Social Security Administration

20 CRF Parts 404 and 416

(Regulation Nos. 4 and 16)

RIN 0960-AG20

Revised Medical Criteria for Evaluating Hearing Impairments and
Disturbance of Labyrinthin-Vestibular Function

Advance Notice of Proposed Rulemaking

Self Help for Hard of Hearing People (SHHH) appreciates the opportunity
to comment on the current SSA criteria used to evaluate people with
hearing loss. 

SHHH, based in Bethesda, Maryland, is the largest consumer organization
for people with hearing loss in the United States. With thirteen state
organizations and 250 chapters, SHHH\'s mission is to open the world of
communication for people with hearing loss through education, advocacy,
and support.

SHHH has hosted annual research symposiums related to hearing
science since 1994, and has had extensive communication and experience
with thousands of people with varying hearing loss conditions that
inform our comments.

**Speech discrimination tests.**  For adults it is important that
testing be done in realistic, lifelike situations. Testing performed in
a clinical setting may not be a reliable predictor of functioning in the
"real" world of work. Testing should be designed to match the
communication demands of the job such as hearing in meetings, a busy
office, or on a noisy factory floor.

Speech may not be the only communication demand on the job. Other
critical listening situations could be the ability to localize sound, be
alert to emergency warnings, communicate over an intercom, and comfort
level using different kinds of telephones to ensure safety and ability
to perform the job.\
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Specific guidance needs to be provided about speech discrimination
tests, which vary greatly in how well they evaluate a person\'s ability
to discriminate speech.  There is a need for speech discrimination tests
that have better predictive value in gauging the person\'s ability to
understand speech in various situations. \
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 Many variables can affect the ability of speech discrimination tests to
assess widespread functional impairment including: whether the speech
used in the test is low-pitched or high-pitched; whether the test is
recorded or spoken live by the audiologist; whether two-syllable words
are used rather than monosyllabic words; whether the tests use words or
nonsense syllables; whether the words are spoken in noise or with an
absence of background noise. There is need for closer guidance on which
speech discrimination tests to use and how they should be administered.

**Specified Hearing Thresholds Levels.**  The specified levels currently
ignore the presence of hearing loss over 2000 hertz for adults and over
3000 hertz for children, but hearing loss over these frequencies has a
significant impact on speech discrimination.   The 1990 Mueller and
Killion \"Count-the-Dots audiogram form for calculation of the
Articulation Index\" indicates that 35% of speech cues occur over 2000
hertz and 24% over 3000 hertz.  The current SSA criteria for adults from
500 hertz to 2000 hertz only evaluate the person\'s ability to hear a
mere 55% of the speech cues.  We recommend expanding the hearing
threshold levels for both adults and children to be more representative
of the person\'s disability across the spectrum of speech frequencies.\
\
**Other considerations not noted in current criteria.**  Some people
with hearing loss will have much greater difficulty functioning if they
have other medical conditions affecting their ability to compensate for
the hearing loss, but these medical conditions may not rise to the level
of disability by themselves.  For example, visual acuity and certain
cognitive processes are needed for speech reading. People with hearing
loss who are also impaired in these capabilities could be significantly
more impaired in their ability to understand communication than someone
who performs more poorly than they do on hearing tests but who has the
capacity to speech read.  Cognitive impairment can also disrupt a
person\'s ability to quickly and fluidly utilize multiple environmental
cues to deduce what is being communicated.  Thus a person with hearing
loss and additional impairments may be able to score over 40% on a
carefully administered speech discrimination test, but the person could
be extremely disabled in responding flexibly to the communication
challenges of everyday life.  

We are additionally concerned that many people with severe hearing loss
may be unable to support themselves financially due to the impact of
their hearing loss, but they could still be deemed ineligible for
benefits due to the eligibility criteria being too restrictive. A
person's audiological status does not necessarily predict their level of
functioning. Hearing loss can be an extremely challenging disability on
many levels but inner and outer resources may not be available to help
the person compensate successfully for the hearing loss. If a person
does not meet the pure tone average or the initial speech discrimination
criterion, the person may still be profoundly disabled and should be
evaluated further, especially if there has been a sustained inability to
maintain substantial gainful employment.

Currently it does not appear that physicians and audiologists are
allowed to consider additional factors for determining that a person is
disabled.  The current requirements pertaining to pure tone averages for
adults and children need to be made less restrictive partly to
accommodate people with multiple impairments or weaknesses which do not
meet the eligibility criteria for a single disability.  Alternatively,
we ask that the SSA allow the use of other supporting evidence to
determine disability due to hearing loss.

The challenge for people with hearing loss is finding access to the
appropriate technology that would enable them to stay on the job and
work productively. Anecdotally we know that many people with hearing
loss retire early who could remain gainfully employed if they had access
to hearing aids, cochlear implants and other assistive technology that
could benefit their performance in the workplace. Few commercial
insurance plans cover hearing aids, Medicare explicitly has an exemption
for hearing aids, Medicaid covers basic hearing aids for children in
most states but due to budget shortfalls, Medicaid is cutting many
programs, including those related to hearing health

Hearing loss can have significant negative effects on all areas of an
individual's life. Criteria for determining eligibility for an
individual with hearing loss needs to be expanded to take into
consideration challenges beyond the results of a hearing test in a
sound-proof booth.

Thank you for the opportunity to comment on this proceeding.

Sincerely, 

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| Brenda Battat\                                                        |
| Associate Executive Director                                          |
|                                                                       |
| Self Help for Hard of Hearing People\                                 |
| www.hearingloss.org                                                   |
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