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  • Severe.net - Title XVI
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  • Severe.net (TM) - Searchable CFR
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  • Listings 20 CFR Pt. 404, Subpt. P, App. 1 - Severe.net
    manifested by the full symptomatic picture of both manic and depressive syndromes and currently characterized by either or both syndromes AND B Resulting in at least two of the following 1 Marked restriction of activities of daily living or 2 Marked difficulties in maintaining social functioning or 3 Marked difficulties in maintaining concentration persistence or pace or 4 Repeated episodes of decompensation each of extended duration OR C Medically documented history of a chronic affective disorder of at least 2 years duration that has caused more than a minimal limitation of ability to do basic work activities with symptoms or signs currently attenuated by medication or psychosocial support and one of the following 1 Repeated episodes of decompensation each of extended duration or 2 A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate or 3 Current history of 1 or more years inability to function outside a highly supportive living arrangement with an indication of continued need for such an arrangement 12 05 Mental retardation Mental retardation refers to significantly subaverage general intellectual functioning with deficits in adaptive functioning initially manifested during the developmental period i e the evidence demonstrates or supports onset of the impairment before age 22 The required level of severity for this disorder is met when the requirements in A B C or D are satisfied A Mental incapacity evidenced by dependence upon others for personal needs e g toileting eating dressing or bathing and inability to follow directions such that the use of standardized measures of intellectual functioning is precluded OR B A valid verbal performance or full scale IQ of 59 or less OR C A valid verbal performance or full scale IQ of 60 through 70 and a physical or other mental impairment imposing an additional and significant work related limitation of function OR D A valid verbal performance or full scale IQ of 60 through 70 resulting in at least two of the following 1 Marked restriction of activities of daily living or 2 Marked difficulties in maintaining social functioning or 3 Marked difficulties in maintaining concentration persistence or pace or 4 Repeated episodes of decompensation each of extended duration 12 06 Anxiety Related Disorders In these disorders anxiety is either the predominant disturbance or it is experienced if the individual attempts to master symptoms for example confronting the dreaded object or situation in a phobic disorder or resisting the obsessions or compulsions in obsessive compulsive disorders The required level of severity for these disorders is met when the requirements in both A and B are satisfied or when the requirements in both A and C are satisfied A Medically documented findings of at least one of the following 1 Generalized persistent anxiety accompanied by three out of four of the following signs or symptoms a Motor tension or b Autonomic hyperactivity or c Apprehensive expectation or d Vigilance and scanning or 2 A persistent irrational fear of a specific object activity or situation which results in a compelling desire to avoid the dreaded object activity or situation or 3 Recurrent severe panic attacks manifested by a sudden unpredictable onset of intense apprehension fear terror and sense of impending doom occurring on the average of at least once a week or 4 Recurrent obsessions or compulsions which are a source of marked distress or 5 Recurrent and intrusive recollections of a traumatic experience which are a source of marked distress AND B Resulting in at least two of the following 1 Marked restriction of activities of daily living or 2 Marked difficulties in maintaining social functioning or 3 Marked difficulties in maintaining concentration persistence or pace or 4 Repeated episodes of decompensation each of extended duration OR C Resulting in complete inability to function independently outside the area of one s home 12 07 Somatoform Disorders Physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms The required level of severity for these disorders is met when the requirements in both A and B are satisfied A Medically documented by evidence of one of the following 1 A history of multiple physical symptoms of several years duration beginning before age 30 that have caused the individual to take medicine frequently see a physician often and alter life patterns significantly or 2 Persistent nonorganic disturbance of one of the following a Vision or b Speech or c Hearing or d Use of a limb or e Movement and its control e g coordination disturbance psychogenic seizures akinesia dyskinesia or f Sensation e g diminished or heightened 3 Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury AND B Resulting in at least two of the following 1 Marked restriction of activities of daily living or 2 Marked difficulties in maintaining social functioning or 3 Marked difficulties in maintaining concentration persistence or pace or 4 Repeated episodes of decompensation each of extended duration 12 08 Personality Disorders A personality disorder exists when personality traits are inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress Characteristic features are typical of the individual s long term functioning and are not limited to discrete episodes of illness The required level of severity for these disorders is met when the requirements in both A and B are satisfied A Deeply ingrained maladaptive patterns of behavior associated with one of the following 1 Seclusiveness or autistic thinking or 2 Pathologically inappropriate suspiciousness or hostility or 3 Oddities of thought perception speech and behavior or 4 Persistent disturbances of mood or affect or 5 Pathological dependence passivity or aggressivity or 6 Intense and unstable interpersonal relationships and impulsive and damaging behavior AND B Resulting in at least two of the following 1 Marked restriction of activities of daily living or 2 Marked difficulties in maintaining social functioning or 3 Marked difficulties in maintaining concentration persistence or pace or 4 Repeated episodes of decompensation each of extended duration 12 09 Substance Addiction Disorders Behavioral changes or physical changes associated with the regular use of substances that affect the central nervous system The required level of severity for these disorders is met when the requirements in any of the following A through I are satisfied A Organic mental disorders Evaluate under 12 02 B Depressive syndrome Evaluate under 12 04 C Anxiety disorders Evaluate under 12 06 D Personality disorders Evaluate under 12 08 E Peripheral neuropathies Evaluate under 11 14 F Liver damage Evaluate under 5 05 G Gastritis Evaluate under 5 04 H Pancreatitis Evaluate under 5 08 I Seizures Evaluate under 11 02 or 11 03 12 10 Autistic disorder and other pervasive developmental disorders Characterized by qualitative deficits in the development of reciprocal social interaction in the development of verbal and nonverbal communication skills and in imaginative activity Often there is a markedly restricted repertoire of activities and interests which frequently are stereotyped and repetitive The required level of severity for these disorders is met when the requirements in both A and B are satisfied A Medically documented findings of the following 1 For autistic disorder all of the following a Qualitative deficits in reciprocal social interaction and b Qualitative deficits in verbal and nonverbal communication and in imaginative activity and c Markedly restricted repertoire of activities and interests OR 2 For other pervasive developmental disorders both of the following a Qualitative deficits in reciprocal social interaction and b Qualitative deficits in verbal and nonverbal communication and in imaginative activity AND B Resulting in at least two of the following 1 Marked restriction of activities of daily living or 2 Marked difficulties in maintaining social functioning or 3 Marked difficulties in maintaining concentration persistence or pace or 4 Repeated episodes of decompensation each of extended duration 13 00 Neoplastic Diseases Malignant A Introduction The determination of the level of impairment resulting from malignant tumors is made from a consideration of the site of the lesion the histogenesis of the tumor the extent of involvement the apparent adequacy and response to therapy surgery irradiation hormones chemotherapy etc and the magnitude of the post therapeutic residuals B Documentation The diagnosis of malignant tumors should be established on the basis of symptoms signs and laboratory findings The site of the primary recurrent and metastatic lesion must be specified in all cases of malignant neoplastic diseases If an operative procedure has been performed the evidence should include a copy of the operative note and the report of the gross and microscopic examination of the surgical specimen If these documents are not obtainable then the summary of hospitalization or a report from the treating physician must include details of the findings at surgery and the results of the pathologist s gross and microscopic examination of the tissues For those cases in which a disabling impairment was not established when therapy was begun but progression of the disease is likely current medical evidence should include a report of a recent examination directed especially at local or regional recurrence soft part or skeletal metastases and significant posttherapeutic residuals C Evaluation Usually when the malignant tumor consists of a local lesion with metastases to the regional lymph nodes which apparently has been completely excised imminent recurrence or metastases is not anticipated A number of exceptions are noted in the specific Listings For adjudicative purposes distant metastases or metastases beyond the regional lymph nodes refers to metastasis beyond the lines of the usual radical en bloc resection Local or regional recurrence after radical surgery or pathological evidence of incomplete excision by radical surgery is to be equated with unresectable lesions except for carcinoma of the breast 13 09C and for the purposes of our program may be evaluated as inoperable Local or regional recurrence after incomplete excision of a localized and still completely resectable tumor is not to be equated with recurrence after radical surgery In the evaluation of lymphomas the tissue type and site of involvement are not necessarily indicators of the degree of impairment When a malignant tumor has metastasized beyond the regional lymph nodes the impairment will usually be found to meet the requirements of a specific listing Exceptions are hormone dependent tumors isotope sensitive metastases and metastases from seminoma of the testicles which are controlled by definitive therapy When the original tumor and any metastases have apparently disappeared and have not been evident for 3 or more years the impairment does not meet the criteria under this body system D Effects of therapy Significant posttherapeutic residuals not specifically included in the category of impairments for malignant neoplasms should be evaluated according to the affected body system Where the impairment is not listed in the Listing of Impairments and is not medically equivalent to a listed impairment the impact of any residual impairment including that caused by therapy must be considered The therapeutic regimen and consequent adverse response to therapy may vary widely therefore each case must be considered on an individual basis It is essential to obtain a specific description of the therapeutic regimen including the drugs given dosage frequency of drug administration and plans for continued drug administration It is necessary to obtain a description of the complications or any other adverse response to therapy such as nausea vomiting diarrhea weakness dermatologic disorders or reactive mental disorders Since the severity of the adverse effects of anticancer chemotherapy may change during the period of drug administration the decision regarding the impact of drug therapy should be based on a sufficient period of therapy to permit proper consideration E Onset To establish onset of disability prior to the time a malignancy is first demonstrated to be inoperable or beyond control by other modes of therapy and prior evidence is nonexistent requires medical judgment based on medically reported symptoms the type of the specific malignancy its location and extent of involvement when first demonstrated 13 01 Category of Impairments Neoplastic Diseases Malignant 13 02 Head and neck except salivary glands 13 07 thyroid gland 13 08 and mandible maxilla orbit or temporal fossa 13 11 A Inoperable or B Not controlled by prescribed therapy or C Recurrent after radical surgery or irradiation or D With distant metastases or E Epidermoid carcinoma occurring in the pyriform sinus or posterior third of the tongue 13 03 Sarcoma of skin A Angiosarcoma with metastases to regional lymph nodes or beyond or B Mycosis fungoides with metastases to regional lymph nodes or with visceral involvement 13 04 Sarcoma of soft parts Not controlled by prescribed therapy 13 05 Malignant melanoma A Recurrent after wide excision or B With metastases to adjacent skin satellite lesions or elsewhere 13 06 Lymph nodes A Hodgkin s disease or non Hodgkin s lymphoma with progressive disease not controlled by prescribed therapy or B Metastatic carcinoma in a lymph node except for epidermoid carcinoma in a lymph node in the neck where the primary site is not determined after adequate search or C Epidermoid carcinoma in a lymph node in the neck not responding to prescribed therapy 13 07 Salivary glands carcinoma or sarcoma with metastases beyond the regional lymph nodes 13 08 Thyroid gland carcinoma with metastases beyond the regional lymph nodes not controlled by prescribed therapy 13 09 Breast A Inoperable carcinoma or B Inflammatory carcinoma or C Recurrent carcinoma except local recurrence controlled by prescribed therapy or D Distant metastases from breast carcinoma bilateral breast carcinoma synchronous or metachronous is usually primary in each breast or E Sarcoma with metastases anywhere 13 10 Skeletal system exclusive of the jaw A Malignant primary tumors with evidence of metastases and not controlled by prescribed therapy or B Metastatic carcinoma to bone where the primary site is not determined after adequate search 13 11 Mandible maxilla orbit or temporal fossa A Sarcoma of any type with metastases or B Carcinoma of the antrum with extension into the orbit or ethmoid or sphenoid sinus or with regional or distant metastases or C Orbital tumors with intracranial extension or D Tumors of the temporal fossa with perforation of skull and meningeal involvement or E Adamantinoma with orbital or intracranial infiltration or F Tumors of Rathke s pouch with infiltration of the base of the skull or metastases 13 12 Brain or spinal cord A Metastatic carcinoma to brain or spinal cord B Evaluate other tumors under the criteria described in 11 05 and 11 08 13 13 Lungs A Unresectable or with incomplete excision or B Recurrence or metastases after resection or C Oat cell small cell carcinoma or D Squamous cell carcinoma with metastases beyond the hilar lymph nodes or E Other histologic types of carcinoma including undifferentiated and mixed cell types but excluding oat cell carcinoma 13 13C and squamous cell carcinoma 13 13D with metastases to the hilar lymph nodes 13 14 Pleura or mediastinum A Malignant mesothelioma of pleura or B Malignant tumors metastatic to pleura or C Malignant primary tumor of the mediastinum not controlled by prescribed therapy 13 15 Abdomen A Generalized carcinomatosis or B Retroperitoneal cellular sarcoma not controlled by prescribed therapy or C Ascites with demonstrated malignant cells 13 16 Esophagus or stomach A Carcinoma or sarcoma of the esophagus or B Carcinoma of the stomach with metastases to the regional lymph nodes or extension to surrounding structure or C Sarcoma of stomach not controlled by prescribed therapy or D Inoperable carcinoma or E Recurrence or metastases after resection 13 17 Small intestine A Carcinoma sarcoma or carcinoid tumor with metastases beyond the regional lymph nodes or B Recurrence of carcinoma sarcoma or carcinoid tumor after resection or C Sarcoma not controlled by prescribed therapy 13 18 Large intestine from ileocecal valve to and including anal canal carcinoma or sarcoma A Unresectable or B Metastases beyond the regional lymph nodes or C Recurrence or metastases after resection 13 19 Liver or gallbladder A Primary or metastatic malignant tumors of the liver or B Carcinoma of the gallbladder or C Carcinoma of the bile ducts 13 20 Pancreas A Carcinoma except islet cell carcinoma or B Islet cell carcinoma which is unresectable and physiologically active 13 21 Kidneys adrenal glands or ureters carcinoma A Unresectable or B With hematogenous spread to distant sites or C With metastases to regional lymph nodes 13 22 Urinary bladder carcinoma With A Infiltration beyond the bladder wall or B Metastases to regional lymph nodes or C Unresectable or D Recurrence after total cystectomy or E Evaluate renal impairment after total cystectomy under the criteria in 6 02 13 23 Prostate gland carcinoma not controlled by prescribed therapy 13 24 Testicles A Choriocarcinoma or B Other malignant primary tumors with progressive disease not controlled by prescribed therapy 13 25 Uterus carcinoma or sarcoma corpus or cervix A Inoperable and not controlled by prescribed therapy or B Recurrent after total hysterectomy or C Total pelvic exenteration 13 26 Ovaries all malignant primary or recurrent tumors With A Ascites with demonstrated malignant cells or B Unresectable infiltration or C Unresectable metastases to omentum or elsewhere in the peritoneal cavity or D Distant metastases 13 27 Leukemia Evaluate under the criteria of 7 00ff Hemic and Lymphatic System 13 28 Uterine Fallopian tubes carcinoma or sarcoma A Unresectable or B Metastases to regional lymph nodes 13 29 Penis carcinoma with metastases to regional lymph nodes 13 30 Vulva carcinoma with distant metastases 14 00 Immune System A Listed disorders include impairments involving deficiency of one or more components of the immune system i e antibody producing B cells a number of different types of cells associated with cell mediated immunity including T lymphocytes macrophages and monocytes and components of the complement system B Dysregulation of the immune system may result in the development of a connective tissue disorder Connective tissue disorders include several chronic multisystem disorders that differ in their clinical manifestation course and outcome They generally evolve and persist for months or years may result in loss of functional abilities and may require long term repeated evaluation and management The documentation needed to establish the existence of a connective tissue disorder is medical history physical examination selected laboratory studies medically acceptable imaging techniques and in some instances tissue biopsy However the Social Security Administration will not purchase diagnostic tests or procedures that may involve significant risk such as biopsies or angiograms Generally the existing medical evidence will contain this information A longitudinal clinical record of at least 3 months demonstrating active disease despite prescribed treatment during this period with the expectation that the disease will remain active for 12 months is necessary for assessment of severity and duration of impairment To permit appropriate application of a listing the specific diagnostic features that should be documented in the clinical record for each of the disorders are summarized for systemic lupus erythematosus SLE systemic vasculitis systemic sclerosis and scleroderma polymyositis or dermatomyositis and undifferentiated connective tissue disorders In addition to the limitations caused by the connective tissue disorder per se the chronic adverse effects of treatment e g corticosteroid related ischemic necrosis of bone may result in functional loss These disorders may preclude performance of any gainful activity by reason of severe loss of function in a single organ or body system or lesser degrees of functional loss in two or more organs body systems associated with significant constitutional symptoms and signs of severe fatigue fever malaise and weight loss We use the term severe in these listings to describe medical severity the term does not have the same meaning as it does when we use it in connection with a finding at the second step of the sequential evaluation processes in 404 1520 416 920 and 416 924 1 Systemic lupus erythematosus 14 02 This disease is characterized clinically by constitutional symptoms and signs e g fever fatigability malaise weight loss multisystem involvement and frequently anemia leukopenia or thrombocytopenia Immunologically an array of circulating serum auto antibodies can occur but are highly variable in pattern Generally the medical evidence will show that patients with this disease will fulfill The 1982 Revised Criteria for the Classification of Systemic Lupus Erythematosus of the American College of Rheumatology Tan E M et al Arthritis Rheum 25 11271 1277 1982 2 Systemic vasculitis 14 03 This disease occurs acutely in association with adverse drug reactions certain chronic infections and occasionally malignancies More often it is idiopathic and chronic There are several clinical patterns including classical polyarteritis nodosa aortic arch arteritis giant cell arteritis Wegener s granulomatosis and vasculitis associated with other connective tissue disorders e g rheumatoid arthritis SLE Sjogren s syndrome cryoglobulinemia Cutaneous vasculitis may or may not be associated with systemic involvement and the patterns of vascular and ischemic involvement are highly variable The diagnosis is confirmed by angiography or tissue biopsy when the disease is suspected clinically Most patients who are stated to have this disease will have the results of the confirmatory angiogram or biopsy in their medical records 3 Systemic sclerosis and scleroderma 14 04 These disorders constitute a spectrum of disease in which thickening of the skin is the clinical hallmark Raynaud s phenomena often severe and progressive are especially frequent and may be the peripheral manifestation of a generalized vasospastic abnormality in the heart lungs and kidneys The CREST syndrome calcinosis Raynaud s phenomena esophageal dysmotility sclerodactyly telangiectasia is a variant that may slowly progress to the generalized process systemic sclerosis over years In addition to skin and blood vessels the major organ body system involvement includes the gastrointestinal tract lungs heart kidneys and muscle Although arthritis can occur joint dysfunction results primarily from soft tissue cutaneous thickening fibrosis and contractures 4 Polymyositis or dermatomyositis 14 05 This disorder is primarily an inflammatory process in striated muscle which can occur alone or in association with other connective tissue disorders or malignancy Weakness and less frequently pain and tenderness of the proximal limb girdle musculature are the cardinal manifestations Involvement of the cervical muscles the cricopharyngeals the intercostals and diaphragm may occur in those with listing level disease Weakness of the pelvic girdle as contemplated in Listing 14 05A may result in significant difficulty climbing stairs or rising from a chair without use of the arms Proximal limb weakness in the upper extremities may result in inability to lift objects and interference with dressing and combing hair Weakness of anterior neck flexors may impair the ability to lift the head from the pillow in bed The diagnosis is supported by elevated serum muscle enzymes creatine phosphokinase CPK aminotransferases aldolase characteristic abnormalities on electromyography and myositis on muscle biopsy 5 Undifferentiated connective tissue disorder 14 06 This listing includes syndromes with clinical and immunologic features of several connective tissue disorders but that do not satisfy the criteria for any of the disorders described for instance the individual may have clinical features of systemic lupus erythematosus and systemic vasculitis and the serologic findings of rheumatoid arthritis It also includes overlap syndromes with clinical features of more than one established connective tissue disorder For example the individual may have features of both rheumatoid arthritis and scleroderma The correct designation of this disorder is important for assessment of prognosis C Allergic disorders e g asthma or atopic dermatitis are discussed and evaluated under the appropriate listing of the affected body system D Human immunodeficiency virus HIV infection 1 HIV infection is caused by a specific retrovirus and may be characterized by susceptibility to one or more opportunistic diseases cancers or other conditions as described in 14 08 Any individual with HIV infection including one with a diagnosis of acquired immunodeficiency syndrome AIDS may be found disabled under this listing if his or her impairment meets any of the criteria in 14 08 or is of equivalent severity to any impairment in 14 08 2 Definitions In 14 08 the terms resistant to treatment recurrent and disseminated have the same general meaning as used by the medical community The precise meaning of any of these terms will depend upon the specific disease or condition in question the body system affected the usual course of the disorder and its treatment and the other circumstances of the case Resistant to treatment means that a condition did not respond adequately to an appropriate course of treatment Whether a response is adequate or a course of treatment appropriate will depend on the facts of the particular case Recurrent means that a condition that responded adequately to an appropriate course of treatment has returned after a period of remission or regression The extent of response or remission and the time periods involved will depend on the facts of the particular case Disseminated means that a condition is spread widely over a considerable area or body system s The type and extent of the spread will depend on the specific disease As used in 14 08I significant involuntary weight loss does not correspond to a specific minimum amount or percentage of weight loss Although for purposes of this listing an involuntary weight loss of at least 10 percent of baseline is always considered significant loss of less than 10 percent may or may not be significant depending on the individual s baseline weight and body habitus For example a 7 pound weight loss in a 100 pound female who is 63 inches tall might be considered significant but a 14 pound weight loss in a 200 pound female who is the same height might not be significant 3 Documentation of HIV infection The medical evidence must include documentation of HIV infection Documentation may be by laboratory evidence or by other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice a Documentation of HIV infection by definitive diagnosis A definitive diagnosis of HIV infection is documented by one or more of the following laboratory tests i A serum specimen that contains HIV antibodies HIV antibodies are usually detected by a screening test The most commonly used screening test is the ELISA Although this test is highly sensitive it may yield false positive results Therefore positive results from an ELISA must be confirmed by a more definitive test e g Western blot immunofluorescence assay ii A specimen that contains HIV antigen e g serum specimen lymphocyte culture or cerebrospinal fluid CSF specimen iii Other test s that are highly specific for detection of HIV e g polymerase chain reaction PCR or that are acceptable methods of detection consistent with the prevailing state of medical knowledge When laboratory testing for HIV infection has been performed every reasonable effort must be made to obtain reports of the results of that testing Individuals who have HIV infection or other disorders of the immune system may undergo tests to determine T helper lymphocyte CD4 counts The extent of immune depression correlates with the level or rate of decline of the CD4 count In general when the CD4 count is 200 mm super3 or less 14 percent or less the susceptibility to opportunistic disease is considerably increased However a reduced CD4 count alone does not establish a definitive diagnosis of HIV infection or document the severity or functional effects of HIV infection b Other acceptable documentation of HIV infection HIV infection may also be documented without the definitive laboratory evidence described in paragraph a provided that such documentation is consistent with the prevailing state of medical knowledge and clinical practice and is consistent with the other evidence If no definitive laboratory evidence is available HIV infection may be documented by the medical history clinical and laboratory findings and diagnosis es indicated in the medical evidence For example a diagnosis of HIV infection will be accepted without definitive laboratory evidence if the individual has an opportunistic disease e g toxoplasmosis of the brain pneumocystis carinii pneumonia PCP predictive of a defect in cell mediated immunity and there is no other known cause of diminished resistance to that disease e g long term steroid treatment lymphoma In such cases every reasonable effort must be made to obtain full details of the history medical findings and results of testing 4 Documentation of the manifestations of HIV infection The medical evidence must also include documentation of the manifestations of HIV infection Documentation may be by laboratory evidence orby other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice a Documentation of the manifestations of HIV infection by definitive diagnosis The definitive method of diagnosing opportunistic diseases or conditions that are manifestations of HIV infection is by culture serological test or microscopic examination of biopsied tissue or other material e g bronchial washings Therefore every reasonable effort must be made to obtain specific laboratory evidence of an opportunistic disease or other condition whenever this information is available If a histological or other test has been performed the evidence should include a copy of the appropriate report If the report is not obtainable the summary of hospitalization or a report from the treating source should include details of the findings and results of the diagnostic studies including radiographic studies or microscopic examination of the appropriate tissues or body fluids Although a reduced CD4 lymphocyte count may show that there is an increased susceptibility to opportunistic infections and diseases see 14 00D3a above that alone does not establish the presence severity or functional effects of a manifestation of HIV infection b Other acceptable documentation of the manifestations of HIV infection Manifestations of HIV infection may also be documented without the definitive laboratory evidence described in paragraph a provided that such documentation is consistent with the prevailing state of medical knowledge and clinical practice and is consistent with the other evidence If no definitive laboratory evidence is available manifestations of HIV infection may be documented by medical history clinical and laboratory findings and diagnosis es indicated in the medical evidence In such cases every reasonable effort must be made to obtain full details of the history medical findings and results of testing Documentation of cytomegalovirus CMV disease 14 08D presents special problems because diagnosis requires identification of viral inclusion bodies or a positive culture from the affected organ and the absence of any other infectious agent A positive serology test identifies infection with the virus but does not confirm a disease process With the exception of chorioretinitis which may be diagnosed by an ophthalmologist documentation of CMV disease requires confirmation by biopsy or other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice 5 Manifestations specific to women Most women with severe immunosuppression secondary to HIV infection exhibit the typical opportunistic infections and other conditions such as pneumocystis carinii pneumonia PCP candida esophagitis wasting syndrome cryptococcosis and toxoplasmosis However HIV infection may have different manifestations in women than in men Adjudicators must carefully scrutinize the medical evidence and be alert to the variety of medical conditions specific to or common in women with HIV infection that may affect their ability to function in the workplace Many of these manifestations e g vulvovaginal candidiasis pelvic inflammatory disease occur in women with or without HIV infection but can be more severe or resistant to treatment or occur more frequently in a woman whose immune system is suppressed Therefore when evaluating the claim of a woman with HIV infection it is important to consider gynecologic and other problems specific to women including any associated symptoms e g pelvic pain in assessing the severity of the impairment and resulting functional limitations Manifestations of HIV infection in women may be evaluated under the specific criteria e g cervical cancer under 14 08E under an applicable general category e g pelvic inflammatory disease under 14 08A5 or in appropriate cases under 14 08N 6 Evaluation The criteria in 14 08 do not describe the full spectrum of diseases or conditions manifested by individuals with HIV infection As in any case consideration must be given to whether an individual s impairment s meets or equals in severity any other listing in appendix 1 of subpart P e g a neoplastic disorder listed in 13 00ff Although 14 08 includes cross references to other listings for the more common manifestations of HIV infection other listings may apply In addition the impact of all impairments whether or not related to HIV infection must be considered For example individuals with HIV infection may manifest signs and symptoms of a mental impairment e g anxiety depression or of another physical impairment Medical evidence should include documentation of all physical and mental impairments and the impairment s should be evaluated not only under the relevant listing s in 14 08 but under any other appropriate listing s It is also important to remember that individuals with HIV infection like all other individuals are evaluated under the full five step sequential evaluation process described in 404 1520 and 416 920 If an individual with HIV infection is working and engaging in substantial gainful activity SGA or does not have a severe impairment the case will be decided at the first or second step of the sequential evaluation process and does not require evaluation under these listings For an individual with HIV infection who is not engaging in SGA and has a severe impairment but whose impairment s does not meet or equal in severity the criteria of a listing evaluation must proceed through the final steps of the sequential evaluation process or as appropriate the steps in the medical improvement review standard before any conclusion can be reached on the issue of disability 7 Effect of treatment Medical treatment must be considered in terms of its effectiveness in ameliorating the signs symptoms and laboratory abnormalities of the specific disorder or of the HIV infection itself e g antiretroviral agents and in terms of any side effects of treatment that may further impair the individual Response to treatment and adverse or beneficial consequences of treatment may vary widely For example an individual with HIV infection who develops pneumonia or tuberculosis may respond to the same antibiotic regimen used in treating individuals without HIV infection but another individual with HIV infection may not respond to the same regimen Therefore each case must be considered on an individual basis along with the effects of treatment on the individual s ability to function A specific description of the drugs or treatment given including surgery dosage frequency of administration and a description of the complications or response to treatment should be obtained The effects of treatment may be temporary or long term As such the decision regarding the impact of treatment should be based on a sufficient period of treatment to permit proper consideration 8 Functional criteria Paragraph N of 14 08 establishes standards for evaluating manifestations of HIV infection that do not meet the requirements listed in 14 08A M Paragraph N is applicable for manifestations that are not listed in 14 08A M as well as those listed in 14 08A M that do not meet the criteria of any of the rules in 14 08A M For individuals with HIV infection evaluated under 14 08N listing level severity will be assessed in terms of the functional limitations imposed by the impairment The full impact of signs symptoms and laboratory findings on the claimant s ability to function must be considered Important factors to be considered in evaluating the functioning of individuals with HIV infection include but are not limited to symptoms such as fatigue and pain characteristics of the illness such as the frequency and duration of manifestations or periods of exacerbation and remission in the disease course and the functional impact of treatment for the disease including the side effects of medication As used in 14 08N repeated means that the conditions occur on an average of 3 times a year or once every 4 months each lasting 2 weeks or more or

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  • Severe.net (TM) - Final Rules
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  • The Grid w/o text - Severe.net
    Transferable Not Disabled 201 27 Younger individual 18 44 High school graduate or more Unskilled or none Not Disabled 201 28 Younger individual 18 44 High school graduate or more Skilled or semi skilled Skills not Transferable Not Disabled 201 29 Younger individual 18 44 High school graduate or more Skilled or semi skilled Skills Transferable Not Disabled FN1 See 201 00 f FN2 See 201 00 d FN3 See 201 00 g FN4 See 201 00 h TABLE No 2 Residual Functional Capacity Maximum Sustained Work Capability Limited to Light Work as a Result of Severe Medically Determinable Impairment s Rule Age Education Previous Work Experience Decision 202 01 Advanced Age 55 Limited or Less Unskilled or None Disabled 202 02 Advanced Age 55 Limited or Less Skilled or semi skilled Skills not Transferable Disabled 202 03 Advanced Age 55 Limited or Less Skilled or semi skilled Skills Transferable Not Disabled 202 04 Advanced Age 55 High School grad or more does not provide for direct entry into skilled work Unskilled or None Disabled 202 05 Advanced Age 55 High School grad or more provide for direct entry into skilled work Unskilled or None Not Disabled 202 06 Advanced Age 55 High School grad or more does not provide for direct entry into skilled work Skilled or semi skilled Skills not Transferable Disabled 202 07 Advanced Age 55 High School grad or more does not provide for direct entry into skilled work Skilled or semi skilled Skills Transferable Not Disabled 202 08 Advanced Age 55 High School grad or more provide for direct entry into skilled work Skilled or semi skilled Skills not Transferable Not Disabled 202 09 Closely Approaching advanced age 50 54 Illiterate or unable to communicate in English Unskilled or none Disabled 202 10 Closely Approaching advanced age 50 54 Limited or less At least literate and able to communicate in English Unskilled or none Not Disabled 202 11 Closely Approaching advanced age 50 54 Limited or Less Skilled or semi skilled Skills not Transferable Not Disabled 202 12 Closely Approaching advanced age 50 54 Limited or Less Skilled or semi skilled Skills Transferable Not Disabled 202 13 Closely Approaching advanced age 50 54 High School grad or more Unskilled or none Not Disabled 202 14 Closely Approaching advanced age 50 54 High School grad or more Skilled or semi skilled Skills not Transferable Not Disabled 202 15 Closely Approaching advanced age 50 54 High School grad or more Skilled or semi skilled Skills Transferable Not Disabled 202 16 Younger Individual Illiterate or unable to communicate in English Unskilled or none Not Disabled 202 17 Younger Individual Limited or less At least literate and able to communicate in English Unskilled or none Not Disabled 202 18 Younger Individual Limited or Less Skilled or semi skilled Skills not Transferable Not Disabled 202 19 Younger Individual Limited or Less Skilled or semi skilled Skills Transferable Not Disabled 202 20 Younger Individual High School grad or more Unskilled or

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  • Severe.net - SSA Disability Rulings
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  • Severe.net (TM) - SSA Handbook
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  • Severe.net (TM) - DOT - Dictionary of Occupational Titles
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