I-5-4-30-A.Processing Supplemental Security Income Childhood Disability Cases Based on Pub. L. 104-193

Table of Contents
I Purpose
II Background
III Summary of the Major Provisions of §§ 211 and 212 of Pub. L. 104-193
IV New Definition of Disability in Title XVI of the Act for Individuals Under Age 18
V Functional Equivalence
VI Hearing Office Procedures
VII Appeals Council Procedures
VIII Inquiries
Attachment 1 - NOTICE OHA WILL SEND TO CLAIMANTS WHO HAD A HEARING BEFORE ENACTMENT OF PUBLIC LAW (Pub. L.) No. 104-193
Attachment 2 - Memorandum Protest Case
Attachment 3 (1 of 2) - OHA CASE CONTROL SYSTEM CHILDHOOD DISABILITY CODES FIRST REGULATION BASIS CODE (1RG, 3RG)
Attachment 4 (1 of 2) - OHA CHILDHOOD DISABILITY REGULATION BASIS AND IMPAIRMENT CODES
Attachment 5 - EXTRACT FROM POMS SECTION DI 26510.015

ISSUED: November 28, 1997

I. Purpose

This instruction provides procedures for implementing the childhood disability provisions of sections 211 and 212 of Public Law (Pub. L.) 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, that provide a new definition of disability for children (i.e., individuals under age 18), mandate changes to the evaluation process for children's disability claims and continuing disability reviews (CDRs), and require that disability redeterminations be performed for certain children under age 18 and for 18-year-olds eligible as children in the month before the month in which they attain age 18. These instructions apply with respect to supplemental security income (SSI) childhood disability claims which are currently pending before the Office of Hearings and Appeals (OHA) and for claims for SSI childhood disability benefits filed on or after August 22, 1996. These procedures amend and supplement existing procedures contained in HALLEX Temporary Instructions (TI) I-5-4-30, issued September 9, 1992. Although some of the questions in the TI are obsolete and not relevant to the new disability standard, the information in the TI is still needed to process those cases that will be decided under the pre-August 22, 1996 standard and for processing Zebley class action cases.

Separate instructions will be issued for processing Zebley class action cases, SSI childhood redetermination cases and CDRs.

II. Background

Pub. L. 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, enacted on August 22, 1996, amends § 1614(a)(3) and (4) of the Social Security Act (the Act) and contains provisions affecting childhood disability claims under title XVI of the Act. The following summary under III. below is drawn from the text of the Preamble to the regulations implementing the childhood disability provisions of section 211 and 212 of Pub. L. 104-193. It does not include all the Preamble text. The regulatory revisions that do not have some relevance to these instructions are not discussed.

III. Summary of the Major Provisions of §§ 211 and 212 of Pub. L. 104-193

Pub. L. 104-193 provides a new statutory definition of disability for children claiming SSI benefits and directs SSA to make significant changes in the way we[1] evaluate childhood disability claims. Under the new law, a child's impairment or combination of impairments must cause more serious impairment-related limitations than the old law and the prior regulations required.

Section 211(a) of Public Law 104-193 amended section 1614(a)(3) of the Act to provide a definition of disability for children separate from that for adults. The “comparable severity” criterion in the Act was repealed and replaced with the following definition:

(C)(i) An individual under the age of 18 shall be considered disabled for the purposes of this title if that individual has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and 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.

(ii) Notwithstanding clause (i), no individual under the age of 18 who engages in substantial gainful activity (determined in accordance with regulations prescribed pursuant to subparagraph (E)) may be considered to be disabled.

The conference report that accompanied Public Law 104-193 further explained:

The conferees intend that only needy children with severe disabilities be eligible for SSI, and the Listing of Impairments and other current disability determination regulations as modified by these provisions properly reflect the severity of disability contemplated by the new statutory definition. In those areas of the Listing that involve domains of functioning, the conferees expect no less than two marked limitations as the standard for qualification. The conferees are also aware that SSA uses the term “severe” to often mean “other than minor” in an initial screening procedure for disability determination and in other places. The conferees, however, use the term “severe” in its common sense meaning.

H.R. Conf. Rep. No. 725, 104th Cong., 2d Sess. 328 (1996), reprinted in 1996 U.S. Code, Cong. and Ad. News 2649, 2716. The House report contains similar language. See H.R. Rep. No. 651, 104th Cong., 2d Sess. 1385 (1996), reprinted in 1996 U.S. Code, Cong. and Ad. News 2183, 2444.

Further provisions concerning childhood disability adjudication are summarized below with references to the relevant sections of Public Law 104-193.

  • The Commissioner was directed to remove references to maladaptive behavior in the personal/behavioral domain from listings 112.00C2 and 112.02B2c(2) of the childhood mental disorders listings (Section 211(b)(1)).

  • The Commissioner was directed to discontinue the IFA for children in 20 CFR 416.924d and 416.924e (Section 211(b)(2)).

  • Within 1 year after the date of enactment, we must redetermine the eligibility of individuals under the age of 18 who were eligible for SSI based on disability as of August 22, 1996, and whose eligibility may terminate by reason of the new law. The cases are to be redetermined using the eligibility criteria for new applicants. The medical improvement review standard in section 1614(a)(4) of the Act and 20 CFR 416.994a, used in CDRs, shall not apply to these redeterminations (Section 211(d)(2)).

  • The medical improvement review standard for determining continuing eligibility for children was revised to conform to the new definition of disability for children (Section 211(c)).

  • Not less frequently than once every 3 years, we must conduct a CDR for any childhood disability recipient eligible by reason of an impairment(s) which is likely to improve. At the option of the Commissioner, we may also perform a CDR with respect to those individuals under age 18 whose impairments are unlikely to improve (Section 212(a)).

  • SSA must redetermine the eligibility of individuals who were eligible for SSI based on disability in the month before the month in which they attained age 18 using the rules for determining initial eligibility for adults. We will do the redetermination during the 1-year period beginning on the individual's 18th birthday. The medical improvement review standard used in CDRs does not apply to these redeterminations (Section 212(b)).

  • SSA must conduct a CDR not later than 12 months after the birth of the child for any child whose low birth weight is a contributing factor material to our determination that the child was disabled (Section 212(c)).

  • At the time of a CDR, a child's representative payee shall present evidence that the child is and has been receiving treatment to the extent considered medically necessary and available for the disabling impairment. If a payee refuses without good cause to provide such evidence, we may select another representative payee, or pay benefits directly to the child, if we determine that it is appropriate and in the best interests of the child (Section 212(a)).

These rules implement all of the provisions of sections 211 and 212 of Public Law 104-193, with the exception of section 211(d)(2). Because Public Law 104-193 repealed the “comparable severity” disability standard for children, and eliminated use of the IFA, step 4 of the prior sequential evaluation process (the comparable severity step) has been removed. To be found disabled under these rules, an individual under age 18 must have “marked and severe functional limitations,” which means that his or her impairment or combination of impairments must meet, or medically equal or functionally equal, the severity of a listed impairment.

Summary of Specific Revisions

These interim final rules revise our prior rules for deciding initial eligibility and continuing eligibility for children claiming SSI benefits based on disability. They also provide rules for redetermining the eligibility of individuals who attain age 18 and who were eligible for SSI based on disability in the month before the month in which they attained age 18.

The major changes to the rules are explained below. In addition, we have added, removed, and revised language throughout subpart I of 20 CFR part 416 to remove references to the “comparable severity” standard and our prior regulatory definition of disability interpreting that standard. Since these are only conforming changes to comply with the new law, we have not summarized each of them in this summary.

These rules do not address every aspect of the evaluation of disability of children and of individuals who have attained age 18. They implement primarily those changes required by Public Law 104-193. Therefore, they must be read in the context of all our other relevant rules for determining disability.

Appendix 1 to Subpart P of Part 404 - Listings 112.00C and 112.02B2

Public Law 104-193 mandates removal of references to “maladaptive behaviors” in listings 112.00C2 and 112.02B2c(2) in the childhood mental disorders section of the Listing of Impairments. Listing 112.00C explains the severity criteria we use to evaluate a mental impairment in most of our childhood mental disorder listings. These severity criteria are often referred to as the “paragraph B” criteria because they are found in paragraph B of most of the listings to which they apply. Listing 112.02B2c(2) was a particular paragraph B criterion for persistent, serious maladaptive behaviors in children aged 3 to 18. Pursuant to Public Law 104-193, we have removed all references to “maladaptive behaviors” in listing 112.00C and deleted all of prior listing 112.02B2c(2); we have also redesignated the “personal/behavioral” area as the area of “personal function.” For this reason, we also removed the reference to “activities of daily living” from former listing 112.02B2c(1), which we now designate as listing 112.02B2c because it is the only paragraph remaining.

The area of personal function now pertains only to self-care; that is, the ability to help oneself and to cooperate with others in taking care of personal needs, health, and safety (e.g., feeding, dressing, toileting, bathing, following medication regimens, and following safety precautions). Further, we have clarified the description of the social area of functioning to make it clearer that many impairment-related behavioral problems (including those previously considered in the prior personal/behavioral area) are likely to have their most significant effects on a child's social functioning.

In addition, we revised the fourth area of function from “concentration, persistence, and pace” to “concentration, persistence, or pace.” This is a technical correction to conform the language of this section to the rules in listings 112.00C3 and 112.02B2d, which have always read “deficiencies of concentration, persistence, or pace.” We made a corresponding change in listing 112.00C4, which also used the word “and.” We also made several clarifications in listing 112.00C2b. The changes are not substantive and are only intended to parallel the adult mental listing 12.00C2 with appropriate language for children.

Section 416.902 General Definitions and Terms for This Subpart

We have added four new definitions. First, we explain that a disability redetermination (see § 416.987) is a redetermination of eligibility based on disability using the rules for new applicants appropriate to the individual's age, except the rules pertaining to performance of substantial gainful activity. Second, we explain that the term impairment(s) means “a medically determinable physical or mental impairment or a combination of medically determinable physical or mental impairments.”

Third, we explain that the term marked and severe functional limitations, when used as a phrase, means the standard of disability in the Act for children claiming SSI benefits, and is a level of severity that meets or medically or functionally equals the requirements of a listing. We explain that the separate words marked and severe are also terms used throughout this subpart, but the meanings of these words in the phrase marked and severe functional limitations is not the same as their meanings when used separately. The meaning of the phrase marked and severe functional limitations derives directly from the legislative history of Public Law 104-193, quoted in the “Summary of the Childhood Disability Provisions of Public Law 104-193,” above. Since the meanings of the separate terms marked and severe predate enactment of Public Law 104-193, they are touched on in this section to minimize any confusion from the new law's use of the same words, used in combination with a different meaning. Finally, we define Commissioner to mean the Commissioner of Social Security.

Section 416.906 Basic Definition of Disability for Children

We have revised this section to replace the prior “comparable severity” standard with the new “marked and severe functional limitations” standard for childhood disability. We also added the statutory provision that an individual under age 18 who files a new claim and who is engaging in substantial gainful activity will not be considered disabled. For clarity, we added language specifying our longstanding policy that we consider the effects of combined impairments in assessing whether a child is disabled.

Section 416.919n Informing the Examining Physician or Psychologist of Examination Scheduling, Report Content, and Signature Requirements

We have amended § 416.919n(c)(6), which concerns the opinion of a consulting physician or psychologist about an individual's ability to function despite his or her impairment(s), to add a discussion specific to childhood cases to make it clear that the provision applies to both adults and children.

Section 416.924 How We Determine Disability for Children

We have extensively revised this section, which provides the sequential evaluation process for childhood disability claims, to conform to the provisions of Public Law 104-193.

We have deleted former paragraphs (a) and (f). Prior paragraph (a) defined comparable severity and prior paragraph (f) discussed the IFA. We redesignated prior paragraphs (b) through (e) as (a) through (d), and revised them as explained below. We added a new paragraph (e) to explain what we will do when children become adults (i.e., they attain age 18) after they file their applications for SSI benefits based on disability but before we make a determination or decision. We redesignated prior paragraph (g) as paragraph (f), but it is otherwise unchanged. Also, we added a new paragraph (g).

In final § 416.924, the new sequential evaluation process for determining initial eligibility is:

  1. Whether the child is engaging in substantial gainful activity;

  2. If not, whether the child has a medically determinable impairment or combination of impairments that is severe; and

  3. If the child's impairment(s) is severe, whether it meets or medically equals the requirements of a listing, or whether the functional limitations caused by the impairment(s) are the same as the disabling functional limitations of any listing and, therefore, functionally equivalent to such listing.

As in the prior sequential evaluation process, we will follow the steps in order. If a determination or decision can be made at a step, we will stop; if not, we will proceed to the next step.

New § 416.924(a), “Steps in evaluating disability,” retains basic guidance from prior § 416.924(b) that is unaffected by the new law. It continues to provide that we will consider all relevant evidence in a child's case record, that we will consider all impairments for which we have evidence and their combined effects, and that we will evaluate any limitations in a child's functioning that result from a child's symptoms, including pain. We have removed the reference to the prior IFA step and made minor revisions to reflect the new statutory standard and the new sequence of evaluation. Because meeting or equaling the severity of a listing is now the last step of the sequence, we have emphasized the importance of the step by specifying that a child will be disabled if his or her impairment(s) meets, medically equals, or functionally equals the severity of any listing. We also changed references to the “ability to function” to “functioning” in order to conform to the new statutory definition of disability, which is now expressed in terms of “marked and severe functional limitations.”

Final paragraphs (b) through (d) provide more detail on the sequential evaluation steps outlined in paragraph (a). Final paragraph (b), “If you are working,” is the same as prior paragraph (c). A child who files a new application, and who is engaging in substantial gainful activity, will be found not disabled as required by the statute. Final paragraph (c), “You must have a severe impairment(s),” is substantively the same as prior paragraph (d), but revised to reflect the new law. At step two of the sequential process, we will continue to evaluate whether a child has a “severe” impairment or combination of impairments. We now provide that if a child has a slight abnormality or a combination of slight abnormalities that causes no more than minimal functional limitations, we will find that the child does not have a severe impairment and, therefore, is not disabled. The phrase “minimal functional limitations” replaces the phrase from our prior rules “minimal limitation in your ability to function, independently, appropriately, and effectively in an age-appropriate manner,” which, as noted above, was derived from the prior statutory definition of disability.

Final paragraph (d), “Your impairment(s) must meet, medically equal, or functionally equal in severity a listed impairment in appendix 1,” explains that an impairment(s) causes marked and severe functional limitations if it meets, medically equals or functionally equals the severity of a listed impairment. Thus, if a child's impairment(s) meets, medically equals, or functionally equals in severity a listing (and meets the duration requirement), we will find the child disabled. If a child's impairment(s) does not meet or medically equal or functionally equal in severity any listing, or does not meet the duration requirement, we will find the child not disabled. We have removed the language from prior paragraph (e) that said a child's claim would not be denied because his or her impairment(s) was not of listing-level severity.

We added a new paragraph (e), “If you attain age 18 after you file your disability application but before we make a determination or decision,” to explain what we will do in such cases. We will use the rules for determining disability in adults when an individual whom we found disabled prior to attaining age 18 attains age 18. (We have always used the adult disability rules beginning at age 18 when we find that an individual was not disabled prior to attaining age 18 to see if the individual became disabled at a later date.) Therefore, final paragraph (e) explains that, for the period during which the individual is under age 18, we will use the disability rules in § 416.924, but for the period starting with the day the individual attains age 18, we will use the disability rules for adults filing new claims in § 416.920.

Except for redesignating prior paragraph (g) as final paragraph (f), “Basic considerations,” has not been changed. We will continue to consider all relevant medical and nonmedical evidence in a child's case record.

Finally, we have added a new paragraph (g) to explain that, when we make an initial or reconsidered determination whether you are disabled or when we make an initial determination about whether your disability continues under section 416.994a, we will complete a standard form, SSA-538, Childhood Disability Evaluation Form. The new form is designed to guide our adjudicators through the new sequential evaluation process and emphasizes the requirements for establishing functional equivalence. In new paragraph (g), we also explain that disability hearing officers, administrative law judges, and the administrative appeals judges on the Appeals Council (when the Appeals Council makes a decision) will not complete the form. This is because these adjudicators issue decisions with detailed rationales and findings that will already reflect the steps of the new sequential evaluation process.

Section 416.924a Age as a Factor of Evaluation in Childhood Disability

Most of the guidance in our prior rules on consideration of age in childhood disability cases has not been changed by Public Law 104-193. We have revised this section to conform to the “marked and severe functional limitations” disability standard. As under our prior rules, we will consider the child's age in determining whether he or she has a severe impairment(s). When evaluating whether the impairment(s) meets, medically equals, or functionally equals the severity of a listing, we will consider the child's age if the listing we consider uses age categories. We have deleted prior paragraphs (a)(4) and (b), which addressed issues related to the IFA.

We redesignated prior paragraph (c), “Correcting chronological age of premature infants,” and prior paragraph (d), “Age and the impact of severe impairments on younger children and older adolescents,” as final paragraphs (b) and (c) and made changes to conform to the new definition of disability; we deleted prior paragraph (d)(4)(ii) because it was based on the prior “comparable severity” standard.

Section 416.924b Functioning in Children

This section discusses some of the terms we use to describe or evaluate functioning in children, including age-appropriate activities, developmental milestones, activities of daily living, and work-related activities. We retained the discussions of these terms with appropriate conforming changes. We also clarified the explanations of the last three terms, which were described in our prior rules as “the most important indicators of functional limitations” in, respectively, infants up to attainment of age 3, children aged 3 to attainment of age 16, and older adolescents aged 16 to attainment of age 18. In the interim final rules, we describe these functions as being “most important as indicators of functional limitations,” because the emphasis should be on whatever age groups for which these indicators of functional limitations are most appropriate.

Although we deleted prior paragraph (b)(5) because it described the domains and behaviors used in performing an IFA under our prior rules, consideration of functional limitations remains an integral part of the childhood disability evaluation process. For example, final § 416.926a describes areas of functioning we will consider when we evaluate whether a child's impairment(s) is functionally equivalent in severity to a listing.

Section 416.924c Other Factors We Will Consider

As under our prior rules, when we evaluate whether a child's impairment(s) is disabling, we will consider all relevant factors, such as the effects of medications, the setting in which the child lives, the child's need for assistive devices, and the child's functioning in school. However, as throughout these interim final rules, we have revised this section to conform to the statutory “marked and severe functional limitations” standard.

Section 416.924d Individualized Functional Assessment for Children

Section 416.924e Guidelines for Determining Disability Using the Individualized Functional Assessment

We deleted both of these sections as required by section 211(b)(2) of Public Law 104-193.

Section 416.925 Listing of Impairments in Appendix 1 of Subpart P of Part 404 of This Chapter

We have revised paragraph (a) of this section, “Purpose of the Listing of Impairments,” to explain that, for children, the Listing of Impairments describes impairments that are considered severe enough to result in marked and severe functional limitations. We revised paragraph (b)(2), which explains the purpose of the childhood listings in part B of the Listings, to explain that the level of severity of the impairments listed in part B is intended to be the same as that expressed in the functional severity criteria of the childhood mental disorders listings (see 112.01 ff.). Therefore, in general, a child's impairment(s) is of “listing-level severity” if it results in marked limitations in two broad areas of functioning, or extreme limitations in one such area. However, we also explain that when we decide whether a child's impairment(s) meets the requirements for any listed impairment, we will decide that the impairment is of “listing-level severity” even if it does not result in marked limitations in two broad areas of functioning, or extreme limitations in one such area, if the listing that we apply does not require such limitations to establish that an impairment(s) is disabling. We also explain that we define the terms “marked” and “extreme” as they apply to children in § 416.926a.

Section 416.926 Medical Equivalence for Adults and Children

In these interim final rules, we moved the rules for deciding whether a child's impairment(s) is medically equivalent in severity to any listing into the same section as the rules for deciding medical equivalence of impairments in adults, reserving § 416.926a for functional equivalence. To make this clear, we revised the heading of final § 416.926 to reflect the inclusion of children. We also revised final paragraph (a), “How medical equivalence is determined,” by replacing the explanation of how we determine medical equivalence with provisions from prior § 416.926a. We also incorporated and revised the last sentence of prior § 416.926a(a), explaining that we consider all relevant evidence in the case record when we decide the issue of medical equivalence because it remains applicable to both adults and children.

We decided to use the provisions of former § 416.926a(b) to explain our rules for determining medical equivalence for both adults and children. This is not a substantive change, but a clearer statement of our longstanding policy on medical equivalence than was previously included in prior § 416.926(a), as it was clarified for children in prior § 416.926a(b). This merely allows us to address only once in our regulations the policy of medical equivalence, which is and always has been the same for adults and children. (Although some of the text of § 416.926(a) will differ from the text of § 404.1526(a), both sections, which are in chapter III of title 20 of the Code of Federal Regulations, will continue to provide the same substantive rules.)

We have also added a new paragraph (d), “Responsibility for determining medical equivalence,” to address our longstanding policy of who is responsible for determining medical equivalence for adults and children.

Section 416.926a Functional Equivalence for Children

Although Public Law 104-193 discontinued the use of the IFA, the legislation nevertheless emphasized that we were still to continue evaluating the functioning of children in our disability assessments, as shown by the new statutory definition of disability, “marked and severe functional limitations.”

Moreover, in the legislative history, the conferees stated:

. . . Where appropriate, the conferees remind SSA of the importance of the use of functional equivalence disability determination procedures.

. . . [T]he conferees do not intend to suggest by this definition of childhood disability that every child need be especially evaluated for functional limitations, or that this definition creates a supposition for any such examination. . . . Nonetheless, the conferees do not intend to limit the use of functional information, if reflecting sufficient severity and is otherwise appropriate.

H.R. Conf. Rep. No. 725, 104th Cong, 2d Sess. 328 (1996), reprinted in 1996 U.S. Code, Cong. and Ad. News 2649, 2716. The House Report also contained similar language about the importance of functional information. See H.R. Rep. No. 651, 104th Cong., 2d Sess. 1385-1386 (1996), reprinted in 1996 U.S. Code, Cong. and Ad. News 2183, 2444-2445.

Thus, even though it eliminated the IFA, Congress directed us to continue to evaluate a child's functional limitations where appropriate, albeit using a higher level of severity than under the former IFA. Congress also explicitly endorsed our functional equivalence policy as a means for evaluating impairments that would not meet or medically equal any of our listings and without which some needy children with severe disabilities would not be eligible.

Therefore, we are retaining our prior policies on determining functional equivalence. Because the changes made by Public Law 104-193 make the functional equivalence provision the last point of adjudication in a child's claim and, therefore, critical to the outcome of many cases, we are also clarifying these rules.

When we published the prior rules in the Federal Register on September 9, 1993, we chose not to adopt a number of public comments about our policy of “functional equivalence.” Some commenters on the 1993 rules thought that, because the functional equivalence policy was unfamiliar, it was important that we provide as much detail as possible in the regulations so that all adjudicators would understand and apply the new rules in the same way. Several commenters also said that § 416.926a should explain the “thought processes” an adjudicator could employ to make a finding of functional equivalence; otherwise, the policy of functional equivalence might be under-utilized. One suggestion was that we incorporate into the rules the more detailed instructions in our operating manuals and training guides. One commenter suggested that we provide separate headings for medical equivalence and functional equivalence to highlight their differences and the novelty of the functional equivalence policy.

Although we did not adopt the comments in 1993, we have made changes in these rules that respond to some of the earlier concerns of 1993 to reflect the increased importance of the functional equivalence policy under the new law.

First, as noted in the explanation of § 416.926, we have separated the discussion of medical equivalence for children from the discussion of functional equivalence for children. We have also incorporated some of the more detailed explanations from our operating manuals regarding the application of functional equivalence.

Final paragraph (a), “General,” and final paragraph (b), “How we determine functional equivalence,” now include, in reorganized form, the rules for functional equivalence previously in § 416.926a(a) and (b)(3). As already indicated, we moved prior (b)(1) and (b)(2), which explained medical equivalence, to § 416.926. Because of the reorganization, we deleted the second sentence from prior paragraph (b)(3) (“If you have more than one impairment, we will consider the combined effects of all your impairments on your overall functioning.”) because it would have been redundant.

In final paragraph (b), we also included some of the more detailed guidelines concerning functional equivalence that commenters on the 1993 childhood disability rules requested that we include in the regulations, and that we believe are necessitated by the new definition of disability. This paragraph explains that there are several methods for determining functional equivalence, and that we may use any one of them to determine whether an impairment is functionally equivalent in severity to a listing. Subparagraphs then explain the various methods that we may employ to determine functional equivalence. We explain that there is no set order in which we must apply these methods and that, when we find that an impairment(s) is functionally equivalent to a listed impairment, we will use any method that is appropriate to, or best describes, a child's impairment(s) and functional limitations. However, we explain that we will consider all of the methods before we decide that an impairment(s) is not functionally equivalent in severity to any listed impairment and refer to final § 416.924(g), which explains how we will use the new Childhood Disability Evaluation Form at the initial and reconsideration levels.

In (b)(1), we explain the first method we may use. An impairment(s) may be functionally equivalent in severity to a listed impairment because of extreme limitations in one specific function, such as walking or talking, or based on a combination or more than one, but less medically severe, specific functional limitations, such as walking and talking. In (b)(2), we explain that an impairment(s) may be functionally equivalent to a listed impairment if it causes functional limitations in broad areas of development or functioning (e.g., in motor or social functioning) that are equivalent in severity to the disabling functional limitations in Listing 112.12 or Listing 112.02. (The areas of functioning in which an impairment(s) may be evaluated are discussed in paragraph (c), described below.) In (b)(3), we explain that an impairment(s) may be functionally equivalent to a listed impairment if it is chronic and characterized by frequent episodes of illness or attacks, or by exacerbations and remissions. In such cases, we may compare a child's functional limitations to those in any listing for a chronic impairment with similar episodic criteria. In (b)(4), we explain that an impairment(s) may be functionally equivalent to a listed impairment if it requires treatment over a long period of time (at least a year) and the treatment itself (e.g., multiple surgeries) causes marked and severe functional limitations, or if the combined effects of limitations caused by ongoing treatment and limitations caused by the impairment(s) result in marked and severe functional limitations.

In final paragraph (c), “Broad areas of development or functioning,” we explain that Listing 112.12, for infants (especially infants who are too young to test) and Listing 112.02 are the listings we will use for comparison when we use this method of functional equivalence. However, when we determine functional equivalence based on broad functional limitations, we will evaluate the functional effects of an impairment(s) in several areas of development or functioning specified in this paragraph of § 416.926a instead of referring to the listings themselves. We also explain that we describe the areas of functioning in general terms in (c)(4) and in more detail for specific age groups in (c)(5). If we find “marked limitations” in two areas of development or functioning, or “extreme limitations” in one area, we will find that an impairment(s) is functionally equivalent to Listing 112.12 or Listing 112.02. Even though the listings we use for reference are mental disorder listings, this evaluation may be done for a physical impairment(s) or for a combination of physical and mental impairments. We define the terms “marked limitations” and “extreme limitations” in (c)(3).

In (c)(1), we explain how we use the areas of development or functioning: We consider the extent of functional limitations in the areas affected by an impairment(s) and how limitations in one area affect development or functioning in other areas. Thus, when a physical impairment(s) produces global limitations (i.e., limitations in the motor area and at least one other area), those limitations must be evaluated in all relevant areas. We also make reference to new areas of motor development and functioning we have added to ensure appropriate consideration of physical impairments.

In (c)(2), “Other considerations,” we explain that we will consider all information in the case record that will help us determine the effect of an impairment(s) on a child's physical and mental functioning. We will consider the nature of the impairment(s), the child's age, the child's ability to be tested given his or her age, the child's need for help from others (and whether such need is age-appropriate), and other relevant factors.

In (c)(3), we define the terms “marked” and “extreme” limitations. The definitions are not new, but are based on longstanding policy in the regulations and interpretations we have used in our internal instructions and training. In (c)(4) and (c)(5), we describe the areas of development or functioning that may be addressed in a determination of functional equivalence, including the new areas of motor development and motor functioning and the revised “personal” area of functioning.

The descriptions are based on our prior descriptions and changes mandated by Public Law 104-193, and contain several clarifications based on our experience evaluating functional equivalence in children since 1991.

Final paragraph (d), “Examples of impairments that are functionally equivalent in severity to a listed impairment,” is substantively the same as prior paragraph (d), “Examples of impairments of children that are functionally equivalent to the listings.” We made minor editorial changes for clarity and, as throughout the rules, to conform the language to the changes in the law. We also updated examples (1) and (11) to remove examples of cardiovascular impairments that are now listed impairments and, therefore, no longer examples of equivalence. We changed example (4) to delete reference to a “marked inability to stand and walk” because the limitation described is actually “extreme.” We changed example (5) to show how the area of motor functioning may be used. We also clarified the primary purpose of example (10), which is primarily for children who are too young to test and for whom a diagnosis and other medical findings may be difficult to specify.

Section 416.927 Evaluating Medical Opinions About Your Impairment(s) or Disability

We have added a description of the “marked and severe functional limitations” standard for children to paragraph (a), “General,” which already included a description of the disability standard for adults.

Section 416.929 How We Evaluate Symptoms, Including Pain

Throughout this section, we have replaced references to a child's ability to “function independently, appropriately, and effectively in an age-appropriate manner” with references to the child's “functioning.” The rules for evaluating a child's symptoms are otherwise unchanged by the new law.

Section 416.930 Need To Follow Prescribed Treatment

This section explains that, in order to receive benefits, an individual must follow treatment prescribed by his or her physician if the treatment can restore his or her ability to work; i.e., if the treatment could end the individual's disability. We have added parallel language explaining that a child must follow prescribed treatment if the treatment can reduce his or her functional limitations so that they are no longer “marked and severe.”

Section 416.987 Disability Redeterminations for Individuals Who Attain Age 18

This section is new. It provides rules for disability redeterminations mandated by section 212(b) of Public Law 104-193.

In paragraphs (a)(1) and (a)(2), we explain that Public Law 104-193 requires these redeterminations and that, when we do these disability redeterminations, we generally will use the rules for adults filing new claims, not the rules we use for CDRs.

In paragraph (a)(3) we explain that we will notify individuals before we begin a disability redetermination. In paragraph (a)(4) we explain that we will notify the individual in writing of the results of the redetermination and explain the individual's rights in connection with our notice of disability redetermination.

Paragraph (b) concerns a group of recipients who are subject to disability redeterminations under section 212(b) of the new law: individuals who became eligible by reason of disability prior to attaining age 18, and who were eligible for SSI benefits based on disability for the month before the month in which they attained age 18. Paragraphs (b)(1) through (b)(7) of this section provide that, during the 1-year period beginning on the individual's eighteenth birthday, we will redetermine the eligibility of these individuals using the rules in §§ 416.920(c) through (f), and not the rules in § 416.920(b) or § 416.994; i.e., we will decide whether an individual is disabled using the rules for adults filing new claims, except the rule that says an individual engaging in substantial gainful activity will be found not disabled. If an individual age 18 or older has a “disabling impairment” as defined in § 416.911 and is working, we will apply the rules for special SSI eligibility in §§ 416.920ff. We also provide that eligibility will end if we find that the individual is not disabled and describe the month in which we may find an individual not disabled. Finally, we explain that, if we find an individual is not disabled, the last month for which benefits can be paid is the second month after the month in which the individual was determined not to be disabled.

Other Changes

Sections that have been changed only so that their language will conform to the new definition of disability for children, or to provide references to new or revised rules, include §§ 416.901, 416.912, 416.913, and 416.919a.

IV. New Definition of Disability in Title XVI of the Act for Individuals Under Age 18

The definition of disability for children claiming SSI benefits is found in the Social Security Act (§ 1614(a)(3)(C)). That definition, and related childhood disability provisions, were enacted on August 22, 1996 as part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law 104-193).

A. Definition of Disability for Children (§ 416.906)

If you are under age 18, we will consider you disabled if you have a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. Notwithstanding the preceding sentence, if you file a new application for benefits and you are engaging in substantial gainful activity we will not consider you disabled.

B. Effective Dates

  1. General

    The new rules are effective August 22, 1996 for all title XVI childhood disability claims that were filed on or after August 22, 1996, and all childhood disability claims that were not finally adjudicated before that date.

    NOTE:

    Zebley class member claims will be handled differently. Separate OHA instructions are now being developed which will apply in Zebley cases.

  2. Final Adjudication

    A claim was not finally adjudicated prior to August 22, 1996 if:

    • the initial claim is pending on or after that date; or,

    • the claim was denied in whole (see 3. below) prior to August 22, 1996 and, on or after that date, there is pending a request for either administrative or judicial review; or

    • on or after that date, there is pending readjudication by SSA pursuant to relief in a class action; or,

    • on or after that date there is pending implementation by SSA of a court remand order.

  3. Effect of “Denied in Whole” Language

    A claim denied in whole prior to August 22, 1996, and in which a request for administrative or judicial review is pending on or after that date, is subject to these rules. Therefore, a claim that was denied in part prior to August 22, 1996, and under appeal, is not subject to these rules for the period prior to that date. Claims denied in part include unfavorable onset cases, “closed period” cases, and claims denied in part for nondisability reasons, such as income and resources.

    1. Appeals on Unfavorable Onset Cases - If a childhood disability claim adjudicated prior to August 22, 1996 involved a favorable determination, but with an onset later than alleged, and a request for administrative or judicial review involves the onset issue, the prior rules apply in deciding the onset issue for the period prior to August 22, 1996. If the reviewer finds that no onset date can be established prior to August 22, 1996, the current rules apply in deciding the onset issue starting on that date.

    2. Appeals on “Closed Period” Cases - In general, closed period issues are adjudicated under the medical improvement review standard (MIRS). However, there are circumstances in which these initial rules are applicable.

    • If a childhood disability claim adjudicated prior to August 22, 1996 involved a favorable determination, but with a cessation date, and a request for administrative or judicial review involves the cessation issue, the prior MIRS rules apply in deciding the cessation issue for the period prior to August 22, 1996.

    • If the adjudicator finds that no cessation date should be established prior to August 22, 1996, and the allowance determination was based on an individualized functional assessment (IFA) or on consideration of maladaptive behaviors in the paragraph B criteria of any childhood mental disorder listing, Pub. L. 104-193 requires that the child's eligibility be redetermined under these rules for determining initial eligibility, rather than the MIRS (except for the rules governing substantial gainful activity (SGA) denials at step 1).

C. Definitions

  1. Adult - an adult is a person who is age 18 or older.

  2. Child - a child is a person who has not attained age 18.

  3. Commissioner - Commissioner means the Commissioner of Social Security.

  4. Disability Redetermination - a redetermination of your eligibility based on disability using the rules for new applicants appropriate to your age, except the rules pertaining to performance of substantial gainful activity. For individuals who are working and for whom a disability redetermination is required, we will apply the rules concerning the work incentive provisions of sections 1619(a) and 1619(b) of the Act. In conducting a disability redetermination, we will not use the rules for determining whether disability continues.

  5. Impairment(s) - a medically determinable physical or mental impairment or a combination of impairments.

  6. Marked and Severe Functional Limitations - when used as a phrase, means the standard of disability in the Social Security Act for children claiming SSI benefits based on disability and is a level of severity that meets or medically or functionally equals the severity of a listing in the Listing of Impairments. The words “marked” and “severe” are also separate terms used to describe measures of functional limitations; the term “marked” is also used in the listings. The meaning of the words “marked” and “severe” when used as part of the term marked and severe functional limitations is not the same as the meaning of the separate terms “marked” and “severe” used elsewhere in these rules.

NOTE:

On February 18, 1997, the Associate Commissioner for Hearings and Appeals transmitted a copy of the interim final rules published in the Federal Register on February 11, 1997 (62 FR 6408 ff.) to all OHA adjudicators. Because the changes made by Pub. L. 104-193 make the functional equivalence provision the last point of adjudication in a child's claim, and therefore, critical to the outcome of many cases, we have included in section V. below, a discussion of the rules on functional equivalence (20 CFR § 416.926). However, it is important to remember that the regulatory provisions on age (§ 416.924a), functioning in children (§ 416.924b) and other factors, including but not limited to chronic illness, effects of medication, effects of structured or highly supportive settings, adaptations, time spent in therapy, school attendance and treatment and intervention (§416.924c) are also applicable to the evaluation of the child's functioning. These provisions are incorporated by reference in these instructions.

V. Functional Equivalence

A. General (§ 416.926a(a))

If your impairment or combination of impairments does not meet, or is not medically equivalent in severity to, any listed impairment in the Listing of Impairments, we will assess all functional limitations caused by your impairment(s), i.e., what you cannot do because of your impairment(s), to determine if your impairment(s) is functionally equivalent in severity to any listed impairment that includes disabling functional limitations in its criteria. While all possible impairments are not addressed within the Listing of Impairments, within the listed impairments are all the physical and mental functional limitations, i.e., what a child cannot do as a result of an impairment, that produce marked and severe functional limitations. If the functional limitation(s) caused by your impairment(s) is the same as the disabling functional limitation(s) caused by a listed impairment, we will find that your impairment(s) is equivalent in severity to that listed impairment, even if your impairment(s) is not medically related to the listed impairment. When we make a determination or decision using this rule, the primary focus will be on whether your functional limitations are disabling, as long as there is a direct, medically determinable cause for these limitations. As with any disabling impairment, the duration requirement must also be met (see §§ 416.909 and 416.924(a)).

B. How We Determine Functional Equivalence (§ 416.926a(b))

We will compare any functional limitations resulting from your impairment(s) with the disabling functional limitations of any listed impairment in part A or part B of the Listings that includes the same functional limitations. The listing we use for comparison need not be medically related to your impairment(s). In paragraphs (b)(1) through (b)(4) of §416.926a we explain the methods we may use to decide that your impairment(s) is functionally equivalent in severity to a listing. There is no set order in which we must consider these methods and we may not consider them all if we find that your impairment(s) is functionally equivalent in severity to a listed impairment. We will use any method that is appropriate to, or best describes, your impairment(s) and functional limitations. However, we will consider all of the methods before we determine that your impairment(s) is not functionally equivalent in severity to any listed impairment.

  1. Limitation of Specific Functions (§ 416.926a(b)(1))

    We may find that your impairment(s) is functionally equivalent in severity to a listed impairment because of extreme limitation of one specific function, such as walking or talking. Some listings also include criteria requiring limitation of more than one specific function, such as limitations in walking and talking; each limitation in itself is not enough to show disability, but the combination of limitations establishes marked and severe functional limitations. If you have limitation of a combination of specific functions that are the same as those in such a listed impairment, we will find that your impairment(s) is functionally equivalent in severity to that listing.

  2. Broad Areas of Development or Functioning (§ 416.926a(b)(2))

    Instead of looking at limitation of specific functions, we may evaluate the effects of your impairment(s) in broad areas of development or functioning, such as social functioning, motor functioning, or personal functioning (i.e., self-care) and determine if your functional limitations are equivalent in severity to the disabling functional limitations in Listing 112.12 or Listing 112.02. If you have extreme limitation in one area of functioning or marked limitation in two areas of functioning, we will find that your impairment(s) is functionally equivalent in severity to a listed impairment.

  3. Episodic Impairments (§ 416.926a(b)(3))

    If you have a chronic impairment(s) that is characterized by frequent illnesses or attacks, or by exacerbations and remissions, we may evaluate your functional limitations using the methods in section B.1. and B.2. above. However, your functional limitations may vary and we may not be able to use the methods in those sections. Instead, we may compare your functional limitations to those in any listing for a chronic impairment with similar episodic criteria to determine if your impairment(s) has such a serious impact on your functioning over time that it is functionally equivalent in severity to one of those listings. Limitations that are characteristic of episodic impairments are not necessarily related to a single, specific function. Episodes of disabling functional limitations may occur with specified frequency despite treatment. If your episodic impairment(s) produces disabling functional limitations that are the same as the disabling functional limitations of a listed impairment with similar episodic criteria, we will find that you are disabled even though you may be able to function adequately between episodes.

  4. Limitations Related To Treatment or Medication Effects (§ 416.926a(b)(4))

    Some impairments require treatment over a long period of time (i.e., at least a year) and the treatment itself (e.g., multiple surgeries) causes marked and severe functional limitations. Marked and severe functional limitations may also result from the combined effects of limitations caused by ongoing treatment and limitations caused by an impairment(s). In many cases, we will be able to evaluate such limitations using the methods for evaluating specific functions or broad areas of development or functioning (§ 416.926a(b)(1) and (2). But we may also compare your functional limitation(s) to criteria in listings based on treatment (including side effects of medication) that is itself disabling or that contributes to functional limitations. If treatment of your impairment(s) produces functional limitations that are the same as the disabling functional limitations of a listed impairment, we will find that your impairment(s) is functionally equivalent in severity to that listing.

C. Broad Areas of Development or Functioning (§ 416.926a(c))

When we determine functional equivalence based on broad areas of development or functioning, we will evaluate the functional effects of your impairment(s) in several areas of development or functioning to determine if your functional limitations are equivalent in severity to the disabling functional limitations of Listing 112.12 or Listing 112.02. However, instead of referring to the areas of development or functioning in those listings, we will refer to the areas of development or functioning described in this section. If you have marked limitation in two areas of development or functioning, or extreme limitation in one area, we will find that your impairment(s) is functionally equivalent in severity to Listing 112.12 or Listing 112.02, even if your impairment(s) is a physical impairment(s) or a combination of physical and mental impairments.

D. How we Use the Areas of Development or Functioning (§ 416.926a(c)(1))

When we make a finding about functional equivalence, we will consider the extent of your functional limitations in the areas affected by your impairment(s). We will also consider how your limitation(s) in one area affects your development or functioning in other areas. In some children, some physical impairments will be evaluated most appropriately only in the areas of motor development or motor functioning. In others, the effects will be more global. If you have a physical impairment(s) that causes a functional limitation(s) not addressed solely in the area of motor development or motor functioning, we will consider the effects of your impairment in all relevant areas in which you have limitations from the impairment(s). A physical impairment(s) may cause limitations in any or all of the areas of development or functioning.

E. Other Considerations (§ 416.926a(c)(2))

When we assess your functioning, we will consider all information in your case record that can help us determine the effect of your impairment(s) on your physical and mental functioning. We will consider the nature of your impairment(s), your age, your ability to be tested given your age, and other relevant factors (see §§ 416.924a through 416.924c). We will consider whether any help that you need from others to enable you to do any particular activity (e.g., dressing) is appropriate to your age.

F. Definition of “Marked” and “Extreme” Limitations (§ 416.926a(c)(3))

  1. Marked limitation means —

    1. When standardized tests are used as the measure of functional abilities, a valid score that is two standard deviations or more below the norm for the test (but less than three standard deviations); or

    2. For children from birth to attainment of age 3, functioning at more than one-half but not more than two-thirds of chronological age; or

    3. For children from age 3 to attainment of age 18, “more than moderate” and “less than extreme.” Marked limitation may arise when several activities or functions are limited, or even when only one is limited, as long as the degree of limitation is such as to interfere seriously with the child's functioning.

  2. Extreme limitation means —

    1. When standardized tests are used as the measure of functional abilities, a valid score that is three standard deviations or more below the norm for the test; or

    2. For children from birth to attainment of age 3, functioning at one-half chronological age or less; or

    3. For children from age 3 to attainment of age 18, “extreme” means no meaningful functioning in a given area. There may be extreme limitation when several activities or functions are limited or even when only one is limited.

G. Areas of Development or Functioning (§ 416.926a(c)(4))

The following are the areas of development or functioning that may be addressed in a finding of functional equivalence.

  1. Cognition/Communication

    1. The ability or inability to learn, understand, and solve problems through intuition, perception, verbal and nonverbal reasoning, and the application of acquired knowledge; the ability to retain and recall information, images, events, and procedures during the process of thinking.

    2. The ability or inability to comprehend and produce language (e.g., vocabulary and grammar) in order to communicate (e.g., to respond as in answering questions, following directions, acknowledging the comments of others; to request, as in demanding action, meeting needs, seeking information, requesting clarification, initiating interaction; to comment, as in sharing information, expressing feelings and ideas, providing explanations, describing events, maintaining interaction), using hearing that is adequate for conversation, and using speech (articulation, voice, and fluency) that is intelligible.

  2. Motor

    The ability or inability to use gross and fine motor skills to relate to the physical environment and serve one's physical purposes. Motor functioning involves general mobility, balance, and the ability to perform age-appropriate physical activities involved in play, physical education, sports, and physically related daily activities other than self-care (see Personal area).

  3. Social

    1. The ability or inability to form and maintain relationships with other individuals and with groups; e.g., parents, siblings, neighborhood children, classmates, teachers. Ability is manifested in responding to and initiating social interaction with others, sustaining relationships, and participating in group activities. It involves cooperative behaviors, consideration for others, awareness of others' feelings, and social maturity appropriate to a child's age.

    2. Ability is also manifested in the absence of inappropriate externalized actions (e.g., running away, physical aggression — but not self-injurious actions, which are evaluated in the personal area of functioning), and the absence of inappropriate internalized actions (e.g., social isolation, avoidance of interpersonal activities, mutism).

    3. Social functioning in play, school, and work situations may involve interactions with adults, including responding appropriately to persons in authority (e.g., teachers, coaches, employers) or cooperative behaviors involving other children.

  4. Responsiveness to Stimuli (Birth to Age 1 Only)

    The ability or inability to respond appropriately to stimulation (visual, auditory, tactile, vestibular, proprioceptive).

  5. Personal (Age 3 to Age 18 Only)

    The ability or inability to help yourself and to cooperate with others in taking care of your personal needs, health, and safety (e.g., feeding, dressing, toileting, bathing; maintaining personal hygiene, proper nutrition, sleep, health habits; adhering to medication or therapy regimens; following safety precautions).

  6. Concentration, Persistence, or Pace (Age 3 to Age 18 Only)

    The ability or inability to attend to, and sustain concentration on, an activity or task, such as playing, reading, or practicing a sport, and the ability to perform the activity or complete the task at a reasonable pace.

    NOTE:

    See 20 CFR § 416.926a(c)(5) for a description of areas of development or functioning for specific age groups and 20 CFR § 416.926a(d) for examples of impairments that are functionally equivalent in severity to a listed impairment.

VI. Hearing Office Procedures

NOTE:

The following instructions do not apply to Zebley class member cases. Separate OHA instructions, now being developed, will apply in those cases.

A. Cases in Which DDS Issued Wholly Unfavorable Determination Before, On or After August 22, 1996 - General

Any case in which the DDS has issued a wholly unfavorable determination before, on or after August 22, 1996 and the claimant has requested an ALJ hearing is subject to the provisions of Pub. L. 104-193, i.e., the new standard of disability for children applies to the entire period.

B. Cases in Which DDS Issued Wholly Unfavorable Determination Before August 22, 1996 - Hearing Held But Decision Not Issued Before August 22, 1996

Hearing offices should screen all title XVI childhood disability cases awaiting issuance of a decision to determine whether the provisions of Pub. L. 104-193 will affect the ALJ's disposition of the case. If applying the new definition of disability will result in a fully favorable decision because the impairment meets, medically equals or functionally equals the requirements of the listings, the case should be processed and a decision issued. (See sample language in section H. below.) If using the new definition of disability would result in a less than fully favorable decision, the ALJ will send a notice (see Attachment 1) which provides the claimant and representative, if any, the opportunity to:

(a) submit additional evidence;

(b) submit written comments; and/or

(c) request a supplemental hearing

(See HALLEX I-2-6-80, Continued or Reopened Hearing.)

C. Cases in Which DDS Issued Wholly Unfavorable Determination Before, On or After August 22, 1996 - Hearing Not Yet Scheduled and New Receipts

Schedule the hearing in the usual manner. The Notice of Hearing sent to the claimant and representative, if any, must include the new definition of disability for children. Sample language addressing the general and specific issues is included in section H. below. (See Notice of Hearing requirements in section G. below when the child has attained age 18).

D. Partially Favorable DDS Determination Dated and Issued Before August 22, 1996- General

A claim that was denied in part prior to August 22, 1996, and is under appeal, is not subject to the new rules for evaluating disability for the period prior to August 22, 1996. Claims denied in part include unfavorable onset cases (i.e., later onset established), “closed period” cases, and claims denied in part for nondisability reasons, such as income and resources.

E. Partially Favorable DDS Determination Dated and Issued Before August 22, 1996 - Unfavorable Onset Cases - DDS Established Later Onset Date

If a childhood disability claim was adjudicated prior to August 22, 1996 and the DDS issued a partially favorable determination establishing an onset later than alleged, the ALJ should, when appropriate, and consistent with Social Security regulations at 20 CFR § 416.1446(a), not disturb the DDS allowance and limit the issue at the hearing to whether an earlier onset is appropriate. The rules in effect prior to enactment of Public Law 104-193 apply in deciding the onset issue for the period prior to August 22, 1996.

If the ALJ issues a fully favorable or partially favorable decision in such case, i.e., establishes onset as alleged or establishes onset earlier than found by the DDS (but not the alleged onset), the hearing office will forward the case for effectuation and annotate the remarks section of Form HA-5051, Transmittal of Decision or Dismissal by Administrative Law Judge, as follows:

SSI Childhood Disability Case Finally Adjudicated Prior to August 22, 1996. Onset Evaluated Under Criteria in Effect Prior to Enactment of Pub. L. 104-193.

If the ALJ issues an unfavorable decision, i.e., an earlier onset is not appropriate, follow existing procedures for routing. See section J. below for system coding instructions

F. Partially Favorable DDS Determination Dated and Issued Before August 22, 1996 - DDS Established “Closed Period” of Disability

If the DDS established a closed period of disability in a childhood disability claim which was adjudicated prior to August 22, 1996 and the claimant is appealing the cessation issue, the ALJ should, when appropriate, and consistent with Social Security regulations at 20 CFR § 416.1446(a), not disturb the DDS allowance. The prior medical improvement review standard (MIRS) rules apply in deciding the cessation issue for the period prior to August 22, 1996.

In such cases, the notice of hearing must advise the claimant that, if the ALJ issues a favorable decision on the cessation issue, i.e., finds that no cessation should be established prior to August 22, 1996, and the allowance was based on an IFA or on consideration of maladaptive behaviors in the paragraph B criteria of childhood mental disorder listing 112.02B2c(2), the ALJ will also decide whether the claimant is disabled based on the new evaluation standard under Pub. L. 104-193, beginning August 22, 1996 and continuing through the date of the decision. The hearing office should forward the case for effectuation and annotate the remarks section of the HA-5051 as follows:

SSI Childhood Disability Case Finally Adjudicated Prior to August 22, 1996. Cessation Issue Evaluated Under Criteria in Effect Prior to Enactment of Pub. L. 104-193. Period beginning August 22, 1996 evaluated under Pub. L. 104-193 criteria.

If the ALJ issues an unfavorable decision, i.e., finding that the DDS-established cessation date is appropriate, follow existing procedures for routing. See section J. below for system coding information.

G. Processing Initial Claims in Which the Child Has Attained Age 18

The ALJ must evaluate whether the claimant is disabled under the new disability standard for the period during which the child was under age 18. Beginning with the day of attainment of age 18, the disability criteria for adults filing new claims is the appropriate standard. Do not apply the MIRS and do not consider the Part B childhood disability listings or functional equivalence for the period starting with the attainment of age 18.

The notice of hearing must cite the new childhood disability criteria (see section H. below for sample language), as well as, the adult criteria and specifically state that both issues will be decided.

The ALJ should issue one decision to adjudicate the entire period, i.e., prior to age 18 and after attainment of age 18. Because the child and adult standards are uncoupled from one another, any combinations of outcomes is possible.

If the individual is found disabled as a child, but not as an adult, or vice versa, appropriate findings must be made. With respect to the period prior to age 18, use the sample findings and decisional language in section H. below. For the period beginning with attainment of age 18, follow existing procedures (except for systems coding and routing) for adult claims.

The HO should annotate the transmittal, HA-5051 with the following statement.

SSI Childhood Disability Case. Period starting with attainment of age 18 adjudicated under adult rules.

H. ALJ Decision

In cases where the criteria of Pub. L. 104-193 apply, i.e., childhood disability claims filed on or after August 22, 1996 and all claims that were not “finally adjudicated” before August 22, 1996 (see section IV.B. above) the ALJ decision must:

  • eliminate all references in the decision describing the prior standard for childhood disability, e.g., “comparable severity” and the child's “ability to function independently, appropriately and effectively in an age-appropriate manner.” References to “marked and severe functional limitations,” or lack of such limitations, is appropriate.

  • include a specific finding and decisional language with respect to the new definition of disability for children. See sample findings and decisional language below.

    NOTE:

    There is no change to OHA's longstanding policy which requires ALJs to obtain opinions on medical equivalence from medical experts. (See Social Security Ruling (SSR) 96-6p for a discussion of when an updated medical opinion from a medical expert is required). However, because of the kind of equivalence determinations required in childhood disability claims, the ALJ may not need to obtain medical expert opinion to decide the issue of functional equivalence. The ALJ however, is not precluded from obtaining medical expert opinion to assist in deciding the issue.

  1. Issues

    Because the definition of disability has been amended, revisions will be necessary with respect to the statement of issues in the Notice of Hearing and in the decision. Use the following language:

    The general issue is whether you are eligible, as an individual under age 18, for Supplemental Security Income within the meaning of sections 1602 and 1614(a)(3)(C) of the Social Security Act.

    The specific issue is whether you are “disabled,” as defined in the Social Security Act. To be found disabled as an individual who has not attained age 18, you must suffer from a medically determinable physical or mental impairment (or combination of impairments) that results in marked and severe functional limitations, and that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. To result in marked and severe limitations, your impairment(s) must meet or medically or functionally equal the requirements of a listing in the Listings of Impairments in appendix 1 of subpart P of our regulations.

    In addition, if the decision covers a period prior to age 18 and after attainment of age 18, include the existing adult issue language for the period beginning with attainment of age 18.

  2. Findings

    A specific finding should be made with respect to the new definition of disability. The finding should use language along the following lines:

    The claimant's impairment (or combination of impairments) meets [does not meet] or medically or functionally equal(s) the requirements of a listing in the Listings of Impairments in appendix 1 of subpart P.

    The claimant has [does not have] a medically determinable physical or mental impairment (or combination of impairments) which results in marked and severe functional limitations.

  3. Decisional Paragraph

    The decisional paragraph must contain language along the following lines:

    Unfavorable

    It is the decision of the Administrative Law Judge that, based on the application filed on ________, the claimant is not eligible for Supplemental Security Income under sections 1602 and 1614(a)(3)(C) of the Social Security Act.

    Favorable

    It is the decision of the Administrative Law Judge that, as of the date of the application filed on ________, the claimant was “disabled” under section 1614(a)(3)(C) of the Social Security Act, and that the claimant's disability has continued at least through the date of this decision.

    The component of the Social Security Administration responsible for authorizing supplemental security income payments will advise the claimant regarding the nondisability requirements for these payments, and if eligible, the amount and the month(s) for which payment will be made.

I. Cover Notice for Transmitting Decision and Routing

Use the standard unfavorable or partially/fully favorable decision cover notice as appropriate. Follow existing procedures for routing. (For routing of favorable decisions in cases finally adjudicated prior to August 22, 1996, i.e., later onset and closed POD cases, see sections E. and F. above.)

J. Hearing Office Tracking System (HOTS) Coding

Congress has allocated funds to SSA specifically for processing the redeterminations of disability for title XVI childhood recipients. In order to account for the spending of these funds, we must be certain to count every action. We must also, for the first time, enter into HOTS the regulation basis code for the decision and impairment codes on all title XVI childhood disability cases. SSA needs this information to report to Congress on the effect of the new childhood disability regulations on the eligibility of childhood claimants with various impairments. A summary of the regulation basis codes, hearing type codes and special case codes are at Attachment 3.

  1. Redeterminations - These are the cases of title XVI claimants who were eligible for benefits on August 22, 1996 and who have been determined to be no longer disabled pursuant to the regulations implementing Pub. L. 104-193 or who have attained age 18 and are not disabled under the adult disability criteria. THESE ARE NOT CDR CESSATION CASES.

    1. Claimant under age 18 will be Hearing Type 90.

    2. Claimant over age 18 will be Hearing Type 95.

    NOTE:

    If both issues are involved in the same case, HOs will create two records, one for the claim for childhood disability and a second record for the age 18 redetermination. One case may be two records with Hearing Types 90 and 95. This will count as two dispositions.

  2. Initial claims - These are new claims for title XVI childhood disability or pending claims.

    1. Claimant under age 18 will be hearing type 10.

    2. Claimant over age 18 will be hearing type 20.

    NOTE:

    If both issues are involved in the same case, HOs will create two records, one for the claim for childhood disability and a second record for the adult portion of the claim. One case may be two records with Hearing Types 10 and 20. These claims will count as two dispositions.

  3. Special Case Codes

    1. Enter “H” for claimant under age 18.

    2. Enter “I” for claimants over age 18.

  4. Regulation Basis Codes — Administrative Law Judges or other OHA adjudicators are responsible for designating the regulation basis codes for their decisions. The adjudicator will circle the correct basis code on Attachment 4.

    NOTE:

    In cases in which the adjudicator must determine disability using both the childhood (under age 18) and the adult (over age 18) criteria, the adjudicator will prepare two coding sheets. Both coding sheets are at Attachment 4.

  5. Impairment coding — Administrative Law Judges or other OHA adjudicators are also responsible for designating the four digit diagnostic codes for the claimants' primary and secondary impairments. The adjudicators will enter these codes on the same coding sheet used for the regulation basis codes. See Attachment 4.

    A list of impairments and codes are at Attachment 5.

    NOTE:

    In most cases, the claimants' primary and secondary impairments will be the same as those listed (and coded) on the SSA-831 (or SSA-832). However, adjudicators must not rely exclusively on the DDS coding because the claimant may now have a new impairment or a more severe impairment than was evident at the initial or reconsideration level.

VII. Appeals Council Procedures

A. Wholly Unfavorable ALJ Decision Dated and Issued Before, On or After August 22, 1996 (No Pre-August 22, 1996 Favorable ALJ Decision)

Any case in which an ALJ has issued a wholly unfavorable decision before, on or after August 22, 1996 and the claimant has requested the Appeals Council (AC) to review the decision is subject to the provisions of Pub. L. 104-193, i.e., the new standard of disability for children applies to the entire period.

The AC may take any of its usual actions in such cases including:

  • denying the request for review (R/R);

  • granting the request for review and issuing a decision;

  • remanding the case to an ALJ; or

  • dismissing the request for review.

  1. AC Denies R/R

    No special action or notice is required when the AC denies a request for review of a wholly unfavorable ALJ decision dated and issued before, on or after August 22, 1996. The current denial of Request for Review notice includes language that the AC considered the applicable statute, regulations and rulings in effect at the time of the action taken.

  2. AC Grants R/R and Issues Decision

    If the AC grants a request for review of a wholly unfavorable ALJ decision issued before, on or after August 22, 1996, the AC must apply the provisions of Pub. L. 104-193. The grant review notice must specify that the issue of disability will be evaluated using the new standard under Pub. L. 104-193.

    AC decision must:

    • eliminate all references describing the prior standard for childhood disability, e.g., “comparable severity” and the child's “ability to function independently, appropriately and effectively in an age-appropriate manner.” References to “marked and severe functional limitations,” or lack of such limitations, is appropriate.

    • Include a specific finding and decisional language with respect to the new definition of disability. (See sample findings and decisional paragraph language in section J. below).

    NOTE:

    There is no change to OHA's longstanding policy which requires ALJs and the AC to obtain opinions on medical equivalence from medical experts. (See Social Security Ruling (SSR) 96-6p for a discussion of when an updated medical opinion from a medical expert is required). However, because of the kind of equivalence determinations required in childhood disability claims, the ALJ or AC may not need to obtain medical expert opinion to decide the issue of functional equivalence. The ALJ or AC, however, is not precluded from obtaining medical expert opinion to assist in deciding the issue.

    Use the standard unfavorable or partially/fully favorable decision cover notice as appropriate. Follow existing procedures for routing. (For routing of favorable decisions in cases finally adjudicated prior to August 22, 1996, i.e., later onset and closed POD cases, see section D. below.)

    See section K. below for coding instructions when the AC reviews a case and issues a decision.

  3. AC Prepared to Remand Case to ALJ

    If the AC is prepared to remand the case to an ALJ for further proceedings, the AC Order of Remand will advise the ALJ to apply the provisions of Pub. L. 104-193.

B. Partially Favorable ALJ Decision Dated and Issued Before August 22, 1996 - General

If a claim was adjudicated prior to August 22, 1996, the date of enactment of Pub. L. 104-193, but has not been denied in whole, (e.g., the ALJ issued a partially favorable decision establishing an onset later than alleged or establishing a “closed period” of disability), such claim is considered to be “finally adjudicated” prior to enactment, notwithstanding a later request for Appeals Council review.

For any case in which a partially favorable ALJ decision is dated and issued prior to August 22, 1996, the rules in effect prior to enactment of Pub. L. 104-193 apply in deciding the onset or cessation issue for the period prior to August 22, 1996.

NOTE:

When the DDS issued a partially favorable determination prior to 8/22/96 establishing an onset later than alleged or establishing a closed period of disability, and the ALJ did not disturb the partially favorable findings, the claim is considered “finally adjudicated” prior to enactment.

EXAMPLE:

The claimant alleges an onset of 1/15/94. In a reconsideration determination dated 6/10/95, the DDS found the child disabled beginning 10/20/94 and continuing. The claimant appealed the onset date and contends that the onset should be 1/15/94, as alleged. The ALJ limits the issue at hearing to the earlier onset and issues an unfavorable decision finding the claimant not disabled for the period 1/15/94 to 10/19/94. Because the ALJ's decision did not disturb the partially favorable DDS determination, the claim has not been “denied in whole” irrespective of the ALJ's unfavorable decision. The claim is considered “finally adjudicated” prior to enactment. In reviewing the case at the AC level, the pre-8/22/96 rules apply in evaluating the disability issue for the period prior to 8/22/96, i.e., in this case from 1/15/94-10/19/94.

C. Partially Favorable ALJ Decision Dated and Issued Before August 22, 1996 - AC Denies the Request for Review

No special action or notice is required when the AC denies a request for review of a favorable or partially favorable hearing decision, (i.e., later onset or closed POD) dated and issued before August 22, 1996. The standard notice of denial of the request for review includes language that the AC considered the applicable statute, regulations and rulings in effect at the time of the action taken.

D. Partially Favorable ALJ Decision Dated and Issued Before August 22, 1996 - AC Grants the Request for Review

If the AC grants a request for review on a claim in which the ALJ decision is dated and issued before August 22, 1996 and the ALJ established an onset later than alleged or established a “closed POD”, the AC should, when appropriate, and consistent with Social Security regulations at 20 CFR § 416.1476(a), adopt the ALJ's favorable findings and limit the issue to the period prior to August 22, 1996 and specifically to whether an earlier onset is appropriate or whether the cessation was appropriate.

  1. AC Proposes Unfavorable Decision

    Onset Issue

    If the AC does not adopt the ALJ's finding regarding the favorable period, and if, by applying the pre-August 22, 1996 criteria, no onset date can be established prior to August 22, 1996, the new criteria of Pub. L. 104-193, i.e., the new definition of disability, apply in deciding the onset issue starting on August 22, 1996.

    Cessation Issue

    If the AC is prepared to issue an unfavorable decision on the cessation issue, i.e., finding that cessation is appropriate, the AC must apply the pre-August 22, 1996 medical improvement review standard (MIRS) rules in deciding the cessation issue for the period prior to August 22, 1996.

  2. AC Proposes Favorable Decision

    Onset Issue

    If the AC is prepared to issue a more favorable decision, i.e., establish an onset earlier than that established by the ALJ, the AC must apply the pre-August 22, 1996 criteria. In routing the favorable decision for effectuation, the AC must annotate the remarks section of Form HA-505, as follows:

    SSI Childhood Disability Case evaluated under criteria in effect prior to enactment of Pub. L. 104-193.

    Cessation Issue

    If the AC is prepared to issue a more favorable decision, i.e., finding that no cessation date should be established prior to August 22, 1996, and the allowance was based on an IFA or on consideration of maladaptive behaviors in childhood mental disorder listing 112.02B2c(2), Pub. L. 104-193 requires that the child's eligibility be redetermined under the new rules for determining initial eligibility, rather than the MIRS. Therefore, the AC will advise the claimant that it will also decide whether the claimant continues to meet the disability requirements under the new standard established by Pub. L. 104-193 for the period beginning August 22, 1996 through the date of the AC decision.

    The AC should forward the case for effectuation and annotate the remarks section of the Form HA-505 as follows:

    SSI Childhood Disability Case Finally Adjudicated Prior to August 22, 1996. Cessation Issue Evaluated Under Criteria in Effect Prior to Enactment of Pub. L. 104-193. Period beginning August 22, 1996 evaluated under Pub. L. 104-193 criteria.

    See section K. below for coding information.

  3. AC Remands Case to ALJ

    If the AC remands the case to an ALJ, the AC Order of Remand will advise the ALJ to apply the provisions of Pub. L. 104-193 for the period beginning August 22, 1996.

E. Favorable (Including Partially Favorable) ALJ Decision Dated and Issued Before August 22, 1996 - AC Took Own Motion

If the AC took own motion review of an ALJ's favorable or partially favorable decision dated and issued before August 22, 1996 and the AC issued a propose-to-find notice, the AC will:

  • Send a revised notice advising the claimant that the pre-August 22, 1996 criteria apply in evaluating the child's disability for the period before August 22, 1996 and the provisions of Pub. L. 104-193 apply for the period beginning August 22, 1996.

  • Continue to process the case and issue a decision. The decision will provide language regarding both the pre-August 22, 1996 criteria and the new definition of disability under Pub. L. 104-193 which will apply for the period beginning August 22, 1996 (see sample issue language in section J. below).

If the AC proposes to take less than fully favorable action on the case, and the claimant received an on-the-record decision from an ALJ or a decision from an Adjudication Officer, the claimant has a right to a hearing. If the claimant waives his or her right to a hearing, the AC will proceed with its decision. However, if the claimant requests a hearing, or merely submits evidence or comments for AC consideration, or does not respond to the AC notice, the AC will remand the case to an ALJ for a hearing. The standard proposed-to-remand notice must be modified to include the right to a hearing in these cases.

F. Processing Initial Claims Where the Child Has Attained Age 18 - Wholly Unfavorable ALJ Decision (No Pre-August 22, 1996 Favorable ALJ Decision)

The AC must evaluate whether the claimant is disabled under the new disability standard for the period during which the child was under age 18. Beginning with the day of attainment of age 18, the disability criteria for adults filing new claims is the appropriate standard. Do not apply the MIRS and do not consider the childhood disability listings of functional equivalence for the period starting with the attainment of age 18.

  1. AC Denies Request for Review

    No special action or notice is required when the AC denies a request for review. The standard notice of denial of request for review includes language that the AC considered the applicable statute, regulations and rulings in effect at the time of the action taken.

  2. AC Grants Request for Review

    If the AC grants a request for review of an ALJ decision and the claimant has attained age 18, the AC will issue one decision to adjudicate the entire period, i.e., prior to age 18 and after attainment of age 18. Because the child and adult standards are uncoupled from one another, any combinations of outcomes is possible.

    If the individual is found disabled as a child, but not as an adult, or vice versa, appropriate findings must be made. With respect to the period prior to age 18, use the sample findings and decisional language in section J. below. For the period beginning with attainment of age 18, follow existing procedures for adult claims.

    The AC must annotate the Form HA-505 with the following statement.

    SSI Childhood Disability Case. Period starting with attainment of age 18 adjudicated under adult rules.

  3. AC Remands Case to ALJ

    If the AC remands the case to an ALJ, the AC Order of Remand will advise the ALJ to apply the provisions of Pub. L. 104-193 for the period before the child attained age 18 and the adult standard for the period after attainment of age 18.

G. Processing Initial Claims Where the Child Attained Age 18 After the Date of the Hearing Decision - Favorable or Partially Favorable Decision Dated and Issued Before August 22, 1996

  1. AC Denies Request for Review

    No special action or notice is required when the AC denies a request for review of a favorable or partially favorable hearing decision, (i.e., later onset or closed POD) dated and issued before August 22, 1996 and the claimant has attained age 18 after the date of the ALJ decision. The standard notice of denial of the request for review includes language that the AC considered the applicable statute, regulations and ruling in effect at the time of the action taken. The age 18 redetermination will be done in a separate determination.

  2. AC Grants Request for Review

    1. AC Issues Decision

      If the AC grants a request for review on a claim in which the child has attained age 18 and the ALJ decision is dated and issued before August 22, 1996 and the ALJ established an onset later than alleged or established a “closed POD”, the AC should, when appropriate, and consistent with Social Security regulations at 20 CFR § 416.1476(a), adopt the ALJ's favorable findings and limit the issue to the period prior to August 22, 1996 and specifically to whether an earlier onset is appropriate or whether the cessation was appropriate.

      Follow the procedures in D.1. above when the AC issues an unfavorable decision and in D.2. above when issuing a favorable decision.

      If the AC does not adopt the ALJ's finding regarding the favorable period, the rules in effect prior to enactment of Pub. L. 104-193 apply in evaluating the child's disability for the period prior to August 22, 1996 and the disability standard under Pub. L. 104-193 applies beginning August 22, 1996 (see section B. above for discussion of a partially favorable ALJ decision dated and issued prior to August 22, 1996). (Also see NOTE in section B. above regarding the treatment of a partially favorable DDS determination dated prior to August 22, 1996 where the ALJ's decision did not disturb the DDS favorable finding). Beginning with the day of attainment of age 18, the disability criteria for adults filing new claims is the appropriate standard. Do not apply the MIRS and do not consider the childhood disability listings of functional equivalence for the period starting with the attainment of age 18. In such cases, the grant review notice must cite the childhood disability criteria as well as the adult criteria and specifically state that both issues will be decided.

      The AC must annotate the Form HA-505 with the following statement.

      SSI Childhood Disability Case. Period starting with attainment of age 18 adjudicated under adult rules.

      See section K. below for coding information.

    2. AC Remands Case to ALJ

      If the AC remands the case to an ALJ, the AC Order of Remand will advise the ALJ to apply the rules in effect prior to enactment of Pub. L. 104-193 in evaluating the child's disability for the period prior to August 22, 1996 and the new disability standard under Pub. L. 104-193 beginning August 22, 1996. Beginning with the day of attainment of age 18, the disability criteria for adults filing new claims is the appropriate standard.

  3. AC Granted Review or Took Own Motion Before August 22, 1996

    If, prior to August 22, 1996, the AC granted review or exercised own motion review authority over an ALJ's favorable or partially favorable decision and issued a proposed to find notice, the AC must:

    • Send a revised notice advising the claimant that the pre-August 22, 1996 criteria apply in evaluating the child's disability for the period before August 22, 1996 and the provisions of Pub. L. 104-193 apply for the period beginning August 22, 1996. The adult rules apply beginning with the attainment of age 18.

    • Continue to process the case and issue a decision or remand order.

      If the AC issues a decision, the AC must annotate the Form HA-505 with the following statement.

      SSI Childhood Disability Case. Period starting with attainment of age 18 adjudicated under adult rules.

      If the AC remands the case to an ALJ, the Order of Remand will advise the ALJ to apply the rules in effect prior to enactment of Pub. L. 104-193 in evaluating the child's disability for the period prior to August 22, 1996 and the new disability standard under Pub. L. 104-193 beginning August 22, 1996. Beginning with the day of attainment of age 18, the disability criteria for adults filing new claims is the appropriate standard.

      When the AC exercises own motion or reopening authority, follow “8001” procedures provided in HALLEX I-3-6-55.

H. Protest Cases — Favorable ALJ Decision Dated and Issued On or After August 22, 1996

Effectuating components (FOs) will return cases with an OHA level decision dated and issued August 22, 1996, or later, in which the ALJ did not apply the provisions of Pub. L. 104-193. The AC will follow the procedures for handling protest cases advising the ALJ to apply the provisions of Pub. L. 104-193.

I. Protest Cases — Own Motion and Period for Reopening Have Elapsed

If the time frames for own motion and reopening under 20 CFR § 416.1488 have elapsed, return the case to the effectuating component through the Regional Office with instructions to effectuate the decision. Use Appeals Council Standardized Text, Temporary COR 31 with draft language in Attachment 2.

J. Appeals Council Decision

  1. Issues

    The AC decision must state the general and specific issues with respect to the new standard of disability for individuals under age 18. The decision should contain language along the following lines:

    The general issue is whether you are eligible, as an individual under age 18, for Supplemental Security Income within the meaning of sections 1602 and 1614(a)(3)(C) of the Social Security Act.

    The specific issue is whether you are “disabled,” as defined in the Social Security Act. To be found disabled as an individual who has not attained age 18, you must suffer from a medically determinable physical or mental impairment (or combination of impairments) that results in marked and severe functional limitations, and that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. To result in marked and severe limitations, your impairment(s) must meet or medically or functionally equal the requirements of a listing in the Listings of Impairments in appendix 1 of subpart P of our regulations.

    In addition, if the decision covers a period prior to age 18 and after attainment of age 18, include the existing adult issue language for the period beginning with attainment of age 18.

  2. Findings

    A specific finding must be made with respect to the new definition of disability. The finding should use language along the following lines:

    The claimant's impairment (or combination of impairments) meets [does not meet] or medically or functionally equal(s) the requirements of a listing in the Listings of Impairments in appendix 1 of subpart P.

    The claimant has [does not have] a medically determinable physical or mental impairment (or combination of impairments) which results in marked and severe functional limitations.

  3. Decisional Paragraph

    The decisional paragraph must contain language along the following lines:

    Unfavorable

    It is the decision of the Appeals Council that, based on the application filed on ________, the claimant is not eligible for Supplemental Security Income under sections 1602 and 1614(a)(3)(C) of the Social Security Act.

    Favorable

    It is the decision of the Appeals Council that, as of the date of the application filed on ________, the claimant was “disabled” under section 1614(a)(3)(C) of the Social Security Act, and that the claimant's disability has continued at least through the date of this decision.

    The component of the Social Security Administration responsible for authorizing supplemental security income payments will advise the claimant regarding the nondisability requirements for these payments, and if eligible, the amount and the month(s) for which payment will be made.

K. OHA Case Control System (CCS) Coding

When the AC reviews a case and issues a decision, the analyst must provide the appropriate regulation basis code (see Attachment 3) and the impairment codes (see Attachment 5) by completing the coding sheet in Attachment 4 to code the case in the OHA Case Control System (CCS).

VIII. Inquiries

Hearing Office personnel should direct any questions concerning this instruction to their Regional Office. Regional Office personnel should contact the Division of Field Practices and Procedures in the Office of the Chief Administrative Law Judge at (703) 305-0022. Headquarters personnel should route questions to their Branch Chiefs who may contact the Office of Appellate Operations at 305-0106.

Attachment 1 -. NOTICE OHA WILL SEND TO CLAIMANTS WHO HAD A HEARING BEFORE ENACTMENT OF PUBLIC LAW (Pub. L.) No. 104-193

This notice tells you about recent changes in the law that may affect your claim.

The new law changes the definition of disability for individuals under age 18. The new law provides that an individual under age 18 shall be considered disabled if he or she has a physical or mental condition or conditions that can be medically proven and that result in marked and severe functional limitations, and the medically proven physical or mental condition or conditions must last at least 12 months or be expected to result in death. To result in marked and severe functional limitations, the physical or mental condition or conditions must meet or medically or functionally equal the requirements of a listing in the Listing of Impairments in appendix 1 of subpart P of our regulations.

The new definition of disability for children applies to claims for SSI childhood disability which were denied in whole and which are finally decided on or after August 22, 1996. Therefore, these provisions apply to your case. Before I issue my decision, you have the opportunity to show that you meet the new definition of disability. You may do any or all of the following:

  1. give us additional information;

  2. give us written comments; and/or

  3. ask for a supplemental hearing.

If you wish to give us additional information, written comment(s), or ask for a supplemental hearing, you must do so, in writing, within ten (10) days of the date you receive this notice. Unless you can show otherwise, we assume you received this notice within five days of the date of the notice.

If you do not let me know within ten (10) days of the date you receive this notice, I will assume you do not wish to give us any written statements or information and that you do not wish to ask for a supplemental hearing. I will then issue my decision based on the information that we now have.

  __________________________
  Administrative Law Judge
  __________________________
  Date

Attachment 2 - Memorandum Protest Case.

MEMORANDUM TO:

Regional Commissioner, SSA
[City, State]

FROM:

Appeals Council
Office of Appellate Operations

SUBJECT:

[ ], Claimant' Name
Social Security Number:
OHA Action on “Protest”

This case was carefully studied as a result of your memorandum dated [ ], concerning the Administrative Law Judge's decision.

The Appeals Council took jurisdiction of this case on [ ], but now has vacated that notice and will take no further action on the case.

or

The Appeals Council has decided not to disturb the Administrative Law Judge's decision.

or

The Appeals Council cannot take jurisdiction of this case because the time for own motion review has ended and the time for reopening has expired.

Administrative Appeals Judge

Attachment 3. (1 of 2) - OHA CASE CONTROL SYSTEM CHILDHOOD DISABILITY CODES FIRST REGULATION BASIS CODE (1RG, 3RG)

BASIS FOR ALLOWANCE (Under Age 18 - Initial Claims/Redeterminations)

  Impairment Meets Listing (A61) A
  Impairment Medically Equals Listing (A65) B
  Impairment Functionally Equals Listing (A66) C
  IFA Shows Comparable Severity (A67) - Zebley Z

BASIS FOR DENIAL (Under Age 18 - Initial Claims/Redeterminations)

  Impairment Does Not Meet, Medically Equal, or Functionally Equal               the Listing (N43) N
  Impairment Not Severe (N44) O
  Engaging in SGA (N33) P
  Impairment Not Expected to Last 12 Months (N34/N35) Q
  Failure or Refusal to Submit to Consultative Examination (N37) R
  Failure to Follow Prescribed Treatment (N39) S
  IFA Shows No Comparable Severity (N40) - Zebley T

BASIS FOR ALLOWANCE (Age 18 Redeterminations)

  Impairment Meets Listing (70) A
  Impairment Medically Equals Listing (72) B
  Medical/Vocational (74) V

BASIS FOR DENIAL (Age 18 Redeterminations)

  Impairment Not Severe (N44) O
  Engaging in SGA (N33) P
  Impairment Not Expected to Last 12 Months (N34/N35) Q
  Failure or Refusal to Submit to Consultative Examination (N37) R
  Failure to Follow Prescribed Treatment (N39) S
  Medical/Vocational (74) D

Attachment 3. (2 of 2) - SECOND REGULATION BASIS CODE (2RG, 4RG)

BASIS FOR PARTIALLY FAVORABLE ALLOWANCE (Under Age 18)

  Impairment Does Not Meet, Medically Equal, or Functionally Equal the Listing (N43) E
  Impairment Not Severe (N44) F
  Engaging in SGA (N33) G
  Failure or Refusal to Submit to Consultative Examination (N37) H
  Failure to Follow Prescribed Treatment (N39) I

DIAGNOSIS IMPAIRMENT CODES (1MP, 2MP, 5MP, 6MP)

Standard impairment codes found in POMS Section DI 26510.015.G will be used.

SPECIAL CASE CODE (SPC)

  Child (Under Age 18) H
  Child (Age 18 Redeterminations) I

HEARING TYPE CODE (HGT)

  Initial Claims (Under Age 18) 10
  Redeterminations (Under Age 18) 90
  Redeterminations (Age 18) 95

Cases in which the claimant reaches age 18 during the appeals process will require two decisions — one using the childhood standard and one using the adult standard. These cases will be entered as two separate cases.

  • For initial cases, hearing type “10” will be used for the childhood decision, hearing type “20” will be used for the adult decision.

  • For redetermination cases, hearing type “90” will be used for the childhood decision, hearing type “95” will be used for the adult decision.

Attachment 4. (1 of 2) - OHA CHILDHOOD DISABILITY REGULATION BASIS AND IMPAIRMENT CODES

Under Age 18 - Initial Claims/Redeterminations

BASIS FOR ALLOWANCE REG BASIS IMPAIRMENTS
 

(Circle One)

   

Impairment Meets Listing (A61)

A

_____

_____

Impairment Medically Equals Listing (A65)

B

_____

_____

Impairment Functionally Equals Listing (A66)

C

_____

_____

IFA Shoes Comparable Severity (A67) - ZEBLEY

Z

_____

_____

BASIS FOR DENIAL REG BASIS IMPAIRMENTS
 

(Circle One)

   

Impairment Does Not Meet, Medically Equal, or Functionally Equal the Listing (N43)

N

_____

_____

Impairment Not Severe (N44)

O

_____

_____

Engaging in SGA (N33)

P

_____

_____

Impairment Not Expected to last 12 Months (N34/N35)

Q

_____

_____

Failure or Refusal to Submit to Consultative Examination (N37)

R

_____

_____

Failure to Follow Prescribed Treatment (N39)

S

_____

_____

IFA Shows No Comparable Severity (N40) - ZEBLEY

T

_____

_____

BASIS FOR PARTIALLY FAVORABLE ALLOWANCE REG BASIS  
 

(Circle One)

   

Impairment Does Not Meet, Medically Equal, or Functionally Equal the Listing (N43)

E

   

Impairment Not Severe (N44)

F

   

Engaging in SGA (N33)

G

   

Failure or Refusal to Submit to Consultative Examination (N37)

H

   

Failure to Follow Prescribed Treatment (N39)

I

   

SSN:_______________     CLAIMANT NAME: ____________________

Attachment 4. (2 of 2) - OHA CHILDHOOD DISABILITY REGULATION BASIS AND IMPAIRMENT CODES

Age 18 Redeterminations

BASIS FOR ALLOWANCE REG BASIS IMPAIRMENTS
 

(Circle One)

   
Impairment Meets Listing (70)

A

_____

_____

Impairment Medically Equals Listing (72)

B

_____

_____

Medical/Vocational (74)

V

_____

_____

BASIS FOR DENIAL REG BASIS IMPAIRMENTS
 

(Circle One)

   
Impairment Not Severe (N44)

O

_____

_____

Engaging in SGA (N33)

P

_____

_____

Impairment Not Expected to Last 12 Months (N34/N35)

Q

_____

_____

Failure or Refusal to Submit to Consultative Examination (N37)

R

_____

_____

Failure to Follow Prescribed Treatment (N39)

S

_____

_____

Medical/Vocational (74)

D

_____

_____

SSN:_______________     CLAIMANT NAME: ____________________

Attachment 5. - EXTRACT FROM POMS SECTION DI 26510.015

G. IMPAIRMENT CODES

1. Adult Impairment Codes

Listing

Diagnostic Category

Impairment Code

 

Musculoskeletal (01)

 
1.02 Rheumatoid Arthritis and Other Inflammatory Polyarthropathies 7140
1.03 Osteoarthrosis and Allied Disorders 7150
1.04 Osteoarthrosis and Allied Disorders 7150
1.05 Ankylosing Spondylitis and Other Inflammatory Spondylopathies 7200
1.05 Disorders of Back (discogenic and degenerative) 7240
1.05B Other Disorders of Bone and Cartilage (Osteoporosis) 7330
1.08 Osteomyelitis, Periostitis, and Other Infections Involving Bone 7300
1.09 Late Effects of Musculoskeletal and Connective Tissue Injuries (amputation) 9050
1.10 Late Effects of Musculoskeletal and Connective Tissue Injuries (amputation) 9050
1.11 Fractures of Lower Limb 8270
1.12 Fractures of Upper Limb 8180
1.13 Open Wound of Upper Limb (Soft Tissue Injury) 8840
1.13 Open Wound of Lower Limb (Soft Tissue Injury) 8940
 

Special Senses and Speech (02)

 
2.02 Retinal Detachments and Defects 3610
2.02 Glaucoma 3650
2.02 Cataract 3660
2.02 Blindness and Low Vision 3690
2.03 Visual Disturbances 3680
2.04 Visual Disturbances 3680
2.05 Visual Disturbances 3680
2.06 Strabismus and Other Disorders of Eye Movements 3780
2.07 Vertiginous Syndromes and Other Disorders of Vestibular System 3860
2.08 Deafness 3890
2.09 Loss of Voice 7840
 

Respiratory (03)

 
3.02 Chronic Pulmonary Insufficiency 4960
3.03 Asthma 4930
3.04 Cystic Fibrosis 2770
3.06 Pneumoconiosis 5050
3.07 Bronchiectasis 4940
3.08 Mycobacterial, Mycotic, and Other Chronic Persistent Infections of the Lung 1170
3.09 Cor Pulmonale secondary to Chronic Pulmonary Vascular Hypertension 4160
3.10 Sleep-related Breathing Disorders 7800
 

Cardiovascular (04)

 
4.02 Chronic Heart Failure 4280
4.03 Hypertensive Cardiovascular Disease 4020
4.04 Ischemic Heart Disease 4140
4.05 Recurrent Arrhythmias 4270
4.06 Symptomatic Congenital Heart Disease 7460
4.07 Valvular Heart Disease or Other Stenotic Defects, or Valvular Regurgitation 4240
4.08 Cardiomyopathies 4250
4.09 Cardiac Transplantation 3750
4.10 Aneurysm of Aorta or Major Branches 4410
4.11 Chronic Venous Insufficiency 4590
4.12 Peripheral Arterial Disease 4430
 

Digestive (05)

 
5.02 Gastrointestinal Hemorrhage 5780
5.03 Diseases of Esophagus 5300
5.04 Peptic Ulcer (Gastric or Duodenal) 5330
5.05 Chronic Liver Disease and Cirrhosis 5710
5.06 Granulomatous Colitis 5550
5.06 Idiopathic Proctocolitis (Chronic Ulcerative Colitis) 5560
5.07 Regional Enteritis (Crohn's Disease) 5550
5.08 Malnutrition (Weight Loss) 2630
 

Genito-Urinary (06)

 
6.02 Chronic Renal Failure 5850
6.06 Nephrotic Syndrome 5810
 

Hemic and Lymphatic (07)

 
7.02 Other Anemias 2850
7.05 Hereditary Hemolytic Anemias (Including all Sickle Cell) 2820
7.06 Purpura and Other Hemorrhagic Conditions 2870
7.07 Disease of Capillaries (Hereditary Telangiectasia) 4480
7.08 Coagulation Defects (Including Hemophilia) 2860
7.09 Neoplasm of Uncertain Behavior of Other Sites and Tissues (Polycythemia Vera) 2380
7.10 Other Diseases of Blood and Blood-Forming Organs 2890
7.11 Leukemias 2070
7.12 Leukemias 2070
7.13 Malignant Neoplasm of Lymphoid and Histiocytic Tissue (Lymphoma) 2020
7.14 Disorders of Plasma Protein Metabolism 2730
7.15 Diseases of White Blood Cells 2880
7.16 Multiple Myeloma and Immunoproliferative Neoplasms 2030
7.17 Aplastic Anemia 2840
 

Skin (08)

 
8.02 Erythematous Conditions (Includes Discoid Lupus) 6950
8.03 Bullous Dermatoses 6940
8.04 Mycotic (Fungus) Infections 1170
8.05 Psoriasis and Similar Disorders 6960
8.06 Disorders of Sweat Glands 7050
 

Endocrine and Obesity (09)

 
9.02 All Disorders of Thyroid (Except Malignant Neoplasm) 2460
9.03 All Disorders of Parathyroid Gland (Except Malignant Neoplasm) 2520
9.04 All Disorders of Parathyroid Gland (Except Malignant Neoplasm) 2520
9.05 All Disorders of Pituitary Gland (Except Malignant Neoplasm) 2530
9.06 All Disorders of Adrenal Glands (Except Malignant Neoplasm) 2550
9.08 Diabetes Mellitus 2500
9.08A Diabetic Neuropathy 3570
9.08B Diabetic Acidosis 2760
9.08C Peripheral Vascular (Arterial) Disease (Diabetic Peripheral Arterial Disease) 4430
9.08D Other Retinal Disorder (Diabetic Retinopathy) 3620
9.09 Obesity 2780
 

Neurological (11)

 
11.02 Epilepsy (Major Motor Seizures) 3450
11.03 Epilepsy (Minor Motor Seizures) 3450
11.04 Late Effects of Cerebrovascular Disease 4380
11.05A Malignant Neoplasm of Brain 1910
11.05B Benign Neoplasm of Brain and Other Parts of Nervous System 2250
11.06 Parkinson's Disease 3320
11.07 Cerebral Palsy 3430
11.08 Other Diseases of Spinal Cord 3360
11.08 Fracture of Vertebral Column with Spinal Cord Lesion 8060
11.09 Multiple Sclerosis 3400
11.10 Anterior Horn Cell Disease (Amyotrophic Lateral Sclerosis) 3350
11.11 Late Effects of Acute Poliomyelitis 1380
11.12 Myoneural Disorders 3580
11.13 Muscular Dystrophies and Other Myopathies 3590
11.14 Peripheral Neuropathy 3570
11.15 Neurosyphilis (Tabes Dorsalis) 0940
11.16 Deficiency Anemias 2810
11.17 Other Cerebral Degenerations 3310
11.18 Late Effects of Injuries to the Nervous System 9070
11.19 Other Diseases of Spinal Cord 3360
 

Mental (12)

 
12.02 Organic Mental Disorders (Chronic Brain Syndrome) 2940
12.03 Schizophrenic, Paranoid and Other Functional Psychotic Disorders 2950
12.04 Affective Disorders 2960
12.05 Mental Retardation 3180
12.06 Anxiety Related Disorders 3000
12.07 Somatoform Disorders 3060
12.08 Personality Disorders 3010
12.09 Substance Addiction Disorder (Alcohol) 3030
12.09 Substance Addiction Disorder (Drug) 3040
12.09G Gastritis and Duodenitis 5350
 

Neoplastic (13)

 
13.02 Malignant Neoplasm of Other Sites (Head and Neck) 1950
13.03 Other Malignant Neoplasm of Skin 1730
13.04 Malignant Neoplasm of Connective and Other Soft Tissue 1710
13.05 Malignant Melanoma of Skin 1720
13.06 Malignant Neoplasm of Lymphoid and Histiocytic Tissue 2020
13.07 Malignant Neoplasm of Major Salivary Glands 1420
13.08 Malignant Neoplasm of Thyroid Gland 1930
13.09 Malignant Neoplasm of Breast 1740
13.10 Malignant Neoplasm of Bone and Articular Cartilage 1700
13.11 Malignant Neoplasm of Bone and Articular Cartilage 1700
13.12A Secondary Malignant Neoplasm (Metastatic Neoplasms of Distant Sites Other Than Regional Lymph Nodes) 1980
13.12B Malignant Neoplasm of Brain 1910
13.13 Malignant Neoplasm of Trachea, Bronchus, or Lung 1620
13.14 Malignant Neoplasm of Pleura 1630
  Malignant Neoplasm of Thymus, Heart or Mediastinum 1640
13.15 Malignant Neoplasm of Other and Ill-Defined Sites Within the Digestive Organs and Peritoneum (Abdomen) 1590
13.16 Malignant Neoplasm of Esophagus 1500
13.16 Malignant Neoplasm of Stomach 1510
13.17 Malignant Neoplasm of Small Intestine, Including Duodenum 1520
13.18 Malignant Neoplasm of Colon, Rectum or Anus 1530
13.19 Malignant Neoplasm of Liver and Intrahepatic Bile Ducts 1550
13.19 Malignant Neoplasm of Gallbladder and Extrahepatic Bile Ducts 1560
13.20 Malignant Neoplasm of Pancreas 1570
13.21 Malignant Neoplasm of Kidney or Other Urinary Organs 1890
13.21 Malignant Neoplasm of Other Endocrine Glands and Related Structures 1940
13.22 Malignant Neoplasm of Bladder 1880
13.23 Malignant Neoplasm of Prostate 1850
13.24 Malignant Neoplasm of Testis 1860
13.25 Malignant Neoplasm of Uterus 1790
13.26 Malignant Neoplasm of Ovary and Other Uterine Adnexa 1830
13.27 Leukemias 2070
13.28 Malignant Neoplasm of Ovary and Other Uterine Adnexa 1830
13.29 Malignant Neoplasm of Penis or Other Male Genital Organs 1870
13.30 Malignant Neoplasm of Other Female Genital Organs 1840
 

Immune System (14)

 
14.02 Systemic Lupus Erythematosus 7100
14.03 Systemic Vasculitis 4460
14.04 Systemic Sclerosis and Scleroderma 7100
14.05 Polymyositis or Dermatomyositis 7100
14.06 Undifferentiated Connective Tissue Disorder 7100
14.07 Immunoglobulin Deficiency Syndromes or Deficiencies of Cell Mediated Immunity 2790
14.08 Human Immunodeficiency Virus (HIV) Infection 0430
2. Childhood Impairment Codes

Listing

Diagnostic Category

Impairment Code

 

Musculoskeletal (01)

 
101.02 Juvenile Rheumatoid Arthritis 7140
101.03 Disorders of Muscle, Ligament and Fascia 7280
101.05A Fracture of Vertebral Column with Spinal Cord Lesion 8060
101.05B& C Curvature of Spine 7370
101.08 Osteomyelitis, Periostitis and Other Infections involving Bone 7300
 

Special Senses (02)

 
102.02 Blindness and Low Vision 3690
102.08 Deafness 3890
 

Respiratory (03)

 
103.02 Chronic Pulmonary Insufficiency 4960
103.03 Asthma 4930
103.04 Cystic Fibrosis 2770
 

Cardiovascular (04)

 
104.02 Chronic Heart Failure 4280
104.03 Hypertensive Cardiovascular Disease 4020
104.05 Recurrent Arrhythmias 4270
104.06 Congenital Heart Disease 7460
104.07 Valvular Heart Disease or Other Stenotic Defects, or Valvular Regurgitation 4240
104.08 Cardiomyopathies 4250
104.09 Cardiac Transplantation 3750
104.13 Chronic Rheumatic Fever or Rheumatic Heart Disease 3910
104.14 Hyperlipidemia 2720
104.15 Kawasaki Syndrome 4460
 

Digestive (05)

 
105.03 Congenital Anomalies of Upper Alimentary Tract (Esophageal Obstruction) 7500
105.05 Chronic Liver Disease and Cirrhosis 5710
105.07 Regional Enteritis 5550
  Idiopathic Proctocolitis 5560
105.08 Malnutrition 2630
 

Genito-Urinary (06)

 
106.02 Chronic Renal Failure 5850
106.06 Nephrotic Syndrome 5810
  Hemic and Lymphatic (07)  
107.03 Hereditary Hemolytic Anemias 2820
107.05 Hereditary Hemolytic Anemia (Sickle Cell) 2820
107.06 Purpura and Other Hemorrhagic Conditions 2870
107.08 Coagulation Defects (Including Hemophilia) 2860
107.11 Leukemia 2070
 

Endocrine (09)

 
109.02 All Disorders of Thyroid Gland (Except Malignant Neoplasm) 2460
109.03 All Disorders of Parathyroid Gland (Except Malignant Neoplasm) 2520
109.04 All Disorders of Parathyroid Gland (Except Malignant Neoplasm) 2520
109.05 All Disorders of Pituitary Gland (Except Malignant Neoplasm) 2530
109.06 All Disorders of Adrenal Glands (Except Malignant Neoplasm) 2550
109.07 All Disorders of Adrenal Glands (Except Malignant Neoplasm) 2550
109.08 Diabetes Mellitus 2500
109.09 All Disorders of Adrenal Glands (Except Malignant Neoplasm) 2550
109.10 All Disorders of Pituitary Gland (Except Malignant Neoplasm) 2530
109.11 All Disorders of Adrenal Gland (Except Malignant Neoplasm) 2550
109.12 Hypoglycemia 2510
109.13 Chromosomal Anomalies 7580
 

Multiple Body Systems (10)

 
110.06 Down Syndrome, excluding Mosaic Down Syndrome 7580
110.07 Multiple Body Dysfunction 7600
110.08 Catastrophic Congenital Abnormalities or Disease 7400
 

Neurological (11)

 
111.02A& B Epilepsy (Major Motor Seizures) 3450
111.03 Epilepsy (Minor Motor Seizures) 3450
111.05A Malignant Neoplasm of Brain 1910
111.05B Benign Neoplasm of Brain or Other Parts of Nervous System 2250
111.06 Other Disorders of Nervous System 3490
111.07 Cerebral Palsy 3430
111.08 Spina Bifida (Meningomyelocele) 7410
111.09 Loss of Voice (Communication Impairment) 7840
 

Mental (12)

 
112.02 Organic Mental Disorders 2940
112.03 Schizophrenic, Delusional (Paranoid), Schizoaffective, and Other Psychotic Disorders 2950
112.04 Mood Disorders 2960
112.05 Mental Retardation 3180
112.06 Anxiety Disorders 3000
112.07 Somatoform Disorders 3060
112.07 Eating and Tic Disorders 3070
112.08 Personality Disorders 3010
112.09 Psychoactive Substance Dependence Disorders, Alcohol 3030
112.09 Psychoactive Substance Dependence Disorders, Drugs 3040
112.10 Autistic Disorders and other Pervasive Developmental Disorders 2990
112.11 Attention Deficit Disorder/ Hyperactivity Disorder 3140
112.12 Developmental and Emotional Disorders of Newborn and Younger Infants 3150
 

Neoplastic (13)

 
113.02 Malignant Neoplasm of Lymphoid and Histiocytic Tissue 2020
113.03 Malignant Neoplasm of Unspecified Site 1990
113.04 Malignant Neoplasm of Other Parts of Nervous Systems (Neuroblastoma) 1920
113.05 Malignant Neoplasm of Eye 1900
 

Immune System (14)

 
114.02 Systemic Lupus Erythematosus 7100
114.03 Systemic Vasculitis 4460
114.04 Systemic Sclerosis and Scleroderma 7100
114.05 Polymyositis or Dermatomyositis 7100
114.06 Undifferentiated Connective Tissue Disorder 7100
114.07 Congenital Immune Deficiency Syndrome 2790
114.08 Human Immunodeficiency Virus (HIV) Infection 0430
 

Growth Impairment (19)

 
100.02 Malnutrition, Marasmus, Failure to Thrive 7830
100.03 Malnutrition, Marasmus, Failure to Thrive 7830
3. Special Diagnostic Situations

Impairment Codes

Diagnostic Category

Musculoskeletal (01)
2740 Gout
7140 Rheumatoid Arthritis and Other Inflammatory Polyarthropathies
7150

Osteoarthrosis and Allied Disorders

7200

Ankylosing Spondylitis and Other Inflammatory Spondylitis

7240 Disorders of Back (Discogenic and Degenerative)
7280 Disorders of Muscle, Ligament and Fascia
7300 Osteomyelitis, Periostitis and Other Infections Involving Bone
7330 Other Disorders of Bone and Cartilage (Osteoporosis)
7370 Curvature of Spine
7830 Malnutrition, Marasmus, Failure to Thrive (Growth Impairment)
8030 Fracture of Skull Without Intracranial Injury
8060 Fracture of Vertebral Column with Spinal Cord Lesion
8180 Fractures of Upper Limb
8270 Fracture of Lower Limb
8290 Other Fractures of Bones
8390 Dislocations-All Types
8480 Sprains and Strains-All Types
8840 Open Wound of Upper Limb (Soft Tissue Injury)
8940 Open Wound of Lower Limb (Soft Tissue Injury)
9050 Late Effects of Musculoskeletal and Connective Tissue Injuries (Amputation)
9480 Burns
Special Senses and Speech (02)
3610 Retinal Detachments and Defects
3620 Other Retina Disorders (Including Diabetic Retinopathy)
3650 Glaucoma
3660 Cataract
3680 Visual Disturbances
3690 Blindness and Low Vision
3780 Strabismus and Other Disorders of Eye Movements
3860 Vertiginous Syndromes and Other Disorders of Vestibular System
3880 Other Disorders of Ear
3890 Deafness
7840 Loss of Voice
Respiratory (03)
0110 Pulmonary Tuberculosis
1170 Mycotic (Fungus) Infections
1350 Sarcoidosis
1360 Other Infectious and Parasitic Disorders
2770 Disorders of Metabolism (Cystic Fibrosis)
4160 Chronic Pulmonary Heart Disease
4910 Chronic Bronchitis
4920 Emphysema
4930 Asthma
4940 Bronchiectasis
4960 Chronic Pulmonary Insufficiency (COPD)
5010 Asbestosis
5050 Pneumoconiosis
5190 Other Disorders of the Respiratory System
Cardiovascular (04)
0930 Cardiovascular Syphilis
3910 Rheumatic Fever with Heart Involvement
3950 Diseases of Aortic Valve
3980 Other Rheumatic Heart Disease
4010 Essential Hypertension
4020 Hypertensive Vascular Disease
4030 Hypertensive Vascular and Renal Disease
4100 Acute Myocardial Infarction
4130 Angina Pectoris Without Ischemic Heart Disease
4140 Chronic Ischemic Heart Disease With or Without Angina
4160 Chronic Pulmonary Heart Disease (Cor Pulmonale)
4250 Cardiomyopathy
4270 Cardiac Dysrhythmias
4280 Heart Failure
4410 Aortic Aneurysm
4430 Peripheral Vascular (Arterial) Disease
4480 Disease of Capillaries (Hereditary Telangiectasia)
4510 Phlebitis and Thrombophlebitis
4540 Varicose Veins of Lower Extremities
4590 Other Diseases of Circulatory System
7460 Congenital Anomalies of Heart
Digestive (05)
1360 Other Infectious and Parasitic Disorders
2630 Malnutrition (Weight Loss)
5300 Diseases of Esophagus
5330 Peptic Ulcer (Gastric or Duodenal)
5350 Gastritis and Duodenitis
5530 Hernias
5550 Regional Enteritis (Crohn's Disease)
5550 Granulomatous Colitis
5560 Idiopathic Proctocolitis (Chronic Ulcerative Colitis)
5690 Other Disorders of Gastrointestinal System
5710 Chronic Liver Disease and Cirrhosis
5780 Gastrointestinal Hemorrhage
7500 Congenital Anomalies of Upper Alimentary Tract
Genito-Urinary (06)
5810 Nephrotic Syndrome
5850 Chronic Renal Failure
5990 Other Disorders of the Urinary Tract
6080 Disorders of the Male Genital Organs
6290 Disorders of the Female Genital Organs
Hemic and Lymphatic (07)
2020 Malignant Neoplasm of Lymphoid and Histiocytic Tissue (Lymphoma)
2030 Multiple Myeloma and Immunoproliferative Neoplasms
2070 Leukemias
2380 Neoplasm of Uncertain Behavior of Other Sites and Tissues (Polycythemia Vera)
2730 Disorders of Plasma Protein Metabolism
2790 Disorders Involving the Immune Mechanism (other than HIV infection)
2810 Deficiency Anemias
2820 Hereditary Hemolytic Anemias (Including All Sickle Cell)
2840 Aplastic Anemia
2850 Other Anemias
2860 Coagulation Defects (Including Hemophilia)
2870 Purpura and Other Hemorrhagic Conditions
2880 Diseases of White Blood Cells
2890 Other Diseases of Blood and Blood-Forming Organsv
4480 Diseases of Capillaries (Hereditary Telangiectasia)
Skin (08)
1170 Mycotic (Fungus) Infections
6940 Bullous Dermatoses
6950 Erythematous Conditions (Includes Discoid Lupus)
6960 Psoriasis and Similar Disorders
7050 Disorders of Sweat Glands
7090 Other Disorders of the Skin and Subcutaneous Tissues
9480 Burns
Endocrine and Obesity (09)
2460 All Disorders of Thyroid (Except Malignant Neoplasm)
2500 Diabetes Mellitus
2510 Hypoglycemia
2520 All Disorders of Parathyroid Gland (Except Malignant Neoplasm)
2530 All Disorders of Pituitary Gland (Except Malignant Neoplasm)
2550 All Disorders of Adrenal Glands (Except Malignant Neoplasm)
2760 Diabetic Acidosis
2780 Obesity and Other Hyper aliment at ion
3570 Diabetic and Other Peripheral Neuropathy
3620 Other Retinal Disorders (Diabetic Retinopathy)
4430 Peripheral Vascular (Arterial) Disease
7580 Chromosomal Anomalies
Multiple Body System (for Children) (10)
3300 Cerebral Degenerations Usually Manifest in Children
7400 Anencephalus and Catastrophic Anomalies
Neurological (11)
0940 Neurosyphilis (Tabes Dorsalis)
1380 Late Effects of Acute Poliomyelitis
1910 Malignant Neoplasm of Brain
2250 Benign Neoplasm of Brain and Other Parts of Nervous System
2810 Deficiency Anemias
3300 Cerebral Degenerations Usually Manifest in Childhood
3310 Other Cerebral Degenerations
3320 Parkinson's Disease
3350 Anterior Horn Cell Disease (Including Amyotrophic Lateral Sclerosis)
3360 Other Diseases of Spinal Cord
3370 Disorders of Autonomic Nervous System
3400 Multiple Sclerosis
3430 Cerebral Palsy
3450 Epilepsy
3460 Migraine
3490 Other Disorders of the Nervous System
3570 Diabetic and Other Peripheral Neuropathy
3580 Myoneural Disorders
3590 Muscular Dystrophies and Other Myopathies
4380 Late Effects of Cerebrovascular Disease
7410 Spina Bifida
7840 Loss of Voice
8060 Fracture of Vertebral Column with Spinal Cord Lesion
8540 Intracranial Injury
9070 Late Effects of Injuries to the Nervous System
Mental (12)
2940 Organic Mental Disorders (Chronic Brain Syndrome)
2950 Schizophrenic, Paranoid and Other Functional Psychotic Disorders
2960 Mood Disorders
2990 Autistic Disorders and Other Pervasive Developmental Disorders
3000 Anxiety Related Disorders
3010 Personality Disorders
3030 Substance Addiction Disorders (Alcohol)
3040 Substance Addiction Disorders (Drug)
3060 Somatoform Disorders
3070 Eating and TIC Disorders
3140 Attention Deficit Hyperactivity Disorder
3150 Developmental and Emotional Disorders of Newborns and Younger Infants
3180 Mental Retardation
Neoplastic (13)
1410 Malignant Neoplasm of Tongue
1420 Malignant Neoplasm of Major Salivary Glands
1500 Malignant Neoplasm of Esophagus
1510 Malignant Neoplasm of Stomach
1520 Malignant Neoplasm of Small Intestine, Including Duodenum
1530 Malignant Neoplasm of Colon, Rectum or Anus
1550 Malignant Neoplasm of Liver and Intrahepatic Bile Ducts
1560 Malignant Neoplasm of Gallbladder and Extrahepatic Bile Ducts
1570 Malignant Neoplasm of Pancreas
1590 Malignant Neoplasm of Other and Ill-Defined Sites Within the Digestive Organs and Peritoneum (Abdomen)
1620 Malignant Neoplasm of Trachea, Bronchus, or Lung
1630 Malignant Neoplasm of Pleura
1640 Malignant Neoplasm of Thymus, Heart or Mediastinum
1700 Malignant Neoplasm of Bone and Articular Cartilage
1710 Malignant Neoplasm of Connective and Other Soft Tissue
1720 Malignant Melanoma of Skin
1730 Other Malignant Neoplasm of Skin
1740 Malignant Neoplasm of Breast
1790 Malignant Neoplasm of Uterus
1830 Malignant Neoplasm of Ovary and Other Uterine Adnexa
1840 Malignant Neoplasm of Other Female Genital Organs
1850 Malignant Neoplasm of Prostate
1860 Malignant Neoplasm of Testis
1870 Malignant Neoplasm of Penis or Other Male Genital Organs
1880 Malignant Neoplasm of Bladder
1890 Malignant Neoplasm of Kidney or Other Urinary Organs
1900 Malignant Neoplasm of Eye
1910 Malignant Neoplasm of Brain
1920 Malignant Neoplasm of Other Parts of Nervous System
1930 Malignant Neoplasm of Thyroid Gland
1940 Malignant Neoplasm of Other Endocrine Glands and Related Structures
1950 Malignant Neoplasm of Other Sites (Head and Neck) or of Unspecified Nature
1980 Secondary Malignant Neoplasms (Metastatic Neoplasms of Distant Sites Other Than Regional Lymph Nodes)
1990 Malignant Neoplasms of Unspecified Site
2020 Malignant Neoplasm of Lymphoid and Histiocytic Tissue (Lymphoma)
2030 Multiple Myeloma and Immunoproliferative Neoplasms
2070 Leukemias
2250 Benign Neoplasm of Brain or Other Parts of Nervous System
2380 Neoplasm of Uncertain Behavior of Other Sites and Tissues (Polycythemia Vera)
2390 Neoplasm of Unspecified or Unknown Nature
Immune System (14)
2790 Disorders Involving the Immune Mechanism (other than HIV Infection)
4460 Periarteritis Nodosa and Allied Conditions
7100 Diffuse Diseases of Connective Tissue (Including Systemic Lupus)
0430 Symptomatic Human Immunodeficiency Virus (HIV) Infection
0440 Asymptomatic Human Immunodeficiency Virus (HIV) Infection
Special/Other (20)
0000 None Established (No Medical Evidence in File)
6490 None Established (Medical Evidence in File But Insufficient to Establish Diagnosis)
2480 Diagnosis Established—No Predetermined List Code of Medical Nature Applicable
7590 Other Congenital Anomalies
8690 Internal Injury
8790 Other Open Wounds, Except Limbs

4. Symptomatic HIV Infection/Secondary Diagnosis Impairment Codes

Whenever symptomatic HIV (code 0430) is used as the primary diagnosis, the secondary diagnosis should be the manifestation of HIV. First, try to select the most appropriate code from the following list as the secondary diagnosis code. Only if the manifestation of HIV is not included in this list, should you select the most appropriate code from the preceding General List of Impairment Codes.

Impairment Codes Diagnostic Categories

Diagnosis

Impairment Code

Anemias 2850
Aspergillosis 1170
Bacterial infections, multiple or recurrent 0410
Bone infection 7300
Brain atrophy 3310
Candidiasis 1120
Carcinoma of the Cervix 1800
Cardiomyopathy 4250
Coccidioidomycosis 1140
Condyloma caused by the human papillomavirus 0780
Cryptococcosis 1170
Cryptosporidiosis 0070
Cytomegalovirus Disease 0780
Diarrhea 5580
Eczema 6920
Endocarditis 4240
Genital ulcerative disease, female 6290
Genital ulcerative disease, male 6080
Granulocytopenia 2880
Growth disturbance 7830
Hepatitis 5730
Herpes Simplex 0540
Herpes Zoster 0530
Histoplasmosis 1150
HIV encephalopathy 3480
HIV wasting syndrome 2630
Impaired brain growth 7420
Isosporiasis 0070
Joint infection 7110
Kaposi's Sarcoma 1760
Leukoencephalopathy 0460
Lymphoid interstitial pneumonia (LIP) 5160
Lymphoma 2000
Meningitis 3220
Microcephaly 7420
Microsporidiosis 1360
Mucormycosis 1170
Mycobacterial infection, avium intracellular, caused by M. Kansasii, or M. tuberculosis (except pulmonary tuberculosis) 0310
Nephropathy 5830
Neurological conditions 3490
Neurosyphilis 0940
Nocardiosis 0390
Pelvic inflammatory disease 6140
Peripheral neuropathy 3560
Pneumocystis carinii infection, extrapulmonary 1360
Pneumocystis Carinii Pneumonia (PCP) 1360
Pneumonia (non-PCP) 4860
Psoriasis 6960
Pulmonary lymphoid hyperplasia (PLH) 2850
Pulmonary tuberculosis 0110
Salmonella Bacteremia 0030
Sepsis 0380
Septic Arthritis 7110
Sinusitis 4730
Squamous Cell Carcinoma of the Anus 1540
Strongyloidiasis 1270
Syphilis 0970
Thrombocytopenia 2870
Toxoplasmosis 1300
Vulvovaginal candida 1120

[1]  1 In the context of the Preamble, the term “we” refers to the Social Security Administration (SSA).