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U.S. Social Security Administration
Disability Evaluation Under Social Security (Blue
Book- September 2008)
Social Security Administration SSA Pub. No. 64-039
Office of Disability Programs ICN 468600
September 2008
The Social Security Administration (SSA) administers two programs that
provide benefits based on disability: the Social Security disability
insurance program (title II of the Social Security Act (the Act)) and
the supplemental security income (SSI) program (title XVI of the Act).
Title II provides for payment of disability benefits to individuals
who are "insured" under the Act by virtue of their contributions to
the Social Security trust fund through the Social Security tax on
their earnings, as well as to certain disabled dependents of insured
individuals. Title XVI provides for SSI payments to individuals
(including children under age 18) who are disabled and have limited
income and resources.
The Act and SSA's implementing regulations prescribe rules for
deciding if an individual is "disabled." SSA's criteria for deciding
if someone is disabled are not necessarily the same as the criteria
applied in other Government and private disability programs.
Definition of Disability
For all individuals applying for disability benefits under title II,
and for adults applying under title XVI, the definition of disability
is the same. The law defines disability as the inability to engage in
any substantial gainful activity (SGA) by reason of any medically
determinable physical or mental impairment(s) which can be expected to
result in death or which has lasted or can be expected to last for a
continuous period of not less than 12 months.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if
he or she has a medically determinable physical or mental impairment
or combination of impairments that causes marked and severe functional
limitations, and that can be expected to cause death or that has
lasted or can be expected to last for a continuous period of not less
than 12 months.
What is a "Medically Determinable Impairment"?
A medically determinable physical or mental impairment is an
impairment that results from anatomical, physiological, or
psychological abnormalities which can be shown by medically acceptable
clinical and laboratory diagnostic techniques. A physical or mental
impairment must be established by medical evidence consisting of
signs, symptoms, and laboratory findings-not only by the individual's
statement of symptoms.
* * *
The Role of the Health Professional
Health professionals play a vital role in the disability determination
process and participate in the process in a variety of ways:
As treating sources or other medical
sources who provide medical evidence on behalf of their patients;
As CE [consultive examination] sources
to perform, for a fee, examinations and/or tests that are needed;
As full-time or part-time medical or
psychological consultants reviewing claims in a DDS, in one of SSA's
regional offices, or in SSA central office; or
As medical experts who testify at
administrative law judge hearings or respond to written
interrogatories from the administrative law judge.
* * *
Q. How is the
disability determination made?
A. SSA’s regulations provide for disability evaluation under a
procedure known as the "sequential evaluation process." For adults,
this process requires sequential review of the claimant's current work
activity, the severity of his or her impairment(s), a determination of
whether his or her impairment(s) meets or medically equals a listing
(see Part III of this guide), the claimant's residual functional
capacity, his or her past work, and his or her age, education, and
work experience. For children applying for SSI, the process requires
sequential review of the child's current work activity (if any), the
severity of his or her impairment(s), and an assessment of whether his
or her impairment(s) results in marked and severe functional
limitations. If an adult or child is found disabled or not disabled at
any point in the evaluation, the evaluation does not continue.
* * *
Part II -
Evidentiary Requirements
Medical Evidence
Under both the Title II and Title XVI programs,
medical evidence is the cornerstone for the determination of
disability.
Each person who files a disability claim is
responsible for providing medical evidence showing he or she has an
impairment(s) and the severity of the impairment(s). However, the
Social Security Administration (SSA), with the claimant’s permission,
will help the claimant get medical reports from his or her own medical
sources. This medical evidence generally comes from sources that have
treated or evaluated the claimant for his or her impairment(s).
Acceptable Medical Sources
Documentation of the existence of a claimant's
impairment must come from medical professionals defined by SSA
regulations as "acceptable medical sources." Once the existence of an
impairment is established, all the medical and non-medical evidence is
considered in assessing impairment severity.
Acceptable medical sources are:
licensed physicians (medical or osteopathic
doctors);
licensed or certified psychologists including
school psychologists (and other licensed or certified individuals with
other titles who perform the same function as school psychologists in
a school setting) only for purposes of establishing mental
retardation, learning disabilities, and borderline intellectual
functioning ;
licensed optometrists only for purposes of
establishing visual disorders (except in the U.S. Virgin Islands where
licensed optometrists are acceptable medical sources only for the
measurement of visual acuity and visual fields);
licensed podiatrists only for purposes of
establishing impairments of the foot, or foot and the ankle,
depending on whether the State in which the podiatrist practices
permits the practice of podiatry on the foot only, or the foot and the
ankle; and
qualified speech-language pathologists only for
purposes of establishing speech or language impairments. For this
source, “qualified” means that the speech-language pathologist must be
licensed by the State education agency in the State in which he or she
practices, or hold a Certificate of Clinical Competence from the
American Speech-Language-Hearing Association.
Medical Evidence from Treating Sources
Currently, many disability claims are decided based
on medical evidence from treating sources. SSA regulations place
special emphasis on evidence from treating sources because they are
likely to be the medical professionals most able to provide a detailed
longitudinal picture of the claimant's impairment(s) and may bring a
unique perspective to the medical evidence that cannot be obtained
from the medical findings alone or from reports of individual
examinations or brief hospitalizations. Therefore, timely, accurate,
and adequate medical reports from treating sources accelerate the
processing of the claim because they can greatly reduce or eliminate
the need for additional medical evidence to complete the claim.
Medical Evidence From Health Facilities
SSA also requests copies of medical evidence from
hospitals, clinics, or other health facilities where a claimant has
been treated. All medical reports received are considered during the
disability determination process.
Other Evidence
Information from other sources may also help show
the extent to which an individual's impairment(s) affects his or her
ability to function in a work setting; or in the case of a child, the
ability to function compared to that of children the same age who do
not have impairments. Other sources include public and private
agencies, non‑medical sources such as schools, parents and caregivers,
social workers and employers, and other practitioners such as
naturopaths, chiropractors, and audiologists.
Medical Reports
Physicians, psychologists, and other health
professionals are frequently asked by SSA to submit reports about an
individual's impairment(s). Therefore, it is important to know what
evidence SSA needs. Medical reports should include:
medical history;
clinical findings (such as the results of physical
or mental status examinations);
laboratory findings (such as blood pressure,
x-rays);
diagnosis;
treatment prescribed with response and prognosis;
a statement about what the claimant can still do
despite his or her impairment(s), based on the medical source's
findings on the above factors.
f the claimant is an adult age 18 or over, this
statement should describe, but is not limited to, the claimant's
ability to perform work-related activities, such as sitting, standing,
walking, lifting, carrying, handling objects, hearing, speaking, and
traveling.
in adult cases involving mental impairments or
mental functional limitations, this statement should describe the
claimant's capacity to understand, to carry out and remember
instructions, and to respond appropriately to supervision, coworkers,
and work pressures in a work setting.
if the claimant is a child under age 18, this
statement should describe the child’s functional limitations compared
to children his or her age who do not have impairments in acquiring
and using information, attending and completing tasks, interacting and
relating with others, moving about and manipulating objects, caring
for yourself, and health and physical well-being.
* * *
Evidence Relating to Symptoms
In developing evidence of the effects of symptoms, such as pain,
shortness of breath, or fatigue, on a claimant's ability to function,
SSA investigates all avenues presented that relate to the complaints.
These include information provided by treating and other sources
regarding:
the claimant's daily activities;
the location, duration, frequency, and intensity of
the pain or other symptom;
precipitating and aggravating factors;
the type, dosage, effectiveness, and side effects
of any medication;
treatments, other than medications, for the relief
of pain or other symptoms;
any measures the claimant uses or has used to
relieve pain or other symptoms; and
other factors concerning the claimant's functional
limitations due to pain or other symptoms.
In assessing the claimant's pain or other symptoms,
the decision makers must give full consideration to all of the
above-mentioned factors. It is important that medical sources address
these factors in the reports they provide.
Part III - Listing Of Impairments
The Listing of Impairments describes, for each major
body system, impairments considered severe enough to prevent an
individual from doing any gainful activity (or in the case of children
under age 18 applying for SSI, severe enought to cause marked and
severe functional limitations). Most of the listed impairments are
permanent or expected to result in death, or the listing includes a
specific statement of duration is made. For all other listings, the
evidence must show that the impairment has lasted or is expected to
last for a continuous period of at least 12 months. The criteria in
the Listing of Impairments are applicable to evaluation of claims for
disability benefits under the Social Security disability insurance
program or payments under both the SSI program.
Part A of the Listing of Impairments contains medical criteria that
apply to the evaluation of impairments in adults age 18 and over. The
medical criteria in
Part A may also be applied in evaluating impairments in children
under age 18 if the disease processes have a similar effect on adults
and younger children.
Part B of the Listing of Impairments contains additional medical
criteria that apply only to the evaluation of impairments of persons
under age 18. Certain criteria in Part A do not give appropriate
consideration to the particular effects of the disease processes in
childhood; that is, when the disease process is generally found only
in children or when the disease process differs in its effect on
children and adults.
Additional criteria are included in
Part B, and the impairment categories are, to the extent possible,
numbered to maintain a relationship with their counterparts in Part A.
In evaluating disability for child under age 18, part B will be used
first. If the medical criteria in part B do not apply, then the
medical criteria in part A will be used.
The criteria in the Listing of Impairments apply only to one step of
the multi-step sequential evaluation process. At that step, the
presence of an impairment that meets the criteria in the Listing of
Impairments (or that is of equal severity) is usually sufficient to
establish that an individual who is not working is disabled.
However, the absence of a listing-level impairment does not mean the
individual is not disabled. Rather, it merely requires the adjudicator
to move on to the next step of the process and apply other rules in
order to resolve the issue of disability.
Listing of
Impairments - Adult Listings (Part A)
The following sections
are applicable to individuals age 18 and over and to children under
age 18 where criteria are appropriate.
This electronic version contains the new Immune System Disorders
Listings effective June 16, 2008.
* * *
2.00 Special Senses and
Speech
* * *
B. Otolaryngology
1. Hearing Impairment. Hearing
ability should be evaluated in terms of the person’s ability to hear
and distinguish speech.
Loss of hearing can be quantitatively determined by
an audiometer which meets the standards of the American National
Standards Institute (ANSI) for air and bone conducted stimuli (i.e.,
ANSI S 3.6‑1969 and ANSI S 3.13-1972, or subsequent comparable
revisions) and performing all hearing measurements in an environment
which meets the ANSI standard for maximal permissible background sound
(ANSI S 3.1‑1977).
Speech discrimination should be determined using a
standardized measure of speech discrimination ability in quiet at a
test presentation level sufficient to ascertain maximum discrimination
ability. The speech discrimination measure (test) used, and the level
at which testing was done must be reported.
Hearing tests should be preceded by an
otolaryngologic examination and should be performed by or under the
supervision of an otolaryngologist or audiologist qualified to perform
such tests.
In order to establish an independent medical
judgment as to the level of impairment in a claimant alleging
deafness, the following examinations should be reported:
Otolaryngologic examination, pure tone air and bone audiometry, speech
reception threshold (SRT), and speech discrimination testing. A copy
of reports of medical examination and audiologic evaluations must be
submitted.
Cases of alleged “deaf mutism” should be documented
by a hearing evaluation. Records obtained from a speech and hearing
rehabilitation center or a special school for the deaf may be
acceptable, but if these reports are not available, or are found to be
inadequate, a current hearing evaluation should be submitted as
outlined in the preceding paragraph.
2. Vertigo associated with disturbances of
labyrinthine‑vestibular function, including Meniere’s disease. These disturbances of balance are characterized by an
hallucination of motion or a loss of position sense and a sensation of
dizziness which may be constant or may occur in paroxysmal attacks.
Nausea, vomiting, ataxia, and incapacitation are frequently observed,
particularly during the acute attack. It is important to differentiate
the report of rotary vertigo from that of “dizziness” which is
described as light‑headedness, unsteadiness, confusion, or syncope.
Meniere’s disease is characterized by paroxysmal
attacks of vertigo, tinnitus, and fluctuating hearing loss. Remissions
are unpredictable and irregular, but may be long-lasting; hence, the
severity of impairment is best determined after prolonged observation
and serial reexaminations.
The diagnosis of a vestibular disorder requires a
comprehensive neuro‑otolaryngologic examination with a detailed
description of the vertiginous episodes, including notation of
frequency, severity, and duration of the attacks. Pure tone and speech
audiometry with the appropriate special examinations, such as Bekesy
audiometry, are necessary. Vestibular function is accessed by
positional and caloric testing, preferably by electronystagmography.
When polytomograms, contrast radiography, or other special tests have
been performed, copies of the reports of these tests should be
obtained in addition to appropriate medically acceptable imaging
reports of the skull and temporal bone. Medically acceptable imaging
includes, but is not limited to, x-ray imaging, computerized axial
tomography (CAT scan) or magnetic resonance imaging (MRI), with or
without contrast material, myelography, and radionuclear bone scans.
“Appropriate” means that the technique used is the proper one to
support the evaluation and diagnosis of the impairment.
* * *
2.07 Disturbance of
labyrinthine‑vestibular function (including Meniere’s disease), characterized by a history of frequent attacks of balance
disturbance, tinnitus, and progressive loss of hearing. With both A
and B:
A. Disturbed
function of vestibular labyrinth demonstrated by caloric or other
vestibular tests; and
B. Hearing
loss established by audiometry.
2.08 Hearing impairments
(hearing not restorable by a hearing aid)
manifested by:
A. Average
hearing threshold sensitivity for air conduction of 90decibels or
greater, and for bone conduction to corresponding maximal levels, in
the better ear, determined by the simple average of hearing threshold
levels at 500, 1000, and 2000hz. (see 2.00B1); or
B. Speech
discrimination scores of 40 percent or less in the better ear.
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