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 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.
* * *
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 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.
Treating Sources
A treating source is a claimant's own physician, psychologist, or
other acceptable medical source who has provided the claimant with
medical treatment or evaluation and has or has had an ongoing
treatment relationship with the claimant. The treating source is
usually the best source of medical evidence about the nature and
severity of an individual's impairment(s).
If an additional examination or testing is needed, SSA usually
considers a treating source to be the preferred source for performing
the examination or test for his or her own patient.
The treating source is neither asked nor expected to make a decision
whether the claimant is disabled. However, a treating source will
usually be asked to provide a statement about an adult claimant's
ability, despite his or her impairments, to do work‑related physical
or mental activities or a child’s functional limitations compared to
children the child’s age who do not have impairments.
* * *
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), 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.
* * *
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 that he or she has an impairment(s) and how
severe the impairment(s) is. However, the Social Security Administration
(SSA) will help claimants get medical reports from their own medical
sources when the claimants give SSA permission to do so. This medical
evidence generally comes from sources who 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.
Included are school psychologists, or other licensed or certified
individuals with other titles who perform the same function as a
school psychologist in a school setting, for purposes of establishing
mental retardation, learning disabilities, and borderline intellectual
functioning only ;
licensed optometrists, for the
measurement of visual acuity and visual fields;
licensed podiatrists (for purposes of
establishing impairments of the foot, or foot and ankle only,
depending on the State in which the podiatrist practices);
and qualified speech-language
pathologists (for purposes of establishing speech or language
impairments only).
Medical Evidence From Health Facilities
Social Security 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.
Medical Evidence from Treating Sources
Currently, many disability claims are decided on the basis of 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 impairments 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.
Other Evidence
Information from other sources may also help show the extent to which a
person'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.
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 providing an opinion about
what the claimant can still do despite his or her impairment(s), based
on the medical source's findings on the above factors. This statement
should describe, but is not limited to, the individual's ability to
perform work-related activities, such as sitting, standing, walking,
lifting, carrying, handling objects, hearing, speaking, and traveling.
In cases involving mental impairments, it should describe the
individual's ability to understand, to carry out and remember
instructions, and to respond appropriately to supervision, coworkers,
and work pressures in a work setting. For a child, the statement
should describe his or her functional limitations in learning, motor
functioning, performing self-care activities, communicating,
socializing, and completing tasks (and, if a child is a newborn or
young infant from birth to age 1, responsiveness to stimuli).
* * *
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 decisionmaker(s) 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 that are considered
severe enough to prevent a person from doing any gainful activity (or in
the case of children under age 18 applying for SSI, cause marked and
severe functional limitations). Most of the listed impairments are
permanent or expected to result in death, or a specific statement of
duration is made. For all others, 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 or payments
under both the Social Security disability insurance and SSI programs.
Part A
This section of the Listing of Impairments contains medical criteria
that apply to adults age 18 and over. The medical criteria in Part A may
also be applied in evaluating impairments in persons under age 18 if the
disease processes have a similar effect on adults and younger persons.
Part B
This section 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, i.e., 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 a person 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 Genitourinary Impairments
listings, effective September 6, 2005; the new Impairments That Affect
Multiple Body Systems listings, effective October 31, 2005; and the new
Cardiovascular System listings, effective April 13, 2006.
* * *
2.00 Special Senses and
Speech
* * *
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 magnet
resonance imaging, (MRI) with or without contrast material, myelography,
and radionuclear bone scans. "Appropriate" means the technique used is
the proper one to support the evaluation and diagnosis of the
impairment.
3. Loss of Speech. In evaluating the loss of speech, the ability to
produce speech by any means includes the use of mechanical or electronic
devices that improve voice or articulation. Impairments of speech may
also be evaluated under the body system for the underlying disorder,
such as neurological disorders, 11.00ff.
* * *
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 90
decibels 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 2000 hz. (see 2.OOB 1); or
B. Speech discrimination scores of 40 percent or less in the better ear.
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