TN 3 (04-11)

Citations:

20 CFR 404.1525;404.1526; 404.1528; 404.1529; 416.925; 416.926; 416.928; and 416.929

A. Listing of impairments

1. What is the purpose of the listing of impairments?

The Listing of Impairments is in DI 34000.000. It describes impairments for each of the major body systems that we consider to be severe enough to prevent a claimant from doing any gainful activity, regardless of his or her age, education, or work experience.

2. How is the listing of impairments organized? There are two parts in the listing of impairments

a. Part A

Contains criteria that apply to claimants age 18 and over. We may also use Part A for claimants who are under age 18 if the disease processes have a similar effect on adults and children.

b. Part B

Contains criteria that apply only to claimants who are under age 18. We never use the listings in Part B to evaluate claimants who are age 18 or older. In evaluating disability for a claimant under age 18, we use Part B first. If the criteria in Part B do not apply, we may use the criteria in Part A when those criteria give appropriate consideration to the effects of the impairment(s) in children. To the extent possible, we number the provisions in Part B to maintain a relationship with their counterparts in Part A.

3. How do we use the listings?

1. Each body system section in Parts A and B of the Listing of Impairments is in two parts: an introduction, followed by the specific listings.

2. The introduction to each body system contains information relevant to the use of the listings in that body system; e.g., examples of common impairments in the body system and definitions used in the listings for that body system. We may also include specific criteria for establishing a diagnosis, confirming the existence of an impairment(s), or establishing that an impairment(s) satisfies the criteria of a particular listing in the body system. Even if we do not include specific criteria for establishing a diagnosis or confirming the existence of an impairment(s), the claimant must still show that he or she has a severe medically determinable impairment(s) as defined in DI 24505.001.

3. The specific listings follow the introduction in each body system, after the heading, “Category of Impairments.” Within each listing, we specify the objective medical and other findings needed to satisfy the criteria of that listing. We will find that an impairment(s) meets the requirements of a listing when it satisfies all of the criteria of that listing, including any relevant criteria in the introduction, and meets the duration requirement.

4. Most of the listed impairments are permanent or expected to result in death. For some listings, we state a specific period of time for which an impairment(s) will meet the listing. For all others, the evidence must show that an impairment(s) has lasted or can be expected to last for a continuous period of at least 12 months.

5. If an impairment(s) does not meet the criteria of a listing, it can medically equal the criteria of a listing. We explain our rules for medical equivalence in DI 24505.015B. in this section. We use the listings only to find that the claimant is disabled or still disabled. If the claimant’s impairment(s) does not meet or medically equal the criteria of a listing, we may find that he or she is disabled or still disabled at a later step in the sequential evaluation process.

4. Can an impairment(s) meet a listing based only on a diagnosis?

No. An impairment(s) cannot meet the criteria of a listing based only on a diagnosis. To meet the requirements of a listing, the claimant must have a medically determinable impairment(s) that satisfies all of the criteria in the listing.

5. How do we consider symptoms when we determine whether an impairment(s) meets a listing?

Some listed impairments include symptoms, such as pain, as criteria. DI 24501.021A.2. explains how we consider symptoms when they are included as criteria in a listing.

B. Medical equivalence

1. What is medical equivalence?

An impairment(s) is medically equivalent to a listed impairment in the Listing of Impairments if it is at least equal in severity and duration to the criteria of any listed impairment.

2. How do we determine medical equivalence?

We can determine medical equivalence in the following three ways:

1. If the claimant has an impairment that is described in the Listing of Impairments, but:

   • The claimant’s impairment does not exhibit one or more of the findings specified in the particular listing; or

   • The claimant’s impairment does exhibit all of the findings, but one or more of the findings is not as severe as specified in the particular listing; then

   • We determine the claimant’s impairment is medically equivalent to that listing if they have other findings related to their impairment that are at least of equal medical significance to the required criteria.

2. If the claimant has an impairment that is not described in the Listing of Impairments, we will compare their findings with those for closely analogous listed impairments. If the findings related to the claimant’s impairment are at least of equal medical significance to those of a listed impairment, we determine their impairment is medically equivalent to the most closely analogous listing.

3. If the claimant has a combination of impairments, none of which meets a listing, we will compare their findings with those for closely analogous listed impairments. If the findings related to the claimant’s impairments are at least of equal medical significance to those of a listed impairment, we determine the combination of impairments is medically equivalent to the most closely analogous listing.

NOTE: DI 24501.021A.2. explains how we consider symptoms, such as pain, when we make findings about medical equivalence.

3. What evidence do we consider when we determine if an impairment(s) medically equals a listing?

When we determine if an impairment(s) medically equals a listing, we consider all evidence in the claimant’s case record about their impairment(s) and its effects on them that are relevant to this finding. We do not consider the vocational factors of age, education, and work experience. We also consider the administrative medical findings given by one or more medical or psychological consultants designated by the Commissioner.

4. Who is a designated medical or psychological consultant?

A medical or psychological consultant designated by the Commissioner includes any medical or psychological consultant employed or engaged to make medical judgments by the Social Security Administration, the Railroad Retirement Board, or a State agency authorized to make disability determinations. For claims adjudicated under the administrative review process, a designated consultant includes a medical or psychological expert. See DI 24501.001 for who can be a medical consultant or psychological consultant.

5. Who is responsible for determining medical equivalence?

In cases where the State agency or other designee of the Commissioner makes the initial or reconsideration disability determination, a State agency medical or psychological consultant or other designee of the Commissioner has the overall responsibility for determining medical equivalence (see DI 24501.001B.2). For cases in the disability hearing process or otherwise decided by a hearing officer, the responsibility for determining medical equivalence rests with the disability hearing officer. For cases at the Administrative Law Judge or Appeals Council level, the responsibility for deciding medical equivalence rests with the Administrative Law Judge or Appeals Council.

6. What are the rationale requirements for each of the three ways to find medical equivalence?

If an impairment(s) medically equals the severity of a listed impairment and meets the duration requirement, find that the claimant is disabled or still disabled. For all medical equivalence determinations, prepare a rationale according to the guidelines in this section. The rationale must reflect consideration of the pertinent evidence of record and reconcile or resolve significant inconsistencies. The adjudicator must include the items listed below in the rationale.

NOTE: When substituting a finding or symptom from a listing, the adjudicator may only substitute symptoms for other symptoms and findings for other findings. Never substitute a symptom for a finding.

1. If a claimant has a listed impairment, there are two possible scenarios.

   First scenario: The claimant’s impairment does not exhibit one or more of the findings specified in the listing:

   • Discuss the claimant’s impairment, medical findings, and non-medical findings.

   • Discuss the findings required to meet the listed impairment.

   • Discuss the required finding(s) that are missing in the findings of the claimant’s impairment.

   • Discuss the finding(s) of the claimant’s impairment that is at least of equal medical significance to the required findings.

   • Explain why we can substitute those findings to medically equal the listed impairment.

   • Cite the listing for the medical equivalence determination.

2. Second scenario: The claimant’s impairment exhibits all of the required findings, but one or more of the findings is not as severe as specified in the listing:

   • Discuss the claimant’s impairment, medical findings, and non-medical findings.

   • Discuss the findings required to meet the listing.

   • Identify the finding or findings related to the claimant’s impairment that is not as severe as specified in the listing.

   • Discuss the finding(s) of the claimant’s impairment that is at least of equal medical significance to the required findings.

   • Explain why we can substitute those findings to medically equal the listed impairment.

   • Cite the listing for the medical equivalence determination.

3. For an unlisted impairment:

   • Discuss the claimant’s impairment(s), medical findings, and non-medical findings.

   • Discuss the listing we are considering to use as the most closely analogous listing.

   • Compare the findings of the claimant’s impairment to the findings for the most closely analogous listing.

   • Explain why the findings of the claimant’s impairment are at least of equal medical significance to the findings of the most closely analogous listing.

   • Cite the most closely analogous listing used to determine medical equivalence.

4. For a combination of impairments:

   • Discuss the claimant’s impairments, medical findings, and non-medical findings.

   • Discuss the listing we are considering to use as the most closely analogous listing.

   • Compare the findings of the claimant’s impairments to the findings for the most closely analogous listing.

   • Explain why the findings of the claimant’s impairments are at least of equal medical significance to the findings of the most closely analogous listing.

   • Cite the most closely analogous listing used to determine medical equivalence.

7. Examples of rationales for medical equivalence determinations

These rationales are examples only.

a. Listed impairment

First Example:

A claimant alleges difficulty walking, chronic pain, and limitation of motion in the left knee. X-ray findings reveal degenerative arthritis without deformity of either knee. Treatment records show the claimant is morbidly obese with a BMI of 56.5 (5’6”; 350 pounds), has chronic joint pain, limitation of motion, and great difficulty walking. He walks very slowly and can walk only short distances before he has to stop and rest. He becomes short of breath on exertion, especially walking up steps.

On the SSA-3367 (Disability Report), the field office claims representative (CR) included observations of the claimant’s gait. The claimant:

• used a walker to move from the waiting room to the interview area;

• leaned on the walker, took only a few steps at a time, and then had to stop and start over again; and

• appeared to be in great pain while walking.

In addition, a Department of Veterans Affairs social worker (SW) made similar observations in the treatment records.

The claimant’s impairment is missing findings (gross anatomical deformity and stiffness) required to meet listing 1.02A. Obesity, which contributes to the claimant’s shortness of breath and inability to walk effectively, is at least of equal medical significance to the required findings in listing 1.02A. Therefore, the claimant’s impairment medically equals listing 1.02A.

Second Example:

A claimant has a history of a left ankle fracture. Post-fracture he developed chronic pain in his right knee. Current medical records show chronic pain on weight-bearing, stiffness, limitation of motion of the left ankle and right knee, and significant difficult walking. His physical therapist prescribed bilateral canes or a walker for ambulation. X-rays show arthritis of the left ankle and degenerative joint disease of the right knee. Listing 1.02A requires involvement of one major weight-bearing peripheral joint. Findings of the claimant’s impairment include all required findings of 1.02A, except gross anatomical deformity. The claimant’s impairment involves two major weight-bearing joints. This medical finding is at least of equal medical significance to the missing finding, gross anatomical deformity. Therefore, the claimant’s impairment medically equals listing 1.02A.

b. Unlisted impairment

First example:

A claimant has Prader-Willi Syndrome (PWS) with cognitive disabilities, decreased muscle tone, short stature, emotional lability, and an insatiable appetite. He is 64” tall and weighs 300 pounds. IQ testing is not available. Genetic clinic records confirm chromosome 15 findings consistent with PWS. The claimant was home-schooled due to his extreme behavior problems, such as temper tantrums, perseveration, and compulsive-like behaviors. When he attended school he would take food from other students. He does not get along with people and has very few social skills. To aid in restricting his food intake at home, his parents placed locks on all food cabinets, the refrigerator, and even garbage cans. Listing 12.02, Neurocognitive Disorders, is the most closely analogous listed impairment. The claimant has behavioral abnormalities associated with his genetic condition. Laboratory tests confirm his diagnosis. He is completely dependent on his parents in all areas of functioning. These findings are at least of equal medical significance to listing 12.02. Therefore, the claimant’s impairment medically equals listing 12.02A.6.B2. and B.4.

Second Example:

A claimant has chronic migraine headaches for which she sees her treating doctor on a regular basis. Her symptoms include aura, alteration of awareness, and intense headache with throbbing and severe pain. She has nausea and photophobia and must lie down in a dark and quiet room for relief. Her headaches last anywhere from 4 to 72 hours and occur at least 2 times or more weekly. Due to all of her symptoms, she has difficulty performing her ADLs. The claimant takes medication as her doctor prescribes. The findings of the claimant’s impairment are very similar to those of 11.02, Epilepsy, Dyscognitive seizures. Therefore, 11.02 is the most closely analogous listed impairment. Her findings are at least of equal medical significance as those of the most closely analogous listed impairment. Therefore, the claimant’s impairment medically equals listing 11.02.D.1.

c. Combination of impairments

First Example:

An adult claimant has chronic venous insufficiency, type 1 diabetes mellitus (DM), and peripheral neuropathy. Medical evidence reveals chronic edema in both legs, stasis dermatitis, and persistent ulcerations on the right lower leg that have not healed despite treatment for more than 6 months. He has numbness, burning sensations, and sometimes weakness in both legs, and walks with a wide-based antalgic gait (a self-protective limp due to pain). He also has difficulty rising from a chair. We determine that the evidence does not document that the claimant’s chronic venous insufficiency satisfies the requirements in listing 4.11(A or B), Chronic venous insufficiency. The evidence does not document extensive brawny edema that we require in listing 4.11A or superficial varicosities (in addition to stasis dermatitis and persistent ulceration) that we require in listing 4.11B. We determine, however, that when we consider the claimant’s combined impairments that listing 4.11B is the most closely analogous listed impairment. The claimant’s combined findings of both chronic venous insufficiency and DM are at least of equal medical significance. Therefore, the combination of the claimant’s impairments medically equals listing 4.11B.

Second Example:

A claimant was involved in a car accident. He was ejected from the car and then trapped under the exhaust system, which resulted in second and third degree burns to his right torso and the left side of his face. The burns were very severe and he spent three months in a burn center where he had multiple surgeries. Eight months after the accident, the claimant attended a consultative exam (CE). He has limitation of motion of both right extremities due to contractures and pain. However, this limitation does not negatively affect his overall physical functioning. The claimant’s primary alleged disability is related to his facial appearance. At the CE, the physical description showed a terribly deformed face and neck on the left side. His left external ear is absent. He has deformity, contractures, scarring, and abnormalities of the entire left side of his face. His appearance is very grotesque and he is very self-conscious. Even at home he wears a bandage to cover his face. He is depressed, has a flat affect, and does not smile. He has severe anxiety about being around people. He refuses to go out unless it is absolutely necessary. He has a sense of panic about driving and being around people, so he avoids these situations when possible. His wife always accompanies him. His mental diagnoses are psychosocial trauma and stressors due to his facial disfigurement; depression and anxiety disorder, both untreated.

The claimant’s impairment does not meet listing 8.08 (specifically the introductory test in 8.08 C and F) because his musculoskeletal residuals from the burns do not seriously limit use of more than one extremity. Per the introductory test in 8.08D.4, we evaluate facial deformities under the 12.00 listings. DDS Psychological Consultant states that claimant does not technically meet listing 12.06, Anxiety and Obsessive-Compulsive Disorders. However, the most closely analogous listed impairment is listing 12.06. Combining the findings of the burn residuals and findings related to his anxiety, the total findings are at least of equal medical significance to the findings in either listing 8.08 or 12.06. Therefore, we determine the claimant’s impairments medically equal listing 12.06A.2.b. B.1. and B.4.

C. References

• DI 22001.001D.3, Impairment(s) Meets or Medically Equals a Listing

• DI 24501.020, Symptoms, Signs, and Laboratory Findings

• DI 24501.021, Evaluating Symptoms

• DI 25220.010, Meets or Medically Equals

• DI 34000.000, Listing of Impairments – Current