[Federal Register Volume 84, Number 97 (Monday, May 20, 2019)]
[Notices]
[Pages 22924-22926]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-10432]



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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2018-0022]


Social Security Ruling, SSR 19-2p; Titles II and XVI: Evaluating 
Cases Involving Obesity

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are providing notice of SSR 19-2p. This SSR provides 
guidance on how we establish that a person has a medically determinable 
impairment of obesity and how we evaluate obesity in disability claims 
under Titles II and XVI of the Social Security Act.

DATES: We will apply this notice on May 20, 2019.

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: Although 5 U.S.C. 552(a)(1) and (a)(2) do 
not require us to publish this SSR, we are doing so under 20 CFR 
402.35(b)(1).
    Through SSRs, we make available to the public precedential 
decisions relating to the Federal old-age, survivors, disability, 
supplemental security income, and special veterans' benefits programs. 
We may base SSRs on determinations or decisions made at all levels of 
administrative adjudication, Federal court decisions, Commissioner's 
decisions, opinions of the Office of the General Counsel, or other 
interpretations of the law and regulations.
    Although SSRs do not have the same force and effect as statutes or 
regulations, they are binding on all of our components. 20 CFR 
402.35(b)(1).
    This SSR will remain in effect until we publish a notice in the 
Federal Register that rescinds it, or until we publish a new SSR that 
replaces or modifies it.

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

Nancy A. Berryhill,
Acting Commissioner of Social Security.

Policy Interpretation Ruling

Titles II and XVI: Evaluating Cases Involving Obesity

    This Social Security Ruling (SSR) rescinds and replaces SSR 02-1p; 
Titles II and XVI: Evaluation of Obesity.
    Purpose: This SSR provides guidance on how we establish that a 
person has a medically determinable impairment (MDI) of obesity and how 
we evaluate obesity in disability claims under Titles II and XVI of the 
Social Security Act (Act).\1\
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    \1\ For simplicity, we refer in this SSR only to initial adult 
claims for disability benefits under Titles II and XVI of the Act. 
The policy interpretations in this SSR, however, also apply to 
claims of children (that is, people who have not attained age 18) 
who apply for benefits based on disability under Title XVI of the 
Act, continuing disability reviews of adults and children under 
sections 223(f) and 1614(a)(4) of the Act, and redeterminations of 
eligibility for benefits we make in accordance with section 
1614(a)(3)(H) of the Act when a child who is receiving Title XVI 
payments based on disability attains age 18.
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    Citations (Authority): Sections 216(i), 223(d), 223(f), 1614(a), 
and 1614(c) of the Act, as amended; Regulations No. 4, subpart P, 
sections 404.1502, 404.1509, 404.1512, 404.1513, 404.1520, 404.1521-
404.1523, 404.1525, 404.1526, 404.1529, 404.1545, 404.1546, 404.1560-
404.1569a, 404.1594 and appendices 1 and 2; Regulations No. 16, subpart 
I, sections 416.902, 416.909, 416.912, 416.913, 416.920, 416.921-
416.923, 416.924, 416.924a, 416.925, 416.926, 416.926a, 416.929, 
416.945, 416.946, 416.960-416.969a, 416.987, 416.994, and 416.994a.

Introduction

    Obesity, when established by objective medical evidence (signs, 
laboratory findings, or both) from an acceptable medical source (AMS), 
is an MDI. We provide guidance in this SSR on how we establish that a 
person has an MDI of obesity, and how we evaluate obesity in disability 
claims. People with obesity have a higher risk for other impairments, 
and the effects of obesity combined with other impairments can be 
greater than the effects of each of the impairments considered 
separately. Obesity is not a listed impairment; however, the functional 
limitations caused by the MDI of obesity, either alone or in 
combination with another impairment(s), may medically equal a 
listing.\2\ Obesity in combination with another impairment(s) may or 
may not increase the severity or functional limitations of the other 
impairment(s). We evaluate each case based on the information in the 
case record.
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    \2\ See 20 CFR 404.1526 and 416.926.
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    On September 12, 2002, we published SSR 02-1p (67 FR 57859) to 
provide guidance on the evaluation of obesity in disability claims. 
Since then, we published several final rules that revise some of the 
criteria we use to evaluate disability claims under Titles II and XVI 
of the Act. We are issuing this SSR to reflect the changes to the rules 
we have published, and advances in medical knowledge, since publication 
of SSR 02-1p.

Policy Interpretation

    The following information is in a question and answer format that 
provides guidance on how we establish that a person has an MDI of 
obesity and how we evaluate obesity in disability claims. Questions 1 
and 2 provide basic background information about obesity and 
impairments associated with obesity. Questions 3 and 4 discuss how we 
establish obesity as an MDI and how we determine if it is a severe MDI. 
Questions 5 and 6 specify how we evaluate obesity under the Listing of 
Impairments (listings),\3\ and how we consider obesity when assessing a 
person's residual functional capacity (RFC).
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    \3\ See 20 CFR part 404, subpart P, Appendix 1.
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List of Questions

    1. How does the medical community diagnose obesity?
    2. Which impairments are associated with obesity?
    3. How do we establish obesity as an MDI?
    4. When is obesity a severe impairment?
    5. How do we evaluate obesity under the listings?
    6. How do we consider obesity in assessing a person's RFC?
    1. How does the medical community diagnose obesity?
    Obesity is a complex disorder characterized by an excessive amount 
of body fat, and is generally the result of many factors including 
environment, family history and genetics, metabolism, and behavior. 
Health care practitioners diagnose obesity based on a person's medical 
history, physical examinations, and body mass index (BMI). For adults, 
BMI is a person's weight in kilograms divided by the square of his or 
her height in meters (kg/m\2\). People with obesity weigh more than 
what is considered the healthy weight for their height. In the medical 
community, obesity is defined as a BMI of 30.0 or

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higher.4 5 No specific weight or BMI establishes obesity as 
a severe impairment within the disability program. For how we establish 
obesity as an MDI, see Question 3. For when we consider obesity to be a 
severe impairment, see Question 4.
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    \4\ Jensen, M. D., Ryan, D. H, Donato, K. A., Apovian, C. M., 
Ard, J.D., Comuzzie, A. G., . . . Yanoski, S. Z. (2014). Guidelines 
(2013) for managing overweight and obesity in adults. Obesity, 
22(S2), S1-S410. doi:10.1002/oby/20660.
    \5\ For children age 2 and older, weight status is determined 
using an age- and gender-specific percentile for BMI rather than the 
BMI categories used for adults. This is because children's body 
composition varies as they age and varies between boys and girls. 
Obesity is defined as a BMI-for-age at or above the 95th percentile. 
See Barlow, S. E. (2007). Expert committee recommendations regarding 
the prevention, assessment, and treatment of child and adolescent 
overweight and obesity: Summary report. Pediatrics, 120, S164-S192. 
doi:10.1542/peds.2007-2329C
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    Health care practitioners may take a waist measurement to help 
diagnose obesity. If a person's BMI is within the normal range, he or 
she may still have obesity if his or her waist measurement is high. 
People who store more fat around their waist rather than their hips may 
have a greater risk of obesity-related complications. The risk 
increases for a waist size greater than 35 inches for women and greater 
than 40 inches for men.\6\
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    \6\ Jensen, M. D., Ryan, D. H, Donato, K. A., Apovian, C. M., 
Ard, J.D., Comuzzie, A. G., . . . Yanoski, S. Z. (2014). Guidelines 
(2013) for managing overweight and obesity in adults. Obesity, 
22(S2), S1-S410. doi:10.1002/oby.20660
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    2. Which impairments are associated with obesity?
    Obesity is often associated with musculoskeletal, respiratory, 
cardiovascular, and endocrine disorders. Obesity also increases the 
risk of developing impairments including:
     Type II diabetes mellitus;
     Diseases of the heart and blood vessels (for example, high 
blood pressure, atherosclerosis, heart attacks, and stroke);
     Respiratory impairments (for example, sleep apnea, asthma, 
and obesity hypoventilation syndrome);
     Osteoarthritis;
     Mental impairments (for example, depression); and
     Cancers of the esophagus, pancreas, colon, rectum, kidney, 
endometrium, ovaries, gallbladder, breast, or liver.
    The fact that obesity increases the risk for developing other 
impairments does not mean that people with obesity necessarily have any 
of these impairments. It means that they are at greater than average 
risk for developing other impairments.
    3. How do we establish obesity as an MDI?
    We establish obesity as an MDI by considering objective medical 
evidence (signs, laboratory findings, or both) from an AMS. We will not 
use a diagnosis or a statement of symptoms to establish the existence 
of an MDI.\7\ Signs and laboratory findings from an AMS that may 
establish an MDI of obesity include measured height and weight, 
measured waist size, and BMI measurements over time.
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    \7\ See 20 CFR 404.1521 and 416.921.
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    We calculate BMI based on the medical evidence in the case record, 
even if the person's medical source(s) has not indicated that the 
person has obesity. We will not calculate BMI based on a person's self-
reported height and weight. In addition, we will not purchase tests to 
measure body fat. When deciding whether a person has an MDI of obesity, 
we consider the person's weight over time. We consider the person to 
have an MDI of obesity as long as his or her weight, measured waist 
size, or BMI shows a consistent pattern of obesity.
    Although there is often a correlation between BMI and excess body 
fat, this is not always the case. Someone who has a BMI of 30 or above 
may not have an MDI of obesity if a large percentage of the person's 
weight is from muscle. It will usually be evident from the information 
in the case record whether the person does not have an MDI of obesity, 
despite a BMI of 30 or above.
    4. When is obesity a severe impairment?
    When we evaluate the severity of obesity, we consider all evidence 
from all sources. We consider all symptoms, such as fatigue or pain 
that could limit functioning.\8\ We consider any functional limitations 
in the person's ability to do basic work activities resulting from 
obesity and from any other physical or mental impairments. If the 
person's obesity, alone or in combination with another impairment(s), 
significantly limits his or her physical or mental ability to do basic 
work activities, we find that the impairment(s) is severe.\9\ We find, 
however, that the impairment(s) is ``not severe'' if it does not 
significantly limit [a person's] physical or mental ability to do basic 
work activities.\10\
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    \8\ See 20 CFR 404.1529 and 416.929.
    \9\ For children applying for disability under Title XVI, we 
find that the impairment(s) is severe when it causes more than 
minimal functional limitations. See 20 CFR 416.924(c).
    \10\ See 20 CFR 404.1522 and 416.922.
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    No specific weight or BMI establishes obesity as a ``severe'' or 
``not severe'' impairment. Similarly, a medical source's descriptive 
terms for levels of obesity, such as ``severe,'' ``extreme,'' or 
``morbid,'' do not establish whether obesity is a severe impairment for 
disability program purposes. We do an individualized assessment of the 
effect of obesity on a person's functioning when deciding whether the 
impairment is severe.
    5. How do we evaluate obesity under the listings?
    Obesity is not a listed impairment; however, the functional 
limitations caused by the MDI of obesity, alone or in combination with 
another impairment(s), may medically equal a listing.\11\ For example, 
obesity may increase the severity of a coexisting or related 
impairment(s) to the extent that the combination of impairments 
medically equals a listing.\12\
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    \11\ See 20 CFR 404.1526 and 416.926.
    \12\ For children applying for disability under Title XVI, we 
may evaluate the functional consequences of obesity (either alone or 
in combination with other impairments) to decide if the child's 
impairment(s) functionally equals the listings. For example, the 
functional limitations imposed by obesity, by itself or in 
combination with another impairment(s), may establish extreme 
limitation of one domain of functioning or marked limitation of two 
domains. See 20 CFR 416.926a.
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    We will not make general assumptions about the severity or 
functional effects of obesity combined with another impairment(s). 
Obesity in combination with another impairment(s) may or may not 
increase the severity or functional limitations of the other 
impairment. We evaluate each case based on the information in the case 
record.
    6. How do we consider obesity in assessing a person's RFC?
    We must consider the limiting effects of obesity when assessing a 
person's RFC.\13\ RFC is the most an adult can do despite his or her 
limitation(s). As with any other impairment, we will explain how we 
reached our conclusion on whether obesity causes any limitations.
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    \13\ See 20 CFR 404.1545 and 416.945.
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    A person may have limitations in any of the exertional functions, 
which are sitting, standing, walking, lifting, carrying, pushing, and 
pulling. A person may have limitations in the nonexertional functions 
of climbing, balancing, stooping, kneeling, crouching, and crawling. 
Obesity increases stress on weight-bearing joints and may contribute to 
limitation of the range of motion of the skeletal spine and 
extremities. Obesity may also affect a person's ability to manipulate 
objects, if there is adipose (fatty) tissue in the hands and fingers, 
or the ability to tolerate extreme heat, humidity, or hazards.
    We assess the RFC to show the effect obesity has upon the person's 
ability to perform routine movement and necessary physical activity 
within the work environment. People with an MDI

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of obesity may have limitations in the ability to sustain a function 
over time. In cases involving obesity, fatigue may affect the person's 
physical and mental ability to sustain work activity. This may be 
particularly true in cases involving obesity and sleep apnea.
    The combined effects of obesity with another impairment(s) may be 
greater than the effects of each of the impairments considered 
separately. For example, someone who has obesity and arthritis 
affecting a weight-bearing joint may have more pain and functional 
limitations than the person would have due to the arthritis alone. We 
consider all work-related physical and mental limitations, whether due 
to a person's obesity, other impairment(s), or combination of 
impairments.
    This SSR is applicable on May 20, 2019.\14\
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    \14\ We will use this SSR beginning on its applicable date. We 
will apply this SSR to new applications filed on or after the 
applicable date of the SSR and to claims that are pending on and 
after the applicable date. This means that we will use this SSR on 
and after its applicable date in any case in which we make a 
determination or decision. We expect that Federal courts will review 
our final decisions using the rules that were in effect at the time 
we issued the decisions. If a court reverses our final decision and 
remands a case for further administrative proceedings after the 
applicable date of this SSR, we will apply this SSR to the entire 
period at issue in the decision we make after the court's remand.
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    Cross References: SSR 82-52: Titles II and XVI: Duration of the 
Impairment; SSR 85-28: Titles II and XVI: Medical Impairments That Are 
Not Severe; SSR 86-8: Titles II and XVI: The Sequential Evaluation 
Process; SSR 96-8p: Titles II and XVI: Assessing Residual Functional 
Capacity in Initial Claims; SSR 16-3p: Titles II and XVI: Evaluation of 
Symptoms in Disability Claims; SSR 17-2p: Titles II and XVI: Evidence 
Needed by Adjudicators at the Hearings and Appeals Council Levels of 
the Administrative Review Process to Make Findings about Medical 
Equivalence; and Program Operations Manual System (POMS) DI 22505.001, 
DI 22505.003, DI 24501.020, DI 24501.021, DI 24503.005, DI 24505.001, 
DI 24505.005, DI 24508.010, DI 24510.005, DI 24515.062, and DI 
24515.063.

[FR Doc. 2019-10432 Filed 5-17-19; 8:45 am]
BILLING CODE 4191-02-P