1

Obsolete - Reserved for future use

2

Amputation of a leg at the hip

3

Allegation of total deafness

4

Allegation of total blindness

5

Allegation of bed confinement and immobility without a wheelchair, walker, or crutches due to a longstanding condition

Exclude a recent accident or recent surgery

6

Allegation of stroke more than 3 months in the past and continued marked difficulty in walking or using a hand or arm

7

Allegation of cerebral palsy, muscular dystrophy, or muscle atrophy and marked difficulty in walking (e.g., the use of braces), speaking, or coordination of the hands or arms

8

Obsolete - Reserved for future use

9

Allegation of Down Syndrome

NOTE: Individuals with Down Syndrome are characterized to have developmental delays, an intellectual disability, and abnormal physical features such as:

• lateral upward slope of the eyes,

• extra skin folds between the eye and nose,

• protruded large tongue,

• short nose with a flat bridge,

• generalized low muscle tone,

• short arms and legs, and hands and feet that tend to be broad and flat.

Individuals with Down syndrome may also have

• congenital heart disease,

• congenital bowel abnormalities,

• vision and hearing problems, or

• other medical conditions.

10

Allegation of intellectual disability or

another neurodevelopmental impairment (for example, autism spectrum disorder) with

complete inability to independently perform basic self-care activities (such as toileting, eating, dressing, or bathing)

made by another person who files on behalf of a claimant who is at least 4 years old.

EXAMPLE: A mother filing for benefits for her child states that the child attends (or has attended) a special school or special classes in school because of a neurodevelopmental impairment, or that the child is unable to attend any type of school (or if beyond school age, was unable to attend), and requires care and supervision of routine daily activities.

11

A child has not attained his or her first birthday, and

the birth certificate or other medical evidence shows a weight below 1200 grams (2 pounds, 10 ounces) at birth.

12

Symptomatic human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS), see DI 11055.241.

You need

• Form SSA-4814-F5 (Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection) or

• Form SSA-4815-F6 (Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection)

13

NOTE: This category only applies to infants whose gestational age (GA) at birth is a minimum of 32 weeks and a maximum GA of 40 weeks. If the GA and birth weight are not within the stated ranges below, this category is not applicable.

DO NOT USE if you can use category 11.

GA is based on the date of conception.

If you see more than one GA or birth weight in the medical evidence, forward the case to the DDS for consideration of a PD finding.

A child has not attained his or her first birthday and available medical evidence shows a GA at birth with the corresponding birth-weight indicated:

GA: 37-40 weeks

Birth Weight: Less than 2000 grams (4 pounds, 6 ounces)

GA: 36 weeks

Birth Weight: 1875 grams (4 pounds, 2 ounces) or less

GA: 35 weeks

Birth Weight: 1700 grams (3 pounds, 12 ounces) or less

GA: 34 weeks

Birth Weight: 1500 grams (3 pounds, 5 ounces) or less

GA: 33 weeks

Birth Weight: 1325 grams (2 pounds, 15 ounces) or less

GA: 32 weeks

Birth Weight: 1250 grams (2 pounds, 12 ounces) or less

For infants weighing under 1200 grams at birth, see category 11.

14

A physician confirms by telephone or in a signed statement that an individual has a terminal illness with a life expectancy of 6 months or less, or

A physician (or hospice official, e.g., hospice coordinator, staff nurse, social worker, or medical records custodian) confirms that an individual is receiving hospice services because of a terminal illness.

For terminal illness procedures, see DI 11005.601.

NOTE: “Hospice” refers to a program of supportive care for terminally ill persons. Such services may be provided in the home or in an inpatient facility.

15

Allegation of a spinal cord injury producing an inability to move without the use of a walker or bilateral hand-held assistive device for more than 2 weeks (with confirmation of such status from an acceptable medical source as defined in DI 22505.003A)

16

Allegation of end stage renal disease (ESRD) requiring chronic dialysis;

You need Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report - Medicare Entitlement or Patient Registration), per HI 00801.233.

(See exhibit of the form in HI 00801.902.)

17

Allegation of amyotrophic lateral sclerosis (ALS) known as Lou Gehrig’s disease