need (see 1.00C6a) for a hand-held assistive 
device(s) (1.00C) and your ability to walk with the device(s).
    c. If you have a non-healing residual limb(s) and are receiving 
ongoing surgical treatment expected to re-establish or improve 
function, and that ongoing surgical treatment has not ended, or is 
not expected to end, within at least 12 months of the initiation of 
the surgical management (see 1.00L1), we evaluate your disorder 
under 1.21 Soft tissue injury or abnormality under continuing 
surgical management.
    L. What do we consider when we evaluate soft tissue injuries or 
abnormalities under continuing surgical management (1.21)?
    1. General.
    a. We consider any soft tissue injury or abnormality involving 
the soft tissues of the body, whether congenital or acquired, when 
an acceptable medical source(s) documents the need for ongoing 
surgical procedures and associated medical treatments to restore 
function of the affected body part(s). Surgical management includes 
the surgery(-ies) itself, as well as various post-surgical 
procedures, surgical complications, infections or other medical 
complications, related illnesses, or related treatments that delay a 
person's attainment of maximum benefit from surgery.
    b. Surgical procedures and associated treatments typically take 
place over extended periods, which may render you unable to perform 
work-related activity on a sustained basis. To document such 
inability, we must have evidence from an acceptable medical 
source(s) confirming that the surgical management has continued, or 
is expected to continue, for at least 12 months from the date of the 
first surgical intervention. These procedures and treatments must be 
directed toward saving, reconstructing, or replacing the affected 
part of the body to re-establish or improve its function, and not 
for cosmetic appearances alone.
    c. Examples include malformations, third and fourth degree 
burns, crush injuries, craniofacial injuries, avulsive injuries, and 
amputations with complications of the residual limb(s).
    d. We evaluate skeletal spine abnormalities or injuries under 
1.15 Disorders of the skeletal spine resulting in compromise of a 
nerve root(s), or 1.16 Lumbar spinal stenosis resulting in 
compromise of the cauda equina, as appropriate. We evaluate 
abnormalities or injuries of bones in the lower extremities under 
1.17 Reconstructive surgery or surgical arthrodesis of a major 
weight-bearing joint, 1.18 Abnormality of a major joint(s) in any 
extremity, or 1.22 Non-healing or complex fracture of the femur, 
tibia, pelvis, or one or more of the tarsal bones. We evaluate 
abnormalities or injuries of bones in the upper extremities under 
1.18 Abnormality of a major joint(s) in any extremity, or 1.23 Non-
healing or complex fracture of an upper extremity.
    2. Documentation. In addition to the objective medical evidence 
we need to establish your soft tissue injury or abnormality, we also 
need all of the following medically documented evidence about your 
continuing surgical management:
    a. Operative reports and related laboratory findings;
    b. Records of post-surgical procedures;
    c. Records of any surgical or medical complications (for 
example, related infections or systemic illnesses);
    d. Records of any prolonged post-operative recovery periods and 
related treatments (for example, surgeries and treatments for 
burns);
    e. An acceptable medical source's plans for additional 
surgeries; and
    f. Records detailing any other factors that have delayed, or 
that an acceptable medical source expects to delay, the saving, 
restoring, or replacing of the involved part for a continuous period 
of at least 12 months following the initiation of the surgical 
management.
    3. Burns. Third- and fourth-degree burns damage or destroy nerve 
tissue, reducing or preventing transmission of signals through those 
nerves. Such burns frequently require multiple surgical procedures 
and related therapies to re-establish or improve function, which we 
evaluate under 1.21 Soft tissue injury or abnormality under 
continuing surgical management. When burns are no longer under 
continuing surgical management, we evaluate the residual 
impairment(s) (see 1.00O). When the residual impairment(s) affects 
the musculoskeletal system, as often occurs in third and fourth 
degree burns, it can result in permanent musculoskeletal tissue 
loss, joint contractures, or loss of extremities. We will evaluate 
such impairments under the relevant musculoskeletal listing(s), for 
example, 1.18 Abnormality of a major joint(s) in any extremity or 
1.20 Amputation due to any cause. When the residual impairment(s) 
involves another body system(s), we will evaluate the impairment(s) 
under the relevant body system listing (for example, 8.08 Burns).
    4. Craniofacial injuries. Surgeons may treat craniofacial 
injuries with multiple surgical procedures. These injuries may 
affect vision, hearing, speech, and the initiation of the digestive 
process, including mastication. When the craniofacial injury-related 
residual impairment(s) involves another body system(s), we will 
evaluate the impairment(s) under the relevant body system listings. 
See 1.00O regarding evaluation of residual impairment(s).
    M. What do we consider when we evaluate non-healing or complex 
fractures of the

[[Page 20663]]

femur, tibia, pelvis, or one or more of the tarsal bones (1.22)?
    1. We evaluate a non-healing (nonunion) or complex fracture of 
the femur, tibia, pelvis, or one or more of the tarsal bones with 
regard to whether you have a documented medical need (see 1.00C6a) 
for a bilateral (two-handed) assistive device (see 1.00C6d), such as 
a walker or bilateral crutches.
    2. Non-healing fracture. A non-healing fracture is a fracture 
that has failed to unite completely. Nonunion is usually established 
when a minimum of 9 months has elapsed since the injury and the 
fracture site has shown no progressive signs of healing for a 
minimum of 3 months.
    3. Complex fracture. A fracture is complex when one or more of 
the following occur:
    a. Comminuted (broken into many pieces) bone fragments,
    b. Multiple fractures in a single bone,
    c. Bone loss due to severe trauma,
    d. Damage to the surrounding soft tissue,
    e. Severe cartilage damage to the associated joint, or
    f. Dislocation of the associated joint.
    4. When a complex fracture involves soft tissue damage, the 
treatment may involve continuing surgical management to restore or 
improve functioning. In such cases, we may evaluate the fracture(s) 
under 1.21 Soft tissue injury or abnormality under continuing 
surgical management.
    N. What do we consider when we evaluate non-healing or complex 
fractures of an upper extremity (1.23)?
    1. We evaluate a non-healing (nonunion) or complex fracture of 
an upper extremity under continuing surgical management (see 
1.00L1a) with regard to whether you have an inability to use both 
upper extremities to independently initiate, sustain, and complete 
fine and gross movements.
    2. Non-healing fracture. A non-healing fracture is a fracture 
that has failed to unite completely. Nonunion is usually established 
when a minimum of 9 months have elapsed since the injury and the 
fracture site has shown no progressive signs of healing for a 
minimum of 3 months.
    3. Complex fracture. A fracture is complex when one or more of 
the following occur:
    a. Comminuted (broken into many pieces) bone fragments,
    b. Multiple fractures in a single bone,
    c. Bone loss due to severe trauma,
    d. Damage to the surrounding soft tissue,
    e. Severe cartilage damage to the associated joint, or
    f. Dislocation of the associated joint.
    O. How do we determine when your soft tissue injury or 
abnormality or your upper extremity fracture is no longer under 
continuing surgical management or you have received maximum 
therapeutic benefit?
    1. Your soft tissue injury or abnormality or your upper 
extremity fracture is no longer under continuing surgical management 
when the last surgical procedure or medical treatment directed 
toward the re-establishment or improvement of function of the 
involved part has occurred. We will find that you have received 
maximum therapeutic benefit from treatment if there are no 
significant changes in physical findings or on appropriate imaging 
for any 6-month period after the last surgical procedure or medical 
treatment. We may also find that you have received maximum 
therapeutic benefit if your medical source(s) indicates that further 
improvement is not expected after the last surgical procedure or 
medical treatment.
    2. When you have received maximum therapeutic benefit from 
treatment, we will evaluate any impairment-related residual 
symptoms, signs, and laboratory findings (including those on 
imaging), any complications associated with your surgical procedures 
or medical treatments, and any residual limitations in your 
functioning. Depending upon all of those factors, we may find that 
your musculoskeletal impairment is no longer severe.
    3. If your impairment(s) remains severe, we will evaluate your 
residual limitations and all other impairment-related factors to 
determine whether your musculoskeletal disorder meets or medically 
equals another listing. If it does not, we will follow the remaining 
steps of the sequential evaluation process to determine whether you 
have the residual functional capacity (RFC) to engage in substantial 
gainful activity. If your impairment involves burns and remains 
severe, we will follow the above sequence by evaluating your 
impairment as described in 1.00L3.
    P. How do we evaluate the severity and duration of your 
established musculoskeletal disorder when there is no record of 
ongoing treatment?
    1. You may not have received ongoing treatment or may not have 
an ongoing relationship with the medical community despite having a 
musculoskeletal disorder(s). In either of these situations, you will 
not have a longitudinal medical record for us to review when we 
evaluate your disorder. We may therefore ask you to attend a 
consultative examination to determine the severity and potential 
duration of your disorder (see Sec. Sec.  404.1519a(b) and 
416.919a(b) of this chapter).
    2. In some instances, we may be able to assess the severity and 
duration of your musculoskeletal disorder based on your medical 
record and current evidence alone. If the information in your case 
record is not sufficient or appropriate to show that you have a 
musculoskeletal disorder that meets the criteria of one of the 
musculoskeletal disorders listings, we will follow the rules in 
1.00R.
    Q. How do we evaluate substance use disorders that co-exist with 
a musculoskeletal disorder?
    If we find that you are disabled and there is medical evidence 
in your case record establishing that you have a substance use 
disorder that co-exists with your musculoskeletal disorder, we will 
determine whether your substance use disorder is a contributing 
factor material to the determination of disability (see Sec. Sec.  
404.1535 and 416.935 of this chapter).
    R. How do we evaluate disorders that do not meet one of the 
musculoskeletal listings?
    1. These listings are only examples of musculoskeletal disorders 
that we consider severe enough to prevent your ability to engage in 
any gainful activity. If your musculoskeletal disorder(s) does not 
meet the criteria of any of these listings, we will consider whether 
you have an impairment(s) that meets the criteria of a listing in 
another body system.
    2. If you have a severe medically determinable impairment(s) 
that does not meet any listing, we will determine whether your 
impairment(s) medically equals a listing. See Sec. Sec.  404.1526 
and 416.926 of this chapter. If it does not medically equal a 
listing, we will assess your RFC. See Sec. Sec.  404.1545 and 
416.945 of this chapter. To assess your RFC, we may require evidence 
in addition to, or different from, the types of evidence that we use 
to determine whether your impairment(s) meets or medically equals a 
listing. We will use the assessment of your RFC to evaluate your 
claim at the fourth, and if necessary, the fifth step of the 
sequential evaluation process to determine whether you can perform 
your past work or adjust to any other work, respectively. See 
Sec. Sec.  404.1520 and 416.920 of this chapter.
    3. We use the rules in Sec. Sec.  404.1594 and 416.994 of this 
chapter, as appropriate, when we decide whether you continue to be 
disabled.

1.01 Category of Impairments, Musculoskeletal Disorders

    1.15 Disorders of the skeletal spine resulting in compromise of 
a nerve root(s) (see 1.00F), documented by A, B, C, and D:
    A. Symptom(s) of neuro-anatomic (radicular) distribution of one 
or more of the following manifestations consistent with compromise 
of the affected nerve root(s):
    1. Pain; or
    2. Paresthesias; or
    3. Muscle fatigue.

AND

    B. Radicular neurological signs present during physical 
examination or testing and evidenced by 1, 2, and 4; or 1, 3, and 4 
below:
    1. Muscle weakness; and
    2. Sensory changes evidenced by:
    a. Decreased sensation; or
    b. Sensory nerve deficit (abnormal sensory nerve latency) on 
electrodiagnostic testing; or
    3. Decreased deep tendon reflexes; and
    4. Sign(s) of nerve root irritation, tension, or compression, 
consistent with compromise of the affected nerve root (see 1.00F2).

AND

    C. Findings on imaging consistent with compromise of a nerve 
root(s) in the cervical or lumbosacral spine (see 1.00C3).

AND

    D. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 1.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or

[[Page 20664]]

    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements.
    1.16 Lumbar spinal stenosis resulting in compromise of the cauda 
equina (see 1.00G), documented by A, B, C, and D:
    A. Symptoms of neurological compromise, such as pain, manifested 
as:
    1. Nonradicular distribution of pain in one or both lower 
extremities; or
    2. Nonradicular distribution of sensory loss in one or both 
extremities; or
    3. Neurogenic claudication.

AND

    B. Nonradicular neurological signs present during physical 
examination or testing and evidenced by 1 and 2, or 1 and 3, below:
    1. Muscle weakness; and
    2. Sensory changes evidenced by:
    a. Decreased sensation; or
    b. Sensory nerve deficit (abnormal sensory nerve latency) on 
electrodiagnostic testing; or
    c. Areflexia, trophic ulceration, or bladder or bowel 
incontinence.
    3. Decreased deep tendon reflexes in one or both lower 
extremities.

AND

    C. Findings on imaging or in an operative report consistent with 
compromise of the cauda equina with lumbar spinal stenosis.

AND

    D. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 1.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity.
    1.17 Reconstructive surgery or surgical arthrodesis of a major 
weight-bearing joint (see 1.00H), documented by A, B, and C:
    A. Documented history of reconstructive surgery or surgical 
arthrodesis of a major weight-bearing joint.

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months.

AND

    C. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 1.00E).
    1.18 Abnormality of a major joint(s) in any extremity (see 
1.00I), documented by A, B, C, and D:
    A. Chronic joint pain or stiffness.

AND

    B. Abnormal motion, instability, or immobility of the affected 
joint(s).

AND

    C. Anatomical abnormality of the affected joint(s) noted on:
    1. Physical examination (for example, subluxation, contracture, 
bony or fibrous ankylosis); or
    2. Imaging (for example, joint space narrowing, bony 
destruction, or ankylosis or arthrodesis of the affected joint).

AND

    D. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 1.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or
    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements.
    1.19 Pathologic fractures due to any cause (see 1.00J), 
documented by A and B:
    A. Three or more medically documented pathologic fractures 
occurring on separate occasions within a 12-month period;

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 1.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or
    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements.
    1.20 Amputation due to any cause (see 1.00K), documented by A, 
B, C, or D:
    A. Amputation of both upper extremities, occurring at any level 
above the wrists (carpal joints), up to and including the shoulder 
(glenohumeral) joint.

OR

    B. Hemipelvectomy or hip disarticulation.

OR

    C. Amputation of one upper extremity, occurring at any level 
above the wrist (carpal joints), and one lower extremity at or above 
the ankle (tarsal joint), and medical documentation of one the 
following (see 1.00E):
    1. The documented medical need for a one-handed assistive device 
requiring the use of the other upper extremity; or
    2. The inability to use the remaining upper extremity to 
independently initiate, sustain, and complete work-related 
activities involving fine and gross movements.

OR

    D. Amputation of one or both lower extremities at or above the 
ankle (tarsal joint), with complications of the residual limb that 
have lasted or can be expected to last for at least 12 months, and 
medical documentation of both 1 and 2 (see 1.00E):
    1. The inability to use a prosthetic device(s); and
    2. The documented medical need for a walker, bilateral canes, or 
bilateral crutches.
    1.21 Soft tissue injury or abnormality under continuing surgical 
management (see 1.00L), documented by A, B, and C in the medical 
record:
    A. Evidence confirms ongoing surgical management directed 
towards saving, reconstructing, or replacing the affected part of 
the body.

AND

    B. The surgical management has been, or is expected to be, 
ongoing for at least 12 months.

AND

    C. Maximum benefit from therapy has not yet been achieved.
    1.22 Non-healing or complex fracture of the femur, tibia, 
pelvis, or one or more of the tarsal bones (see 1.00M), documented 
by A and B and C:
    A. Solid union not evident on appropriate medically acceptable 
imaging and not clinically solid;

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months,

AND

    C. Medical documentation of medical need for a walker, bilateral 
canes, or bilateral crutches (see 1.00E).
    1.23 Non-healing or complex fracture of an upper extremity (see 
1.00N), documented by A and B and C:
    A. Nonunion of a fracture, or complex fracture of the shaft of 
the humerus, radius, or ulna, under continuing surgical management, 
as defined in 1.00O, directed toward restoration of functional use 
of the extremity;

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months;

AND

    C. Medical documentation of at least one of the following (see 
1.00E):
    1. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or
    2. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and

[[Page 20665]]

complete work-related activities involving fine and gross movements.
* * * * *

4.00 CARDIOVASCULAR SYSTEM

* * * * *
    G. Evaluating Peripheral Vascular Disease
* * * * *
    4. What is lymphedema and how will we evaluate it?
* * * * *
    b. * * * We will evaluate lymphedema by considering whether the 
underlying cause meets or medically equals any listing or whether 
the lymphedema medically equals a cardiovascular listing, such as 
4.11 Chronic venous insufficiency, or a musculoskeletal listing, 
such as 1.18 Abnormality of a major joint(s) in any extremity. * * *
* * * * *

14.00 IMMUNE SYSTEM DISORDERS

* * * * *
    C. Definitions
* * * * *
    2. Assistive device(s) has the same meaning as in 1.00C6a.
* * * * *
    5. Documented medical need has the same meaning as in 1.00C6a.
* * * * *
    8. Fine and gross movements has the same meaning as in 1.00E3.
    9. Hand-held assistive device has the same meaning as in 
1.00C6d.
    10. Major joint of an upper or lower extremity has the same 
meaning as in 1.00I1.
* * * * *
    D. How do we document and evaluate the listed autoimmune 
disorders?
* * * * *
    4. Polymyositis and dermatomyositis (14.05).
* * * * *
    c. * * *
    (i) Weakness of your pelvic girdle muscles that results in your 
inability to rise independently from a squatting or sitting position 
or to climb stairs may be an indication that you are unable to walk 
without physical or mechanical assistance. * * *
* * * * *
    d. * * *
    6. * * *
    a. General. * * * Clinically, inflammation of major joints in an 
upper or lower extremity may be the dominant manifestation causing 
difficulties with walking or performing fine and gross movements; 
there may be joint pain, swelling, and tenderness. The arthritis may 
affect other joints, or cause less limitation in walking or 
performing fine and gross movements. * * *
* * * * *
    e. * * *
    (i) Listing-level severity in 14.09 Inflammatory arthritis is 
shown by the presence of an impairment-related, significant 
limitation cited in the criteria of these listings. In 14.09A, 
listing-level severity is satisfied with persistent inflammation or 
deformity in one major joint in a lower extremity resulting in a 
documented medical need for a walker, bilateral canes, or bilateral 
crutches as required in 14.09A1, or one major joint in each upper 
extremity resulting in an impairment-related, significant limitation 
in the ability to perform fine and gross movements as required in 
14.09A2. In 14.09C1, if you have the required ankylosis (fixation) 
of your cervical or dorsolumbar spine, we will find that you have an 
impairment-related significant limitation in your ability to see in 
front of you, above you, and to the side. Therefore, a listing-level 
impairment in the ability to walk is implicit in 14.09C1, even 
though you might not require bilateral upper limb assistance.
    (ii) Listing-level severity is shown in 14.09B, 14.09C2, and 
14.09D by inflammatory arthritis that involves various combinations 
of complications of one or more major joints in an upper or lower 
extremity or other joints, such as inflammation or deformity, extra-
articular features, repeated manifestations, and constitutional 
symptoms or signs. * * *
* * * * *
    14.04 Systemic sclerosis (scleroderma). As described in 14.00D3. 
With:
* * * * *
    B. One of the following:
    1. Toe contractures or fixed deformity of one or both feet, 
resulting in one of the following:
    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 14.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 14.00C9) that requires the use of the 
other upper extremity; or
    2. Finger contractures or fixed deformity in both hands, 
resulting in an inability to use both upper extremities to the 
extent that neither can be used to independently initiate, sustain, 
and complete work-related activities involving fine and gross 
movements; or
    3. Atrophy with irreversible damage in one or both lower 
extremities, resulting in one of the following:
    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 14.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 14.00C9) that requires the use of the 
other upper extremity; or
    4. Atrophy with irreversible damage in both upper extremities, 
resulting in an inability to use both upper extremities to the 
extent that neither can be used to independently initiate, sustain, 
and complete work-related activities involving fine and gross 
movements.

OR

    C. Raynaud's phenomenon, characterized by:
* * * * *
    2. Ischemia with ulcerations of toes or fingers, resulting in 
one of the following:
    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 14.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 14.00C9) that requires the use of the 
other upper extremity; or
    c. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements.
* * * * *
    14.05 Polymyositis and dermatomyositis. As described in 14.00D4. 
With:
    A. Proximal limb-girdle (pelvic or shoulder) muscle weakness, 
resulting in one of the following:
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 14.00C9); or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 14.00C9) that requires the use of the 
other upper extremity; or
    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements.
* * * * *
    14.09 Inflammatory arthritis. As described in 14.00D6. With:
    A. Persistent inflammation or persistent deformity of:
    1. One or more major joints in a lower extremity(ies) resulting 
in one of the following:
    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 14.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete work-related activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 14.00C9) that requires the use of the 
other upper extremity; or
    2. One or more major joints in each upper extremity resulting in 
an inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
work-related activities involving fine and gross movements.

OR

    B. Inflammation or deformity in one or more major joints of an 
upper or lower extremity(ies) with: * * *
* * * * *

Part B

* * * * *
    101.00 Musculoskeletal Disorders.
* * * * *

101.00 Musculoskeletal Disorders

    A. Which disorders do we evaluate under these listings?

[[Page 20666]]

    1. We evaluate disorders of the skeletal spine (vertebral 
column) or of the upper or lower extremities that affect 
musculoskeletal functioning in the musculoskeletal body system 
listings. We use the term ``skeletal'' when we are referring to the 
structure of the bony skeleton. The skeletal spine refers to the 
bony structures, ligaments, and discs making up the spine. We refer 
to the ``skeletal'' spine in some musculoskeletal listings to 
differentiate it from the neurological spine (see 101.00B1). 
Disorders may be congenital or acquired, and may include 
deformities, amputations, or other musculoskeletal abnormalities. 
These disorders may involve the bones or major joints; or the 
tendons, ligaments, muscles, or other soft tissues.
    2. We also evaluate soft tissue abnormalities or injuries 
(including burns) that are under continuing surgical management (see 
101.00L). The abnormalities or injuries may affect any part of the 
body, including the face and skull.
    B. Which related disorders do we evaluate under other listings?
    1. We evaluate a disorder or injury of the skeletal spine that 
results in damage to, and neurological dysfunction of, the spinal 
cord and its associated nerves (for example, paraplegia or 
quadriplegia) under the criteria in 111.00 Neurological Disorders.
    2. We evaluate inflammatory arthritis (for example, rheumatoid 
arthritis) under the criteria in 114.00 Immune System Disorders.
    3. We evaluate curvatures of the skeletal spine under these 
musculoskeletal disorders listings and other listings as appropriate 
for the affected body system. Curvatures of the skeletal spine that 
affect musculoskeletal functioning are evaluated under 101.15 
Disorders of the skeletal spine resulting in compromise of a nerve 
root(s). If a curvature of the skeletal spine is under continuing 
surgical management, we can evaluate it for medical equivalence to 
101.21 Soft tissue injury or abnormality under continuing surgical 
management. Skeletal curvatures may also adversely affect 
functioning in body systems other than the musculoskeletal system. 
For example, the curvature may interfere with your ability to 
breathe (see 103.00 Respiratory Disorders); there may be impaired 
myocardial function (see 104.00 Cardiovascular System); or there may 
be disfigurement resulting in social withdrawal or depression (see 
112.00 Mental Disorders).
    4. We evaluate non-healing or pathological fractures due to 
cancer, whether it is a primary site or metastases, under the 
criteria in 113.00 Cancer (Malignant Neoplastic Diseases).
    5. We evaluate the leg pain associated with peripheral vascular 
claudication under the criteria in 104.00 Cardiovascular System.
    6. We evaluate burns that do not require continuing surgical 
management under the criteria in 108.00 Skin Disorders.
    C. What evidence do we need to evaluate your musculoskeletal 
disorder under these listings?
    1. General. To establish the presence of a musculoskeletal 
disorder as a medically determinable impairment, we need objective 
medical evidence from an acceptable medical source who has examined 
you for the disorder. To assess the severity and duration of your 
disorder, we evaluate evidence from both medical and nonmedical 
sources who can describe how you function. If there is no record of 
ongoing medical treatment for your disorder, we will follow the 
guidelines in 101.00Q How do we evaluate the severity and duration 
of your established musculoskeletal disorder when there is no record 
of ongoing treatment? We will determine the extent and kinds of 
evidence we need from medical and non-medical sources based on the 
individual facts about your disorder. For our basic rules on 
evidence, see Sec. Sec.  416.902, 416.912, 416.913, 416.913a, and 
416.920b of this chapter. For our rules on evidence about your 
symptoms, see Sec.  416.929 of this chapter.
    2. Physical examination report(s). In the report(s) of your 
physical examination, we need a detailed description of the 
orthopedic, neurologic, or other objective clinical findings 
appropriate to your specific musculoskeletal disorder. We require 
objective clinical findings from the medical source's direct 
observations during your physical examination, not simply his or her 
report of your statements about your symptoms and limitations. When 
the medical source reports that a clinical test sign(s) is positive, 
unless we have evidence to the contrary, we will assume that he or 
she performed the test properly. For instance, we will assume a 
straight-leg raising test was conducted properly, i.e., in a sitting 
and supine position, even if the medical source does not specify the 
positions in which the test was performed. In the absence of 
evidence to the contrary, we will accept the medical source's 
interpretation of the test. If you use an assistive device (see 
101.00C6), the report must support the medical need for the device. 
If reduction in muscle strength is a factor, we require medical 
documentation of measurement of the strength of the muscle(s) in 
question, generally based on a grading system of 0 to 5. Zero (0) 
indicates complete loss of strength and 5 indicates maximum 
strength, consistent with Table 1 below. The documentation should 
also include measurements of grip and pinch strength, if there is 
evidence of involvement of one or both hands.

                                 Table 1
------------------------------------------------------------------------
 
------------------------------------------------------------------------
                Grading Scale of Muscle Function: 0 to 5
------------------------------------------------------------------------
0.............................  None.............  No visible or
                                                    palpable
                                                    contraction.
1.............................  Trace............  Visible or palpable
                                                    contraction with no
                                                    motion.
2.............................  Poor.............  Active range of
                                                    motion (ROM) with
                                                    gravity eliminated.
3.............................  Fair.............  Active ROM against
                                                    gravity only,
                                                    without resistance.
4.............................  Good.............  Active ROM against
                                                    gravity, moderate
                                                    resistance.
5.............................  Normal...........  Active ROM against
                                                    gravity, maximum
                                                    resistance.
------------------------------------------------------------------------

    3. Laboratory findings: Imaging and other diagnostic tests
    a. Imaging refers to medical imaging techniques, such as x-ray, 
computed tomography (CT), magnetic resonance imaging (MRI), and 
radionuclide scanning. For the purpose of these listings, the 
imaging technique(s) must be consistent with the generally accepted 
standards of medical knowledge and clinical practice.
    b. Findings on imaging must have lasted, or must be expected to 
last, for a continuous period of at least 12 months.
    c. Imaging and other diagnostic tests can provide evidence of 
physical abnormalities; however, they may correlate poorly with your 
symptoms, including pain, or with your musculoskeletal functioning. 
Accordingly, we cannot use such tests as a substitute for physical 
examination findings about your ability to function, nor can we 
infer severity or functional limitations based solely on such tests.
    d. For our policies about when we will purchase imaging and 
other diagnostic tests, see Sec. Sec.  416.919k and 416.919m of this 
chapter.
    4. Operative reports. If you have had a surgical procedure(s), 
we need either the operative reports, including details of the 
findings at surgery and information about any medical complications 
that may have occurred, or confirmatory evidence of the surgical 
procedure(s) from a medical source (for example, detailed follow-up 
reports or notations in the medical records concerning your past 
medical history).
    5. Effects of treatment
    a. General. Treatments for musculoskeletal disorders may have 
beneficial or adverse effects, and responses to treatment vary from 
person to person. We will evaluate all of the effects of treatment 
(including surgical treatment, medications, and therapy) on the 
symptoms, signs, and laboratory findings of your musculoskeletal 
disorder, and on your musculoskeletal functioning.
    b. Response to treatment. To evaluate your musculoskeletal 
functioning in response to treatment, we need specific information 
related to your impairment, including the following: A description 
of your medications, including frequency of administration; the type 
and frequency of therapy you receive; and a description of your 
response to treatment and any complications you experience related 
to your impairment. The effects of treatment may be temporary or 
long-term. We need information over a sufficient period to determine 
the effect of

[[Page 20667]]

treatment on your current musculoskeletal functioning and to permit 
reasonable projections about your future functioning. In some cases, 
we will need additional evidence to make an assessment about your 
response to treatment. Depending upon the timing of this treatment 
in relation to the alleged onset date of disability, we may need to 
defer evaluation of the impairment for a period of up to 3 months 
from the date treatment began to permit consideration of treatment 
effects, unless we can make a determination or decision using the 
evidence we have.
    6. Assistive devices
    a. General. An assistive device, for the purposes of these 
listings, is any device that is used to improve stability, 
dexterity, or mobility. An assistive device can be worn (see 
101.00C6b and c), or hand-held (see 101.00C6d). If you use any type 
of assistive device(s), we need evidence from a medical source 
regarding the documented medical need for the device(s). When we use 
the term ``documented medical need,'' we mean that there is evidence 
from a medical source(s) in the medical record that supports your 
need for an assistive device (see Sec.  416.913 of this chapter). 
The evidence must include documentation from a medical source(s) 
describing any limitation(s) in your upper or lower extremity 
functioning that supports your need for the assistive device, and 
supporting the circumstances for which you need it. The evidence 
does not have to include a specific prescription for the device.
    b. Prosthesis(es). A prosthesis is a wearable device, such as an 
artificial limb, that takes the place of an absent body part. We 
need evidence from a medical source documenting your ability to 
walk, or to perform fine and gross movements (see 101.00E4), with 
the prosthesis(es) in place. When amputation(s) involves a lower 
extremity or extremities, it is not necessary to evaluate your 
ability to walk without the prosthesis(es) in place. If you cannot 
use your prosthesis(es) due to complications affecting your residual 
limb(s), we need documentation from a medical source regarding the 
condition of your residual limb(s) and the medical basis for your 
inability to use the prosthesis(es).
    c. Orthosis(es). An orthosis is a wearable device that prevents 
or corrects a dysfunction or deformity by aligning or supporting the 
affected body part. An orthosis may also be referred to as a 
``brace.'' If you have an orthosis(es), we need evidence from a 
medical source documenting your ability to walk, or to perform fine 
and gross movements, with the orthosis(es) in place. If you cannot 
use your orthosis(es), we need evidence from a medical source 
documenting the medical basis for your inability to use the 
device(s).
    d. Hand-held assistive devices. Hand-held assistive devices 
include canes, crutches, or walkers, and are carried in your hand(s) 
to support or aid you in walking. When you require a one-handed 
assistive device for ambulation, such as a cane or single crutch, 
and your other upper extremity has limitations preventing its use 
for fine or gross movement(s) (see 101.00E4), the need for the 
assistive device limits the use of both upper extremities. If you 
use a hand-held assistive device, we need evidence from a medical 
source documenting your need for the device(s) and describing how 
you walk with the device(s).
    7. Longitudinal evidence
    a. We generally need a longitudinal medical record to assess the 
duration of your musculoskeletal disorder, because symptoms, signs, 
and laboratory findings related to most musculoskeletal disorders 
may wax and wane, may improve over time, or may respond to 
treatment. By providing evidence over an extended period, the 
medical record will show whether your musculoskeletal functioning is 
improving, worsening, or unchanging.
    b. For 101.19 Pathologic fractures due to any cause and 101.21 
Soft tissue injury or abnormality under continuing surgical 
management, the required 12-month duration period is stated in the 
listing itself. For 101.20A (amputation of both upper extremities) 
or 101.20B (hemipelvectomy or hip disarticulation), we presume 
satisfaction of the duration requirement.
    c. For all listings not referenced in 101.00C7b above, all of 
the required criteria must be present simultaneously, or within a 
close proximity of time, to satisfy the level of severity needed to 
meet the listing. When we use the term ``close proximity of time,'' 
we mean that all of the relevant criteria have to appear in the 
medical record within a period not to exceed 4 months of one 
another. When the criterion in question is imaging, we mean those 
findings on imaging that we could reasonably expect to have been 
present at the date of impairment or date of onset. To meet a 
listing that uses the word ``and'' or ``AND'' to link the elements 
of the required criteria, the medical record must establish the 
simultaneous presence, or presence within a close proximity of time, 
of all the required medical criteria. Once this level of severity is 
established, the medical record must also show that this level of 
severity has continued, or is expected to continue, for a continuous 
period of at least 12 months.
    8. Surgical treatment
    For some musculoskeletal disorders, a medical source may 
recommend surgery. If you have not yet had the recommended surgery, 
we will not deny your claim based on an assumption that surgery will 
resolve or improve your disorder. We will assess each case on an 
individual basis. Depending on your response to treatment, or 
depending on your medical sources' treatment plans, we may defer our 
findings regarding the effect of surgical intervention until a 
sufficient period has passed to permit proper consideration or 
judgment about your future functioning. See 101.00C5b Response to 
treatment.
    D. How do we consider symptoms, including pain, under these 
listings?
    1. Individuals with musculoskeletal disorders may experience 
pain or other symptoms; however, statements alone about your pain or 
other symptoms cannot establish that you are disabled. Further, an 
alleged or reported increase in the intensity of a symptom, such as 
pain, no matter how severe, cannot be substituted for a medical sign 
or diagnostic finding present in the listing criteria. Pain is 
included as just one consideration in paragraph A in listings 
101.15, 101.16, and 101.18, but is not required to satisfy the 
criteria in these listings. Examples of other findings that will 
satisfy the criteria in paragraph A include muscle fatigue, 
nonradicular distribution of sensory loss in one or both 
extremities, and joint stiffness.
    2. To consider your pain, we require objective medical evidence 
from an acceptable medical source showing the existence of a 
medically determinable impairment(s) (MDI) that could reasonably be 
expected to produce the pain. When your musculoskeletal MDI could 
reasonably be expected to produce the pain or other symptoms 
alleged, we consider all your symptoms, including pain, and the 
extent to which your symptoms can reasonably be accepted as 
consistent with all of the objective medical evidence, including 
medical signs and laboratory or diagnostic findings. See Sec.  
416.929 of this chapter for information on how we evaluate pain or 
other symptoms related to a musculoskeletal impairment.
    E. How do we use the functional criteria under these listings?
    1. General. We will determine that your musculoskeletal disorder 
meets a listing if it satisfies the medical criteria; includes at 
least one of the functional criteria, if included in the listing; 
and satisfies the 12-month duration requirement. We will use the 
relevant evidence that we have to compare your musculoskeletal 
functioning to the functioning of children your age who do not have 
impairments. For example, if you are able to walk at home without an 
assistive device, we will not consider that to be conclusive 
evidence that you have similar functioning to other children your 
age who do not have impairments.
    2. Medical and functional criteria, birth to attainment of age 
3. The medical and functional criteria for children in this age 
group are in 101.24 Musculoskeletal disorders of infants and 
toddlers, from birth to attainment of age 3, with developmental 
motor delay.
    3. Functional criteria, age 3 to attainment of age 18. The 
functional criteria are based on impairment-related physical 
limitations in your ability to use both upper extremities, one or 
both lower extremities, or a combination of one upper and one lower 
extremity. A musculoskeletal disorder satisfies the functional 
criteria of a listing when the medical documentation shows the 
presence of at least one of the impairment-related limitations cited 
in the listing. The functional criteria require impairment-related 
physical limitation of musculoskeletal functioning that has lasted, 
or can be expected to last, for a continuous period of at least 12 
months, medically documented by one of the following:
    a. A documented medical need (see 101.00C6a) for a walker, 
bilateral canes, or bilateral crutches (see 101.00C6d);
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements (see 101.00E4), and a documented medical 
need (see 101.00C6a) for a one-handed assistive device (see 
101.00C6d) that requires the use of your other upper extremity;

[[Page 20668]]

    c. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
age-appropriate activities involving fine and gross movements (see 
101.00E4).
    4. Fine and gross movements. Fine movements, for the purposes of 
these listings, involve use of your wrists, hands, and fingers; such 
movements include picking, pinching, manipulating, and fingering. 
Gross movements involve use of your shoulders, upper arms, forearms, 
and hands; such movements include handling, gripping, grasping, 
holding, turning, and reaching. Gross movements also include 
exertional abilities such as lifting, carrying, pushing, and 
pulling.
    5. When we do not use the functional criteria. We do not use the 
functional criteria to evaluate amputation of both upper extremities 
under 101.20A, hemipelvectomy or hip disarticulation under 101.20B, 
and soft tissue injuries or abnormalities under continuing surgical 
management under 101.21.
    F. What do we consider when we evaluate disorders of the 
skeletal spine resulting in compromise of a nerve root(s) (101.15)?
    1. General. We consider musculoskeletal disorders such as 
skeletal dysplasias, caudal regression syndrome, tethered spinal 
cord syndrome, vertebral slippage (spondylolisthesis), scoliosis, 
and vertebral fracture or dislocation. Spinal disorders may cause 
cervical or lumbar spine dysfunction when abnormalities of the 
skeletal spine compromise nerve roots of the cervical spine, a nerve 
root of the lumbar spine, or a nerve root of both cervical and 
lumbar spines.
    2. Compromise of a nerve root(s). Compromise of a nerve root(s), 
sometimes referred to as ``nerve root impingement,'' is a term used 
when a physical object is seen pushing on the nerve root in an 
imaging study or during surgery. Objects such as tumors, herniated 
discs, foreign bodies, or arthritic spurs may cause compromise of a 
nerve root. It can occur when a musculoskeletal disorder produces 
irritation, inflammation, or compression of the nerve root(s) as it 
exits the skeletal spine between the vertebrae. Related symptoms 
must be associated with, or follow the path of, the specific nerve 
root(s), thereby presenting a neuro-anatomic (usually referred to as 
``radicular'') distribution of symptoms and signs, including pain, 
paresthesia (for example, burning, prickling, or tingling), sensory 
loss, and usually muscle weakness specific to the affected nerve 
root(s).
    a. Compromise of unilateral nerve root of the cervical spine. 
Compromise of a nerve root as it exits the cervical spine between 
the vertebrae may affect the functioning of the associated upper 
extremity. The clinical examination reproduces the related symptoms 
based on radicular signs and clinical tests (for example, a positive 
Spurling's Test) appropriate to the specific cervical nerve root.
    b. Compromise of bilateral nerve roots of the cervical spine. 
Although uncommon, if compromise of a nerve root occurs on both 
sides of the cervical spinal column, functioning of both upper 
extremities may be limited.
    c. Compromise of a nerve root(s) of the lumbar spine. Compromise 
of a nerve root as it exits the lumbar spine between the vertebrae 
may limit the functioning of the associated lower extremity. The 
clinical examination reproduces the related symptoms based on 
radicular signs and clinical tests. When a nerve root of the lumbar 
spine is compromised, we require a positive straight-leg raising 
test (also known as a Lasegue test) in both supine and sitting 
positions appropriate to the specific lumbar nerve root that is 
compromised. (See 101.00C2 for guidance on interpreting information 
from a physical examination report.)
    G. What do we consider when we evaluate lumbar spinal stenosis 
resulting in compromise of the cauda equina (101.16)?
    1. We consider the limiting effects of pain, sensory changes, 
and muscle weakness caused by compromise of the cauda equina due to 
lumbar spinal stenosis. The cauda equina is a bundle of nerve roots 
that descends from the lower part of the spinal cord. Lumbar spinal 
stenosis can compress the nerves of the cauda equina, causing 
sensory changes and muscle weakness that may affect your ability to 
stand or walk. Pain related to compromise of the cauda equina is 
``nonradicular,'' because it is not typically associated with a 
specific nerve root (as is radicular pain in the cervical or lumbar 
spine).
    2. Compromise of the cauda equina due to spinal stenosis can 
affect your ability to walk because of neurogenic claudication (also 
known as pseudoclaudication), a disorder usually causing non-
radicular pain that starts in the low back and radiates bilaterally 
(or less commonly, unilaterally) into the buttocks and lower 
extremities (or extremity). Extension of the lumbar spine, as when 
walking or merely standing, provokes the pain of neurogenic 
claudication. It is relieved by forward flexion of the lumbar spine 
or by sitting.
    H. What do we consider when we evaluate reconstructive surgery 
or surgical arthrodesis of a major weight-bearing joint (101.17)?
    1. We consider reconstructive surgery or surgical arthrodesis 
when an acceptable medical source(s) documents the surgical 
procedure(s) and associated medical treatments to restore function 
of the affected body part(s). The reconstructive surgery may be a 
single event or it may be a series of procedures directed toward the 
salvage or restoration of functional use of the affected joint.
    2. Major weight-bearing joints. The major weight-bearing joints 
are the hip, knee, and ankle-foot. The ankle and foot are considered 
together as one major joint.
    3. Surgical arthrodesis. Surgical arthrodesis is the artificial 
fusion of the bones that form a joint, essentially eliminating the 
joint.
    I. What do we consider when we evaluate abnormality of a major 
joint(s) in any extremity (101.18)?
    1. General. We consider musculoskeletal disorders that produce 
anatomical abnormalities of major joints of the extremities, 
resulting in functional abnormalities in the upper or lower 
extremities (for example, infections of bones and joints). Major 
joint of an upper extremity refers to the shoulder, elbow, and 
wrist-hand. We consider the wrist and hand together as one major 
joint. Major joint of a lower extremity refers to the hip, knee, and 
ankle-foot. We consider the ankle and hindfoot together as one major 
joint, because it is necessary for walking. Abnormalities affecting 
the joints may include ligamentous laxity or rupture, soft tissue 
contracture, or tendon rupture, and can cause muscle weakness of the 
affected body part.
    2. How do we define abnormality in the extremities? An 
anatomical abnormality in any extremity(ies) is one that is readily 
observable by a medical source during a physical examination (for 
example, subluxation or contracture), or is present on imaging (for 
example, ankylosis, bony destruction, joint space narrowing, or 
deformity). A functional abnormality is abnormal motion or 
instability of the affected part(s), including limitation of motion, 
excessive motion (hypermobility), movement outside the normal plane 
of motion for the joint (for example, lateral deviation), or 
fixation of the affected parts.
    J. What do we consider when we evaluate pathologic fractures due 
to any cause (101.19)? We consider pathologic fractures of the bones 
in the skeletal spine, extremities, or other parts of the skeletal 
system. Pathologic fractures result from disorders that weaken the 
bones, making them vulnerable to breakage. For non-healing or 
complex traumatic fractures without accompanying pathology, see 
101.22 Non-healing or complex fracture of the femur, tibia, pelvis, 
or one or more of the tarsal bones, or 101.23 Non-healing fracture 
of an upper extremity. Pathologic fractures may occur with 
osteoporosis, osteogenesis imperfecta or any other skeletal 
dysplasias, side effects of medications, and disorders of the 
endocrine or other body systems. They must occur on separate, 
distinct occasions, rather than multiple fractures occurring at the 
same time, but they may affect the same bone(s) multiple times. 
There is no required period between the incidents of fracture(s), 
but they must all occur within a 12-month period; for example, 
separate incidents may occur within hours or days of each other. 
However, the associated limitation(s) of function must last, or be 
expected to last, at least 12 months.
    K. What do we consider when we evaluate amputation due to any 
cause (101.20)?
    1. General. We consider amputations (the full or partial loss or 
absence of any extremity) due to any cause, including trauma, 
congenital abnormality or absence, or surgery for treatment of 
conditions such as cancer or infection.
    2. Amputation of both upper extremities (101.20A). Upper 
extremity amputations, for the purposes of this listing, may occur 
at any level above the wrists (carpal joints), up to and including 
disarticulation of the shoulder (glenohumeral) joint. We do not 
evaluate amputations below the wrists under this listing, because 
the resulting limitation of function of the thumb(s), finger(s), or 
hand(s) will vary, depending on the extent of loss and corresponding 
effect on fine and gross

[[Page 20669]]

movements (see 101.00E4). For amputations below the wrist, we will 
follow our rules for determining functional equivalence to the 
listings (see Sec.  416.926a of this chapter).
    3. Hemipelvectomy or hip disarticulation (101.20B). 
Hemipelvectomy involves amputation of an entire lower extremity 
through the sacroiliac joint. Hip disarticulation involves 
amputation of an entire lower extremity through the hip joint 
capsule and closure of the remaining musculature over the exposed 
acetabular bone.
    4. Amputation of one upper extremity at any level above the 
wrist and one lower extremity at or above the ankle (101.20C). We 
evaluate the absence of one upper extremity and one lower extremity 
with regard to whether you have a documented medical need (see 
101.00C6a) for a one-handed assistive device (see 101.00C6d), such 
as a cane or crutch. In this situation, you may wear a prosthesis 
(see 101.00C6b) on your lower extremity, but nevertheless have a 
documented medical need for a one-handed assistive device. If you 
do, you would need to use your other upper extremity to hold the 
assistive device, making the extremity unavailable to perform other 
fine and gross movements (see 101.00E4) such as carrying. In such a 
case, your disorder would meet this listing.
    5. Amputation of one or both lower extremities at or above the 
ankle (tarsal joint), (101.20D). When we evaluate amputations of one 
or both lower extremities:
    a. We consider the condition of your residual limb(s), and 
whether you can wear a prosthesis(es) (see 101.00C6b). When you have 
a prosthesis(es), we will examine your residual limb with the 
prosthesis(es) in place. If you are unable to use a prosthesis(es) 
because of residual limb complications that have lasted, or are 
expected to last, for at least 12 months, and you are not currently 
undergoing surgical management (see 101.00L1) of your condition, we 
evaluate your disorder under this listing.
    b. Under 101.20D ``Amputation of one or both lower extremities 
at or above the ankle (tarsal joint),'' we consider whether you have 
a documented medical need (see 101.00C6a) for a hand-held assistive 
device(s) (see 101.00C6d) and your ability to walk with the 
device(s).
    c. If you have a non-healing residual limb(s) and are receiving 
ongoing surgical treatment expected to re-establish or improve 
function, and that ongoing surgical treatment has not ended, or is 
not expected to end, within at least 12 months of the initiation of 
the surgical management (see 101.00L1), we evaluate your disorder 
under 101.21  Soft tissue injury or abnormality under continuing 
surgical management.
    L. What do we consider when we evaluate soft tissue injury or 
abnormality under continuing surgical management (101.21)?
    1. General.
    a. We consider any soft tissue injury or abnormality involving 
the soft tissues of the body, whether congenital or acquired, when 
an acceptable medical source(s) documents the need for ongoing 
surgical procedures and associated medical treatments to restore 
function of the affected body parts. Surgical management includes 
the surgery(-ies) itself, as well as various post-surgical 
procedures, surgical complications, infections or other medical 
complications, related illnesses, or related treatments that delay a 
person's attainment of maximum benefit from therapy.
    b. Surgical procedures and associated treatments typically take 
place over extended periods, which may render you unable to perform 
age-appropriate activity on a sustained basis. To document such 
inability, we must have evidence from an acceptable medical 
source(s) confirming that the surgical management has continued, or 
is expected to continue, for at least 12 months from the date of the 
first surgical intervention. These procedures and treatments must be 
directed toward saving, reconstructing, or replacing the affected 
part of the body to re-establish or improve its function, and not 
for cosmetic appearances alone.
    c. Examples include malformations, third- and fourth-degree 
burns, crush injuries, craniofacial injuries, avulsive injuries, and 
amputations with complications of the residual limb(s).
    d. We evaluate skeletal spine abnormalities or injuries under 
101.15 Disorders of the skeletal spine resulting in compromise of a 
nerve root(s) or 101.16 Lumbar spinal stenosis resulting in 
compromise of the cauda equina, as appropriate. We evaluate 
abnormalities or injuries of bones in the lower extremities under 
101.17 Reconstructive surgery or surgical arthrodesis of a major 
weight-bearing joint, 101.18 Abnormality of a major joint(s) in any 
extremity, or 101.22 Non-healing fracture of the femur, tibia, 
pelvis, or one or more of the tarsal bones. We evaluate 
abnormalities or injuries of bones in the upper extremities under 
101.18 Abnormality of a major joint(s) in any extremity, or 101.23 
Non-healing or complex fracture of an upper extremity.
    2. Documentation. In addition to the objective medical evidence 
we need to establish your soft tissue injury or abnormality, we also 
need all of the following medically documented evidence about your 
continuing surgical management:
    a. Operative reports and related laboratory findings;
    b. Records of post-surgical procedures;
    c. Records of any surgical or medical complications (for 
example, related infections or systemic illnesses);
    d. Records of any prolonged post-operative recovery periods and 
related treatments (for example, surgeries and treatments for 
burns); and
    e. An acceptable medical source's plans for additional 
surgeries;
    f. Records detailing any other factors that have delayed, or 
that an acceptable medical source expects to delay, the saving, 
restoring, or replacing of the involved part for a continuous period 
of at least 12 months following the initiation of the surgical 
management.
    3. Burns. Third- and fourth-degree burns damage or destroy nerve 
tissue, reducing or preventing transmission of signals through those 
nerves. Such burns frequently require multiple surgical procedures 
and related therapies to re-establish or improve function, which we 
evaluate under 101.21 Soft tissue injury or abnormality under 
continuing surgical management. When burns are no longer under 
continuing surgical management, we evaluate the residual 
impairment(s) (see 101.00P). When the residual impairment(s) affects 
the musculoskeletal system, as often occurs in third and fourth 
degree burns, it can result in permanent musculoskeletal tissue 
loss, joint contractures, or loss of extremities. We will evaluate 
such impairments under the relevant musculoskeletal listing(s), for 
example, 101.18 Abnormality of a major joint(s) in any extremity or 
101.20 Amputation due to any cause. When the residual impairment(s) 
involves another body system(s), we will evaluate the impairment(s) 
under the relevant body system listing (for example, 108.08 Burns).
    4. Congenital abnormalities or craniofacial injuries. Surgeons 
may treat craniofacial injuries or abnormalities with multiple 
surgical procedures. These injuries or abnormalities may affect 
vision, hearing, speech, and the initiation of the digestive 
process, including mastication. When the craniofacial injury-related 
or congenital residual impairment(s) involves another body 
system(s), we will evaluate the impairment(s) under the relevant 
body system listings. See 101.00P regarding evaluation of residual 
impairment(s).
    M. What do we consider when we evaluate non-healing or complex 
fractures of the femur, tibia, pelvis, or one or more of the tarsal 
bones (101.22)?
    1. We evaluate a non-healing (nonunion) or complex fracture of 
the femur, tibia, pelvis, or one or more of the tarsal bones with 
regard to whether you have a documented medical need (see 101.00C6a) 
for a bilateral (two-handed) assistive device (see 101.00C6d), such 
as a walker or bilateral crutches.
    2. Non-healing fracture. A non-healing fracture is a fracture 
that has failed to unite completely. Nonunion is usually established 
when a minimum of 9 months has elapsed since the injury and the 
fracture site has shown no progressive signs of healing for a 
minimum of 3 months.
    3. Complex fracture. A fracture is complex when one or more of 
the following occur:
    a. Comminuted (broken into many pieces) bone fragments,
    b. Multiple fractures in a single bone,
    c. Bone loss due to severe trauma,
    d. Damage to the surrounding soft tissue,
    e. Severe cartilage damage to the associated joint, or
    f. Dislocation of the associated joint.
    4. When a complex fracture involves soft tissue damage, the 
treatment may involve continuing surgical management to restore or 
improve functioning. In such cases, we may evaluate the fracture(s) 
under 101.21 Soft tissue injury or abnormality under continuing 
surgical management.
    N. What do we consider when we evaluate non-healing or complex 
fractures of an upper extremity (101.23)?
    1. We evaluate a non-healing (nonunion) or complex fracture of 
an upper extremity under continuing surgical management (see 
101.00L1a) with regard to whether you have an inability to use both 
upper extremities to

[[Page 20670]]

independently initiate, sustain, and complete fine and gross 
movements.
    2. Non-healing fracture. A non-healing fracture is a fracture 
that has failed to unite completely. Nonunion is usually established 
when a minimum of 9 months has elapsed since the injury and the 
fracture site has shown no progressive signs of healing for a 
minimum of 3 months.
    3. Complex fracture. A fracture is complex when one or more of 
the following occur:
    a. Comminuted (broken into many pieces) bone fragments
    b. Multiple fractures in a single bone
    c. Bone loss due to severe trauma
    d. Damage to the surrounding soft tissue
    e. Severe cartilage damage to the associated joint
    f. Dislocation of the associated joint.
    O. What do we consider when we evaluate musculoskeletal 
disorders of infants and toddlers from birth to attainment of age 3 
with developmental motor delay (101.24)?
    1. Under listing 101.24 Musculoskeletal disorders of infants and 
toddlers, from birth to attainment of age 3, with developmental 
motor delay, we use reports from an acceptable medical source(s) to 
establish a diagnosis of delay in your motor development. To 
evaluate the severity level of your developmental motor delay, we 
accept developmental test reports from an acceptable medical source, 
or from early intervention specialists, physical and occupational 
therapists, and other sources.
    a. If there is a standardized developmental assessment in your 
medical record, we will use the results to evaluate your 
developmental motor delay under 101.24A. Such an assessment compares 
your level of development to the level typically expected for 
children of your chronological age. If you were born prematurely, we 
use your corrected chronological age (CCA) for comparison. Your CCA 
is your chronological age adjusted by a period of gestational 
prematurity (CCA = (chronological age)--(number of weeks premature)) 
(see Sec.  416.924b(b) of this chapter).
    b. If there is no standardized developmental assessment in your 
medical record, we will use narrative developmental reports from a 
medical source(s) to evaluate your developmental motor delay under 
101.24B. These reports must provide detailed information sufficient 
for us to assess the severity of your motor delay. If we cannot 
obtain sufficient detail from narrative reports, we may purchase 
standardized developmental assessments.
    (i) A narrative developmental report is based on clinical 
observations, progress notes, and well-baby check-ups, and must 
include your developmental history; examination findings (with 
abnormal findings noted on repeated examinations); and an overall 
assessment of your development (that is, more than one or two 
isolated skills) by the medical source.
    (ii) Some narrative developmental reports may include results 
from developmental screening tests, which can show that you are not 
developing or achieving skills within expected timeframes. Although 
medical sources may refer to screening test results as supporting 
evidence in the narrative developmental report, screening test 
results alone cannot establish a medically determinable impairment 
or the severity of developmental motor delay.
    2. Examples of disorders we evaluate include arthrogryposis, 
clubfoot, osteogenesis imperfecta, caudal regression syndrome, 
fracture complications, disorders affecting the hip and pelvis, and 
complications associated with your disorder or its treatment. Some 
medical records may simply document your condition as 
``developmental motor delay.''
    P. How do we determine when your soft tissue injury or 
abnormality or your upper extremity fracture is no longer under 
continuing surgical management or you have received maximum 
therapeutic benefit?
    1. Your soft tissue injury or abnormality or your upper 
extremity fracture is no longer under continuing surgical management 
when the last surgical procedure or medical treatment directed 
toward the re-establishment or improvement of function of the 
involved part has occurred. We will find that you have received 
maximum therapeutic benefit from treatment if there are no 
significant changes in physical findings or on appropriate imaging 
for any 6-month period after the last surgical procedure or medical 
treatment. We may also find that you have received maximum 
therapeutic benefit if your medical source(s) indicates that further 
improvement is not expected after the last surgical procedure or 
medical treatment.
    2. When you have received maximum therapeutic benefit from 
treatment, we will evaluate any impairment-related residual 
symptoms, signs, and laboratory findings (including those on 
imaging), any complications associated with your surgical procedures 
or medical treatments, and any residual limitations in your 
functioning. Depending upon all of those factors, we may find that 
your musculoskeletal impairment is no longer severe.
    3. If your impairment(s) remains severe, we will evaluate your 
residual limitations and all other impairment-related factors to 
determine whether your musculoskeletal disorder meets or medically 
equals another listing or functionally equals the listings. If your 
impairment involves burns and remains severe, we will follow the 
above sequence by evaluating your impairment as described in 
101.00L3.
    Q. How do we evaluate the severity and duration of your 
established musculoskeletal disorder when there is no record of 
ongoing treatment?
    1. You may not have received ongoing treatment or may not have 
an ongoing relationship with the medical community despite having a 
musculoskeletal disorder(s). In either of these situations, you will 
not have a longitudinal medical record for us to review when we 
evaluate your disorder. We may therefore ask you to attend a 
consultative examination to determine the severity and potential 
duration of your disorder (see Sec.  416.919a(b) of this chapter).
    2. In some instances, we may be able to assess the severity and 
duration of your musculoskeletal disorder based on your medical 
record and current evidence alone. If the information in your case 
record is not sufficient or appropriate to show that you have a 
musculoskeletal disorder that meets the criteria of one of the 
musculoskeletal disorders listings, we will follow the rules in 
101.00R.
    R. How do we evaluate disorders that do not meet one of the 
musculoskeletal listings?
    1. These listings are only examples of musculoskeletal disorders 
that we consider severe enough to result in marked and severe 
functional limitations. If your musculoskeletal disorder(s) does not 
meet the criteria of any of these listings, we will consider whether 
you have an impairment(s) that meets the criteria of a listing in 
another body system.
    2. If you have a severe medically determinable impairment(s) 
that does not meet any listing, we will determine whether your 
impairment(s) medically equals a listing (see Sec.  416.926 of this 
chapter). If it does not medically equal a listing, we will 
determine whether it functionally equals the listings (see Sec.  
416.926a of this chapter).
    3. We use the rules in Sec.  416.994a of this chapter when we 
decide whether you continue to be disabled.

101.01 Category of Impairments, Musculoskeletal Disorders

    101.15 Disorders of the skeletal spine resulting in compromise 
of a nerve root(s) (see 101.00F), documented by A, B, C, and D:
    A. Symptom(s) of neuro-anatomic (radicular) distribution of one 
or more of the following manifestations consistent with compromise 
of the affected nerve root(s):
    1. Pain; or
    2. Paresthesias; or
    3. Muscle fatigue.

AND

    B. Radicular neurological signs present during physical 
examination or testing and evidenced by 1, 2, and 4; or 1, 3, and 4 
below:
    1. Muscle weakness; and
    2. Sensory changes evidenced by:
    a. Decreased sensation; or
    b. Sensory nerve deficit (abnormal sensory nerve latency) on 
electrodiagnostic testing; or
    3. Decreased deep tendon reflexes; and
    4. Sign(s) of nerve root irritation, tension, or compression, 
consistent with compromise of the affected nerve root (see 
101.00F2).

AND

    C. Findings on imaging consistent with compromise of a nerve 
root(s) in the cervical or lumbosacral spine (see 101.00C3).

AND

    D. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 101.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or

[[Page 20671]]

    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
age-appropriate activities involving fine and gross movements.
    101.16 Lumbar spinal stenosis resulting in compromise of the 
cauda equina (see 101.00G), documented by A, B, C, and D:
    A. Symptoms of neurological compromise, such as pain, manifested 
as:
    1. Nonradicular distribution of pain in one or both lower 
extremities; or
    2. Nonradicular distribution of sensory loss in one or both 
extremities; or
    3. Neurogenic claudication.

AND

    B. Nonradicular neurological signs present during physical 
examination or testing and evidenced by 1 and 2, or 1 and 3, below:
    1. Muscle weakness; and
    2. Sensory changes evidenced by:
    a. Decreased sensation; or
    b. Sensory nerve deficit (abnormal sensory nerve latency) on 
electrodiagnostic testing; or
    c. Areflexia, trophic ulceration, or bladder or bowel 
incontinence.
    3. Decreased deep tendon reflexes in one or both lower 
extremities.

AND

    C. Findings on imaging or in an operative report consistent with 
compromise of the cauda equina with lumbar spinal stenosis.
    AND

    D. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 101.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity.
    101.17 Reconstructive surgery or surgical arthrodesis of a major 
weight-bearing joint (see 101.00H), documented by A and B and C:
    A. Documented history of reconstructive surgery or surgical 
arthrodesis of a major weight-bearing joint.

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months.

AND

    C. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 101.00E).
    101.18 Abnormality of a major joint(s) in any extremity (see 
101.00I), documented by A, B, C, and D:
    A. Chronic joint pain or stiffness.

AND

    B. Abnormal motion, instability, or immobility of the affected 
joint(s).

AND

    C. Anatomical abnormality of the affected joint(s) noted on:
    1. Physical examination (for example, subluxation, contracture, 
bony or fibrous ankylosis); or
    2. Imaging (for example, joint space narrowing, bony 
destruction, or ankylosis or arthrodesis of the affected joint).

AND

    D. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 101.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or
    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
age-appropriate activities involving fine and gross movements.
    101.19 Pathologic fractures due to any cause (see 101.00J), 
documented by A and B:
    A. Three or more medically documented pathologic fractures 
occurring on separate occasions within a 12-month period;

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months, and medical documentation 
of at least one of the following (see 101.00E):
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches; or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or
    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
age-appropriate activities involving fine and gross movements.
    101.20 Amputation due to any cause (see 101.00K), documented by 
A, B, C, or D:
    A. Amputation of both upper extremities, occurring at any level 
above the wrists (carpal joints), up to and including the shoulder 
(glenohumeral) joint.

OR

    B. Hemipelvectomy or hip disarticulation.

OR

    C. Amputation of one upper extremity, occurring at any level 
above the wrist (carpal joints), and one lower extremity at or above 
the ankle (tarsal joint), and medical documentation of one the 
following (see 101.00E):
    1. The documented medical need for a one-handed assistive device 
requiring the use of the other upper extremity, or
    2. The inability to use the remaining upper extremity to 
independently initiate, sustain, and complete age-appropriate 
activities involving fine and gross movements.

OR

    D. Amputation of one or both lower extremities at or above the 
ankle (tarsal joint), with complications of the residual limb that 
have lasted or can be expected to last for at least 12 months, and 
medical documentation of both 1 and 2 (see 101.00E):
    1. The inability to use a prosthetic device(s); and
    2. The documented medical need for a walker, bilateral canes, or 
bilateral crutches.
    101.21 Soft tissue injury or abnormality under continuing 
surgical management (see 101.00L), documented by A, B, and C in the 
medical record:
    A. Evidence confirms ongoing surgical management directed 
towards saving, reconstructing, or replacing the affected part of 
the body.

AND

    B. The surgical management has been, or is expected to be, 
ongoing for at least 12 months.

AND

    C. Maximum benefit from therapy has not yet been achieved.
    101.22 Non-healing or complex fracture of the femur, tibia, 
pelvis, or one or more of the tarsal bones (see 101.00M), documented 
by A and B and C:
    A. Solid union not evident on appropriate medically acceptable 
imaging and not clinically solid;

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months,

AND

    C. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 101.00E).
    101.23 Non-healing or complex fracture of an upper extremity 
(see 101.00N), Documented by A and B and C:
    A. Nonunion of a fracture, or complex fracture, of the shaft of 
the humerus, radius, or ulna, under continuing surgical management, 
as defined in 1.00P, directed toward restoration of functional use 
of the extremity;

AND

    B. Impairment-related physical limitation of musculoskeletal 
functioning that has lasted, or can be expected to last, for a 
continuous period of at least 12 months,

AND

    C. Medical documentation of at least one of the following (see 
101.00E):
    1. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device that requires the use of the other upper 
extremity; or
    2. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and

[[Page 20672]]

complete age-appropriate activities involving fine and gross 
movements.
    101.24 Musculoskeletal disorders of infants and toddlers, from 
birth to attainment of age 3, with developmental motor delay (see 
101.00O), as documented by A or B:
    A. A standardized developmental motor assessment that:
    1. Shows motor development not more than one-half the level 
typically expected for child's age; or
    2. Results in a valid score that is at least three standard 
deviations below the mean.

OR

    B. Two narrative developmental reports that:
    1. Are dated at least 120 days apart; and
    2. Show motor development not more than one-half of the level 
typically expected for child's age.
* * * * *

104.00 CARDIOVASCULAR SYSTEM

* * * * *
    F. Evaluating Other Cardiovascular Impairments
* * * * *
    9. What is lymphedema and how will we evaluate it?
* * * * *
    b. * * * We will evaluate lymphedema by considering whether the 
underlying cause meets or medically equals any listing or whether 
the lymphedema medically equals a cardiovascular listing, such as 
4.11 Chronic venous insufficiency, or a musculoskeletal listing, 
such as 101.18 Abnormality of a major joint(s) in any extremity. * * 
*
* * * * *

114.00 IMMUNE SYSTEM DISORDERS

* * * * *
    C. Definitions
* * * * *
    2. Assistive device(s) has the same meaning as in 101.00C6a.
* * * * *
    5. Documented medical need has the same meaning as in 101.00C6a.
* * * * *
    8. Fine and gross movements have the same meaning as in 
101.00E4.
    9. Hand-held assistive device has the same meaning as in 
101.00C6d.
    10. Major joint of an upper or lower extremity has the same 
meaning as in 101.00I1.
* * * * *
    D. How do we document and evaluate the listed autoimmune 
disorders?
* * * * *
    4. Polymyositis and dermatomyositis (114.05).
* * * * *
    c. Additional information about how we evaluate polymyositis and 
dermatomyositis under the listings.
* * * * *
    (ii) If you are of preschool age through adolescence (age 3 to 
attainment of age 18), weakness of your pelvic girdle muscles that 
results in your inability to rise independently from a squatting or 
sitting position or to climb stairs may be an indication that you 
are unable to walk without physical or mechanical assistance. * * *
* * * * *
    6. Inflammatory arthritis (114.09).
    a. General. * * * Clinically, inflammation of major joints in an 
upper or lower extremity may be the dominant manifestation causing 
difficulties with walking or performing fine and gross movements; 
there may be joint pain, swelling, and tenderness. The arthritis may 
affect other joints, or cause less limitation in walking or 
performing fine and gross movements. * * *
* * * * *
    e. How we evaluate inflammatory arthritis under the listings.
    (i) Listing-level severity in 114.09 Inflammatory arthritis A 
and C1 is shown by the presence of an impairment-related, 
significant limitation cited in the criteria of these listings. In 
114.09A, listing-level severity is satisfied with persistent 
inflammation or deformity in one major joint in a lower extremity 
resulting in a documented medical need for a walker, bilateral 
canes, or bilateral crutches as required in 114.09A1, or one major 
joint in each upper extremity resulting in an impairment-related, 
significant limitation in the ability to perform fine and gross 
movements as required in 114.09A2. In 114.09C1, if you have the 
required ankylosis (fixation) of your cervical or dorsolumbar spine, 
we will find that you have an impairment-related significant 
limitation in your ability to see in front of you, above you, and to 
the side. Therefore, a listing-level impairment in the ability to 
walk is implicit in 114.09C1, even though you might not require 
bilateral upper limb assistance.
    (ii) Listing-level severity is shown in 114.09B and 114.09C2 by 
inflammatory arthritis that involves various combinations of 
complications of one or more major joints in an upper or lower 
extremity or other joints, such as inflammation or deformity, extra-
articular features, repeated manifestations, and constitutional 
symptoms and signs. * * *
* * * * *

114.01 Category of Impairments, Immune System Disorders

* * * * *
    114.04 Systemic sclerosis (scleroderma). As described in 
114.00D3. With:
* * * * *
    B. One of the following:
    1. Toe contractures or fixed deformity of one or both feet, 
resulting in one of the following:
    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 114.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 114.00C9) that requires the use of the 
other upper extremity; or
    2. Finger contractures or fixed deformity in both hands, 
resulting in an inability to use both upper extremities to the 
extent that neither can be used to independently initiate, sustain, 
and complete age-appropriate activities involving fine and gross 
movements; or
    3. Atrophy with irreversible damage in one or both lower 
extremities, resulting in one of the following:
    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 114.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 114.00C9) that requires the use of the 
other upper extremity; or
    4. Atrophy with irreversible damage in both upper extremities, 
resulting in an inability to use both upper extremities to the 
extent that neither can be used to independently initiate, sustain, 
and complete age-appropriate activities involving fine and gross 
movements.

OR

    C. Raynaud's phenomenon, characterized by:
* * * * *
    2. Ischemia with ulcerations of toes or fingers, resulting in 
one of the following:
    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 114.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 114.00C9) that requires the use of the 
other upper extremity; or
    c. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
age-appropriate activities involving fine and gross movements.
* * * * *
    114.05 Polymyositis and dermatomyositis. As described in 
114.00D4. With:
    A. Proximal limb-girdle (pelvic or shoulder) muscle weakness, 
resulting in one of the following:
    1. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 114.00C9); or
    2. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 114.00C9) that requires the use of the 
other upper extremity; or
    3. An inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
age-appropriate activities involving fine and gross movements.
* * * * *
    114.09 Inflammatory arthritis. As described in 114.00D6. With:
    A. Persistent inflammation or persistent deformity of:
    1. One or more major joints in a lower extremity(ies) resulting 
in one of the following:

[[Page 20673]]

    a. A documented medical need for a walker, bilateral canes, or 
bilateral crutches (see 114.00C9); or
    b. An inability to use one upper extremity to independently 
initiate, sustain, and complete age-appropriate activities involving 
fine and gross movements, and a documented medical need for a one-
handed assistive device (see 114.00C9) that requires the use of the 
other upper extremity; or
    2. One or more major joints in each upper extremity resulting in 
an inability to use both upper extremities to the extent that 
neither can be used to independently initiate, sustain, and complete 
age-appropriate activities involving fine and gross movements.

OR

    B. Inflammation or deformity in one or more major joints of an 
upper or lower extremity(ies) with: * * *
* * * * *

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

Subpart I--[Amended]

0
3. The authority citation for subpart I of part 416 continues to read 
as follows:

    Authority:  Secs. 221(m), 702(a)(5), 1611, 1614, 1619, 1631(a), 
(c), (d)(1), and (p), and 1633 of the Social Security Act (42 U.S.C. 
421(m), 902(a)(5), 1382, 1382c, 1382h, 1383(a), (c), (d)(1), and 
(p), and 1383b); secs. 4(c) and 5, 6(c)-(e), 14(a), and 15, Pub. L. 
98-460, 98 Stat. 1794, 1801, 1802, and 1808 (42 U.S.C. 421 note, 423 
note, and 1382h note).

0
4. Amend Sec.  416.926a by removing paragraph (m)(1) through (m)(2) and 
redesignating paragraphs (m)(3) through (m)(5) as (m)(1) through 
(m)(3).

[FR Doc. 2018-08889 Filed 5-4-18; 8:45 am]
 BILLING CODE 4191-02-P