September 2008

Commissioner of Social Security

PO Box 17703

Baltimore, Maryland 21235-7703

Dear Commissioner Astrue:

The National Association of Disability Examiners (NADE) welcomes the
opportunity to offer comments on the notice of proposed rulemaking
(NPRM) that outlined proposed revisions regarding the criteria for
evaluating Hearing Loss.

NADE is a professional association whose mission is to advance the art
and science of disability evaluation. Our membership base includes
members that represent a brad perspective of interests regarding the
Social Security and Supplemental Security Income (SSI) disability
programs. While a majority of our members are employed in the State
Disability Determination Services (DDS) offices, and are directly
involved in processing claims for Social Security and Supplemental
Security Income (SSI) disability benefits, our membership also includes
personnel from Social Security's Central Offices, Attorneys, claimant
advocates and physicians. We believe that the diversity of our
membership combined with our hands on experience, which we believe
provides us with the unique understanding of the challenges and
opportunities facing the Social Security and SSI disability programs
today.

SSA proposes to amend the regulations in 20 CFR, Part 404 to revise the
criteria we use to evaluate claims involving hearing loss, found in
section 2.00 in adults and 102.00, in children of the listings of
impairments in appendix P of Part 404 of the regulations ( the
listings). NADE fully supports the proposed revisions and the need for
such revisions, considering the amount of time that has elapsed since
these listings were last updated.

I reviewing the proposed amendments to cases involving hearing loss,
NADE concurs with the following revisions:

-   The change from otolaryngologic exams to just otological exams, as
    this allows the use of a wider variety of Consultative Examiners
    (CE), shortens the exam time and reduces potential discomfort of the
    claimants. This is consistent with other listings that allow for
    obtaining only updated testing when an MDI has already been
    established.

-   We agree that hearing testing should be preceded by otologic
    examination to ensure that there are no conditions present that
    would prevent valid testing.

-   Allowing the use of audiometric testing alone when a MDI has already
    been established is also a step forward in both efficiency and cost
    savings.

-   Encouraging the use of otoscopic evaluation prior to testing will
    strengthen the validity of the results and improve the accuracy of
    the decision. It should be made clear who is considered capable of
    performing this test (i.e. is this within the scope of training of
    an audiologist). Similarly, the request for clarification and
    documentation of discrepancies is both valuable guidance and
    educational, perhaps it should be strengthened or highlighted.

-   The educational points added to the preamble are useful in improving
    the understanding of the listings and the intent of the testing
    required. This tool is anticipated to save time and money; we would
    encourage other listings revisions to include such information.

-   The recognition that some individuals do not speak English is long
    overdue. Using the native tongue testing appears appropriate for
    word discrimination testing.

-   For individuals who cannot be tested for word recognition, some
    other sources to consider are - contact with treating sources, other
    health care professionals, therapists, counselors, etc. and other
    third parties who have been in communication with the claimant,
    including past employers - to help determine the communication level
    of the individual besides just family members, interpreters and
    others who speak the language.  If the individual is able to
    communicate either directly with these sources or through an
    interpreter, this will help in determining the severity of the
    impairment.

-   NADE supports the changes to listing 2.08A in that the current
    listing does not specify the hearing sensitivity for bone
    conduction, the proposed change that the average bone conduction
    hearing threshold must be at 60DB or greater in the better ear gives
    clear instructions in the adjudication of this listing.

-   We agree that in the case of listing 2.08B replacing speech
    discrimination of 40% or less in the better ear for the "word
    recognition" testing is reasonable and more user/claimant friendly
    for adjudication purposes.

-   Separate listings and guidance for cochlear implants are
    appropriate.

-   The NPRM proposes the elimination of the requirements for testing
    with hearing aids. NADE is not entirely comfortable with the
    elimination of evaluating the impact of aides on hearing. The
    elimination of aided testing is overall reasonable, being both fair
    to the claimants and practical. Some individuals are cleared for
    aids however and do benefit significantly. We ask that a functional
    criteria be considered to help discriminate between those who get
    some benefit and can afford individualized aids and those who do
    not.

-   102.005ai uses 60% as the level of intelligibility that is
    considered 'marked' in contrast to POMS (DI 25599.001) where
    two-thirds or 67% is the criteria for a 'marked' impairment. We feel
    the two-thirds requirement should be used.

-   We agree with the NPRM recommended one (1) year diary for adults and
    up to five (5) years in the case of children for individuals who
    have had a cochlear implant, in order to allow the individual time
    for rehabilitation and training after the implant.

-   NADE believes that changes are needed to the childhood listings
    acknowledging that those who are developing bi- or multi-lingual
    environments have different rates of speech education and
    articulation. This setting invalidates almost every speech test that
    is done. Some guidance on how to accommodate these changes would be
    appropriate.

> We appreciate this opportunity to provide comments on this NPRM.
>
> Sincerely,
>
> Georgina B. Huskey
>
> NADE President