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Last Modified Friday, November 08, 2013


U.S. Social Security Administration
Disability Evaluation Under Social Security
(Blue Book- September 2008)
Social Security Administration SSA Pub. No. 64-039
Office of Disability Programs ICN 468600
September 2008

[Source:  http://www.ssa.gov/disability/professionals/bluebook/]

[Excerpts Pertaining to Meniere's Disease]

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Part I - General Information

Program Description

The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act (the Act)) and the supplemental security income (SSI) program (title XVI of the Act).

Title II provides for payment of disability benefits to individuals who are "insured" under the Act by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals. Title XVI provides for SSI payments to individuals (including children under age 18) who are disabled and have limited income and resources.

The Act and SSA's implementing regulations prescribe rules for deciding if an individual is "disabled." SSA's criteria for deciding if someone is disabled are not necessarily the same as the criteria applied in other Government and private disability programs.

Definition of Disability
 
For all individuals applying for disability benefits under title II, and for adults applying under title XVI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

Disability in Children

Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

What is a "Medically Determinable Impairment"?

A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings-not only by the individual's statement of symptoms.

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The Role of the Health Professional

Health professionals play a vital role in the disability determination process and participate in the process in a variety of ways:

  • As treating sources or other medical sources who provide medical evidence on behalf of their patients;

  • As CE [consultive examination] sources to perform, for a fee, examinations and/or tests that are needed;

  • As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of SSA's regional offices, or in SSA central office; or

  • As medical experts who testify at administrative law judge hearings or respond to written interrogatories from the administrative law judge.

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Q. How is the disability determination made?

A. SSA’s regulations provide for disability evaluation under a procedure known as the "sequential evaluation process." For adults, this process requires sequential review of the claimant's current work activity, the severity of his or her impairment(s), a determination of whether his or her impairment(s) meets or medically equals a listing (see Part III of this guide), the claimant's residual functional capacity, his or her past work, and his or her age, education, and work experience. For children applying for SSI, the process requires sequential review of the child's current work activity (if any), the severity of his or her impairment(s), and an assessment of whether his or her impairment(s) results in marked and severe functional limitations. If an adult or child is found disabled or not disabled at any point in the evaluation, the evaluation does not continue.

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Part II - Evidentiary Requirements

Medical Evidence

Under both the Title II and Title XVI programs, medical evidence is the cornerstone for the determination of disability.

Each person who files a disability claim is responsible for providing medical evidence showing he or she has an impairment(s) and the severity of the impairment(s). However, the Social Security Administration (SSA), with the claimant’s permission, will help the claimant get medical reports from his or her own medical sources. This medical evidence generally comes from sources that have treated or evaluated the claimant for his or her impairment(s).

Acceptable Medical Sources

Documentation of the existence of a claimant's impairment must come from medical professionals defined by SSA regulations as "acceptable medical sources." Once the existence of an impairment is established, all the medical and non-medical evidence is considered in assessing impairment severity.
Acceptable medical sources are:

  • licensed physicians (medical or osteopathic doctors);  
  • licensed or certified psychologists including school psychologists (and other licensed or certified individuals with other titles who perform the same function as school psychologists in a school setting) only for purposes of establishing mental retardation, learning disabilities, and borderline intellectual functioning ; 
  • licensed optometrists only for purposes of establishing visual disorders (except in the U.S. Virgin Islands where licensed optometrists are acceptable medical sources only for the measurement of visual acuity and visual fields);
  • licensed podiatrists only for purposes of establishing impairments of the foot, or foot and  the ankle, depending on whether the State in which the podiatrist practices permits the practice of podiatry on the foot only, or the foot and the ankle; and
  • qualified speech-language pathologists only for purposes of establishing speech or language impairments. For this source, “qualified” means that the speech-language pathologist must be licensed by the State education agency in the State in which he or she practices, or hold a Certificate of Clinical Competence from the American Speech-Language-Hearing Association.

Medical Evidence from Treating Sources

Currently, many disability claims are decided based on medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant's impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.

Medical Evidence From Health Facilities

SSA also requests copies of medical evidence from hospitals, clinics, or other health facilities where a claimant has been treated. All medical reports received are considered during the disability determination process.

Other Evidence

Information from other sources may also help show the extent to which an individual's impairment(s) affects his or her ability to function in a work setting; or in the case of a child, the ability to function compared to that of children the same age who do not have impairments. Other sources include public and private agencies, non‑medical sources such as schools, parents and caregivers, social workers and employers, and other practitioners such as naturopaths, chiropractors, and audiologists.

Medical Reports

Physicians, psychologists, and other health professionals are frequently asked by SSA to submit reports about an individual's impairment(s). Therefore, it is important to know what evidence SSA needs. Medical reports should include:

  • medical history;
  • clinical findings (such as the results of physical or mental status examinations);
  • laboratory findings (such as blood pressure, x-rays);
  • diagnosis;
  • treatment prescribed with response and prognosis;
  • a statement about what the claimant can still do despite his or her impairment(s), based on the medical source's findings on the above factors.
  • f the claimant is an adult age 18 or over, this statement should describe, but is not limited to, the claimant's ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.
  • in adult cases involving mental impairments or mental functional limitations, this statement should describe the claimant's capacity to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting.

if the claimant is a child under age 18, this statement should describe the child’s functional limitations compared to children his or her age who do not have impairments  in acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for yourself, and health and physical well-being.

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Evidence Relating to Symptoms

In developing evidence of the effects of symptoms, such as pain, shortness of breath, or fatigue, on a claimant's ability to function, SSA investigates all avenues presented that relate to the complaints. These include information provided by treating and other sources regarding:

  • the claimant's daily activities;
  • the location, duration, frequency, and intensity of the pain or other symptom;
  • precipitating and aggravating factors;
  • the type, dosage, effectiveness, and side effects of any medication;
  • treatments, other than medications, for the relief of pain or other symptoms;
  • any measures the claimant uses or has used to relieve pain or other symptoms; and
  • other factors concerning the claimant's functional limitations due to pain or other symptoms.

In assessing the claimant's pain or other symptoms, the decision makers must give full consideration to all of the above-mentioned factors. It is important that medical sources address these factors in the reports they provide.

Part III - Listing Of Impairments

The Listing of Impairments describes, for each major body system, impairments considered severe enough to prevent an individual from doing any gainful activity (or in the case of children under age 18 applying for SSI, severe enought to cause marked and severe functional limitations). Most of the listed impairments are permanent or expected to result in death, or the listing includes a specific statement of duration is made. For all other listings, the evidence must show that the impairment has lasted or is expected to last for a continuous period of at least 12 months. The criteria in the Listing of Impairments are applicable to evaluation of claims for disability benefits under the Social Security disability insurance program or payments under both the SSI program.

Part A of the Listing of Impairments contains medical criteria that apply to the evaluation of impairments in adults age 18 and over. The medical criteria in Part A may also be applied in evaluating impairments in children under age 18 if the disease processes have a similar effect on adults and younger children.

Part B of the Listing of Impairments contains additional medical criteria that apply only to the evaluation of impairments of persons under age 18. Certain criteria in Part A do not give appropriate consideration to the particular effects of the disease processes in childhood; that is, when the disease process is generally found only in children or when the disease process differs in its effect on children and adults.

Additional criteria are included in Part B, and the impairment categories are, to the extent possible, numbered to maintain a relationship with their counterparts in Part A. In evaluating disability for child under age 18, part B will be used first. If the medical criteria in part B do not apply, then the medical criteria in part A will be used.

The criteria in the Listing of Impairments apply only to one step of the multi-step sequential evaluation process. At that step, the presence of an impairment that meets the criteria in the Listing of Impairments (or that is of equal severity) is usually sufficient to establish that an individual who is not working is disabled.

However, the absence of a listing-level impairment does not mean the individual is not disabled. Rather, it merely requires the adjudicator to move on to the next step of the process and apply other rules in order to resolve the issue of disability.

Listing of Impairments -  Adult Listings (Part A)

The following sections are applicable to individuals age 18 and over and to children under age 18 where criteria are appropriate.

This electronic version contains the new Immune System Disorders Listings effective June 16, 2008.

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2.00 Special Senses and Speech

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B. Otolaryngology

1. Hearing Impairment. Hearing ability should be evaluated in terms of the person’s ability to hear and distinguish speech.

Loss of hearing can be quantitatively determined by an audiometer which meets the standards of the American National Standards Institute (ANSI) for air and bone conducted stimuli (i.e., ANSI S 3.6‑1969 and ANSI S 3.13-1972, or subsequent comparable revisions) and performing all hearing measurements in an environment which meets the ANSI standard for maximal permissible background sound (ANSI S 3.1‑1977).

Speech discrimination should be determined using a standardized measure of speech discrimination ability in quiet at a test presentation level sufficient to ascertain maximum discrimination ability. The speech discrimination measure (test) used, and the level at which testing was done must be reported.

Hearing tests should be preceded by an otolaryngologic examination and should be performed by or under the supervision of an otolaryngologist or audiologist qualified to perform such tests.

In order to establish an independent medical judgment as to the level of impairment in a claimant alleging deafness, the following examinations should be reported: Otolaryngologic examination, pure tone air and bone audiometry, speech reception threshold (SRT), and speech discrimination testing. A copy of reports of medical examination and audiologic evaluations must be submitted.

Cases of alleged “deaf mutism” should be documented by a hearing evaluation. Records obtained from a speech and hearing rehabilitation center or a special school for the deaf may be acceptable, but if these reports are not available, or are found to be inadequate, a current hearing evaluation should be submitted as outlined in the preceding paragraph.

2. Vertigo associated with disturbances of labyrinthine‑vestibular function, including Meniere’s disease. These disturbances of balance are characterized by an hallucination of motion or a loss of position sense and a sensation of dizziness which may be constant or may occur in paroxysmal attacks. Nausea, vomiting, ataxia, and incapacitation are frequently observed, particularly during the acute attack. It is important to differentiate the report of rotary vertigo from that of “dizziness” which is described as light‑headedness, unsteadiness, confusion, or syncope.

Meniere’s disease is characterized by paroxysmal attacks of vertigo, tinnitus, and fluctuating hearing loss. Remissions are unpredictable and irregular, but may be long-lasting; hence, the severity of impairment is best determined after prolonged observation and serial reexaminations.

The diagnosis of a vestibular disorder requires a comprehensive neuro‑otolaryngologic examination with a detailed description of the vertiginous episodes, including notation of frequency, severity, and duration of the attacks. Pure tone and speech audiometry with the appropriate special examinations, such as Bekesy audiometry, are necessary. Vestibular function is accessed by positional and caloric testing, preferably by electronystagmography. When polytomograms, contrast radiography, or other special tests have been performed, copies of the reports of these tests should be obtained in addition to appropriate medically acceptable imaging reports of the skull and temporal bone. Medically acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast material, myelography, and radionuclear bone scans. “Appropriate” means that the technique used is the proper one to support the evaluation and diagnosis of the impairment.

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2.07  Disturbance of labyrinthine‑vestibular function (including Meniere’s disease), characterized by a history of frequent attacks of balance disturbance, tinnitus, and progressive loss of hearing. With both A and B:

A. Disturbed function of vestibular labyrinth demonstrated by caloric or other vestibular tests; and

B. Hearing loss established by audiometry.

2.08  Hearing impairments (hearing not restorable by a hearing aid) manifested by:

A. Average hearing threshold sensitivity for air conduction of 90decibels or greater, and for bone conduction to corresponding maximal levels, in the better ear, determined by the simple average of hearing threshold levels at 500, 1000, and 2000hz. (see 2.00B1); or

B. Speech discrimination scores of 40 percent or less in the better ear.

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