[Federal Register Volume 80, Number 52 (Wednesday, March 18, 2015)]
[Notices]
[Pages 14215-14220]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-05680]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2014-0053]


Social Security Ruling, SSR 15-1p; Titles II and XVI: Evaluating 
Cases Involving Interstitial Cystitis (IC)

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are providing notice of SSR 15-1p. This SSR provides 
guidance on how we develop evidence to establish that a person has a 
medically determinable impairment of interstitial cystitis (IC), and 
how we evaluate IC in disability claims and continuing disability 
reviews under titles II and XVI of the Social Security Act.

DATES: Effective Date: March 18, 2015.

FOR FURTHER INFORMATION CONTACT: Cheryl Williams, Office of Medical 
Policy, Social Security Administration, 6401 Security Boulevard, 
Baltimore, Maryland 21235-6401, (410) 965-1020.

SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do 
not require us to publish this SSR, we are doing so in accordance with 
20 CFR 402.35(b)(1).
    Through SSRs, we convey to the public SSA precedential decisions 
relating to the Federal old-age, survivors, disability, supplemental 
security income, and special veterans benefits programs. We may base 
SSRs on determinations or decisions made at all levels of 
administrative adjudication, Federal court decisions, Commissioner's 
decisions, opinions of the Office of the General Counsel, or other 
interpretations of the law and regulations.
    Although SSRs do not have the same force and effect as statutes or 
regulations, they are binding on all components of the Social Security 
Administration. 20 CFR 402.35(b)(1).
    This SSR will remain in effect until we publish a notice in the 
Federal Register that rescinds it, or we publish a new SSR that 
replaces or modifies it.

(Catalog of Federal Domestic Assistance, Programs Nos. 96.001, 
Social Security--Disability Insurance; 96.002, Social Security--
Retirement Insurance; 96.004, Social Security--Survivors Insurance; 
96.006--Supplemental Security Income.)


    Dated: March 3, 2015.
Carolyn W. Colvin,
Acting Commissioner of Social Security.

Policy Interpretation Ruling

Titles II and XVI: Evaluating Cases Involving Interstitial Cystitis 
(IC)

    This Social Security Ruling (SSR) rescinds and replaces SSR 02-2p: 
``Titles II and XVI: Evaluation of Interstitial Cystitis.'' \1\
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    \1\ We will use this Social Security Ruling (SSR) beginning on 
its effective date. We will apply this SSR to new applications filed 
on or after the effective date of the SSR and to claims that are 
pending on and after the effective date. This means that we will use 
these rules on and after their effective date in any case in which 
we make a determination or decision. We expect that Federal courts 
will review our final decisions using the rules that were in effect 
at the time we issued the decisions. If a court reverses our final 
rules and remands a case for further administrative proceedings 
after the effective date of these final rules, we will apply these 
final rules to the entire period at issue in the decision we make 
after the court's remand.
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    Purpose: This SSR clarifies our policy on how we develop evidence 
to establish that a person has a medically determinable impairment 
(MDI) of IC and how we evaluate this impairment in disability claims 
and continuing disability reviews under titles II and XVI of the Social 
Security Act (Act).\2\
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    \2\ For simplicity, we refer in this SSR only to initial adult 
claims for disability benefits under titles II and XVI of the Act 
and to the steps of the sequential evaluation process we use to 
determine disability in those claims. 20 CFR 404.1520 and 416.920. 
The policy interpretations in this SSR apply to all cases in which 
we must make determinations about disability, including claims of 
children (that is, people who have not attained age 18) who apply 
for benefits based on disability under title XVI of the Act, 
disability redeterminations for children who became eligible for 
Supplemental Security Income under title XVI as a child and who were 
eligible for such benefits for the month before the month in which 
they attained age 18, and to continuing disability reviews of adults 
and children under titles II and XVI of the Act. 20 CFR 404.1594, 
416.924, 416.987, 416.994, and 416.994a.

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[[Page 14216]]

    Citations: Sections 216(i), 223(d), 223(f), 1614(a)(3) and 
1614(a)(4) of the Social Security Act, as amended; Regulations No. 4, 
subpart P, sections 404.1502, 404.1505, 04.1508-404.1513, 404.1519a, 
404.1520, 404.1520a, 404.1520b, 404.1521, 404.1523, 404.1526, 404.1527-
404.1529, 404.1545, 404.1560-404.1569a, 404.1593, 404.1594, appendices 
1 and 2; and Regulations No. 16, subpart I, sections 416.902, 416.905, 
416.906, 416.908-416.913, 416.919a, 416.920, 416.920a, 416.920b, 
416.921, 416.923, 416.924, 416.924a, 416.926, 416.926a, 416.925, 
416.927-416.929, 416.945, 416.960-416-969a, 416.987, 416.993, 416.994, 
and 416.994a.

Introduction

    IC is a complex genitourinary disorder involving recurring pain or 
discomfort in the bladder and pelvic region. The American Urological 
Association (AUA), National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK), and other medical experts may use the terms 
``interstitial cystitis/bladder pain syndrome (IC/BPS)'' and 
``interstitial cystitis/painful bladder syndrome (IC/PBS)'' to describe 
this disorder because they consider the term ``interstitial cystitis'' 
to be synonymous with the terms ``bladder pain syndrome'' and ``painful 
bladder syndrome.'' When we refer to IC in this SSR, we include IC/BPS 
and IC/PBS.
    The AUA has developed guidelines providing a clinical framework for 
diagnosing and treating IC/BPS.\3\ These guidelines use a definition of 
IC accepted by the Society for Urodynamics and Female Urology: ``An 
unpleasant sensation (pain, pressure, discomfort) perceived to be 
related to the urinary bladder, associated with lower urinary tract 
symptoms of more than six weeks duration, in the absence of infection 
or other identifiable causes.'' \4\ NIDDK's National Kidney and 
Urologic Diseases Information Clearinghouse explains that the term IC/
PBS (and IC/BPS) includes all cases of urinary pain not attributed to 
other causes, such as infection or urinary stones.\5\ NIDDK further 
explains that the term ``interstitial cystitis'' is used alone (without 
PBS or BPS) to describe cases of urinary pain that meet all of the IC 
criteria NIDDK established in 1987 for research purposes.\6\ We took 
into consideration the AUA and NIDDK descriptions of IC when we 
formulated the criteria in this SSR. For example, we adapted the AUA 
and NIDDK descriptions to help develop criteria for establishing an MDI 
of IC.\7\
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    \3\ Hanno, P.M., et al., Diagnosis and treatment of interstitial 
cystitis/bladder pain syndrome, American Urological Association, 
(2014) (available at: http://www.auanet.org/common/pdf/education/clinical-guidance/IC-Bladder-Pain-Syndrome-Revised.pdf).
    \4\ Hanno, P. and Dmochowski, R., Status of international 
consensus on interstitial cystitis/bladder pain syndrome/painful 
bladder syndrome: 2008 snapshot, Neurology and Urodynamics, 
Apr;28(4), 274-286 (2009).
    \5\ See NIDDK National Kidney and Urologic Diseases Information 
Clearinghouse, ``Interstitial Cystitis/Painful Bladder Syndrome'' 
(2013) available at: http://kidney.niddk.nih.gov/KUDiseases/pubs/interstitialcystitis/index.aspx.
    \6\ Gillenwater, J.Y., et al., Summary of the National Institute 
of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on 
Interstitial Cystitis, National Institutes of Health, Bethesda, 
Maryland, August 28-29, 1987, The Journal of Urology, Jul;140(1), 
203-206 (1988).
    \7\ We adapted the AUA and NIDDK descriptions of IC, which are 
mainly symptom-based, because the Act and our regulations require a 
claimant to establish by objective medical evidence (that is, 
medical signs and laboratory findings) that he or she has a 
medically determinable impairment. See 223(d)(5)(A) and 
1614(a)(3)(D) of the Act, 20 CFR 404.1508 and 416.908, and SSR 96-
4p: Titles II and XVI: Symptoms, Medically Determinable Physical and 
Mental Impairments, and Exertional and Nonexertional Limitations, 61 
FR 34388 (1996) (also available at: http://www.ssa.gov/OP_Home/rulings/di/01/SSR96-04-di-01.html).
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    Except for statutory blindness, we find a person to be ``disabled'' 
if he or she is unable to do any substantial gainful activity by reason 
of a medically determinable physical or mental impairment(s) or 
combination of impairments that can be expected to result in death or 
has lasted or can be expected to last for a continuous period of not 
less than 12 months.\8\ We require an MDI to result from anatomical, 
physiological, or psychological abnormalities, as shown by medically 
acceptable clinical and laboratory diagnostic techniques.\9\ The Act 
and our regulations further require that medical evidence establishing 
an MDI consist of signs, symptoms, and laboratory findings. Thus, we 
cannot determine that a person who has IC is disabled on the basis of 
his or her statement of symptoms alone.\10\ In this SSR, we explain 
that IC, when accompanied by appropriate symptoms and medical signs or 
laboratory findings, is an MDI that can be the basis for a finding of 
``disability.'' We also explain how we evaluate IC in disability 
claims.
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    \8\ See 20 CFR 404.1505 and 416.905.
    \9\ See sections 223(d)(3) and 1614(a)(3)(D) of the Act, and 20 
CFR 404.1508 and 416.908.
    \10\ See sections 223(d)(5)(A) and 1614(a)(3)(D) of the Act; 20 
CFR 404.1508 and 416.908; and SSR 96-4p.
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Policy Interpretation

    IC constitutes an MDI when producing appropriate symptoms and 
medical signs or laboratory findings, and may result in a disabling 
impairment. There are some signs and findings that could indicate IC, 
but there are no specific signs or findings that are universally 
accepted. However, for our program purposes, we are choosing to rely 
upon certain signs and findings to establish the existence of an MDI of 
IC. Once we establish that a person has an MDI of IC by taking into 
consideration these signs or findings, we use the sequential evaluation 
process to determine whether the person is disabled. This policy 
interpretation clarifies how our adjudicators should apply our 
regulations in establishing an MDI of IC and determining disability 
under titles II and XVI of the Act.

I. What is IC?

    A. IC is a complex genitourinary disorder resulting in recurring 
pain or discomfort in the bladder and pelvic region. The AUA and other 
medical experts characterize IC, in part, as an unpleasant sensation 
(pain, pressure, discomfort) perceived to be related to the urinary 
bladder, associated with lower urinary tract symptoms of more than six 
weeks duration, in the absence of infection or other identifiable 
causes. IC is most common in women and sometimes occurs before age 
18.\11\ It is not unusual for people to have prodromal (early 
predictive) symptoms years or decades before they get IC. Prodromal 
symptoms may include periodic episodes of urinary frequency, bladder 
pain, or pelvic pain.
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    \11\ See NIDDK National Kidney and Urologic Diseases Information 
Clearinghouse (available at: http://kidney.niddk.nih.gov/KUDiseases/pubs/interstitialcystitis/index.aspx).
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    B. In accordance with the AUA guidelines, a physician should make a 
diagnosis of IC only after reviewing the person's medical history and 
conducting a physical examination. The physician should also conduct 
laboratory tests to rule out certain medical conditions that may result 
in the same or similar symptoms. For example, the AUA guidelines 
recommend a basic laboratory

[[Page 14217]]

examination that includes urinalysis and urine culture. NIDDK notes 
that diagnostic tests physicians may also use to rule out other 
conditions include cystoscopy, biopsy of the bladder wall and urethra, 
distention of the bladder under anesthesia, and, in men, culture of 
prostate secretions.\12\
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    \12\ Descriptions of these tests are available at http://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/#diagnosis. Evidence that a physician used any of these tests or 
other laboratory tests to make a diagnosis of IC (that is, to rule 
out other diseases that could explain the person's symptoms) helps 
establish the existence of an MDI of IC.
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    C. IC may co-occur with fibromyalgia, chronic fatigue syndrome, 
irritable bowel syndrome, inflammatory bowel disease, vulvodynia, 
chronic headaches, Sj[ouml]gren's syndrome, endometriosis, or systemic 
lupus erythematosus.
    D. Treatments for IC are mostly directed at symptom control. They 
include, but are not limited to: Changes in diet; physical therapy and 
pelvic floor strengthening exercises; stress management; bladder 
distention; bladder instillation; oral drugs, such as prescription 
drugs indicated for IC (for example, Elmiron and dimethyl sulfoxide), 
antidepressants, antihistamines, antacids, anticoagulants, and narcotic 
analgesics; transcutaneous electrical nerve stimulation; and surgery, 
such as substitution cystoplasty or urinary diversion with or without 
cystectomy. Treatment is not effective for everyone because response 
varies among patients.

II. How does a person establish an MDI of IC?

A. General

    1. A person can establish that he or she has an MDI of IC by 
providing appropriate evidence from an acceptable medical source.\13\ A 
licensed physician (a medical or osteopathic doctor) is the only 
acceptable medical source who can provide evidence establishing an MDI 
of IC. This acceptable medical source often is the person's treating 
source(s) who makes the diagnosis of IC. A treating source(s) may be 
the person's own physician or other acceptable medical source who 
provides, or has provided, medical evaluation or treatment and who has, 
or has had, an ongoing treatment relationship with the person.\14\
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    \13\ See 20 CFR 404.1513(a) and 416.913(a).
    \14\ We may consider an acceptable medical source who has 
treated or evaluated the person only a few times or only after long 
intervals (for example, twice a year) to be a treating source. See 
20 CFR 404.1502 and 416.902.
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    2. We generally will rely on the judgment of a licensed physician 
who has made a diagnosis of IC. The evidence must document that this 
physician reviewed the person's medical history and conducted a 
physical examination, and that his or her diagnosis is not inconsistent 
with the other substantial evidence in the person's case record.\15\ 
However, we cannot rely on the physician's diagnosis alone to establish 
an MDI of IC. The physician may make a diagnosis of IC based only on 
the person's reported symptoms, after examining the person and ruling 
out other diseases that could cause the symptoms. Thus, as previously 
mentioned, there must also be medical signs or laboratory findings to 
establish an MDI of IC.
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    \15\ We use the term ``not inconsistent'' to indicate that a 
diagnosis of IC need not be supported directly by all the other 
evidence (that is, it does not have to be consistent with all the 
other evidence) as long as there is no other substantial evidence in 
the case record that contradicts or conflicts with the diagnosis. 
Whether a diagnosis of IC is ``not inconsistent'' with the other 
substantial evidence is a judgment that adjudicators must make in 
each case. In situations in which the diagnosis of IC is 
inconsistent with the other substantial evidence in the person's 
case record, the adjudicator may determine that the diagnosis is not 
entitled to ``controlling weight'' in establishing whether the 
person has an MDI. However, the adjudicator should not reject the 
diagnosis, but instead must weigh it using all of the factors 
provided in 20 CFR 404.1527 and 416.927. See SSR 96-2p, Titles II 
and XVI: Giving Controlling Weight to Treating Source Medical 
Opinions, 61 FR 34492 2006 (also available at: http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-02-di-01.html).
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    3. If we cannot establish that a person has an MDI of IC, but there 
is evidence of another MDI, we will not evaluate the impairment under 
this SSR. Instead, we will evaluate it under the rules that apply for 
that impairment.
    B. Symptoms. IC symptoms may vary in incidence, duration, and 
severity from person to person, and even in the same person. For 
example, a woman's symptoms may worsen around the time of menstruation. 
Symptoms of IC include, but are not limited to:
    1. Pain. People who have IC report chronic bladder and pelvic pain, 
pressure, and discomfort. This pain may range from mild discomfort to 
extreme distress. The intensity of the pain may increase as the bladder 
fills and decrease as it empties. In addition to bladder and pelvic 
pain, people with IC may experience vaginal, testicular, penile, low 
back, or thigh pain.
    2. Urinary urgency and frequency. People who have IC may report an 
urgent need to urinate (urgency) or a frequent need to urinate 
(frequency), or both. Some people with severe cases of IC may need to 
void as often as 60 times per day, including nighttime urinary 
frequency (nocturia) with associated sleep disruption.\16\
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    \16\ See NIDDK National Kidney and Urologic Diseases Information 
Clearinghouse (available at: http://kidney.niddk.nih.gov/KUDiseases/pubs/interstitialcystitis/index.aspx.) As used by the NIDDK, the 
word ``severe'' is not meant in the same sense that we use the word 
to describe a severe impairment at the second step of our sequential 
evaluation process.
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    3. Other symptoms. In addition to chronic pain and urinary urgency 
or frequency or both, the person may report additional IC symptoms, 
such as:
    <bullet> Suprapubic tenderness on physical examination;
    <bullet> Sexual dysfunction (including dyspareunia);
    <bullet> Sleep dysfunction; and
    <bullet> Chronic fatigue or tiredness.
    C. Medical signs. Medical signs can support a diagnosis of IC and 
help establish the MDI. These signs include the following, which can be 
detected during a medical procedure that stretches the bladder with 
fluid (cystoscopy under anesthesia with bladder distention): \17\
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    \17\ We will not purchase this procedure to establish an MDI of 
IC because it is an invasive procedure.
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    1. Fibrosis (bladder-wall stiffening);
    2. Diffuse glomerulations (pinpoint bleeding caused by recurrent 
irritation) on the bladder wall; and
    3. Hunner's ulcers (patches of broken skin) on the bladder 
wall.\18\
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    \18\ Hunner's ulcers are rare and may be present in only 5-10 
percent of individuals with IC.
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    D. Laboratory findings. Laboratory test findings can also support a 
diagnosis of IC. We will make every reasonable effort to obtain the 
results of appropriate laboratory testing. However, we will not 
purchase complex, costly, or invasive tests. Some laboratory tests and 
findings are more widely used and accepted than others. The following 
laboratory findings can help establish an MDI of IC:
    1. Repeated sterile urine cultures while IC symptoms continue;
    2. Positive potassium sensitivity test (Parson's test); \19\ and
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    \19\ Although validated by some studies, the potassium 
sensitivity test is not yet recommended for routine clinical use and 
can be painful for the patient. We will not purchase this procedure 
to establish an MDI of IC because it is an invasive procedure.
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    3. Antiproliferative factor (APF) accumulation in the urine.\20\
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    \20\ Physicians do not routinely measure APF.
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    E. Other signs and findings. Because of the ongoing research into 
the etiology and manifestations of IC, the medical criteria discussed 
above are only examples of signs and laboratory findings that help 
establish an MDI of IC; they are not all-inclusive. As medical research 
advances regarding IC, we may rely on other signs and laboratory 
findings to help establish an MDI of IC. For example, gene studies are 
exploring whether there are various

[[Page 14218]]

subtypes of IC. Thus, we may document the existence of IC as an MDI 
with medical signs and laboratory findings other than those listed 
above, provided such evidence is consistent with medically accepted 
clinical practice and the other evidence in the case record.
    F. Mental conditions. People who have IC may report ongoing mental 
conditions directly associated with their IC. For example, a person may 
report having anxiety or depression associated with IC symptoms of 
chronic bladder and pelvic pain, and urinary urgency, frequency, or 
both. When these mental conditions are documented by mental status 
examination(s) or psychological testing, they may constitute medical 
signs or (in the case of psychological testing) laboratory findings 
that help establish an MDI of IC.\21\
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    \21\ See 20 CFR 404.1528 and 416.928.
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III. How do we document IC?

    A. General. In cases of alleged IC, we generally need to have 
longitudinal evidence because symptoms, signs, and laboratory findings 
of IC may fluctuate in frequency and severity and may continue over a 
period of months or years.
    1. Longitudinal clinical records reflecting ongoing medical 
evaluation and treatment from the person's medical sources, especially 
treating sources, are extremely helpful in documenting the presence of 
any signs or laboratory findings, as well as the person's limitations 
over time. The longitudinal record should contain medical observations, 
information about treatment, the person's response to treatment, and a 
detailed description of how the impairment affects the person's ability 
to function.
    2. In addition to obtaining evidence from a physician, we may 
request evidence from other acceptable medical sources, such as 
psychologists, both to determine whether the person has another MDI(s) 
and to evaluate the severity and functional effects of IC in 
combination with other impairments the person may have. Under our 
regulations and SSR 06-03p, we also may consider evidence from other 
medical sources we do not consider acceptable medical sources to help 
us evaluate the severity and functional effects of the 
impairment(s).\22\ Nurse practitioners, physician assistants, and 
physical therapists are examples of these other medical sources.
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    \22\ See 20 CFR 404.1513(d)(1), 416.913(d)(1); SSR 06-03p: 
Titles II and XVI: Considering Opinions and Other Evidence from 
Sources Who Are Not ``Acceptable Medical Sources'' in Disability 
Claims; Considering Decisions on Disability by Other Governmental 
and Nongovernmental Agencies, 71 FR 45593 (2006) (also available at: 
http://www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03-di-01.html).
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    3. Information from nonmedical sources can also help us evaluate 
the severity of a person's IC.\23\ This information may help us assess 
the person's ability to function day-to-day and over time. It may also 
help us when we make findings about credibility of the person's 
allegations about symptoms and their effects. Examples of nonmedical 
sources include:
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    \23\ See 20 CFR 404.1513(d)(2-4) and 416.913(d)(2-4), and also 
SSR 06-03p.
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    <bullet> Spouses, parents, siblings, other relatives, neighbors, 
friends, and clergy;
    <bullet> Past employers, rehabilitation counselors, and teachers; 
and
    <bullet> Statements from SSA and State agency personnel who 
interviewed the person.
    4. Before we make a determination whether or not the person is 
disabled, we will make every reasonable effort to develop his or her 
complete medical history and help the person get medical reports from 
his or her medical sources. Generally, we will request evidence from 
the person's medical sources for the 12-month period preceding the 
month of application unless there is reason to believe that development 
of an earlier period is necessary, or unless the alleged onset of 
disability is less than 12 months before the date of application.\24\
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    \24\ See 20 CFR 404.1512(d) and 416.912(d).
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    5. When the alleged onset of disability secondary to IC occurred 
less than 12 months before adjudication, we must evaluate the medical 
evidence and project the degree of impairment severity that is likely 
to exist at the end of 12 months.\25\ Information about the person's 
treatment and response to treatment, including any medical source 
opinions about the person's prognosis at the end of 12 months, helps us 
decide whether to expect an MDI of IC to be of disabling severity for 
at least 12 consecutive months.
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    \25\ To meet the statutory requirement for ``disability,'' a 
person must have been unable to engage in any substantial gainful 
activity because of any medically determinable physical or mental 
impairment that is expected to result in death or that has lasted or 
can be expected to last for a continuous period of not less than 12 
months. Thus, the existence of an impairment(s) for 12 continuous 
months is not controlling; rather, it is the existence of a 
disabling impairment that has lasted or can be expected to last for 
at least 12 months that meets the duration requirement of the Act. 
See 20 CFR 404.1509 and 416.909.
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B. What do we do if there is insufficient evidence to determine whether 
the person has an MDI of IC or is disabled?

    1. When there is insufficient evidence for us to determine whether 
the person has an MDI of IC or is disabled, we may take one or more 
actions to try to resolve the insufficiency: \26\
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    \26\ See 20 CFR 404.1520b(c) and 416.920b(c).
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    <bullet> We may recontact the person's treating or other source(s) 
to see if the information we need is available;
    <bullet> We may request additional existing records from treating 
or other sources;
    <bullet> We may ask the person or others for more information; or
    <bullet> We may purchase a consultative examination (CE) at our 
expense.\27\
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    \27\ See 20 CFR 404.1520b(c)(3), and 416.920b(c)(3). The type of 
CE we purchase will depend on the nature of the person's symptoms 
and the extent of the evidence already in the case record. For 
example, we may purchase a CE to help evaluate depression, anxiety, 
or other mental conditions associated with the person's IC. We may 
purchase a CE without recontacting a person's treating or other 
source if the source cannot provide the necessary information or the 
information is not available from the source. See 20 CFR 
404.1519a(b) and 416.919a(b).
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    2. When we are unable to resolve an insufficiency in the evidence, 
and we need to determine whether the person has an MDI of IC or is 
disabled, we may make a determination or decision based on the evidence 
we have.\28\
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    \28\ See 20 CFR 404.1520b(d) and 416.920b(d).
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    C. How do we resolve conflicts in the evidence? Conflicting 
evidence in the medical record is not unusual in cases of IC due to the 
complicated diagnostic process involved. We will consider conflicting 
medical evidence in accordance with our rules.\29\
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    \29\ See 20 CFR 404.1520b and 416.920b.
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IV. How do we evaluate a person's statements about his or her symptoms 
and functional limitations?

    Generally, we follow a two-step symptom evaluation process:
    A. First step of the symptom evaluation process. There must be 
medical signs or laboratory findings that show the person has an MDI(s) 
which we could reasonably expect to produce the pain or other symptoms 
alleged.\30\ If we find that a person has an MDI that we could 
reasonably expect to produce the alleged symptoms, the first step of 
our two-step process for evaluating symptoms is satisfied.
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    \30\ See 20 CFR 404.1520, 416.920, and 416.924.
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    B. Second step of the symptom evaluation process. After finding 
that the MDI could reasonably be expected to produce the alleged 
symptoms, we evaluate the intensity and persistence of the person's 
symptoms and determine the extent to which they limit the person's 
functional capacity for work. In evaluating the intensity, persistence, 
and functionally limiting effects of symptoms, we consider all of the 
evidence in the case record, including the person's daily activities;

[[Page 14219]]

medications or other treatments the person uses, or has used, to 
alleviate symptoms; the nature and frequency of the person's attempts 
to obtain medical treatment for symptoms; and statements by other 
people about the person's symptoms. We will make a finding about the 
extent to which symptoms, such as pain, affect his or her capacity to 
perform basic work activities.\31\ When we need additional information 
to assess the person's statements about symptoms and their effects, we 
will make every reasonable effort to obtain available information that 
could shed light on the person's statements.
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    \31\ See 20 CFR 404.1529 and 416.929. See also SSR 96-7p: Titles 
II and XVI: Evaluation of Symptoms in Disability Claims: Assessing 
the Credibility of an Individual's Statements, 61 FR 34483 (1996) 
(also available at: http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-07-di-01.html).
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V. How do we find a person disabled based on an MDI of IC?

    Once we establish that a person has an MDI of IC, we will consider 
this MDI in the sequential evaluation process to determine whether the 
person is disabled.\32\ As we explain in section VI below, we consider 
the severity of the impairment, whether the impairment meets or 
medically equals the requirements of a listed impairment, and whether 
the impairment prevents the person from doing his or her past relevant 
work or other work that exists in significant numbers in the national 
economy.
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    \32\ See 20 CFR 404.1520, 416.920, and 416.924.
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VI. How do we use the sequential evaluation process to evaluate IC?

    We adjudicate claims involving IC using the sequential evaluation 
process, just as we do for any impairment. Once we find that an MDI(s) 
exists (see section II), we must establish the severity of the 
impairment(s) based on the totality of signs, symptoms, and laboratory 
findings, and the effects of the impairment(s), including any related 
symptoms, on the person's ability to function. Additionally, several 
other disorders may share characteristics similar to those of IC. When 
there is evidence of the potential presence of another disorder that 
may adequately explain the person's symptoms, it may be necessary to 
pursue additional medical or other development. As mentioned, if we 
cannot find that the person has an MDI of IC but there is evidence of 
another MDI, we will not evaluate the impairment under this SSR. 
Instead, we will evaluate it under the rules that apply for that 
impairment.
    A. Step 1. We consider the person's work activity. If a person with 
IC is engaged in substantial gainful activity, we will find that he or 
she is not disabled.
    B. Step 2. If we find that a person with IC has an MDI that meets 
the duration requirement,\33\ and the person alleges pain and other 
symptoms consistent with IC, we must consider these symptoms in 
deciding whether the person's impairment is ``severe'' at step 2 of the 
sequential evaluation process, and at any later steps reached in the 
sequential evaluation process. If we find that the person's pain, 
urinary urgency or urinary frequency, or other symptoms have more than 
a minimal effect on a person's ability to perform basic work 
activities, we must find that the person has a ``severe'' 
impairment.\34\
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    \33\ See 20 CFR 404.1509 and 416.909.
    \34\ See SSR 96-3p: Titles II and XVI: Considering Allegations 
of Pain and Other Symptoms in Determining Whether a Medically 
Determinable Impairment Is Severe, 61 FR 34468 (1996) (also 
available at: http://www.ssa.gov/OP_Home/rulings/di/01/SSR96-03-di-01.html).
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    C. Step 3. When we find that a person with IC has a severe MDI, we 
must proceed to step three and consider the medical severity of the 
impairment(s). At this step, we consider whether a person's 
impairment(s) meets or equals in severity one of the impairments in the 
Listing of Impairments.\35\ IC is not a listed impairment; therefore, 
we cannot find that a person with IC alone has an impairment that meets 
a listing. However, we will compare the specific findings in each case 
to any pertinent listing to determine whether medical equivalence may 
exist.\36\ We also may find medical equivalence if the person has 
multiple impairments, including IC, none of which meets or medically 
equals the requirements of a listing, but the combination of 
impairments is medically equivalent in severity to a listed impairment. 
In cases in which a person with IC has psychological manifestations 
related to IC, we must consider whether the person's impairment meets 
or equals the severity of any impairment in the mental disorders 
listings (see section IIF).\37\
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    \35\ See 20 CFR, part 404, subpart P, appendix 1.
    \36\ In evaluating title XVI claims for disability benefits for 
people under age 18, we will consider whether the impairment(s) 
functionally equals the listings. See 20 CFR 416.926a. For example, 
the functional limitations of IC, by itself or in combination with 
another impairment(s), may establish an extreme limitation in one 
broad area of functioning (for example, attending and completing 
tasks) or marked limitation in two broad areas (for example, 
attending and completing tasks, and interacting or relating with 
others).
    \37\ See sections 12.00 and 112.00 of 20 CFR, part 404, subpart 
P, appendix 1.
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    D. Steps 4 and 5. For those impairments that do not meet or 
medically equal the severity of a listing, we must make an assessment 
of the person's residual functional capacity (RFC). The RFC assessment 
must be based on all the relevant evidence in the record.\38\ In 
assessing RFC related to an MDI of IC, we must consider all of the 
person's impairment-related symptoms in deciding how such symptoms may 
affect functional capacity.\39\ For example, many people with IC have 
chronic pelvic pain, which can affect the ability to focus and sustain 
attention on the task at hand. Nocturia may disrupt sleeping patterns 
and lead to drowsiness and lack of mental clarity during the day. 
Urinary frequency can necessitate trips to the bathroom as often as 
every 10 to 15 minutes, day and night. Consequently, some individuals 
with IC essentially may confine themselves to their homes. After we 
consider such impairment-related symptoms and we make our RFC 
assessment, our evaluation must proceed to the fourth step of the 
sequential evaluation process, unless an expedited process applies.\40\ 
If necessary, we then proceed to the fifth step of the sequential 
evaluation process.\41\ If we do not use an expedited process, we must 
determine whether the person's impairment(s) precludes the performance 
of past relevant work (unless we determine that there was no past 
relevant work). If we determine that the person's impairment(s) 
precludes performance of past relevant work or there was no past 
relevant work, we must make a finding about the person's ability to 
perform other work. We must apply the usual vocational considerations 
in determining the person's ability to perform other work.\42\
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    \38\ See 20 CFR 404.1545(a) and 416.945(a), and also SSR 96-8p: 
Titles II and XVI: Assessing Residual Functional Capacity in Initial 
Claims, 61 FR 34474 (1996) (also available at http://www.ssa.gov/OP_Home/rulings/di/01/SSR96-08-di-01.html). Our RFC assessments must 
consider the person's maximum ability to do sustained work 
activities in an ordinary work setting on a regular and continuous 
basis. Generally, a ``regular and continuous basis'' means eight 
hours a day, for five days a week, or an equivalent work schedule of 
40 hours per week. In cases involving IC, chronic fatigue may affect 
the person's physical and mental ability to sustain work activity, 
and this may be especially true in cases involving urinary 
frequency.
    \39\ See 20 CFR 404.1529(d) and 416.929(d), and SSR 96-7p.
    \40\ See 20 CFR 404.1520(h) and 416.920(h).
    \41\ The fourth and fifth steps of the sequential evaluation 
process are not applicable to claims for benefits under title XVI 
for people under age 18. See 20 CFR 416.924.
    \42\ See 20 CFR 404.1560-404.1569a and 416.960-416.969a, and SSR 
11-2p: Titles II and XVI: Documenting and Evaluating Disability in 
Young Adults, 76 FR 56263 (2011) (also available at http://www.ssa.gov/OP_Home/rulings/di/01/SSR2011-02-di-01.html).

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[[Page 14220]]

    1. Pain and other symptoms associated with IC may result in 
exertional limitations that prevent a person from doing a full range of 
unskilled work in one or more of the exertional categories in appendix 
2 of subpart P of part 404 (appendix 2).\43\ People with IC may also 
have nonexertional physical or mental limitations because of their pain 
or other symptoms.\44\ Some may have environmental restrictions, which 
are also nonexertional.
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    \43\ See SSR 83-12: Title II and SVI: Capability To Do Other 
Work--The Medical-Vocational Rules as a Framework for Evaluating 
Exertional Limitations Within a Range of Work or Between Ranges of 
Work (available at http://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR83-12-di-02.html).
    \44\ See SSR 85-15: Titles II and XVI: Capability To Do Other 
Work--Medical-Vocational Rules as a Framework for Evaluating Solely 
Nonexertional Impairments (available at: http://www. social 
security. gov/OP_Home/rulings/di/02/SSR85-15-di-02.html).
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    2. Exertional and nonexertional limitations resulting from IC may 
affect the person's ability to perform routine movement and necessary 
physical activity in the work environment, such as sitting, standing, 
walking, lifting, carrying, pushing, and pulling. These limitations may 
also affect the person's ability to do postural functions, such as 
climbing, balancing, stooping, and crouching, or they may affect the 
person's ability to tolerate extreme heat, humidity, or hazards.
    3. Adjudicators must be alert to the possibility that there may be 
exertional or nonexertional (for example, postural or environmental) 
limitations that erode a person's occupational base sufficiently to 
preclude the use of a rule in appendix 2 to direct a decision. In such 
cases, adjudicators must use the rules in appendix 2 as a framework for 
decision-making and may need to consult a vocational resource.\45\
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    \45\ See SSR 83-12; SSR 83-14: Titles II and XVI: Capability To 
Do Other Work--The Medical-Vocational Rules as a Framework for 
Evaluating a Combination of Exertional and Nonexertional Impairments 
(available at http://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR83-14-di-02.html); SSR 85-15; and SSR 96-9p, Titles II and XVI: 
Determining Capability to Do Other Work--Implications of a Residual 
Functional Capacity for Less Than a Full Range of Sedentary Work, 61 
FR 34478 (July 2, 1996) (also available at http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-09-di-01.html).
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    E. Continuing disability reviews. In those cases in which we find 
that a person has a disability based on IC, we will conduct an 
appropriate continuing disability review as required by law.\46\ For 
this review, we take into account relevant individual case facts, such 
as the combined severity of other chronic or static impairments, and 
the person's vocational factors.
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    \46\ See 20 CFR 404.1594, 416.994, and 416.994a.
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    Effective Date: This SSR is effective on March 18, 2015.
    Cross-References: SSR 82-63: Titles II and XVI: Medical-Vocational 
Profiles Showing an Inability To Make an Adjustment to Other Work; SSR 
83-12: Titles II and XVI: Capability To Do Other Work--The Medical-
Vocational Rules as a Framework for Evaluating Exertional Limitations 
Within a Range of Work or Between Ranges of Work; SSR 83-14: Titles II 
and XVI: Capability To Do Other Work--The Medical-Vocational Rules as a 
Framework for Evaluating a Combination of Exertional and Nonexertional 
Impairments; SSR 85-15: Titles II and XVI: Capability To Do Other 
Work--The Medical-Vocational Rules as a Framework for Evaluating Solely 
Nonexertional Impairments; SSR 96-2p, Titles II and XVI: Giving 
Controlling Weight to Treating Source Medical Opinions; SSR 96-3p, 
Titles II and XVI: Considering Allegations of Pain and Other Symptoms 
in Determining Whether a Medically Determinable Impairment Is Severe; 
SSR 96-4p, Titles II and XVI: Symptoms, Medically Determinable Physical 
and Mental Impairments, and Exertional and Nonexertional Limitations; 
SSR 96-5p, Titles II and XVI: Medical Source Opinions on Issues 
Reserved to the Commissioner; SSR 96-7p, Titles II and XVI: Evaluation 
of Symptoms in Disability Claims: Assessing the Credibility of an 
Individual's Statements; SSR 96-8p, Titles II and XVI: Assessing 
Residual Functional Capacity in Initial Claims; SSR 96-9p, Titles II 
and XVI: Determining Capability to Do Other Work--Implications of a 
Residual Functional Capacity for Less Than a Full Range of Sedentary 
Work; SSR 06-03p, Titles II and XVI: Considering Opinions and Other 
Evidence from Sources Who Are Not ``Acceptable Medical Sources'' in 
Disability Claims; Considering Decisions on Disability by Other 
Governmental and Nongovernmental Agencies; SSR 12-2p, Titles II and 
XVI: Evaluation of Fibromyalgia; SSR 14-1p, Titles II and XVI: 
Evaluating Cases Involving Chronic Fatigue Syndrome (CFS); and Program 
Operations Manual System (POMS) DI 22505.001, DI 22505.003, DI 
24505.003, DI 24510.057, DI 24515.012, DI 24515.061-DI 24515.063, DI 
24515.066, DI 24515.067, DI 24515.075, DI 24555.001, DI 25010.001, and 
DI 25025.001.

[FR Doc. 2015-05680 Filed 3-17-15; 8:45 am]
 BILLING CODE 4191-02-P