Health Hippo: Evaluations of Social Security Disability

Step 1 || Step 2 || Step 3 || RFC || Step 4 || Step 5 || Children || Cessation || Other
Table I: Impairment/SSR || Table II: Listing of Impairments
FindLaw: Government Benefits: Supreme Court Decisions

The Social Security Administration administers two programs that provide benefits based on disability: the Social Security disability program (Title II) and the supplemental security income program (Title XVI). Title II provides benefits to individuals who are insured under the Act by virtue of their contributions to the Social Security trust fund through tax on their earnings. Title XVI provides payments to individuals who are disabled and have limited income and resources.

What follows is a linked outline to legal resources organized under the Office of Hearings and Appeals five-step sequential evaluation process for reviewing social security disability claims, as set out in 20 CFR 404.1520. The rules under Title II and XVI are identical in most cases, so only Title II rules are linked below.

Social Security Ruling 86-8: THE SEQUENTIAL EVALUATION PROCESS. The regulations state that a sequential evaluation process is followed whereby current work activity, severity and duration of the impairment(s), ability to do past work and vocational factors are considered in that order.

1. Substantial Gainful Activity

Social Security Ruling 83-34: SELF-EMPLOYED PERSONS. In determining whether a self-employed individual is engaging in SGA, consideration must be given to the individual's activities and their value to his or her business.

Social Security Ruling 83-35: AVERAGING OF EARNINGS. Method of averaging earnings for determinations as to whether work is substantial gainful activity (SGA) under the disability provisions of the law.

Social Security Ruling 84-25: UNSUCCESSFUL WORK ATTEMPT. Determining whether substantial work activity that is discontinued or reduced below a specified level may be considered an unsuccessful work attempt (UWA) under the disability provisions of the law.

Social Security Ruling 85-5c: AVERAGING EARNINGS FROM EMPLOYMENT. Claimant's employment at the department store, along with the evidence of her satisfactory work performance, showed that she had engaged in SGA.

Social Security Ruling 94-1c: ILLEGAL ACTIVITY AS SUBSTANTIAL GAINFUL ACTIVITY. Finding that neither the Act nor the regulations recognizes a distinction between lawful and unlawful activity for purposes of determining SGA, the court of appeals concluded that illegal activity can constitute SGA.

20 CFR 404.429, Earnings; defined.

20 CFR 404.1571, General.

20 CFR 404.1572, What we mean by substantial gainful activity.

20 CFR 404.1573, General information about work activity.

20 CFR 404.1574, Evaluation guides if you are an employee.

20 CFR 404.1575, Evaluation guides if you are self-employed.

20 CFR 404.1576, Impairment-related work expenses.

2. Severe Impairment

BOWEN v. YUCKERT, 482 U.S. 137 (1987) The severity regulation increases the efficiency and reliability of the disability evaluation process by identifying at an early stage those claimants whose medical impairments are so slight that it is unlikely they would be found to be disabled even if their age, education, and experience were taken into account.

Social Security Ruling 82-52: DURATION OF THE IMPAIRMENT. In considering "duration," it is the inability to engage in SGA because of the impairment that must last the required 12-month period.

Social Security Ruling 85-28: MEDICAL IMPAIRMENTS THAT ARE NOT SEVERE. To clarify the policy for determining when a person's impairment(s) may be found "not severe" and, thus, the basis for a finding of "not disabled" in the sequential evaluation of disability, and thereby reflect certain circuit court decisions that have taken issue with the Secretary's previously stated definition of "not severe" impairments.

Social Security Ruling 96-3p: CONSIDERING ALLEGATIONS OF PAIN AND OTHER SYMPTOMS IN DETERMINING WHETHER A MEDICALLY DETERMINABLE IMPAIRMENT IS SEVERE. An individual's symptoms may cause limitations and restrictions in functioning which, when considered at step 2, may require a finding that there is a "severe" impairment(s) and a decision to proceed to the next step of sequential evaluation.

Social Security Ruling 96-4p: SYMPTOMS, MEDICALLY DETERMINABLE PHYSICAL AND MENTAL IMPAIRMENTS, AND EXERTIONAL AND NONEXERTIONAL LIMITATIONS.

A "symptom" is not a "medically determinable physical or mental impairment" and no symptom by itself can establish the existence of such an impairment.
In the absence of a showing that there is a "medically determinable physical or mental impairment," an individual must be found not disabled at step 2 of the sequential evaluation process. No symptom or combination of symptoms can be the basis for a finding of disability, no matter how genuine the individual's complaints may appear to be, unless there are medical signs and laboratory findings demonstrating the existence of a medically determinable physical or mental impairment.
The terms "exertional" and "nonexertional" in the regulations describe types of functional limitations or restrictions resulting from a medically determinable physical or mental impairment; i.e., exertional limitations affect an individual's ability to meet the strength demands of jobs, and nonexertional limitations or restrictions affect an individual's ability to meet the nonstrength demands of jobs. Therefore, a symptom in itself is neither exertional nor nonexertional. Rather, it is the nature of the functional limitations or restrictions caused by an impairment-related symptom that determines whether the impact of the symptom is exertional, nonexertional, or both.
The application of the medical-vocational rules in appendix 2 of subpart P of Regulations No. 4 depends on the nature of the limitations and restrictions imposed by an individual's medically determinable physical or mental impairment(s), and any related symptoms.

Social Security Ruling 99-2p: EVALUATING CASES INVOLVING CHRONIC FATIGUE SYNDROME (CFS). This Ruling explains that CFS, when accompanied by appropriate medical signs or laboratory findings, is a medically determinable impairment that can be the basis for a finding of "disability." It also provides guidance for the evaluation of claims involving CFS.

20 CFR 404.1504, Determinations by other organizations and agencies. A decision by any nongovernmental agency or any other governmental agency about whether you are disabled or blind is based on its rules and is not our decision about whether you are disabled or blind. We must make a disability or blindness determination based on social security law. Therefore, a determination made by another agency that you are disabled or blind is not binding on us.

20 CFR 404.1508, What is needed to show an impairment.

20 CFR 404.1509, How long the impairment must last.

20 CFR 404.1512, Evidence of your impairment.

20 CFR 404.1513, Medical evidence of your impairment (acceptable sources).

20 CFR 404.1519, The consultative examination..

20 CFR 404.1519a, When we will purchase a consultative examination and how we will use it.

20 CFR 404.1521, What we mean by an impairment that is not severe.

3. Meets or Equals a Listing

Listing of Impairments -- Appendix 1 to Subpart P of Part 404.

Listing of Impairments — hyperlinked version.

Social Security Ruling 96-6p: MEDICAL EQUIVALENCE. The administrative law judge or the Appeals Council must obtain an updated medical expert opinion before a decision of disability based on medical equivalence can be made. Equals = 1) missing a sign; 2) different impairment; 3) combination of impairments.

Obesity: Revised Medical Criteria for Determination of Disability (Final Rule: August 24, 1999). Although many individuals with obesity are appropriately found "disabled" within the meaning of the Social Security Act (the Act), we have determined that the criteria in listing 9.09 were not appropriate indicators of listing-level severity because they did not represent a degree of functional limitation that would prevent an individual from engaging in any gainful activity.

3.5. Residual Functional Capacity

Social Security Ruling 96-2p: GIVING CONTROLLING WEIGHT TO TREATING SOURCE MEDICAL OPINIONS. The provision recognizes the deference to which a treating source's medical opinion should be entitled. It does not permit us to substitute our own judgment for the opinion of a treating source on the issue(s) of the nature and severity of an impairment when the treating source has offered a medical opinion that is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence.

Social Security Ruling 96-5p: MEDICAL SOURCE OPINIONS ON ISSUES RESERVED TO THE COMMISSIONER. How we consider medical source opinions on issues reserved to the Commissioner, including whether an individual's impairment(s) meets or is equivalent in severity to the requirements of any impairment(s) in the Listing of Impairments in appendix 1, subpart P of 20 CFR part 404 (the listings); what an individual's residual functional capacity (RFC) is; whether an individual's RFC prevents him or her from doing past relevant work; how the vocational factors of age, education, and work experience apply; and whether an individual is "disabled" under the Social Security Act (the Act).

Social Security Ruling 96-6p: CONSIDERATION OF ADMINISTRATIVE FINDINGS OF FACT BY STATE AGENCY MEDICAL AND PSYCHOLOGICAL CONSULTANTS AND OTHER PROGRAM PHYSICIANS AND PSYCHOLOGISTS AT THE ADMINISTRATIVE LAW JUDGE AND APPEALS COUNCIL LEVELS OF ADMINISTRATIVE REVIEW. Findings of fact made by State agency medical and psychological consultants and other program physicians and psychologists regarding the nature and severity of an individual's impairment(s) must be treated as expert opinion evidence of non-examining sources at the administrative law judge and Appeals Council levels of administrative review. Administrative law judges and the Appeals Council may not ignore these opinions and must explain the weight given to these opinions in their decisions.

Social Security Ruling 96-7p: ASSESSING THE CREDIBILITY OF AN INDIVIDUAL'S STATEMENTS.

No symptom or combination of symptoms can be the basis for a finding of disability, no matter how genuine the individual's complaints may appear to be, unless there are medical signs and laboratory findings demonstrating the existence of a medically determinable physical or mental impairment(s) that could reasonably be expected to produce the symptoms.
When the existence of a medically determinable physical or mental impairment(s) that could reasonably be expected to produce the symptoms has been established, the intensity, persistence, and functionally limiting effects of the symptoms must be evaluated to determine the extent to which the symptoms affect the individual's ability to do basic work activities. This requires the adjudicator to make a finding about the credibility of the individual's statements about the symptom(s) and its functional effects.
Because symptoms, such as pain, sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone, the adjudicator must carefully consider the individual's statements about symptoms with the rest of the relevant evidence in the case record in reaching a conclusion about the credibility of the individual's statements if a disability determination or decision that is fully favorable to the individual cannot be made solely on the basis of objective medical evidence.
In determining the credibility of the individual's statements, the adjudicator must consider the entire case record, including the objective medical evidence, the individual's own statements about symptoms, statements and other information provided by treating or examining physicians or psychologists and other persons about the symptoms and how they affect the individual, and any other relevant evidence in the case record. An individual's statements about the intensity and persistence of pain or other symptoms or about the effect the symptoms have on his or her ability to work may not be disregarded solely because they are not substantiated by objective medical evidence.
It is not sufficient for the adjudicator to make a single, conclusory statement that "the individual's allegations have been considered" or that "the allegations are (or are not) credible." It is also not enough for the adjudicator simply to recite the factors that are described in the regulations for evaluating symptoms. The determination or decision must contain specific reasons for the finding on credibility, supported by the evidence in the case record, and must be sufficiently specific to make clear to the individual and to any subsequent reviewers the weight the adjudicator gave to the individual's statements and the reasons for that weight.

Social Security Ruling 96-8p: ASSESSING RESIDUAL FUNCTIONAL CAPACITY IN INITIAL CLAIMS.

Ordinarily, RFC is an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis. A "regular and continuing basis" means 8 hours a day, for 5 days a week, or an equivalent work schedule.
The RFC assessment considers only functional limitations and restrictions that result from an individual's medically determinable impairment or combination of impairments, including the impact of any related symptoms. Age and body habitus are not factors in assessing RFC. It is incorrect to find that an individual has limitations beyond those caused by his or her medically determinable impairment(s) and any related symptoms, due to such factors as age and natural body build, and the activities the individual was accustomed to doing in his or her previous work.
When there is no allegation of a physical or mental limitation or restriction of a specific functional capacity, and no information in the case record that there is such a limitation or restriction, the adjudicator must consider the individual to have no limitation or restriction with respect to that functional capacity.
The RFC assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions in paragraphs (b), (c), and (d) of 20 CFR 404.1545 and 416.945. Only after that may RFC be expressed in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy.
RFC is not the least an individual can do despite his or her limitations or restrictions, but the most.
Medical impairments and symptoms, including pain, are not intrinsically exertional or nonexertional. It is the functional limitations or restrictions caused by medical impairments and their related symptoms that are categorized as exertional or nonexertional.

20 CFR 404.1502, Definition of treating source.

20 CFR 404.1513, Medical evidence of your impairment.

20 CFR 404.1527, Evaluating medical opinions about your impairment or disability (examining, treating, nature & extent, support, consistency, specialization, issues reserved to the Commissioner and more).

20 CFR 404.1528, Symptoms, signs and laboratory findings.

20 CFR 404.1529, How we evaluate symptoms, including pain (includes the 7 pain factors).

20 CFR 404.1545, Your residual functional capacity.

20 CFR 404.1546, Responsibility for assessing and determining residual functional capacity.

4. Past Relevant Work

Social Security Ruling 82-40: THE VOCATIONAL RELEVANCE OF THE PAST WORK PERFORMED IN A FOREIGN COUNTRY. The proper test in the fourth step of the sequential evaluation process is whether the individual can do his or her previous work, whether in the U.S. or in a foreign economy.

Social Security Ruling 82-61: PAST RELEVANT WORK -- THE PARTICULAR JOB OR THE OCCUPATION AS GENERALLY PERFORMED. Under sections 404.1520(e) and 416.920(e) of the regulations, a claimant will be found to be "not disabled" when it is determined that he or she retains the RFC to perform: 1) The actual functional demands and job duties of a particular past relevant job; or 2) The functional demands and job duties of the occupation as generally required by employers throughout the national economy.

Social Security Ruling 82-62: A DISABILITY CLAIMANT'S CAPACITY TO DO PAST RELEVANT WORK, IN GENERAL. Capacity to do past work may be indicative of the capacity to engage in SGA when that work experience constituted SGA and has current relevance considering duration and recency.

20 CFR 404.2(a)(4), Attainment of age.

20 CFR 404.1560, When your vocational background will be considered.

20 CFR 404.1562, If you have done only arduous unskilled physical labor.

5. Other Work

The "Grids" -- Appendix 2 to Subpart P of Part 404--Medical-Vocational Guidelines. These rules reflect the analysis of the various vocational factors (i.e., age, education, and work experience) in combination with the individual's residual functional capacity (used to determine his or her maximum sustained work capability for sedentary, light, medium, heavy, or very heavy work) in evaluating the individual's ability to engage in substantial gainful activity in other than his or her vocationally relevant past work. Notes: 1) no need to discuss transferable skills for claimants under age 50; 2) age 50+, RFC of simple, unskilled work = no transferable skills; 3) unskilled work provides no transferable skills (duh?); 4) age 55+, light work w/o transferable skills = disabled; 5) age 50-54, sedentary work w/o transferable skills = disabled.

Social Security Ruling 82-63: MEDICAL-VOCATIONAL PROFILES SHOWING AN INABILITY TO MAKE AN ADJUSTMENT TO OTHER WORK. There are two "medical-vocational profiles" which show an inability to make a vocational adjustment to other work (or any work) and which must be considered before a disability decision-maker refers to Appendix 2 of Subpart P of Regulations No. 4 to determine whether a claimant can do work which exists in significant numbers in the national economy, considering the interaction of the claimant's residual functional capacity (RFC), age, education, and work experience. The characteristics of these two profiles are: (1) marginal education and long work experience limited to arduous unskilled physical labor and (2) advanced age, limited education and no work experience.

Social Security Ruling 83-10: THE MEDICAL-VOCATIONAL RULES OF APPENDIX 2. Addresses the issue of capability to do other work, and provides definitions of terms and concepts frequently used in evaluating disability under the medical-vocational rules.

Social Security Ruling 83-11: CAPABILITY TO DO OTHER WORK -- THE EXERTIONALLY BASED MEDICAL-VOCATIONAL RULES MET

Social Security Ruling 83-12: THE MEDICAL-VOCATIONAL RULES AS A FRAMEWORK FOR EVALUATING EXERTIONAL LIMITATIONS WITHIN A RANGE OF WORK OR BETWEEN RANGES OF WORK. Includes "significantly eroding the occupational base" explanation, "less than a full range", sit/stand option and more.

Social Security Ruling 83-14: THE MEDICAL-VOCATIONAL RULES AS A FRAMEWORK FOR EVALUATING A COMBINATION OF EXERTIONAL AND NONEXERTIONAL IMPAIRMENTS. No table rule applies to direct a conclusion of "Disabled" or "Not disabled" where an individual has a nonexertional limitation or restriction imposed by a medically determinable impairment. However, a particular additional exertional or nonexertional limitation may have very little effect on the range of work remaining that an individual can perform. The person, therefore, comes very close to meeting a table rule that directs a conclusion of "Not Disabled."

Social Security Ruling 85-15: THE MEDICAL-VOCATIONAL RULES AS A FRAMEWORK FOR EVALUATING SOLELY NONEXERTIONAL IMPAIRMENTS. (1) The potential job base for mentally ill claimants without adverse vocational factors is not necessarily large even for individuals who have no other impairments, unless their remaining mental capacities are sufficient to meet the intellectual and emotional demands of at least unskilled, competitive, remunerative work on a sustained basis; and (2) that a finding of disability can be appropriate for an individual who has a severe mental impairment which does not meet or equal the Listing of Impairments, even where he or she does not have adversities in age, education, or work experience. (dust & fumes don't significantly erode the base).

Social Security Ruling 96-4p: SYMPTOMS, MEDICALLY DETERMINABLE PHYSICAL AND MENTAL IMPAIRMENTS, AND EXERTIONAL AND NONEXERTIONAL LIMITATIONS.

The terms "exertional" and "nonexertional" in the regulations describe types of functional limitations or restrictions resulting from a medically determinable physical or mental impairment; i.e., exertional limitations affect an individual's ability to meet the strength demands of jobs, and nonexertional limitations or restrictions affect an individual's ability to meet the nonstrength demands of jobs. Therefore, a symptom in itself is neither exertional nor nonexertional. Rather, it is the nature of the functional limitations or restrictions caused by an impairment-related symptom that determines whether the impact of the symptom is exertional, nonexertional, or both.
The application of the medical-vocational rules in appendix 2 of subpart P of Regulations No. 4 depends on the nature of the limitations and restrictions imposed by an individual's medically determinable physical or mental impairment(s), and any related symptoms.

Social Security Ruling 96-9p: IMPLICATIONS OF A RESIDUAL FUNCTIONAL CAPACITY FOR LESS THAN A FULL RANGE OF SEDENTARY WORK. Guidelines for evaluating the ability to do less than a full range of sedentary work.

20 CFR 404.1512, Evidence of your impairment (burden of proof shift).

20 CFR 404.1563, Your age as a vocational factor.

20 CFR 404.1564, Your education as a vocational factor.

20 CFR 404.1565, Your work experience as a vocational factor.

20 CFR 404.1566, Work which exists in the national economy.

20 CFR 404.1567, Physical exertion requirements (sedentary, light, medium, etc., defined).

20 CFR 404.1568, Skill requirements.

20 CFR 404.1569, Listing of Medical-Vocational Guidelines in appendix 2.

20 CFR 404.1569a, Exertional and nonexertional limitations (defines both).

Continuing or Stopping Disability or Blindness

20 CFR 404.1579, How we will determine whether your disability continues or ends.

20 CFR 404.1594, How we will determine whether your disability continues or ends.

20 CFR 416.994, How we will determine whether your disability continues or ends.

20 CFR 404.1571, How we will determine whether your disability continues or ends.

20 CFR 404.1572, How we will determine whether your disability continues or ends.

20 CFR 404.1573, How we will determine whether your disability continues or ends.

20 CFR 404.1574, How we will determine whether your disability continues or ends.

20 CFR 404.1575, How we will determine whether your disability continues or ends.

20 CFR 416.988 Your responsibility to tell us of events that may change your disability or blindness status.

20 CFR 416.989 We may conduct a review to find out whether you continue to be disabled.

20 CFR 416.989a We may conduct a review to find out whether you continue to be blind.

20 CFR 416.990 When and how often we will conduct a continuing disability review.

20 CFR 416.991 If your medical recovery was expected and you returned to work.

20 CFR 416.992 The trial work period.

20 CFR 416.992a The reentitlement period.

20 CFR 416.993 Medical evidence in continuing disability review cases.

20 CFR 416.994 How we will determine whether your disability continues or ends.

20 CFR 416.994a How we will determine whether your disability continues or ends, and whether you are and have been receiving treatment that is medically necessary and available, disabled children.

20 CFR 416.995 If we make a determination that your physical or mental impairment(s) has ceased, did not exist or is no longer disabling (Medical Cessation Determination).

Medicare Part A - Disability Beneficiaries

20 CFR 406.12 Individual under age 65 who is entitled to social security or railroad retirement disability benefits (25-month requirement; deemed retroactive entitlement; duration; SGA).

SSR TABLE RELATED TO PARTICULAR LIMITATIONS

Activity

RFC

SSR

Amputation

Medium

83-12

Cannot be performed with an above-elbow amputation

Amputation

Heavy

83-12

Cannot be performed with an above-elbow amputation

Arm

Medium

83-12

Cannot be performed with an above-elbow amputation

Arm

Heavy

83-12

Cannot be performed with an above-elbow amputation

Arms

Sedentary

83-12

Sedentary work cannot be performed by one who has lost use of an upper extremity since most unskilled, sedentary jobs require good use of hands and fingers

Arms

Sedentary

83-10

Most unskilled, sedentary jobs require good use of hands and fingers for repetitive hand-finger actions

Arms

Light

83-10

Requires use of arms and hands to grasp, hold and turn objects and generally does not require use of the fingers for fine activities to the extent required in sedentary work

Arms

Medium

83-10

Use of the arms and hands is necessary to grasp, hold and turn objects as opposed to finer activities in much sedentary work

Arms

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Assistive Devices

Sedentary

96-9p

If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded

Balancing

Sedentary

96-9p

Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work

Balancing

All

85-15

"Some" limitations in climbing and balancing are not significant

Bending

Sedentary

83-14,

85-15

Stooping, crouching and bending required occasionally at most

Bending

Light

83-14,

85-15

Stooping and bending are required occasionally

Bending

Medium

85-15

Stooping, crouching and bending are required frequently

Bending

Heavy

85-15

Stooping, crouching and bending are required frequently

Cane

Sedentary

96-9p

If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded

Climbing

Sedentary

96-9p

Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work

Climbing

All

85-15

"Some" limitations in climbing and balancing are not significant

Climbing

All

83-14

The inability to ascend or descend ladders or scaffolding is not significant

Communication

Sedentary

96-9p

If a claimant retains the abilities to hear and understand simple, oral instructions or to communicate simple information, the sedentary occupational base is not significantly eroded

Crawling

Sedentary

96-9p

Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work

Crawling

Sedentary

85-15

Inability to crawl does not significantly affect range of sedentary work

Crawling

All

85-15

Kneeling and crawling limitations do not have a significant impact on the broad world of work

Crouching

Sedentary

96-9p

Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work

Crouching

Sedentary

83-14,

85-15

Stooping, crouching and bending required occasionally at most

Crouching

Sedentary

83-14

Crouching is not required

Crouching

Light

83-14

Crouching in not required

Crouching

Medium

85-15

Stooping, crouching and bending are required frequently

Crouching

Heavy

85-15

Stooping, crouching and bending are required frequently

Crutches

Sedentary

96-9p

If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded

Dexterity

Sedentary

96-9p

Significant manipulative limitation of one’s ability to handle and work with small objects justifies a finding of disabled

Dexterity

Sedentary

83-10

Most unskilled, sedentary jobs require good use of hands and fingers for repetitive hand-finger actions

Dexterity

Sedentary

83-12

Sedentary work cannot be performed by one who has lost use of an upper extremity since most unskilled, sedentary jobs require good use of hands and fingers

Dexterity

Sedentary

85-15

Fine manual dexterity is required

Dexterity

Sedentary

85-15

Bilateral manual dexterity is required

Dexterity

Light

83-10

Requires use of arms and hands to grasp, hold and turn objects and generally does not require use of the fingers for fine activities to the extent required in sedentary work

Dexterity

Medium

83-10

Use of the arms and hands is necessary to grasp, hold and turn objects as opposed to finer activities in much sedentary work

Dexterity

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Environmental

Sedentary

96-9p

The need to avoid all exposure to extreme cold, extreme heat, wetness, humidity, vibration, or unusual hazards such as moving mechanical parts of equipment, tools or machinery; electrical shock; working in high, exposed places; exposure to radiation; working with explosives; and exposure to toxic, caustic chemicals would not result in significant erosion of the sedentary occupational base.

Environmental

Sedentary

83-12

The need to avoid frequent contact with petroleum-based solvents does not significantly compromise the full range of sedentary work.

Environmental

Sedentary

83-14

The vast majority of sedentary occupations are performed indoors, so outside environmental limitations (like ragweed pollen) are not significant

Feeling

Sedentary

96-9p

Ability to feel the size, shape, temperature or texture of an object by the fingertips is required in very few jobs and impairment of this ability, by itself would not significantly erode the unskilled, sedentary job base

Feeling

All

85-15

The ability to feel the size, shape, temperature or texture by fingertips is not significant

Fingers

Sedentary

83-10

Most unskilled, sedentary jobs require good use of hands and fingers for repetitive hand-finger actions

Fingertips

All

85-15

The ability to feel the size, shape, temperature or texture by fingertips is not significant

Grasping

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Handling

All

85-15

Significant limitations in reaching and handling significantly limit jobs

Hands

Sedentary

83-10

Most unskilled, sedentary jobs require good use of hands and fingers for repetitive hand-finger actions

Hands

Sedentary

83-12

Sedentary work cannot be performed by one who has lost use of an upper extremity since most unskilled, sedentary jobs require good use of hands and fingers

Hands

Light

83-10

Requires use of arms and hands to grasp, hold and turn objects and generally does not require use of the fingers for fine activities to the extent required in sedentary work

Hands

Medium

83-10

Use of the arms and hands is necessary to grasp, hold and turn objects as opposed to finer activities in much sedentary work

Hearing

Sedentary

96-9p

If a claimant retains the abilities to hear and understand simple, oral instructions or to communicate simple information, the sedentary occupational base is not significantly eroded

Heights

All

85-15

Restrictions against unprotected elevations and proximity to dangerous, moving machinery are not significant at all exertional levels

Holding

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Indoors

Sedentary

83-14

The vast majority of sedentary occupations are performed indoors, so outside environmental limitations (like ragweed pollen) are not significant

Kneeling

Sedentary

96-9p

Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work

Kneeling

All

85-15

Kneeling and crawling limitations do not have a significant impact on the broad world of work

Lifting

Sedentary

96-9p

Inability to lift or carry more than one or two pounds justifies finding of disabled

Lifting

Sedentary

96-9p

If a claimant has the ability to lift/carry slightly less than 10 pounds, with no other limitations or restrictions in the ability to perform the requirements of sedentary work, the unskilled sedentary occupational base would not be significantly

Machinery

All

85-15

Restrictions against unprotected elevations and proximity to dangerous, moving machinery are not significant at all exertional levels

Manipulation

Sedentary

96-9p

Significant manipulative limitation of one’s ability to handle and work with small objects justifies a finding of disabled

Manipulation

Light

83-10

Requires use of arms and hands to grasp, hold and turn objects and generally does not require use of the fingers for fine activities to the extent required in sedentary work

Manipulation

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Mental

Sedentary

96-9p

Substantial loss of ability to meet any one of the mental activities generally required by competitive, remunerative, unskilled work justifies a finding of disabled

Outdoors

Sedentary

83-14

The vast majority of sedentary occupations are performed indoors, so outside environmental limitations (like ragweed pollen) are not significant

Petroleum

Sedentary

83-12

The need to avoid frequent contact with petroleum-based solvents does not significantly compromise the full range of sedentary work.

Postural Limitations

Sedentary

96-9p

Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work

Pushing/pulling

Sedentary

96-9p

Limitations or restrictions on the ability to push or pull will generally have little effect on the unskilled sedentary occupational base

Raising

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Reaching

All

85-15

Significant limitations in reaching and handling significantly limit jobs

Sight

Light

85-15,

96-9p

As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.

Sight

Medium

85-15,

96-9p

As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.

Sight

Heavy

85-15,

96-9p

As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.

Sit/Stand

Sedentary

83-12

Sedentary work does not contain sit/stand jobs

Sit/stand

Light

83-12

Does not include sit/stand jobs

Solvents

Sedentary

83-12

The need to avoid frequent contact with petroleum-based solvents does not significantly compromise the full range of sedentary work.

Speaking

Sedentary

96-9p

If a claimant retains the abilities to hear and understand simple, oral instructions or to communicate simple information, the sedentary occupational base is not significantly eroded

Standing

Sedentary

96-9p

If an individual can stand and walk slightly less than two hours per eight hour day, this, by itself, would not cause the sedentary occupational base to be significantly eroded

Standing

Sedentary

96-9p

A limitation to standing and walking for a total of only a few minutes during the workday justifies finding of disabled

Stooping

Sedentary

96-9p

A restriction to occasional stooping would, by itself, only minimally erode the unskilled occupational base of sedentary work

Stooping

Sedentary

96-9p

Complete inability to stoop justifies finding of disabled

Stooping

Sedentary

83-14,

85-15

Stooping, crouching and bending required occasionally at most

Stooping

Light

83-14,

85-15

Stooping and bending are required occasionally

Stooping

Medium

85-15

Stooping, crouching and bending are required frequently

Stooping

Heavy

85-15

Stooping, crouching and bending are required frequently

Turning

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Understanding

Sedentary

96-9p

If a claimant retains the abilities to hear and understand simple, oral instructions or to communicate simple information, the sedentary occupational base is not significantly eroded

Upper extremities

Medium

83-10

Use of the arms and hands is necessary to grasp, hold and turn objects as opposed to finer activities in much sedentary work

Upper Extremities

All

83-14

The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects

Upper Extremity

Sedentary

83-12

Sedentary work cannot be performed by one who has lost use of an upper extremity since most unskilled, sedentary jobs require good use of hands and fingers

Vision

Light

85-15,

96-9p

As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.

Vision

Medium

85-15,

96-9p

As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.

Vision

Heavy

85-15,

96-9p

As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.

Walking

Sedentary

96-9p

If an individual can stand and walk slightly less than two hours per eight hour day, this, by itself, would not cause the sedentary occupational base to be significantly eroded

Walking

Sedentary

96-9p

If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded

Walking

Sedentary

96-9p

A limitation to standing and walking for a total of only a few minutes during the work day justifies a finding of disabled

Appendix 1 to Subpart P of Part 404--Listing of Impairments

Part A

Criteria applicable to individuals age 18 and over and to children under age 18 where criteria are appropriate.

1.00 Musculoskeletal System.

1.02 Active rheumatoid arthritis and other inflammatory arthritis.

1.03 Arthritis of a major weight-bearing joint (due to any cause)

1.04 Arthritis of one major joint in each of the upper extremities (due to any cause)

1.05 Disorders of the spine

1.08 Osteomyelitis or septic arthritis (established by X-ray)

1.09 Amputation or anatomical deformity

1.10 Amputation of one lower extremity

1.11 Fracture of the femur, tibia, tarsal bone or pelvis

1.12 Fractures of an upper extremity

1.13 Soft tissue injuries of an upper or lower extremity

2.00 Special Senses and Speech.

2.02 Impairment of central visual acuity.

2.03 Contraction of peripheral visual fields in the better eye.

2.04 Loss of visual efficiency.

2.05 Complete homonymous hemianopsia

2.06 Total bilateral ophthalmoplegia.

2.07 Disturbance of labyrinthine-vestibular function (including Meniere's disease)

2.08 Hearing impairments

2.09 Organic loss of speech

3.00 Respiratory System.

3.02 Chronic pulmonary insufficiency

3.03 Asthma

3.04 Cystic fibrosis

3.06 Pneumoconiosis

3.07 Bronchiectasis

3.08 Mycobacterial, mycotic, and other chronic persistent infections of the lung

3.09 Cor pulmonale secondary to chronic pulmonary vascular hypertension

3.10 Sleep-related breathing disorders

4.00 Cardiovascular System.

4.02 Chronic heart failure

4.03 Hypertensive cardiovascular disease

4.04 Ischemic heart disease

4.05 Recurrent arrhythmias

4.06 Symptomatic congenital heart disease

4.07 Valvular heart disease or other stenotic defects, or valvular regurgitation

4.08 Cardiomyopathies

4.09 Cardiac transplantation

4.10 Aneurysm of aorta or major branches

4.11 Chronic venous insufficiency

4.12 Peripheral arterial disease

5.00 Digestive System.

5.02 Recurrent upper gastrointestinal hemorrhage from undetermined cause

5.03 Stricture, stenosis, or obstruction of the esophagus

5.04 Peptic ulcer disease

5.05 Chronic liver disease

5.06 Chronic ulcerative or granulomatous colitis

5.07 Regional enteritis

5.08 Weight loss due to any persisting gastrointestinal disorder

6.00 Genito-Urinary System.

6.02 Impairment of renal function, due to any chronic renal disease expected to last 12 months

6.06 Nephrotic syndrome, with significant anasarca, persistent for at least 3 months despite prescribed therapy

7.00 Hemic and Lymphatic System.

7.02 Chronic anemia

7.05 Sickle cell disease, or one of its variants

7.06 Chronic thrombocytopenia

7.07 Hereditary telangiectasia

7.08 Coagulation defects (hemophilia or a similar disorder)

7.09 Polycythemia vera (with erythrocytosis, splenomegaly, and leukocytosis or thrombocytosis).

7.10 Myelofibrosis (myeloproliferative syndrome).

7.11 Acute leukemia

7.12 Chronic leukemia

7.13 Lymphomas

7.14 Macroglobulinemia or heavy chain disease

7.15 Chronic granulocytopenia (due to any cause).

7.16 Myeloma (confirmed by appropriate serum or urine protein electrophoresis and bone marrow findings).

7.17 Aplastic anemias or hematologic malignancies

8.00 Skin.

8.02 Exfoliative dermatitis, ichthyosis, ichthyosiform erythroderma.

8.03 Pemphigus, erythema multiforme bullosum, bullous pemphigoid, dermatitis herpetiformis

8.04 Deep mycotic infections

8.05 Psoriasis, atopic dermatitis, dyshidrosis

8.06 Hydradenitis suppurative, acne conglobata

9.00 Endocrine System and Obesity.

9.02 Thyroid Disorders.

9.03 Hyperparathyroidism

9.04 Hypoparathyroidism

9.05 Neurohypophyseal insufficiency (diabetes insipidus)

9.06 Hyperfunction of the adrenal cortex

9.08 Diabetes mellitus

9.09 Obesity. But see Obesity: Revised Medical Criteria for Determination of Disability.

10.00 [Reserved]

11.00 Neurological.

11.02 Epilepsy--Major motor seizures, (grand mal or psychomotor)

11.03 Epilepsy--Minor motor seizures (petit mal, psychomotor, or focal)

11.04 Central nervous system vascular accident

11.05 Brain tumors

11.06 Parkinsonian syndrome

11.07 Cerebral palsy

11.08 Spinal cord or nerve root lesions

11.09 Multiple sclerosis

11.10 Amyotrophic lateral sclerosis

11.11 Anterior poliomyelitis

11.12 Myasthenia gravis

11.13 Muscular dystrophy

11.14 Peripheral neuropathies

11.15 Tabes dorsalis

11.16 Subacute combined cord degeneration (pernicious anemia)

11.17 Degenerative disease not elsewhere such as Huntington's chorea, Friedreich's ataxia, and spino-cerebellar degeneration

11.18 Cerebral trauma

11.19 Syringomyelia

12.00 Mental Disorders.

12.02 Organic Mental Disorders

12.03 Schizophrenic, Paranoid and Other Psychotic Disorders

12.04 Affective Disorders

12.05 Mental Retardation and Autism

12.06 Anxiety Related Disorders

12.07 Somatoform Disorders

12.08 Personality Disorders

12.09 Substance Addiction Disorders

13.00 Neoplastic Diseases, Malignant.

13.02 Head and neck

13.03 Sarcoma of skin

13.04 Sarcoma of soft parts

13.05 Malignant melanoma

13.06 Lymph nodes

13.07 Salivary glands

13.08 Thyroid gland

13.09 Breast

13.10 Skeletal system

13.11 Mandible, maxilla, orbit, or temporal fossa

13.12 Brain or spinal cord

13.13 Lungs

13.14 Pleura or mediastinum

13.15 Abdomen

13.16 Esophagus or stomach

13.17 Small intestine

13.18 Large intestine

13.19 Liver or gallbladder

13.20 Pancreas

13.21 Kidneys, adrenal glands, or ureters–carcinoma

13.22 Urinary bladder–carcinoma

13.23 Prostate gland

13.24 Testicles

13.25 Uterus

13.26 Ovaries

13.27 Leukemia

13.28 Uterine

13.29 Penis

13.30 Vulva

14.00 Immune System.

14.02 Systemic lupus erythematosus

14.03 Systemic vasculitis

14.04 Systemic sclerosis and scleroderma

14.05 Polymyositis or dermatomyositis

14.06 Undifferentiated connective tissue disorder

14.07 Immunoglobulin deficiency syndromes or deficiencies of cell-mediated immunity

14.08 Human immunodeficiency virus (HIV) infection

1.00 Musculoskeletal System

A. Loss of function may be due to amputation or deformity. Pain may be an important factor in causing functional loss, but it must be associated with relevant abnormal signs or laboratory findings. Evaluations of musculoskeletal impairments should be supported where applicable by detailed descriptions of the joints, including ranges of motion, condition of the musculature, sensory or reflex changes, circulatory deficits, and X-ray abnormalities.

B. Disorders of the spine, associated with vertebrogenic disorders as in 1.05C, result in impairment because of distortion of the bony and ligamentous architecture of the spine or impingement of a herniated nucleus pulposus or bulging annulus on a nerve root. Impairment caused by such abnormalities usually improves with time or responds to treatment. Appropriate abnormal physical findings must be shown to persist on repeated examinations despite therapy for a reasonable presumption to be made that severe impairment will last for a continuous period of 12 months. This may occur in cases with unsuccessful prior surgical treatment.

Evaluation of the impairment caused by disorders of the spine requires that a clinical diagnosis of the entity to be evaluated first must be established on the basis of adequate history, physical examination, and roentgenograms. The specific findings stated in 1.05C represent the level required for that impairment; these findings, by themselves, are not intended to represent the basis for establishing the clinical diagnosis. Furthermore, while neurological examination findings are required, they are not to be interpreted as a basis for evaluating the magnitude of any neurological impairment. Neurological impairments are to be evaluated under 11.00-11.19.

The history must include a detailed description of the character, location, and radiation of pain; mechanical factors which incite and relieve pain; prescribed treatment, including type, dose, and frequency of analgesic; and typical daily activities. Care must be taken to ascertain that the reported examination findings are consistent with the individual's daily activities.

There must be a detailed description of the orthopedic and neurologic examination findings. The findings should include a description of gait, limitation of movement of the spine given quantitatively in degrees from the vertical position, motor and sensory abnormalities, muscle spasm, and deep tendon reflexes. Observations of the individual during the examination should be reported; e.g., how he or she gets on and off the examining table. Inability to walk on heels or toes, to squat, or to arise from a squatting position, where appropriate, may be considered evidence of significant motor loss. However, a report of atrophy is not acceptable as evidence of significant motor loss without circumferential measurements of both thighs and lower legs (or upper or lower arms) at a stated point above and below the knee or elbow given in inches or centimeters. A specific description of atrophy of hand muscles is acceptable without measurements of atrophy but should include measurements of grip strength.

These physical examination findings must be determined on the basis of objective observations during the examination and not simply a report of the individual's allegation, e.g., he says his leg is weak, numb, etc. Alternative testing methods should be used to verify the objectivity of the abnormal findings, e.g., a seated straight-leg raising test in addition to a supine straight-leg raising test. Since abnormal findings may be intermittent, their continuous presence over a period of time must be established by a record of ongoing treatment. Neurological abnormalities may not completely subside after surgical or nonsurgical treatment, or with the passage of time. Residual neurological abnormalities, which persist after it has been determined clinically or by direct surgical or other observation that the ongoing or progressive condition is no longer present, cannot be considered to satisfy the required findings in 1.05C.

Where surgical procedures have been performed, documentation should include a copy of the operative note and available pathology reports.

Electrodiagnostic procedures and myelography may be useful in establishing the clinical diagnosis, but do not constitute alternative criteria to the requirements in 1.05C.

C. After maximum benefit from surgical therapy has been achieved in situations involving fractures of an upper extremity (see 1.12) or soft tissue injuries of a lower or upper extremity (see 1.13), i.e., there have been no significant changes in physical findings or X-ray findings for any 6-month period after the last definitive surgical procedure, evaluation should be made on the basis of demonstrable residuals.

D. Major joints as used herein refer to hip, knee, ankle, shoulder, elbow, or wrist and hand. (Wrist and hand are considered together as one major joint.)

E. The measurements of joint motion are based on the techniques described in the "Joint Motion Method of Measuring and Recording," published by the American Academy of Orthopedic Surgeons in 1965, or the "Guides to the Evaluation of Permanent Impairment--The Extremities and Back" (Chapter I); American Medical Association, 1971.
1.01 Category of Impairments, Musculoskeletal

1.02 Active rheumatoid arthritis and other inflammatory arthritis.

With both A and B.

A. History of persistent joint pain, swelling, and tenderness involving multiple major joints (see 1.00D) and with signs of joint inflammation (swelling and tenderness) on current physical examination despite prescribed therapy for at least 3 months, resulting in significant restriction of function of the affected joints, and clinical activity expected to last at least 12 months; and

B. Corroboration of diagnosis at some point in time by either.

1. Positive serologic test for rheumatoid factor; or

2. Antinuclear antibodies; or

3. Elevated sedimentation rate; or

4. Characteristic histologic changes in biopsy of synovial membrane or subcutaneous nodule (obtained independent of Social Security disability evaluation).

1.03 Arthritis of a major weight-bearing joint (due to any cause):

With history of persistent joint pain and stiffness with signs of marked limitation of motion or abnormal motion of the affected joint on current physical examination. With:

A. Gross anatomical deformity of hip or knee (e.g, subluxation, contracture, bony or fibrous ankylosis, instability) supported by X-ray evidence of either significant joint space narrowing or significant bony destruction and markedly limiting ability to walk and stand; or

B. Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint and return to full weight-bearing status did not occur, or is not expected to occur, within 12 months of onset.

1.04 Arthritis of one major joint in each of the upper extremities (due to any cause):

With history of persistent joint pain and stiffness, signs of marked limitation of motion of the affected joints on current physical examination, and X-ray evidence of either significant joint space narrowing or significant bony destruction. With:

A. Abduction and forward flexion (elevation) of both arms at the shoulders, including scapular motion, restricted to less than 90 degrees; or

B. Gross anatomical deformity (e.g., subluxation, contracture, bony or fibrous ankylosis, instability, ulnar deviation) and enlargement or effusion of the affected joints.

1.05 Disorders of the spine:

A. Arthritis manifested by ankylosis or fixation of the cervical or dorsolumbar spine at 30° or more of flexion measured from the neutral postion, with X-ray evidence of:

1. Calcification of the anterior and lateral ligaments; or

2. Bilateral ankylosis of the sacroiliac joints with abnormal apophyseal articulations; or

B. Osteoporosis, generalized (established by X-ray) manifested by pain and limitation of back motion and paravertebral muscle spasm with X-ray evidence of either:

1. Compression fracture of a vertebral body with loss of at least 50 percent of the estimated height of the vertebral body prior to the compression fracture, with no intervening direct traumatic episode; or

2. Multiple fractures of vertebrae with no intervening direct traumatic episode; or

C. Other vertebrogenic disorders (e.g., herniated nucleus puplosus, spinal stenosis) with the following persisting for at least 3 months despite prescribed therapy and expected to last 12 months. With both 1 and 2:

1. Pain, muscle spasm, and significant limitation of motion in the spine; and

2. Appropriate radicular distribution of significant motor loss with muscle weakness and sensory and reflex loss.

1.08 Osteomyelitis or septic arthritis (established by X-ray):

A. Located in the pelvis, vertebra, femur, tibia, or a major joint of an upper or lower extremity, with persistent activity or occurrence of at least two episodes of acute activity within a 5-month period prior to adjudication, manifested by local inflammatory, and systemic signs and laboratory findings (e.g., heat, redness, swelling, leucocytosis, or increased sedimentation rate) and expected to last at least 12 months despite prescribed therapy; or

B. Multiple localizations and systemic manifestations as in A above.

1.09 Amputation or anatomical deformity of (i.e., loss of major function due to degenerative changes associated with vascular or neurological deficits, traumatic loss of muscle mass or tendons and X-ray evidence of bony ankylosis at an unfavorable angle, joint subluxation or instability):

A. Both hands; or

B. Both feet; or

C. One hand and one foot.

1.10 Amputation of one lower extremity (at or above the tarsal region):

A. Hemipelvectomy or hip disarticulation; or

B. Amputation at or above the tarsal region due to peripheral vascular disease or diabetes mellitus; or

C. Inability to use a prosthesis effectively, without obligatory assistive devices, due to one of the following:

1. Vascular disease; or

2. Neurological complications (e.g., loss of position sense); or

3. Stump too short or stump complications persistent, or are expected to persist, for at least 12 months from onset; or

4. Disorder of contralateral lower extremity which markedly limits ability to walk and stand.

1.11 Fracture of the femur, tibia, tarsal bone or pelvis with solid union not evident on X-ray and not clinically solid, when such determination is feasible, and return to full weight-bearing status did not occur or is not expected to occur within 12 months of onset.

1.12 Fractures of an upper extremity with non-union of a fracture of the shaft of the humerus, radius, or ulna under continuing surgical management directed toward restoration of functional use of the extremity and such function was not restored or expected to be restored within 12 months after onset.

1.13 Soft tissue injuries of an upper or lower extremity requiring a series of staged surgical procedures within 12 months after onset for salvage and/or restoration of major function of the extremity, and such major function was not restored or expected to be restored within 12 months after onset.
2.00 Special Senses and Speech

A. Ophthalmology

1. Causes of impairment. Diseases or injury of the eyes may produce loss of central or peripheral vision. Loss of central vision results in inability to distinguish detail and prevents reading and fine work. Loss of peripheral vision restricts the ability of an individual to move about freely. The extent of impairment of sight should be determined by visual testing.

2. Central visual acuity. A loss of central visual acuity may be caused by impaired distant and/or near vision. However, for an individual to meet the level of severity described in 2.02 and 2.04, only the remaining central visual acuity for distance of the better eye with best correction based on the Snellen test chart measurement may be used. Correction obtained by special visual aids (e.g., contact lenses) will be considered if the individual has the ability to wear such aids.

3. Field of vision. Impairment of peripheral vision may result if there is contraction of the visual fields. The contraction may be either symmetrical or irregular. The extent of the remaining peripheral visual field will be determined by usual perimetric methods at a distance of 330 mm. under illumination of not less than 7-foot candles. For the phakic eye (the eye with a lens), a 3 mm. white disc target will be used, and for the aphakic eye (the eye without the lens), a 6 mm. white disc target will be used. In neither instance should corrective spectacle lenses be worn during the examination but if they have been used, this fact must be stated.

Measurements obtained on comparable perimetric devices may be used; this does not include the use of tangent screen measurements. For measurements obtained using the Goldmann perimeter, the object size designation III and the illumination designation 4 should be used for the phakic eye, and the object size designation IV and illumination designation 4 for the aphakic eye.

Field measurements must be accompanied by notated field charts, a description of the type and size of the target and the test distance. Tangent screen visual fields are not acceptable as a measurement of peripheral field loss.

Where the loss is predominantly in the lower visual fields, a system such as the weighted grid scale for perimetric fields described by B. Esterman (see Grid for Scoring Visual Fields, II. Perimeter, Archives of Ophthalmology, 79:400, 1968) may be used for determining whether the visual field loss is comparable to that described in table 2.

4. Muscle function. Paralysis of the third cranial nerve producing ptosis, paralysis of accommodation, and dilation and immobility of the pupil may cause significant visual impairment. When all the muscle of the eye are paralyzed including the iris and ciliary body (total ophthalmoplegia), the condition is considered a severe impairment provided it is bilateral. A finding of severe impairment based primarily on impaired muscle function must be supported by a report of an actual measurement of ocular motility.

5. Visual efficiency. Loss of visual efficiency may be caused by disease or injury resulting in a reduction of central visual acuity or visual field. The visual efficiency of one eye is the product of the percentage of central visual efficiency and the percentage of visual field efficiency. (See tables no. 1 and 2, following 2.09.)

6. Special situations. Aphakia represents a visual handicap in addition to the loss of central visual acuity. The term monocular aphakia would apply to an individual who has had the lens removed from one eye, and who still retains the lens in his other eye, or to an individual who has only one eye which is aphakic. The term binocular aphakia would apply to an individual who has had both lenses removed. In cases of binocular aphakia, the central efficiency of the better eye will be accepted as 75 percent of its value. In cases of monocular aphakia, where the better eye is aphakic, the central visual efficiency will be accepted as 50 percent of the value. (If an individual has binocular aphakia, and the central visual acuity in the poorer eye can be corrected only to 20/200, or less, the central visual efficiency of the better eye will be accepted as 50 percent of its value.)

Ocular symptoms of systemic disease may or may not produce a disabling visual impairement. These manifestations should be evaluated as part of the underlying disease entity by reference to the particular body system involved.

7. Statutory blindness. The term "statutory blindness" refers to the degree of visual impairment which defines the term "blindness" in the Social Security Act. Both 2.02 and 2.03 A and B denote statutory blindness.

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 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 lightheadedness, 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 longlasting; 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 functions is assessed by positional and caloric testing, preferably by electronystagmography. When polytograms, contrast radiography, or other special tests have been performed, copies of the reports of these tests should be obtained in addition to reports of skull and temporal bone X-rays.

3. Organic loss of speech. Glossectomy or laryngectomy or cicatricial laryngeal stenosis due to injury or infection results in loss of voice production by normal means. In evaluating organic loss of speech (see 2.09), ability to produce speech by any means includes the use of mechanical or electronic devices. Impairment of speech due to neurologic disorders should be evaluated under 11.00-11.19.
2.01 Category of Impairments, Special Senses and Speech <

Activity	RFC	SSR
Amputation	Medium	83-12	Cannot be performed with an above-elbow amputation
Amputation	Heavy	83-12	Cannot be performed with an above-elbow amputation
Arm	Medium	83-12	Cannot be performed with an above-elbow amputation
Arm	Heavy	83-12	Cannot be performed with an above-elbow amputation
Arms	Sedentary	83-12	Sedentary work cannot be performed by one who has lost use of an upper extremity since most unskilled, sedentary jobs require good use of hands and fingers
Arms	Sedentary	83-10	Most unskilled, sedentary jobs require good use of hands and fingers for repetitive hand-finger actions
Arms	Light	83-10	Requires use of arms and hands to grasp, hold and turn objects and generally does not require use of the fingers for fine activities to the extent required in sedentary work
Arms	Medium	83-10	Use of the arms and hands is necessary to grasp, hold and turn objects as opposed to finer activities in much sedentary work
Arms	All	83-14	The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects
Assistive Devices	Sedentary	96-9p	If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded
Balancing	Sedentary	96-9p	Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work
Balancing	All	85-15	"Some" limitations in climbing and balancing are not significant
Bending	Sedentary	83-14, 85-15	Stooping, crouching and bending required occasionally at most
Bending	Light	83-14, 85-15	Stooping and bending are required occasionally
Bending	Medium	85-15	Stooping, crouching and bending are required frequently
Bending	Heavy	85-15	Stooping, crouching and bending are required frequently
Cane	Sedentary	96-9p	If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded

Climbing	Sedentary	96-9p	Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work
Climbing	All	85-15	"Some" limitations in climbing and balancing are not significant
Climbing	All	83-14	The inability to ascend or descend ladders or scaffolding is not significant
Communication	Sedentary	96-9p	If a claimant retains the abilities to hear and understand simple, oral instructions or to communicate simple information, the sedentary occupational base is not significantly eroded
Crawling	Sedentary	96-9p	Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work
Crawling	Sedentary	85-15	Inability to crawl does not significantly affect range of sedentary work
Crawling	All	85-15	Kneeling and crawling limitations do not have a significant impact on the broad world of work
Crouching	Sedentary	96-9p	Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work
Crouching	Sedentary	83-14, 85-15	Stooping, crouching and bending required occasionally at most
Crouching	Sedentary	83-14	Crouching is not required
Crouching	Light	83-14	Crouching in not required
Crouching	Medium	85-15	Stooping, crouching and bending are required frequently
Crouching	Heavy	85-15	Stooping, crouching and bending are required frequently
Crutches	Sedentary	96-9p	If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded
Dexterity	Sedentary	96-9p	Significant manipulative limitation of one’s ability to handle and work with small objects justifies a finding of disabled
Dexterity	Sedentary	83-10	Most unskilled, sedentary jobs require good use of hands and fingers for repetitive hand-finger actions

Hands	Sedentary	83-12	Sedentary work cannot be performed by one who has lost use of an upper extremity since most unskilled, sedentary jobs require good use of hands and fingers
Hands	Light	83-10	Requires use of arms and hands to grasp, hold and turn objects and generally does not require use of the fingers for fine activities to the extent required in sedentary work
Hands	Medium	83-10	Use of the arms and hands is necessary to grasp, hold and turn objects as opposed to finer activities in much sedentary work
Hearing	Sedentary	96-9p	If a claimant retains the abilities to hear and understand simple, oral instructions or to communicate simple information, the sedentary occupational base is not significantly eroded
Heights	All	85-15	Restrictions against unprotected elevations and proximity to dangerous, moving machinery are not significant at all exertional levels
Holding	All	83-14	The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects
Indoors	Sedentary	83-14	The vast majority of sedentary occupations are performed indoors, so outside environmental limitations (like ragweed pollen) are not significant
Kneeling	Sedentary	96-9p	Postural limitations or restrictions related to climbing ladders, ropes or scaffolds, balancing, kneeling, crouching or crawling would not usually erode the occupational base for a full range of sedentary unskilled work significantly because those activities are not usually required in sedentary work
Kneeling	All	85-15	Kneeling and crawling limitations do not have a significant impact on the broad world of work
Lifting	Sedentary	96-9p	Inability to lift or carry more than one or two pounds justifies finding of disabled
Lifting	Sedentary	96-9p	If a claimant has the ability to lift/carry slightly less than 10 pounds, with no other limitations or restrictions in the ability to perform the requirements of sedentary work, the unskilled sedentary occupational base would not be significantly
Machinery	All	85-15	Restrictions against unprotected elevations and proximity to dangerous, moving machinery are not significant at all exertional levels
Manipulation	Sedentary	96-9p	Significant manipulative limitation of one’s ability to handle and work with small objects justifies a finding of disabled
Manipulation	Light	83-10	Requires use of arms and hands to grasp, hold and turn objects and generally does not require use of the fingers for fine activities to the extent required in sedentary work

Standing	Sedentary	96-9p	If an individual can stand and walk slightly less than two hours per eight hour day, this, by itself, would not cause the sedentary occupational base to be significantly eroded
Standing	Sedentary	96-9p	A limitation to standing and walking for a total of only a few minutes during the workday justifies finding of disabled
Stooping	Sedentary	96-9p	A restriction to occasional stooping would, by itself, only minimally erode the unskilled occupational base of sedentary work
Stooping	Sedentary	96-9p	Complete inability to stoop justifies finding of disabled
Stooping	Sedentary	83-14, 85-15	Stooping, crouching and bending required occasionally at most
Stooping	Light	83-14, 85-15	Stooping and bending are required occasionally
Stooping	Medium	85-15	Stooping, crouching and bending are required frequently
Stooping	Heavy	85-15	Stooping, crouching and bending are required frequently
Turning	All	83-14	The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects
Understanding	Sedentary	96-9p	If a claimant retains the abilities to hear and understand simple, oral instructions or to communicate simple information, the sedentary occupational base is not significantly eroded
Upper extremities	Medium	83-10	Use of the arms and hands is necessary to grasp, hold and turn objects as opposed to finer activities in much sedentary work
Upper Extremities	All	83-14	The claimant must have certain use of the arms and head to grasp, hold, turn, raise and lower objects
Upper Extremity	Sedentary	83-12	Sedentary work cannot be performed by one who has lost use of an upper extremity since most unskilled, sedentary jobs require good use of hands and fingers
Vision	Light	85-15, 96-9p	As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.
Vision	Medium	85-15, 96-9p	As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.
Vision	Heavy	85-15, 96-9p	As long as sufficient visual acuity to be able to handle and work with rather large objects and avoid workplace hazards exists, substantial numbers of jobs remain at the light exertional level and greater.

Walking	Sedentary	96-9p	If an individual can stand and walk slightly less than two hours per eight hour day, this, by itself, would not cause the sedentary occupational base to be significantly eroded
Walking	Sedentary	96-9p	If a medically required hand-held assistive device is needed only for prolonged ambulation, walking on uneven terrain, or ascending or descending slopes, the unskilled sedentary occupational base will not be ordinarily significantly eroded
Walking	Sedentary	96-9p	A limitation to standing and walking for a total of only a few minutes during the work day justifies a finding of disabled