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4.1 Introduction

This chapter discusses acceptable medical evidence sources and the types of evidence 

to be used in evaluating disability claims. It describes medical evidence development 

by the Disability Benefits Division (DBD), directly and through the field offices. It also 

gives guidelines for the evaluation of that medical evidence. Since development and 

evaluation are so closely related, it will be necessary to refer to the evaluation 

guidelines with some frequency in order to determine which forms of medical evidence 

should be developed, particularly when developing additional evidence.

The appendices to this chapter contain various guides useful in development of medical 

evidence, a body systems guide useful for development and evaluation with a glossary 

of terms and abbreviations, the field office's guide for developing medical evidence and 

the schedule of specialized medical services and fees.

4.2 Acceptable Medical Sources And Evidence

4.2.1 Acceptable Medical Sources

Although evidence from non-medical sources may be helpful in adding to the total 

record, evidence from a medical source is required to determine the existence or 

severity of an impairment. In order to have complete and accurate case records to 

make disability determination decisions, the RRB will obtain and consider all evidence 

that may or may not support the applicant’s claimed impairment(s). Reports about the 

applicant's impairments must come from acceptable medical sources. Acceptable 

medical sources are:

• Licensed physicians, (including psychiatrists),

• Licensed osteopaths,

• Licensed optometrists for the measurement of visual acuity and visual fields (we 

may need a report from a physician to determine other aspects of eye diseases),

• Licensed or certified clinical psychologists, and

• Persons authorized to send us a copy or summary of the medical records of a 

hospital, clinic, sanitarium, mental institution or health care facility.

Information submitted by optometrists, audiologists, chiropractors, naturopaths or other 

practitioners not licensed to practice medicine or surgery should be made a part of the 

record. However, when the only evidence in file is from one of these sources and the 

other information in file identifies a severe impairment, a consultative examination may 

be scheduled to determine if the claimant is disabled.
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Although a measurement of visual acuity and visual fields reported by an optometrist 

may be used, diagnosis, prognosis, or remediability of visual impairment can be 

evaluated only on the basis of a licensed physician's report.

Although the results of I.Q. tests administered by educational psychologists, vocational 

rehabilitation counselors, or specially trained school system personnel are acceptable 

as evidence of impairment, the severity of the impairment can only be evaluated on the 

basis of standardized tests administered by psychologists or psychiatrists qualified by 

training and experience to perform such tests.

4.2.2 Definition Of Treating (Personal) Physician

A "treating (personal) physician" is a doctor to whom the claimant has been going for 

treatment on a continuing basis. A claimant may have more than one treating 

physician.

4.2.3 Definition Of Non-Treating (Consulting) Physician

A "non treating" or "consulting" physician is a doctor (often a specialist) to whom the 

claimant is referred for an examination once or on a limited basis, at the expense of 

RRB or SSA.

4.3 Development

4.3.1 Nature Of Development

Medical evidence consists of reports about the disability from acceptable medical 

sources. Usually only recent (within 12 months) medical evidence will be developed by 

the field. Older evidence will be developed for establishing that a child's disability began 

before age 22, for establishing that a widow's disability began within the prescribed 

period, for establishing the claimants alleged disability onset date, or at the request of 

DBD in other cases.

Medical evidence should be obtained from the treating physician whenever possible. If 

there is medical evidence in file that indicates the claimant’s condition meets/equals an

SSA listing, if the claimant’s job title is covered in the Occupational Tables and there is 

medical evidence in file that can be used to establish a ‘D’ rating, or the claimant is 

carrier disqualified, it is not necessary to develop additional medical evidence, such as 

the RL-11D1, Request for Medical Evidence from Employers. Adjudicate the disability 

case accordingly.

The main thrust of development action should be towards resolving questions about 

onset, severity, and duration of the impairment. In closed period disability cases, 

development should also aim at determining the date on which disability ceased.
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4.3.2 Definitions Pertaining To Medical Evidence

A. MEDICAL ASSESSMENT - A medical assessment describes a person's ability to 

do work related activities such as sitting, standing, walking, lifting, carrying, 

handling objects, hearing, and speaking.

In case of mental impairment, it describes the person's ability to reason or make 

occupational, personal, or social adjustments.

B. MEDICAL EVIDENCE - Medical evidence consists of reports from acceptable 

sources (see 4.2.1) about the disability. Substantial evidence is such relevant 

evidence as a reasonable person would accept as adequate to support a 

conclusion regarding disability.

C. MEDICAL FINDINGS - Medical findings consist of symptoms, signs and 

laboratory findings:

1. Symptoms - This is the claimant's own description of his(her) physical or 

mental impairment.

2. Signs - These are anatomical, physiological, or psychological 

abnormalities which can be observed, apart from his(her) symptoms. 

Signs must be shown by medically acceptable clinical diagnostic 

techniques. Psychiatric signs are medically demonstrable phenomenon

which indicate specific abnormalities of behavior, affect, thought, memory, 

orientation, and contact with reality. They must also be shown by 

observable facts that can be medically described and evaluated.

3. Differences Between Symptoms and Signs - Although there are many 

instances in which a particular manifestation might be considered as a 

symptom in one context and as a sign in another, it is recognized that 

there are qualities that distinguish one from the other. First, signs are 

more difficult for the claimant to fashion or control. Second, there are 

distinctive, characteristic signs that clinicians repeatedly associate with 

particular symptoms. Third, signs can be observed by the clinician or can 

be elicited in response to a stimulus or action by the clinician. Fourth, they 

require professional skill and judgment to evaluate their presence and 

severity as opposed to the mere noting and reporting of a claimant's 

statements.

4. Laboratory Finding - These are anatomical, physiological, or psychological 

phenomena which can be shown by the use of medically acceptable 

laboratory diagnostic techniques. They include chemical tests, 

electrophysiological studies, (electrocardiogram, electroencephalogram, 

etc.), roentgenological studies (X-rays), and psychological tests.
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4.3.3 Authorization To Release Medical Evidence

Authorization to release medical evidence must be obtained from the applicant and 

enclosed with a request for medical evidence unless:

• DBD is paying for the medical services;

• the evidence request is a routine use under the Privacy Act, (i.e., SSA or OPM); or

• authorization was previously submitted to this medical source and DBD is requesting 

additional medical evidence.

NOTE: Requests to VA for medical evidence require authorization unless we are 

paying for the medical services.

RRB Form G-197 is used to secure authorization to release medical evidence.

4.3.4 Type Of Medical Evidence Development

Development of medical evidence is usually initiated by the field office, but there are 

some cases where DBD initiates development. The following types of medical evidence 

should be considered in the development process. 

A. Personal Physician Records - Whenever possible, personal physicians are to be 

contacted for evidence needed for evaluation because of their knowledge of the 

claimant's medical problems through diagnosis and treatment.

Because the personal physician is not always aware of the specific information 

necessary for our purposes, the clinical findings, as submitted, may not be 

sufficient to allow proper adjudication. If this is the case, it should not be 

assumed that the additional required information is not contained in the 

physician's records; rather, the needed information should be requested from the 

personal physician.

Medical evidence from the personal physician is acceptable in the following 

forms:

• Form G-250, Report of Examination,

• Form G-260, Report of Epilepsy convulsions,

• Narrative report on the physician's business stationery, and

• Copies of the physician's patient records.
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B. Records from Hospitals or Other Institutions - The best hospital/institution record 

consist of a copy of the discharge summary or final report. If such a report is not 

available, a copy of admission history, physical findings, laboratory, and X-ray 

findings, as well as diagnosis, should be obtained. Field offices use a RL-11b 

letter to request these records.

C. Employer Records - Many employers can furnish valuable medical evidence 

through their medical departments or affiliated hospital association. An employer 

can also advise us whether the applicant was disqualified from service because 

of this physical condition.

Medical evidence should be requested from an applicant's railroad and 

nonrailroad employer by the field office with an RL-11D1, Request for Medical 

Evidence from Employers, letter to obtain any medical evidence of an 

employee’s disability that they may have for the last 18 months. Form G-197, 

Authorization to Disclose Information to the Railroad Retirement Board, must be 

signed by the applicant or his/her authorized representative and attached to 

Form RL-11D1. 

Medical evidence should be requested from an occupational disability applicant's 

railroad employer by the field office with an RL-11, Letter For G-3EMP 

Disqualification Request for Medical Evidence from Railroad Employers, letter if

the applicant claims disqualification by his employer due to his physical condition. 

Some employers attach other forms or reports in lieu of completing some or all 

items of the G-3EMP. Accept these attachments as if the information had been 

entered on the Form G-3EMP. 

NOTE: Form G-3EMP should not be release if the applicant does not meet the 

requirements for an occupational disability. (See DCM 3.2.1) 

Form G-197, Authorization to Disclose Information to the Railroad Retirement 

Board, must be signed by the applicant or his/her authorized representative and 

enclosed with the RL-11 and G-3EMP forms. The field office assumes in these 

cases that a specialized examination will not be necessary.

D. Records from Other Agencies - 

1. SSA - The field office requests copies of medical evidence from SSA by 

releasing RR-5 to the Disability Review Section at Great Lakes Program 

Service Center.

2. VA - The Veterans Administration maintains records in its hospitals and its 

regional offices. VA sources of information include VA hospitals, 

outpatient clinics, physicians, military services, and other hospitals. The 

VA will provide medical evidence on record and, where a veteran is 

currently hospitalized, medical information about the veteran's current 

condition. The field office will request VA records by releasing Form RL-
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11a. Before releasing Form RL-11a, the field office will evaluate the 

usefulness of VA medical evidence if it is not current.

3. Worker's Compensation/Public Disability Benefit - Medical evidence will be 

requested only if the agency is considered a "key" source. A key source is 

a hospital or clinic which has treated or examined the employee since or 

shortly before the earliest possible disability onset date.

The field office will not request medical evidence from the paying agency if 

the applicant has been rated by SSA, because SSA probably has the 

evidence in their records.

The field office releases an RL-11d letter to the address shown on form G214 (Worker's Compensation and Public Disability Benefit Questionnaire). 

All requests for federal civil service records will be sent to OPM.

OPM will provide medical evidence for a former civil service employee 

who has filed for a civil service disability benefit. Their records often 

include evidence from a claimant's physician, a Certificate of Medical 

Examination together with a detailed report of clinical and laboratory 

findings, and a report from the employing agency describing the claimant's 

job duties and ability to perform them.

4. Supplemental Security Income (SSI) or Other Income Maintenance - The 

field office will request medical evidence by releasing an RL-11d to the 

paying agency.

E. Specialized Examination - If medical evidence obtained from the previous listed 

records does not appear sufficient for disability rating purposes, the Disability 

Benefits Division staff will schedule a specialized examination.

4.3.5 Developing Medical Evidence

If a disability application is received and no medical evidence is being developed, 

release a memo or electronic mail message requesting the field office to develop 

the necessary data.

A. Release a memo or electronic mail message requesting the field office to contact 

the personal physician if additional medical data is necessary and you believe 

the personal physician may have the necessary data. However, the disability 

examiner will only request the field office to obtain additional medical evidence 

from the treating physician if the medical evidence is not too technical, such as a 

request for a copy of a particular record. In most cases, the disability examiner 

should request the additional medical evidence directly from the treating 

physician by phone call or releasing a letter. 
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B. Schedule specialized examinations when information in file indicates the 

personal physician does not have the necessary data and

• the data previously obtained is insufficient for a disability rating; or

• the information is received indicating the disability annuitant may have 

recovered; or

• a disability freeze denial letter was never released and it has been more than 

a year since the disability rating was done. The medical condition of the 

applicant should be reevaluated.

Copies of medical evidence in file should be sent with all requests to schedule 

examination No. 12 (neurological examination) or No. 13 (psychiatric 

examination). If both examinations are scheduled at the same time, send two 

copies of the medical evidence. When there is no medical evidence in file, state 

"no medical evidence in file."

Specialized examinations should not be scheduled less than 3 months after the 

claimant had a cerebral vascular accident, surgery or hospitalization.

C. Request the field office by memo or electronic mail to request any necessary 

medical records from hospitals, employers, or other agencies (see exceptions in 

DCM 4.3.6).

D. If an AA-1d (alone or with an AA-1) and medical evidence are needed, release 

G-239 to field office.

E. If the AA-1d indicates that the employee has been disqualified by the railroad and 

the applicant meets the requirements for an occupational disability annuity (See 

DCM 3.2.1), instruct the field office to obtain a Form G-3EMP or a disqualification 

notice.

F. Deferred development may be necessary when the evidence is too current to 

determine if the condition will meet the duration requirement and establish 

severity for disability. If the AA-1D or medical evidence indicates the applicant 

has had recent surgery (within 3 months) or has an impairment that requires 

evaluation after a certain period of time (i.e. cardiac exacerbation/stroke), 

examiners can request additional medical evidence through the field office or 

contact the claimant directly for the necessary evidence for the specific 

timeframe.

4.3.6 DBD Development Directly From The Source

A. If additional data is necessary from the personal physician and the request is 

very technical and difficult to explain to the field office, the disability examiner 

may release a letter or call the physician to request the necessary data. If the 
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disability examiner receives the medical evidence from the physician over the 

phone, the disability examiner must send a copy of the phone conversation 

(Form G-94b) to the physician for the physician's signature.

B. If an application for Social Security disability benefits (Title II [Disability Insurance 

Benefits; DIB] or Title XVI [Supplemental Security Income; SSI]) has been filed, 

the Social Security Administration (SSA) has not furnished their evidence, and 

the field office has not requested it, request SSA's evidence and decision by 

Form RR-5 from Great Lakes Program Service Center. When the case needs to 

be expedited, the examiner should request the medical evidence by phone or by 

email. See DCM 11, RR-5 for details on how to request evidence from SSA. 

See DCM 4.3.8C2 for details on how to trace for evidence from SSA.

C. When the applicant indicated he has applied for or is receiving a disability benefit 

from the Office of Personnel Management, request OPM's evidence and decision 

by special letter. Employee authorization is not required as this request is a 

routine use under the Privacy Act.

D. When a disability application is submitted by a resident of a foreign country:

1. If no medical evidence is submitted, request the necessary medical data by 

releasing a letter to the applicant.

2. If insufficient medical data is submitted, request additional data from the 

personal physician if medical evidence submitted was current and it appears 

the physician would still be treating the applicant.

3. If insufficient medical data is submitted or if medical evidence received was 

not current or other information in file indicates the personal physician does 

not have the necessary data, schedule specialized medical examinations 

through the American Embassy or Consulate if the individual resides in a 

country other than Canada or Mexico. Refer the case to P&S – RAC for 

necessary information pertaining to the American Embassy or Consulate. 

Form RL-259 is used to request a medical examination through an American 

Embassy or Consulate after P&S - RAC returns the case. (See 

DCM 11 RL-259 for specific information about the form.) 

If the individual lives in Canada or Mexico, attempt to order specialized 

examinations with the RRB medical examination provider, QTC Medical 

Services, Inc. through FMIS. 

If QTC’s attempt to schedule a specialized examination for an individual 

residing in Mexico is unsuccessful, refer the case to P&S - RAC for necessary 

information pertaining to the American Embassy or Consulate. Use Form RL259 after P&S - RAC returns the case.
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If QTC’s attempt to schedule a specialized examination for an individual 

residing in Canada is unsuccessful, contact the assigned field office to obtain 

the name, telephone number, and fax number of a current or past treating 

physician and/or psychologist who may be willing to perform the examinations 

following RRB examination protocol. Fax the examination protocol (and, if 

necessary, a cover letter) to the physician and/or psychologist once that 

information is obtained. Complete the disability rating using the available 

evidence in file if it is not possible to schedule a specialized examination and 

no other evidence is expected.

NOTE: Development of a disability application from an individual residing in 

Canada or Mexico is handled by an assigned RRB field office. See 

FOM1 Article 1, Appendix H for list of the RRB field office assignments to 

Canada and FOM1, Article 1, Appendix I for the list of RRB field office 

assignments to Mexico.

E. When an application is submitted from a resident of an American possession or 

Puerto Rico:

1. Request the necessary medical evidence by releasing a letter to the 

applicant. (Exception: Do not follow this procedure if the personal 

physician lives in an area serviced by a field office. The Chicago field 

office is responsible for development involving individuals living in Puerto 

Rico.) 

2. If medical evidence submitted is insufficient and the personal physician 

does not have the necessary medical data, attempt to order specialized 

examinations with the RRB medical record provider, QTC Medical 

Services, Inc. through FMIS. 

4.3.7 Determining When To Develop Medical Evidence

Medical evidence should be developed from the earliest date following the alleged onset 

of disability. Certain pertinent evidence (such as hospital records for a claimant who 

alleges a recent heart attack) should be developed as early as possible, even though it 

may be necessary to obtain additional information at a later date before final

adjudication can take place.

Many claimants have impairments which are by nature either static or progressive and, 

therefore, significant improvement within 12 months is not expected. Since severity is 

the main issue in such cases, the case can be documented and evaluated immediately. 

Avoid unnecessary development. Also, if there is medical evidence in file that indicates 

the claimant’s condition is severe enough to meet/equal a SSA listing or the claimant is 

carrier disqualified, it is not necessary to develop additional medical evidence. 

Adjudicate the disability case accordingly. For instance, if the impairment has already 

been found to be severe and it is of a chronic or progressive nature, additional evidence 

would be unnecessary. However, even if the impairment is static or progressive, care 
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must be taken to establish that the duration requirement is met and the onset date is 

correct if it differs from the claimant's alleged onset date.

If the initial evidence indicates that the claimant is not currently disabled, a 

determination of "not disabled" can be made, unless there is a closed period of 

disability.

If initial evidence is not sufficient to establish that the claimant's impairment is currently 

disabling, develop additional medical evidence immediately.

If the claimant's condition is likely to improve but the initial evidence is not sufficient to 

establish that he or she could be expected to return to work within 12 months after 

onset, delay development until such time as the condition can be expected to have 

stabilized. The on-site medical consultants in DBD will provide advice regarding when 

development should be undertaken.

4.3.8 Tracing On Evidence Necessary To Make A Disability Determination

A. General

The following tracing schedule is intended as a general guide for normal handling of 

outstanding evidence. Since each case has different circumstances, use discretion in 

deciding when it is appropriate to trace, the method of tracing and how long to delay a 

determination while continuing to trace.

General information regarding tracing of necessary disability evidence is found in RRB 

regulation 20 CFR section 220.45(b).

B. Abandonment

If the claimant cannot be contacted in person or by phone, the field office will send a 

letter to the claimant's last known address requesting they contact them within 2 weeks. 

If no response is received in that time, the field office will abandon development and 

contact DBD or Reconsideration Section (RECON). If the disability adjudicator notices 

that an applicant has not been in contact with the field office for an extended period, 

bring this to their attention and request an abandonment letter be released. If the claim 

is abandoned, DBD or RECON should then make a disability determination based on 

the information in file. See DCM 4.4 for additional information regarding abandonment.

Field office managers shall determine that development of evidence should or should 

not be abandoned for lack of cooperation in accordance with FOM1 1325.15.3 and 

FOM1 1325.20.7. When abandoning attempts to secure any information, the field office 

should provide the results of all attempted contacts that led to the abandonment.

C. Tracing Schedule

1. Medical Evidence - Indicated on the G-626 as to be submitted or requested by 

DBD or RECON: 
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1st Tracer - 20 calendar days after the initial request. Send an electronic mail 

message to the manager of the field office involved. The electronic mail 

message should be identified as a tracer so as not to be confused with an initial 

assignment.

2nd Tracer - 10 calendar days after the first tracer, if no response is received, 

send the second tracer via electronic mail to the network manager (responsible 

for the field office that the first tracer was sent to) for the status. Identify the 

electronic mail message as a second tracer.

3rd Tracer - 10 calendar days after the second tracer, if no response is received, 

refer the case to your supervisor or senior examiner who will send any additional 

tracers via electronic mail to the Director of Field Service if a response is still 

outstanding. Identify the electronic mail message as a third tracer.

2. SSA Evidence and Decisions - Whenever possible, SSA medical and vocational 

evidence and decisions should be developed for RRB disability determinations. 

However, claims adjudicators should not defer the processing and certification of 

RRB disability claims for a determination by SSA. If, at the time of filing, the 

claimant indicates he/she has filed at SSA, the field office should release a RR-5. 

If, after filing, the claimant informs RRB that he/she has filed with SSA, DBD or 

RECON should release a RR-5. See DCM 11, RR-5 for guidance on how to 

request evidence from SSA.

Trace as follows (also use this tracing procedure for the G-26F):

RR-5/G-26F

a) If DBD or RECON has received no response to an RR-5/G-26F request within

30 days, email (Form G-460) to GLPSC-DPB (formerly DRS). The email 

address is: CHI.ARC.PCO.DPB.RRB@ssa.gov. The e-mail subject line 

should include “Tracing on the RR-5”. 

b) GLPSC-DPB will respond to status requests to DBD or RECON either by fax 

at 312-751-7167 or by email. 

c) If the medical evidence or a status report has not been received within 15 

days of the email follow-up, DBD or RECON should contact the SSA GLPSCDPB main line at 312-575-4700. 

d) If no status or response is received at this point, the DBD Initial or Post 

Section Supervisory Claims Examiner or Chief of RECON will contact the 

DPB Section Chief at 312-575-6295 within 5 working days. 

e) If issues still cannot be resolved at this level, the DBD supervisor or Chief of 

RECON should make any further referrals through RRB's SSA coordinator 

(x4396).
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f) If the request involves a critical or sensitive case, e.g., Congressional or 

Board member interest, RRB will alert SSA to this fact when making the initial 

RR-5/G-26F or follow-up request. While referral though the SSA coordinator 

is always available with critical or sensitive cases, every effort should be 

made to obtain the needed evidence through the established procedures.

g) If GLPSC-DPB encounters problems with DBD or RECON requests for or 

receipt of medical evidence, they should contact the DBDInitial or Post 

Section Supervisory Claims Examiner or Chief of RECON. 

h) If issues still cannot be resolved, GLPSC-DPB will make any further referrals 

though its RRB coordinator.

NOTE: GLPSC-DPB will make every effort to obtain needed medical evidence as 

expeditiously as possible. However, there are circumstances over which 

GLPSC-DPB has no control. Delays can be encountered in retrieving files from 

certain locations, folders can be lost or mis-filed, and certain components will not 

release the folder until its actions have been completed. GLPSC-DPB will advise 

DBD or RECON when delays are encountered or a folder cannot be located. 

The fact that GLPSC-DPB indicates that a folder cannot be located should not by 

itself be a reason to refer the issue to the SSA coordinator.

3. Evidence from Other Government Agencies (except evidence through an 

American Embassy or Consulate) - If the application indicates medical evidence, 

or any other information, may be available from other government agencies (i.e., 

VA, State agencies, etc.,) examiners should attempt to obtain it. See RCM 10.6

for what forms need to be completed or for the address to send a letter to request 

information.

1st Tracer - 30 calendar days from the date the form or letter were released, 

send another copy marked "Second Request."

2nd Tracer - 10 calendar days after the first tracer release another tracer 

indicating this is the third request. If the information is not received after the 

second tracer, abandon efforts to obtain it and make a disability determination 

based on all other evidence that is developed.

4. Evidence from an American Embassy or Consulate - If evidence was previously 

requested through an American Embassy or Consulate but no information has 

been received within 90 days of the date that Form RL-259 was released, refer 

the case to P&S - RAC for further guidance.

5. Railroad Employer Information - Material to be obtained from a railroad employer 

(i.e., G-88a, G-3EMP, medical evidence, etc.,) is traced through the field office 

that is in the railroad contact official's area. The Contact Official Book shows who 

the railroad contact official is and his/her location.
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1st Tracer - 30 calendar days from the initial request. Send an electronic mail 

message to the manager of the field office involved. The electronic mail should 

be identified as a tracer so as not to be confused with an initial assignment.

2nd Tracer - 10 calendar days after the first tracer, if no response is received, 

send the second tracer via electronic mail to the network manager (responsible 

for the field office that the first tracer was sent to) for the status. Identify the 

electronic mail message as a second tracer.

If the information is not received after a second tracer abandon efforts to obtain it 

and make a disability determination based on all other evidence that is 

developed.

6. Other Data Requested, Not Covered Above - Any other evidence requested, but 

not covered in the above, should be traced as follows:

1st Tracer - 30 calendar days after the initial request. Send an electronic mail to 

the network manager who is responsible for the field office for the status. The 

electronic mail message should be identified as a tracer so as not to be confused 

with an initial assignment.

2nd Tracer - 10 calendar days after the first tracer, if no response is received,

send a second tracer via electronic mail to the network manager (responsible for 

the field office that the first tracer was sent to) for the status. Identify the 

electronic mail message as a second tracer.

3rd Tracer - 10 calendar days after the second tracer, if no response is received , 

consult with your supervisor or senior examiner before abandoning efforts to 

obtain it and making a disability determination based on all other evidence that is 

developed. If an additional tracer is necessary, send it via electronic mail to the 

Associate Director of Field Service. Identify the electronic mail message as a 

third tracer.

4.3.9 Guidelines For The Inclusion/Exclusion Of Cases From Processing 

Statistics

At times, extenuating circumstances, beyond the control of the Disability Section or the 

RRB Medical Contractor exist that delay a disability decision. It is essential to exclude 

these cases from the timeliness statistics in order to accurately reflect the agency’s 

performance in rating disability cases. However, it is very important that cases be 

excluded from timeliness statistics only when warranted by circumstances. Therefore, 

the following sections provide a guidelines and individual responsibilities for excluding 

cases from processing statistics.
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4.3.9.1 Examples for timeliness exclusions:

Use the following examples for guidelines when cases are allowed to be excluded from 

processing statistics.

A. Claimant Delay - The claimant causes a consultative examination to be delayed. 

Example: The claimant is a no-show for an examination, requests a later date 

for an examination, or requests a different location for the examination; or the 

medical provider, through no fault of their own was unable to contact the claimant 

timely. 

NOTE: The examiner must have ordered the exam within a timely manner from 

when the application was filed. 

Example: The application was filed November 12, 2014. The examiner was 

assigned the case on November 20, 2014. All information was submitted from 

the field office by January 01, 2015. The examiner does not order the exam until 

January 07, 2016. When the contractor attempts to schedule the claimant for 

exam, the claimant needs the date of appointment to be changed. This case 

should not be excluded from timeliness because examiner failed to order the 

exam timely.

B. Recovery Delay - The claimant has an impairment that requires a recovery 

period or has undergone a medical treatment that may improve his/her condition, 

and a reassessment of the condition must be conducted after the recovery 

period.

Example 1: A 40 year old claimant files on February 13, 2016, for a Total and 

Permanent disability due to a herniated intervertebral disc in the lumbar spine. 

On April 20, 2016, s/he undergoes a discectomy. An assessment of his/her 

condition, to see if the condition has improved from surgery, should be conducted 

3 months after surgery. This case should be excluded from the timeliness 

reports.

Example 2: Claimant underwent surgery July 2, 2016 (discectomy and fusion) 

and files a disability application July 24, 2016. The examiner pends the case for 

October 2, 2016, to see if the claimant’s condition improved from surgery. 

Examiner traces for follow-up medical evidence and is told claimant has an 

appointment scheduled with his/her surgeon for October 8, 2016. Follow-up 

medical evidence is received or scanned into imaging October 24, 2016. Since 

development was suspended pending follow-up medical evidence, the case 

should be excluded from the timeliness reports.

C. Evidence Delay - Medical or non-medical evidence which (in the examiner’s 

judgment) is vital to a proper disability determination has been requested from a 

specific source (i.e., hospital, doctor, government agency, etc.). The claimant, 
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field office, and Disability have all tried to obtain this evidence, but the source has 

not responded. Depending on the nature of the delay, this evidence should be 

abandoned as cited in DCM 4.3.8B and the claim may be excluded from 

timeliness reports if the delay is justified.

Example 1: The claimant has been a patient in a mental institution for a year 

prior to a representative payee filing an application at the Railroad Retirement 

Board. The representative payee has signed all releases for medical evidence 

from the institution, but, due to confidentiality, the institution will not release any 

information from the past year without a court order. This type of a claim should 

be excluded from timeliness reports since a legal issue that may take an 

extended amount of time must be decided.

Example 2: An applicant files an application for disability on August 1, 2016, 

based on coronary artery disease. The field office indicates medical records are 

to be submitted. On August 25, 2016, Disability receives some of the medical 

records (some examinations and hospital records). An examiner reviews the file 

September 2, 2016, and pends the file until September 30, 2016, for the 

additional evidence. An examiner reviews the file on October 3, 2016 and emails the field office for the outstanding evidence. The field office e-mails 

Disability on October 6, 2016, stating they are having difficulty obtaining the 

applicant’s treadmill stress test and catherization report but hope to get it soon. 

The examiner determines this medical evidence is vital to the rating and opts to 

wait for this evidence rather than order examinations. On October 29, the field 

office e-mails Disability stating the doctor will provide the reports soon. On 

November 14, 2016, final medical records are received or scanned into imaging. 

This case should be excluded from the timeliness report.

Example 3: The claimant states on his/her AA-1d that his/her personal 

physician has treating notes, examination reports, X-rays, etc. The examiner 

believes this medical evidence is vital to a proper disability determination. 

However, the physician does not release the medical records timely, despite 

tracing from Disability/Field Office. This case should be excluded, even if 

additional medical evidence still needs to be developed. However, if the 

disability examiner is informed at the time of filing that the personal physician 

refuses to release medical evidence due to situations such as an unpaid past 

due bill, law suits, etc. then the case should not be excluded since the disability 

examiner should have begun developing the necessary information from another 

source. 

Example 4: The claimant filed an application on August 1, 2016. The SSA 

DEQY revealed self-employment earnings. An AA-4, Self-employment and 

Substantial Service Questionnaire, and a G-252, Self-Employment/Corporate 

Office Work and Earnings Monitoring, were released to the claimant. A copy of 

the client’s federal tax returns was also requested. Medical development 

continued while pending the outstanding self-employment forms. The claimant 

did not submit the AA-4/G252 or the copy of the Federal tax returns was delayed 
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until December 1, 2016. This case should be excluded from the timeliness report

due a non-medical evidence delay. 

D. Filing Delay - The filing date is prior to the date the application is submitted and 

one of the following circumstances exists:

• The claimant was deterred from filing an application; or

• A protected filing date is to be used as the official filing date; 

NOTE: The field office does not always indicate that a protected filing 

date is involved. Check the application filing date, the date the paper file 

is received or the application is scanned into imaging, and the date the 

application is signed. In addition, you should check the remarks of the G626, contact log and APPLE Summary Screen PF24 to see it the field 

office indicated that there was a protected filing date. 

Example: An application is received in Disability December 15, 2016. 

The filing date is October 31, 2016, and the examiner notes the 

application was not signed until November 28, 2016. This case should be 

excluded from the timeliness report.

• The claimant previously filed at SSA and SSA’s filing date will be used.

E. Confinement Delay - The claimant files an application for a disability and, at any 

time during development, is confined to a correctional institution.

F. Other Delay – Some other reasons for time lapse exclusions are:

• The claimant does not reside in a field office area and development of 

medical evidence is conducted through an American Embassy, the State 

Department, or other agency.

• The file containing an active disability application is requested by another 

bureau, which has a higher priority action.

Example: A spouse files an application for an annuity based on a 

disabled child while the Reconsideration Section is working on a 

reconsideration request for an earlier onset date from the employee. 

Since this file may be in Reconsideration for an indeterminate amount of 

time, it should be excluded from timeliness reports.

• The claimant files an application for a disability and a previous disability 

decision is in the appeals process, at any level. No action can be taken 

on the new application until the appeal has been completed.
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• Another unit mishandles a file or mistakenly sends the file to Claim Files 

and causes a delay in making a determination.

4.3.9.2 Responsibilities 

These guidelines should be used in determining the inclusion/exclusion of timeliness 

statistics in initial disability cases only. There may be other situations beyond 

Disability’s or the RRB Medical Contractor’s control that are not covered by the 

guidelines that could cause a delay in rating. 

A. Examiner Action: 

If an examiner feels that a case should be excluded because it meets the guidelines or 

for any other reason not covered by the guidelines, they should:

• Complete D-Brief, or the OLDDS screen (if D-Brief is not being completed) 

with the correct exclusion code (See DCM 12.5.6.7). 

• Complete Form G-226, Time Lapse Exclusion Case, and send it to the 

Disability Initial Authorization folder.

NOTE: The G-226 form must be completed by the initial examiner prior to 

sending the case to authorization.

• After the G-226 is sent to the Disability Initial Authorization folder, send an 

email to the Disability Initial supervisor with a cc to the Disability post 

supervisor,Disability Director, lead examiners, and individual(s) 

designated by a management official to review and sign off on the form. 

In this email, indicate that there is a G-226 in the Disability Authorization 

folder for claim number xxx-xx-xxxx which needs to be reviewed and 

approved. 

• If exclusion is approved – Once the examiner receives an email back from 

the authorized individual, as indicated above, that the form was approved 

and imaged from RRAILS, the case can be sent to the authorization 

folder.

• If exclusion is denied – Once the examiner receives email notification 

from the authorized individual, as indicated above, that the exclusion was 

denied, the examiner is to update DBrief and/or OLDDS to reflect that the 

case was not excluded from timeliness When that action is complete, the 

case can then be sent to the authorization folder for review.

 

B. Action By Authorized Individual Reviewing Form G-226 for Approval or 

Denial: 
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Only the individuals identified above in Part A of this section are authorized to sign off 

on the form. After receiving an email from an examiner that a G-226 is in the Disability 

Initial Authorization folder, the individual responsible for reviewing the form will indicate 

the outcome of the review by indicating it is approved or denied:

• Approval – The authorized individual will review the form and if they agree 

with the exclusion, will approve it and release the form to imaging through 

RRAILS. Once the form is sent to imaging, the individual who is 

authorized to review Form G-226 will send an email back to the examiner 

advising that the exclusion was approved and the form is imaged. 

NOTE: The exclusion must be reviewed, approved or denied, and imaged 

by an authorized individual prior to sending the case to authorization.

• Denial - If the authorized individual responsible for reviewing Form G-226 

disagrees with the exclusion, they will send an email to the examiner with 

the reason for the disagreement. 

See DCM 11.2 G-226 for form completion instructions.

4.4 Abandonment

4.4.1 Responsibility For Development

Although the field office has the main responsibility for developing medical evidence, it 

is the claimant's responsibility to cooperate with and assist the field office in obtaining 

existing evidence and to provide information as to his/her condition and treatment.

The claimant, in most cases, can be expected to provide records from the personal 

physician. The field office will provide any assistance the claimant may need in 

obtaining such records.

4.4.2 Abandoning Development For A Specific Report

While a claim is being developed, the field office will generally pend a request for 

medical evidence for 30 days, at which time a tracer or second request will be made, 

generally in addition to a follow-up phone call. If no response is received after 15 days, 

efforts to obtain that piece of medical evidence will be abandoned, unless it is known 

that the evidence can be obtained within a reasonable period. The field office will 

advise DBD or RECON of their action. (See FOM1 1325.15.3 and FOM1 1325.20.7) 
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4.4.3 Abandoning A Request For Specialized Examination, Laboratory Test Or XRay

If a claimant fails to report for a specialized examination, laboratory test or X-ray, the 

field office will contact the claimant. If the claimant is willing to submit to the 

examination or test, it will be rescheduled. If the claimant is unwilling, or, without good 

cause, fails to report for the second appointment, the field office will abandon efforts to 

secure such medical evidence. The field office will advise DBD or RECON of their 

action.

4.4.4 Abandonment For Lack Of Cooperation

The field office will abandon medical evidence development for lack of cooperation by 

the claimant after it has been determined by the field office manager that the claimant 

was contacted in person or by phone, the importance of the claimant's cooperation was 

explained, the lack of cooperation is willful and future cooperation is unlikely.

If the claimant cannot be contacted in person or by phone, the field office will send a 

letter to the claimant's last known address requesting him/her to contact the field office 

within two weeks because the claim is still pending and the claimant's cooperation is 

needed. Field Service will send a copy of all tracer letters to imaging and update 

Contact Log documenting all tracing actions. If no response is received within two 

weeks, the field office will abandon development.

When the field office abandons for lack of claimant cooperation, a report will be 

submitted via E-mail to the DBD Group Mailbox or, if known, the personal E-mail inbox 

of the Reconsideration Section disability adjudicator covering the actions taken and the 

reason for abandonment. (See FOM1 1325.15.3 and FOM1 1325.20.7) 

4.4.5 Action By Disability Benefits Division When Medical Evidence Cannot Be 

Obtained

If development of medical evidence is abandoned, it does not necessarily follow that the 

claim must be denied. Make a disability determination based on whatever evidence is 

available. If no medical evidence was submitted, a determination should be made 

based on non-medical evidence in file.

If the field office reports that efforts to obtain medical evidence have been unsuccessful, 

but there is non-medical evidence or reports from practitioners who are not licensed to 

practice medicine, the claim may be denied without further development, provided the 

evidence in file indicates there is not a severe impairment (an RFC must be obtained 

based on what is in file). The denial letter should cite the failure to submit medical 

evidence and the efforts to secure it as well as the factors contained in the existing 

evidence which support a finding of "not disabled."
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If there is reason to believe that a claimant's lack of cooperation is due to incompetence, 

have the field office seek a representative to act in the claimant's behalf for medical 

evidence development.

If the claimant is unable to cooperate with requests for medical evidence or specialized 

examination because of illness or some other valid reason, and a favorable 

determination cannot be made without such evidence, the case should be pended and 

the field office should make arrangements to obtain the evidence at a later date. 

NOTE: In single freeze cases where a case is being denied due to abandonment, the 

examiner is to deny the case on OLDDS without having it authorized by another claims 

examiner. For this situation the examiner can submit and review the case on OLDDS 

themselves. This is done by entering a "Y" in the SUBMIT field and then entering the 

date and a "Y" in the REVIEW field.

4.5 Transmittal Of Medical Evidence

4.5.1 Application For Monthly Disability Annuity

A. The field office will submit medical evidence with the application even if all the 

medical evidence is not available for submission. Any medical evidence the field 

office has will be submitted since DBD may be able to make a favorable disability 

determination without all the medical evidence available.

B. After the application is transmitted, the field office will submit any additional 

medical evidence received via Form G-26b. The G-26b will indicate:

• what medical evidence is attached,

• what medical evidence is still being developed, and

• the expected date the outstanding evidence will be submitted.

4.5.2 Medical Evidence Submitted on a CD

In some instances DBD may receive medical evidence from other governmental 

agencies, hospitals, doctors, etc. on a CD. In these cases examiners will need to open 

the CD to determine exactly what is being submitted. Disability claims examiners need 

to take the following action:

A. Medical Evidence Received on CD from a Treating Source 

1. CDs that can be opened and have:

a. Medical Evidence that has images only – In cases where the CD is opened 

and shows that it contains images only, check the file to see if a 

corresponding written report has been already placed in the file. If a 
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corresponding report is in file, enter a note to file that only images appear on 

the CD, but that a corresponding written report is in the file. If there is no 

corresponding written report, contact the field office to obtain the report.

b. Medical evidence that has images and reports – Make the determination 

that the written report corresponds to the images being shown. When the 

images and reports correspond print the report out for the file. In the cases 

where the images and reports do not correspond, it will be necessary for the 

examiner to contact the field office to obtain the report that corresponds with 

the images.

c. Medical evidence that has written reports only – Print out a copy of all 

reports that are on the CD. Place a note in file to indicate that all medical 

evidence on the CD has been printed out and is in the file.

In all cases in which a CD is present, the CD along with all written reports are to be 

matched to the file.

2. If the CD cannot be opened, place the CD in an envelope with a note stating that 

the CD cannot be opened and place it in the file. Contact the field office and ask 

them to have the applicant obtain the information on the CD in another format. 

Instruct the field to tell the employee that if the information on the CD is images 

only, those images are not needed for our file. Instead the employee will need to 

obtain the report based on the images on the CD. 

B. Medical Received on CD from SSA

These CDs are to be opened and the information contained on the CD is to be 

printed out. A note to file indicating that an action has been taken is to be created 

and dated (For example, “All M/E on the CD has been printed out and matched to 

the file.”). The printed reports and CD are then matched to file.

In some instances the amount of medical evidence on the CD may be very large. In 

those cases do not print out the large sources of data. Rather indicate on the note 

to file that all medical evidence has been printed out on the CD except for the noted 

medical evidence. You would then note the medical evidence you did not print out 

(this would be the medical evidence that involved large volumes of paper). For 

example, “All M/E on the SSA CD has been printed out and attached except for the 

350 pages of VA records. If upon review of the file it is determined that these 

records are needed, contact the disability Quality Analyst.” 

4.6 Specialized Examinations, Laboratory Tests And X-Rays

4.6.1 Authority To Schedule Specialized Examinations

Disability Benefits Division staff are authorized to request and schedule most 

specialized examinations, laboratory tests, and X-rays listed in DCM 4, Appendix C
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without prior approval from the Director of Disability Benefits Division. Note: Field office 

staff are not authorized to order specialized examinations.

4.6.2 When Specialized Examinations Should Not Be Scheduled

Before taking action to schedule specialized examinations, consider if the information 

needed may be available from the records of the claimant's personal physician. Further, 

specialized examinations should not be contracted under the following circumstances:

A. Applicant is confined to a hospital or institution or was hospitalized within the last 

three months. Secure the hospital report.

B. Applicant is confined to his home because of his disability.

C. The applicant's disability is based solely on an obvious condition such as a loss 

of a limb. Schedule specialized examinations if employer or applicant source 

medical evidence is not sufficient for rating purposes.

D. Employer or railroad hospital association is expected to submit medical evidence, 

and that employer's source's evidence is usually adequate for rating purposes.

E. Applicant's personal physician is the only doctor in the area, and the applicant 

cannot travel.

4.6.3 When Specialized Examinations Should Be Scheduled

Take action to schedule specialized services for the following purposes:

A. clarification of clinical findings and diagnosis,

B. acquisition of highly technical or specialized medical information otherwise 

unavailable,

C. resolution of a pertinent conflict or contradiction in the evidence,

D. determination of current severity in continuance cases.

.

4.6.4 Processing Payment For Medical Examinations And Services

Payments for medical examinations and services are processed on the Financial 

Management Information System (FMIS). This system provides the necessary database 

for budgetary planning and assures compliance with provisions of the Prompt Payment 

Act which requires payment to providers within 30 days. There are essentially two 

steps to processing medical fee payments on FMIS. First, appropriated funds are 

obligated by completing a Medical Exam Order (ME) entry when services are scheduled 

with the provider. Upon receipt of requested services, a Medical Exam Payment 
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Voucher (MPV) entry is completed to set up payment. Both ME and MPV entries are 

centrally processed by the Disability Benefits Division (DBD). Copies of the MPV 

screens that verify payment and specify what exam(s) are being paid for should be 

scanned to Work Desk for documentation purposes. The Bureau of Fiscal Operations 

(BFO) authorizes entries and payments are disbursed promptly to the provider.

To view instructions on using FMIS, click the following links:

RRB FMIS Medical Exam Order Entry QRG

RRB FMIS Medical Exam Order Entry QRG (2)

RRB FMIS Medical Exam Receipt Payment Entry QRG

RRB FMIS Consulting Opinion Order Entry QRG

RRB FMIS Consulting Opinion Receipt Payment Entry QRG 

4.6.5 DBD Handling Of Claims For Payment

The data entry for both MOs and PVs required to effect payments to medical providers 

is centrally processed in the DBD-Support Section. 

The field office is responsible for submitting hospital or institution bills for copies or 

transcripts of records with Form G-370 (See Exhibit 13).

4.6.6 Chief Medical Officer (CMO) Handling Of Specialized Consultative 

Examinations (SCE) Involving Single Source Medical

In accordance with Board Order 20-37 issued on August 28, 2020, prior to the 

adjudication of a disability application in which the primary impairment is orthopedic or 

psychological and the applicant only has one source of medical information from a 

single medical source, the CMO will review the medical evidence to determine whether 

a consultative examination would be necessary. See Board Order 20-37. This applies 

to disability determinations completed under the Railroad Retirement Act (not solely a 

disability freeze and/or disability Medicare determination under the Social Security Act). 

For more information on use of medical consultants see DCM 4.11. 

A single medical source is also referred to as a “single source applicant”. Both terms 

are interchangeable and mean the same thing. Single Source Medical (or single 

source applicant) is defined as one treating physician who provides all physical findings, 

and may include x-rays, EMG and other ancillary testing results performed by the same 

treating physician at the treating physician’s practice. In these types of cases, no 

consultative examination(s)/testing has been secured. Single source medical may or 

may not include longitudinal treatment notes. See DCM 4.10.7 for more information on 

the content of medical evidence. 
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NOTE: A single medical source (single source applicant) is different from “Stand-Alone 

Medical Evidence” as described in DCM 8.8.2. Stand-Alone Medical refers to when 

the entire medical record/disability package is submitted by one treating physician and 

includes physical findings, x-rays, EMG and other ancillary testing provided by other 

medical professionals (e.g., other physicians, x-ray technicians, physician assistants, 

etc.). In these types of cases, no consultation examination(s)/testing has been 

requested. Stand-alone medical evidence may or may not include longitudinal treatment 

notes.

Below are a few examples of cases that can be used as a guide to determine when a 

case should be referred to the CMO for review.

Example 1 – Single Source Medical Information, Refer to CMO

On December 1, 2020, Jane Doe filed for a disability annuity due to herniated disc in the 

lumbar spine. A review of the file by the disability examiner reveals that Dr. John 

Alphabet is the only medical source that submitted medical evidence for consideration 

in the disability decision. Included in the medical notes from Dr. Alphabet are 

references to x-ray and MRI testing conducted at his practice. The findings from these 

test indicate that Jane Doe has degenerative changes including narrowing. However, 

the actual reports are not in file. Since Dr. John Alphabet is the only medical source 

and the reports are not in file, the disability examiner must refer the file to the CMO for 

review after all development has been completed (including efforts to obtain any 

missing records) before making a decision. The CMO will review the file to determine if 

the SCE is necessary to adjudicate the disability application. 

Example 2 – Single Source Medical Information, Refer to CMO

On June 3, 2020, Blake Doe filed for a disability annuity due to posttraumatic stress 

disorder based on a train accident. A review of the file by the disability examiner 

reveals that Harmony Counseling Services is the only medical source that submitted 

medical evidence. Harmony Counseling Services provided bi-weekly progress notes, 

which include multiple mental status exams (MSEs). The claimant is on medication 

prescribed by a psychiatrist who is part of the Harmony Counseling Services. However, 

the medical source notes from this physician are not in file. The disability examiner 

must refer the file to the CMO for review after all development has been completed 

(including efforts to obtain any missing records) before making a decision because the 

medical evidence is from a single medical source. The CMO will review the file to 

determine if the SCE is necessary to adjudicate the disability application and advise the 

examiner accordingly. 

Example 3 – Multiple Providers, Do Not Refer to CMO

On May 1, 2020, Larry Doe filed for an occupational disability annuity due to plantar 

fasciitis and hip fracture. A review of the file by the disability examiner reveals that Dr. 

John Alphabet, Dr. Ryan Number and MRI R Us Specialty Group each submitted 

medical evidence for consideration in the disability decision. The documentation from 
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Drs. Alphabet and Number are consistent with findings on the MRI. Since there are 

multiple providers who submitted evidence that is consistent with one another, the 

disability examiner does not need to refer the case to the CMO for review.

Example 4 – Stand-Alone Medical Evidence with Longitudinal Treatment Notes, 

Do Not Refer to CMO

On December 1, 2020, Jane Doe filed for a disability annuity due to herniated disc in the 

lumbar spine. A review of the file by the disability examiner reveals that Dr. John 

Alphabet is the only medical provider that submitted medical evidence. Dr. Alphabet 

records show that he has treated Jane Doe for several years. Included in the medical 

notes submitted by Dr. Alphabet is a copy of an MRI from A-Z MRI that confirms a 

herniated disc in a location consistent with the claimant’s symptoms, exam findings, 

and treatment. The disability examiner can proceed with review of the file and does not 

need to refer the file to the CMO because this is stand-alone medical evidence.

4.7 Disability Standards And Guides 

4.7.1 Published Medical Guides

Disability claims adjudicators routinely refer to published medical reference information 

to assist in making sound disability determinations. The Railroad Retirement Board 

recognizes the need to allow disability claims adjudicators to access both print and 

electronic sources of medical reference as a legitimate business need for our 

customers. Therefore any online reference source may be accessed presuming that:

• It is necessary in the performance of the adjudicator’s duties;

• No personally identifiable information (PII) pertaining to a Railroad Retirement 

applicant or annuitant is transmitted;

• No personal medical information is transmitted; and

• It is reasonably certain that the website does not host malicious software or is not 

otherwise inappropriate.

Click here for an Excel spreadsheet containing a list of some medical references 

available to disability adjudicators. If a reference is available online, hyperlinks are 

provided. Note the tabs at the bottom of the spreadsheet. Disability adjudicators 

needing to register at a website may do so with a personal logon.

There may be other websites which are not recognized but may also provide 

information useful to disability adjudicators. Requests to add other medical reference 

websites to the list may be referred through proper supervisory channels to Policy & 

Systems - RAC.
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NOTE: Downloading software in order to obtain access to or view a website is not 

permitted without proper authorization.

Notify Policy & Systems - RAC of obsolete website addresses in the list through 

supervisory channels.

4.7.2 Additional Aids

Additional aids to reaching legal, just and equitable disability decisions are as follows:

A. Advanced training sessions - These sessions are tape recorded, and the tapes 

are available for reference or review.

B. Individual counseling by the section chief or on-site medical consultants.

C. Policy decisions and internal office memoranda.

D. Three-member Board decisions in appealed cases.

E. Legislative enactments, court decision summaries and legal opinions (L).

F. Audit Review Guide For Body Systems prepared by Consultative Examinations, 

Inc. 

G. Social Security Rulings - Disability (SSR).

H. SSA's Instructor Manual for DDS Disability Examiner basic Training Program 

(includes SSA's Listing of Impairments).

I. Railroad Retirement Board Regulations.

J. Social Security Administration Regulations.

K. Provisional Occupational Disability Rating Schedule.

L. Law she Studies.

4.7.3 Mental Residual Functional Capacity Assessment

When evaluating an applicant’s mental residual functional capacity (RFC), RRB medical 

consultant’s complete Form SSA-4734. On this form each mental activity is to be 

evaluated within the context of the individual’s capacity to sustain that activity over a 

normal workday and workweek, on an ongoing basis. Any mental activity that indicates 

a limitation must be documented in the medical consultant’s rationale. 
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As a general guide, in mental cases when an applicant is markedly limited in any of the 

following activities an allowance may be warranted and the examiner may want to 

consider if a listing is met or equaled:

• The ability to remember locations and work-like procedures;

• The ability to make simple work-related decisions;

• The ability to ask simple questions or request assistance; and/or

• The ability to be aware of normal hazards and take appropriate precautions.

In addition, if the applicant is markedly limited in any of the following activities an 

allowance may be warranted:

• The ability to understand and remember detailed instructions;

• The ability to carry out very short and simple instructions;

• The ability to maintain attention and concentration for extended periods;

• The ability to perform activities within a schedule, maintain regular attendance, and 

be punctual within customary tolerances;

• The ability to sustain an ordinary routine without special supervision;

• The ability to complete a normal; workday and workweek without interruptions from 

psychologically based symptoms and to perform at a consistent pace without an 

unreasonable number and length of rest periods;

• The ability to accept instructions and respond appropriately to criticism from 

supervisors;

• The ability to get along with coworkers or peers without distracting them or exhibiting 

behavioral extremes; and

• The ability to respond appropriately to changes in the work setting.

The rationale provided by the medical consultant must support the markedly limited 

restriction. 

4.7.4 Manipulative Limitation Chart

The following describes the impact of bilateral restrictions of handling and/or fingering 

on the remaining occupational base. This chart provides guidance for decisionmaking. The general conclusions in the chart do not direct any decisions and 

each case must be evaluated on its own merits. Consultation with a medical 

consultant is recommended.
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MANIPULATIVE 

LIMITATION

SEDENTARY 

UNSKILLED 

OCCUPATIONAL 

BASE

LIGHT UNSKILLED 

OCCUPATIONAL 

BASE

MEDIUM 

UNSKILLED 

OCCUPATION 

BASE

Occasional 

Fingering

Less than 

Sedentary (38) 

Light Framework (856) Light Framework 

(1510)

Occasional 

Handling

Less than 

Sedentary (3)

Less than

Sedentary (40)

Less than Sedentary 

(48)

Occasional 

Handling and 

Fingering

Less than 

Sedentary (3)

Less than

Sedentary (35)

Less than Sedentary 

(42)

Frequent 

Fingering

Sedentary 

Framework (113)

Light Framework 

(1579) 

Medium Framework 

(2518)

Frequent 

Handling

Sedentary 

Framework (95)

Light Framework 

(1357) 

Medium Framework 

(2181)

Frequent 

Handling and 

Fingering

Sedentary 

Framework (95)

Light Framework 

(1356)

Medium Framework 

(2180)

1. This chart assumes no other non-exertional limitations than those described in 

the chart.

2. The chart assumes the manipulative limitations are bilateral.

3. The term “fingering “ refers to fine manipulation, while the term “handling” refers 

to gross manipulation.

4. The numbers in ( ) are the numbers of DOT occupational titles remaining at each 

occupational base, considering the manipulative limitation noted (based on 

Denver DOT).
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4.8 Types Of Impairments

4.8.1 Exertional Impairments

These are impairments which manifest themselves by limitations in meeting the physical 

strength requirements (e.g., lifting, carrying, walking, etc.).

4.8.2 Non-Exertional Impairments

These are mental, sensory or skin impairments (e.g. alcoholism, pain which is 

attributable to a psychiatric disorder, loss of hearing, loss of sight); or impairments 

which impose environmental restrictions (e.g. inability to tolerate dust or fumes.)

4.8.3 Non-Severe Impairment

An impairment is non-severe if it does not significantly limit the person's physical or 

mental abilities to do basic work activities. Basic work activities are the abilities and 

aptitudes needed to do most jobs, such as walking standing, sitting, lifting, seeing, 

hearing, speaking, understanding, carrying out and remembering simple instructions.

4.8.4 Alcoholism

The effects of alcoholism on a disability determination are explained in L79-232 and in 

the excerpt from the OHA Law Reporter Judicial Survey - Disability Based on 

Alcoholism and in L-2008-6 and L-2008-6.1. 

If an individual is permanently addicted to alcohol and his addiction prevents him from 

engaging in regular employment, he is disabled within the meaning of the Railroad 

Retirement Act regardless of whether there exists any end organ damage. For 

purposes of this section, end organ damage is defined as damage to an organ, such as 

brain, liver, or pancreas that is caused by the addiction.

When alcohol or drug addiction is indicated, the answers to the following questions will 

determine whether entitlement to railroad retirement disability benefits exists:

1. Is the impairment permanent (that is: has it lasted, or can it be expected to last, 

for a continuous period of not less than 12 months)?

2. If the answer to the above is "yes," has it prevented the applicant from 

performing work duties in a regular and customary manner for substantial 

wages?

The criteria used for alcoholism can also be used for other types of drug addiction. It 

can always be applied to both occupational and total and permanent annuities, including 

decisions regarding survivor disability annuities and spouse annuities based on a 

disabled child. However, per L-2008-06, the date the application is filed will determine 
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whether or not these criteria can be applied to a disability freeze or the SSA portion of a 

disability decision for survivors and IPI cases.

Applications Filed Before January 1, 2008

For cases in which the application was filed prior to January 1, 2008, L79-232 may be 

used in disability freeze decisions and the SSA portion of survivor disability annuity and 

IPI child disability decisions, however, it should only be used if all other means of 

favorably rating the case have been exhausted.

Applications Filed January 1, 2008 or Later

Per L-2008-6 and L-2008-6.1, effective with cases in which the disability application is 

filed on January 1, 2008 or later, L79-232 cannot be applied to disability freeze 

decisions, or the SSA portion of any other disability decision. Therefore you must 

determine whether the claim can be allowed based on end organ damage or other 

impairments that are independent of the addiction. It may be difficult to determine 

whether an impairment, especially a mental impairment, is severe enough to be 

permanently disabling independent of the addiction. In such cases, a medical opinion 

must be requested. The consulting physician must be asked to provide an opinion as to 

which impairments, if any, would continue to exist, and the severity of the impairment(s)

if the claimant were to maintain sobriety for 1 month. If the impairment(s) would not 

continue to be severe after one month of sobriety, that impairment(s) cannot be 

considered in the disability freeze decision for a case in which the application was filed 

January 1, 2008 or later. If there is no end organ damage or any other impairment upon 

which an allowance can be made independent of the addiction, the disability freeze or 

SSA portion of a disability decision must be denied. 

However, per L-2008-6.1, an employee VDB may be payable from the ABD even if the 

DF is denied. Refer cases in which the annuity is granted based on L-79-232 and the 

DF is denied based on L-2008-6 and L-2008-6.1 to P&S to determine vesting status.

NOTE: A joint disability freeze case should be sent to SSA as usual. If RRB 

determines that the claimant would be disabled even without considering the addiction, 

and SSA disagrees, refer the case to the post lead examiner with a request to handle as 

a unilateral freeze.

A widow or survivor or child would not be entitled to Medicare or SSEB status in this 

situation. An IPI child cannot be included in the O/M in this situation. An IPI child can 

qualify a spouse for an annuity, but the child would not be entitled to Medicare and the 

spouse would not be entitled to SSEB tax status. Survivor cases of this type cannot be 

done on D-BRIEF, as it would not pre-fill the third page of OLDDS properly.

Use the following means of notification to annuitants in these decisions:

For employee DF denial decisions, 
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• use RL-260d as a notification letter if a total and permanent disability annuity has 

been granted; 

• use RL-260 for occupational disability annuities.

For other annuity types, include the appropriate code paragraphs on the RL-121f letter 

to explain the Medicare denial and non-SSEB tax status. The text of these code 

paragraphs (2828-2831) can be found in RCM 10.5.180. A new question has been 

added to the dialogue box on the RL-121f letter: Is the disability decision based solely 

on drug or alcohol addiction? If the question is answered yes, one of the following 

paragraphs will be included in the letter:

• code paragraph 2828 for spouse with disabled child, 

• code paragraph 2830 for disabled widow(er)s, and 

• code paragraph 2831 for survivor disabled children. 

Do not re-adjudicate cases filed before January 1, 2008. 

NOTE: Do not use diagnostic codes 30505 or 30605 on cases in which an annuity or a 

freeze is being allowed based on end organ damage or impairments other than 

addiction. Instead, use the diagnostic code associated with the end organ damage or 

other impairment, such as the codes for liver disease, depression, or organic mental 

disorder. Only use codes 30505 or 30605 in cases in which the decision is based solely 

on the addiction itself.

In summary, the types of cases that are affected by L-2008-6 and L-2008-6.1 are:

• Disabled employees,

• Disabled widow(er)s,

• Remarried disabled widow(er)s,

• Disabled surviving divorced spouses,

• Disabled children, and

• Young mothers, fathers, widows, and widowers with a qualifying disabled child in 

care over the age of 18 whose disability is based on drug or alcohol addiction.

Because these individuals do not meet SSA’s criteria for disability, they are NOT 

entitled to the following considerations unless/until they meet criteria based on age:

• Medicare coverage,

• PIA 1 and PIA 9 increases and corresponding Tier 1 re-computations,

• Consideration for annuity increase under the O/M formula, and 

• Tier 1 payments taxed as SSEB.
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4.8.5 Statutory Blindness

Statutory blindness is defined in law as central visual acuity of 20/200 or less in the 

better eye with the use of correcting lens. An eye which has a limitation in the field of 

vision so that the widest diameter of the visual field subtends an angle no greater than 

20 degrees meets the definition of statutory blindness.

This type of impairment is not based on refractive error, retina detachment or 

inflammatory disease.

Further information concerning statutory blindness can be found in POMS DI 

26000.000. 

4.9 Duration Requirements

4.9.1 Duration Of Impairment Defined

The "duration of impairment" refers to that period of time during which an individual is 

continuously unable, because of a medically determinable physical or mental 

impairment(s), to:

A. work in his regular railroad occupation for an RR Act 2(a)(1)(iv)

B. perform regular employment for an RR Act 2(a)(1)(v) disability case or RR a Act 

widow(er) or disabled child; or,

C. engage in any substantial gainful activity (SGA) for SS Act determination for a 

DF: or,

D. perform any gainful activity in the case of a remarried widow(er) or surviving 

divorced spouse.

It extends from the date of onset of "disability" to the time the impairment(s) does not 

prevent the individual from performing his regular railroad occupation, regular 

employment, substantial gainful activity, or gainful activity, as appropriate, as 

demonstrated by medical evidence or the actual performance of such work.

4.9.2 Duration Requirement For A Disability Annuity And Freeze (5- Month Waiting 

Period)

To meet this requirement, an individual must be permanently disabled for at least 5 full 

calendar months after the date the freeze earnings and disability requirements were 

met.

NOTE: A 5- month waiting period is not required if a previous period of disability ended 

within 5 years before the month the current disability began.
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4.9.3 Permanently Disabled (The 12-Month Duration Requirement)

A. General - To be permanently disabled, a claimant must have a medically 

determinable physical or mental impairment or condition that:

1. has lasted, or is expected to last, for at least 12 consecutive calendar 

months, or, to result in death, and

2. prevents SGA.

B. Several Impairments Lasting Less Than 12 Months Each - If the claimant had 

two consecutive unrelated incapacitating impairments, each lasting less than 12 

months, they cannot be combined to meet the 12 month duration requirement. 

Disability onset cannot be extended back to the date of the first impairment if that 

impairment itself was disabling for less than 12 months.

EXAMPLE 1: The individual had two unrelated incapacitating impairments, one 

lasting for only 9 months and the other developing 6 months after onset of the 

first and lasting for only 7 months. The duration requirement is not met since 

neither impairment lasted at least 12 months even though the individual's inability 

to work lasted for a total of more than 12 months.

EXAMPLE 2: Same facts as above except the second incapacitating impairment 

lasted at least 12 months. Onset of disability is the first day that the second 

impairment became disabling.

4.10 Acceptability Of Medical Information

4.10.1 Carrier Medical Information

Each railroad develops, and may change at any time, the manner of internal handling of 

the RL-11 request for completion of Form G-3EMP. When the response reaches the 

Disability Benefits Division (DBD), it has passed through a railroad’s company channels 

to the source authorized to respond to all parts of our request. The G-3EMP is 

completed by the contact official designated for medical matters for a particular railroad 

employer. Upon review, there may be some cases that require additional investigation 

by DBD staff (ex: no signature or title, incomplete form, or discrepant information). 

Some employers attach other forms or reports in lieu of completing some or all items of 

the G-3EMP. Accept these attachments as if the information had been entered on the 

Form G-3EMP. Railroad employers may also use several terms in lieu of the word/term 

"disqualification". Provided it is clear that the employee has been held out of service for 

any medical reason that has lasted, or can be expected to last, for a continuous period 

of not less than 12 months, accept it as a carrier disqualification.
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4.10.2 Definition Of Carrier (Employer) Disqualification

For disability purposes, the term "carrier disqualification" means a railroad employer 

does not allow an employee to continue working, in his/her regular railroad occupation, 

for a medical reason.

4.10.3 General Carrier Medical Information

The information needed from the carrier in connection with an employee's claim for a 

disability annuity is indicated on Form G-3EMP, "Report of Medical Condition by 

Employer." This includes (generally);

A. Employee's name and address.

B. RRB claim number.

C. SSA number.

D. A detailed description of the employee's adverse medical conditions of which the 

employer is aware or copies of relevant past or present medical evidence that the 

employee may have.

E. The employer's opinion of whether the employee is able to work in his/her last 

occupation at present or in the future.

F. The employer's opinion of whether the employee is able to perform some type of 

work at present or in the future and the job title of this work.

G. An indication of whether the employee was disqualified for service in his regular 

railroad occupation. Any disqualifications or restrictions should be explained.

H. Certification by the appropriate employer officer that the above information is 

correct.

4.10.4 Medical Information From Illinois Central Gulf Railroad

The Chief Medical Officer of the Illinois Central Gulf Railroad will order or approve the 

medical examination of an employee only when either:

A. The case involves on-the-job injury; or,

B. The report or credentials of the individual's physician cause question; or,

C. The personal physician releases the employee to return to work and the medical 

department has question of the employee's ability.

Otherwise, the ICG accepts and acts according to the personal physician's opinion. 

They will not allow the man to work without his personal doctor's release and will not 
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have him examined in order to make an independent decision concerning his 

qualification to perform his job. He is, for all intents and purposes, disqualified by his 

personal physician's statement.

The chief medical officer at ICG does not "disqualify" based on the personal physician's 

report, but places the employee on extended leave of absence. To avoid continued 

paperwork, after an employee has been on a leave of absence for 3-5 years, he may 

order an examination by a company examiner on the basis of which the employee's 

qualification for work will be officially determined for the company records.

In the ICG employee cases where an extended leave of absence based on a personal 

physician's report is involved (e.g. as indicated on G-271 or G-3EMP), generally 

consider a leave of absence as a disqualification when there is indication that the 

employee will be held out of service for medical reasons for 12 months or more.

4.10.5 Effect Of Carrier Disqualification On Disability Rating

Refer to DCM 13, Section 7. 

4.10.6 Physician Independence

This depends on the relationship of the physician to the applicant.

A. Personal Physician - The applicant's personal physician may have a familial, 

financial or other relationship to the claimant, e.g., as an actual or potential 

representative payee. Conflicts of interest should be avoided as much as 

possible.

B. Consulting Physician - All implications of possible conflicts of interest must be 

avoided. For example, the physician doing the examination or test must not be a 

full-time or part-time employee of the RRB or SSA, unless there is no other 

qualified medical resource available. In such instances, the physician cannot 

participate in the disability decision-making or review process on that claim. Also, 

the physician must not have any familial, financial, or other relationship to the 

claimant, e.g., as an actual or potential representative payee.

4.10.7 Content Of Medical Evidence

An accurate disability decision requires medical evidence which shows the nature of the 

claimant's impairment(s) and the extent of the impairment(s) from the date disability is 

alleged to have occurred. The compilation of evidence in the file should be sufficient to 

allow the disability examiner to make an independent determination as to the nature and 

limiting extent of the claimant's impairment(s) and the probable duration.

In general, medical evidence should include the following information:
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A. A History of The Impairment - Its origin and the course of the condition, dates of 

any confinement, type of treatment response to treatment.

B. Current Objective Findings Which Support The Diagnosis and Document Any 

Physical or Mental Changes Which Have Occurred - Physical examination 

results, clinical and laboratory tests such as blood pressure, x-rays, EKG, blood 

test.

C. The factual medical data upon which the diagnosis and prognosis are based.

D. A Description of Objective Findings Regarding the Claimant's Functional 

Limitations and Remaining Functional Capabilities - Extent of movement in the 

affected areas, ability to reason, activities which cause shortness of breath, 

distance the claimant can walk, weight which claimant can lift, ability to handle 

objects and operate hand and foot controls, etc.

E. Certification by the physician or physiologist submitting the medical report.

NOTE: Copies of a personal physician's notes and records do not require a 

signature by the physician. However, if the personal physician submits a report 

of Physical Examination (Form G-250) or a formal narrative report, a signature is 

required by the physician to attest to the fact that the physician is responsible for 

the report contents, explanations, and conclusions.

4.10.8 Reports Of Consultative Examinations And Tests

Consultative examinations and tests purchased in connection with the adjudication of 

disability claims must be performed by qualified sources. The reports must provide as 

much information as possible to aid in the disability determination.

A. Physician Qualifications - The physician (or psychologist, audiologists etc.) doing 

the examination or test must be competent to do so. While it is not required that 

the physician be a specialist in the medical field in which the examination or test 

is requested, the physician's qualifications must indicate that he or she is 

licensed and has the training and experience to perform the type of examination 

or test requested. The physician's professional conduct and reputation must be 

such as to avoid an unfavorable reflection upon the government and erosion of 

public confidence in the administration of the disability program.

B. Report Content - The reported results of the history, examinations, pertinent 

requested laboratory findings, discussions and conclusions must conform to 

accepted professional standards and practices in the medical field for a complete 

and competent examination. The detail and format for reporting the results of a 

purchased examination will vary depending upon the type of examination or 

testing requested.
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Therefore, the extent and detail of information expected in a report of a general 

internal medicine examination will differ from that expected when a neurological, 

orthopedic, psychological, ophthalmological, otological or other examination is 

requested to address a specific issue. Moreover, the reporting of information will 

differ when the requested examination evidence relates to the performance of 

tests such as ventilatory function tests, treadmill exercise test, or audiological 

tests. When a complete examination is involved, the report should include:

1. The major or chief complaint(s) of the claimant.

2. Within the area of specialty of the examination, a detailed description of 

the history of the major complaint(s).

3. A description and disposition of pertinent "positive," as well as "negative", 

detailed findings based on the history, examination and laboratory tests 

related to the major complaint(s) and any other abnormalities reported or 

found during examination or laboratory testing.

4. The results of requested laboratory tests performed that are necessary as 

a result of the physician's examination.

5. Diagnosis and prognosis.

6. A medical assessment which shows the ability of an individual to do workrelated activities or to function in a work setting.

EXCEPTION: Do not request a medical assessment for statutory blindness.

In addition to the above, the consultative physician must consider, and provide 

some explanation or comment on, the major complaint(s) and any other 

abnormalities found during the history and examination or reported from the 

laboratory tests. The history, examination, examination, evaluation of laboratory 

tests results, and the conclusions must represent the information provided by the 

physician who signs the report.

C. Physician Signature - The physician actually performing the consultative 

examination or testing must personally review and sign the report; the signature 

of any other physician or person is not acceptable. This attests to the fact that 

the physician doing the examination or testing is solely responsible for the report 

of contents and for the conclusions, explanations or comments provided with 

respect to the history, examination and evaluation of laboratory tests results.

4.10.9 Action To Take When A Medical Provider Signature Is Required

Do not hold up the award or denial of a disability application or a DF decision when a 

signature is required on a disqualification notice (Form G-3EMP), a Medical 

Assessment of Residual Functional Capacity (Form G-250a) or a consultative 

examination. Instead, send a memo with the document to the field office for the 
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required signature and keep a copy of the document in file. While the field office is 

securing the signature, the disability determination can be processed. When the signed 

copy is returned, it should be filed down for documentation. If the signed medical 

evidence is altered or additional information is provided, review it and, if appropriate, 

reopen the case in accordance with RCM 6.2. 

4.10.10 Report Content for Internal Medicine Examination

Report content will, of course, vary according to the type of consultative examination or 

special service requested. Requirements for various examination reports are described 

in Appendix A under the specific body systems involved.

The reporting requirements for a general internal medicine examination are as follows:

A. The report should state the major complaints alleged as the reason for inability to 

work.

B. The history portion of the report should discuss in narrative form each major 

complaint, including a detailed longitudinal description of pertinent past history of 

the impairment as well as a detailed description of the current complaints. As 

much as possible, pertinent claimant statements, such as description of 

symptoms, should be in the claimant's own words. The description of current 

complaints should cite the factors which increase the problem, the factors which 

provide relief, and how the claimant believes the impairment limits his/her 

functional abilities.

In as much detail as possible the history should include the claimant's description 

of significant events related to the impairment such as changes in status of the 

complaint(s), hospitalization (name of hospital, hospitalization dates, findings and 

treatment) and ongoing treatment. The names and dosages of current 

medication should be mentioned.

The past history should also describe other previous illness, injuries, operations 

and hospitalization, including the dates of each event. A family history should 

also be part of the report.

The physician should state from whom the history was obtained and provide an 

estimate as to its reliability.

C. The physical examination narrative should describe the claimant's general 

appearance and actions pertinent to the complaint (e.g., if there is a complaint of 

musculoskeletal disease, how the claimant stool, walked, got on/off the 

examining table, etc.).

Parts of the examination which relate directly to the claimant's major complaints 

should be described in particular detail, noting both negative and positive 

findings.
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If a joint is found to have no abnormality of range of motion, it should be so 

stated. Otherwise, the specific range of motion, in degrees, should be stated for 

joints in which there is significant limitation of motion.

The report should include the claimant's height and weight without shoes, pulse 

rate and blood pressure.

D. The actual values for laboratory tests must be given. The laboratory should 

provide the normal ranges of values for that laboratory for the tests which were 

performed. Electrocardiographic tracings and spirographic tracings must be 

provided when such tests are performed.

The interpretation of laboratory tests, such as EKG, X-rays, ventilatory function 

tests, must correlate with the history and physical examination findings. If the 

formal reading or interpretation of laboratory tests has been provided by a 

physician other than the physician signing the report, the name and address of 

the physician providing the formal interpretation must be given.

E. Diagnosis and prognosis based on the clinical and laboratory findings must be 

supplied by the physician obtaining the history and performing the physical 

examination.

F. The physician signing the report must review the reported history and physical 

examination findings. The conclusions stated in the report must be consistent 

with the findings from the history, physical examination and any laboratory tests 

obtained in conjunction with the examination. All abnormalities should be 

explained. If a definitive explanation cannot be made, the physician should 

comment on the abnormality.

4.10.11 Weight Given To Testimony Or Treating Or Non-Treating Physician

Refer to L82-165, "Weight to be given testimony of treating physician."

4.10.12 Hearsay Evidence

An acceptable medical opinion as to disability must contain more than merely a 

statement that the claimant is disabled. It must be supported by clinical or laboratory 

findings.

With the exception of the on-site medical consultants, medical evidence from physicians 

who have not examined the claimant should be avoided because such evidence is 

vulnerable on appeal as "hearsay" evidence.

This problem is discussed in SSR 71-53c - "Section 205IG, Disability Insurance 

Benefits, Hearsay Medical Evidence as substantial Evidence, Use of Medical Advisers."
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4.10.13 Age of Medical Evidence 

Before deciding that the claimant is not disabled, the Board will develop a complete 

medical history (i.e., evidence from the records of the claimant’s medical sources) 

covering at least the preceding 12 months, unless the claimant says that his or her 

disability began less than 12 months before he or she filed an application (20 CFR § 

220.45b). In addition, the medical evidence of record must be complete and detailed 

enough to allow the Board to make a determination about whether or not the claimant is 

disabled (20 CFR § 220.46c). The decision as to whether or not to develop medical 

evidence covering the preceding 12 months should be made on a case-by-case basis.

A. It has been accepted practice in disability cases to require medical evidence that is 

less than a year old when making a disability determination. Historically, the only 

exception to this practice is in occupational disability cases where a disqualification 

notice was received. For these cases, the required medical evidence needs to 

establish the disqualifying impairment. It is acceptable for this disqualifying medical 

evidence to be greater than a year old.

B. It is acceptable in single freeze cases only, to use medical evidence that is up to 

eighteen months old in cases where the medical evidence directs a disability grant. 

Medical evidence that is up to eighteen months old is considered current for these 

type ratings and makes it unnecessary to order new examinations or develop for 

additional medical evidence. 

 

C. In accordance with legal opinion L-2017-59, if the disability examiner is adjudicating 

a case and the medical evidence is dated more than 12 months earlier than the date 

of adjudication the disability examiner may be able to adjudicate the case without 

further development by taking the following steps:

Examiner Actions

a. Notify the supervisor* in writing via email.

i. The email subject line should read “Medical Development”. 

b. Explain how the evidence in file is sufficient to establish continued severity.

c. Explain in the rationale why there was a delay in adjudication.

*If a supervisor is not available, send request for review to the Director of 

Disability.

Supervisor Actions

a. The supervisor will respond in writing with a file note within 2 business days.
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b. If the supervisors (post and initial will discuss) cannot agree that the 

development is necessary or not, he/she will forward the request to the 

Director of Disability for consideration.

A copy of email and response must be imaged. 

 

4.11 Use Of Medical Consultants

Prior to requesting medical advice, disability examiners must verify the following:

• eligibility criteria is met;

• sequential evaluation process has been met; and

• there is sufficient medical evidence in the last 12 months to establish that the 

impairment exists. Note: medical evidence in file should also support the 

alleged onset date.

If a conflict exists after verifying the information, refer the case for medical advice using 

Form G-137, Medical Consult Opinion.

4.11.1 When To Request Advice

The Disability and RECON examiners will refer any claim requiring medical advice to 

the medical consultant. The most common instances are:

A. Advice is needed concerning an examination to be scheduled, or interpretation of 

medical report or test results; (See 4.11.3) 

B. Conflicting medical reports are contained in the evidence secured; (See 4.11.4)

C. Limiting effects of the applicant's impairments are not specifically or completely 

addressed in the medical reports secured, and the disability examiner needs to 

request that the medical consultant provide the residual functional capacity 

(RFC) remaining to the claimant; (See 4.11.5) 

D. The case involves a joint freeze determination on Form SSA- 831-U5;

E. A protest of a denial, or a request for reconsideration has been made, and there 

is new evidence or a previous opinion is not in file; (See 4.11.6)

F. In continuance cases, when a severity assessment is needed to determine if the 

disability should continue or terminate using the medical improvement standards; 

(See 4.11.7) 
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G. To determine if the impairment(s) meets or equals the level of severity of 

impairments in the SSA Listing of Impairments. (See 4.11.8) 

4.11.2 How To Request Advice

When Disability or RECON examiners need to request advice from the medical 

consultant in order to make disability decisions, Form G-137, Medical Consultant 

Opinion, should be used in the instances described above in DCM 4.11.1, When 

to Request Advice. The medical consultant will respond to the Form G-137 by 

sending:

• Form G-137SUP, Medical Consultant Determination Worksheet, (for disability

based on the physical impairments in the case). A G-137a may be included 

and/or, 

• Note to File, and/or,

• Form SSA-2506-BK, Psychiatric Review Technique, (based on psychological 

impairments) and/or,

• Form SSA-4734-F4-SUP, Mental Residual Functional Capacity Assessment,

(based on psychological impairments). 

Form G-137: Form G-137, Medical Consultant Opinion, is used by DBD and 

RECON examiners to refer a disability case to the medical consultant for a medical 

opinion. Form G-137 is completed by the examiner. Examples of when to use 

Form G-137 include but are not limited to the common instances described above 

in DCM 4.11.1, When to Request Advice, Items A through G. 

Form G-137a: Form G-137a, Medical Consultant Opinion - Continuation Sheet. 

This form is used when the medical consultant needs additional pages for their 

opinion continuing from the G-137 SUP. On page 4 of the SUP, the box labeled 

“check if additional pages are included” should be checked). The G-137a is 

completed, signed, and dated by the medical consultant. 

Form G-137SUP: Form G-137 SUP, Medical Consultant Determination 

Worksheet, is completed, signed, and dated by the medical consultant in response 

to the G-137 (in cases with physical impairments). The medical consultant 

completes Part 1 with the residual functional capacity (RFC) assessment and also 

completes Part II with comments and review of the medical records used to support 

the Part I RFC. The Form G-137 SUP may also be used by the medical consultant 

to advise the examiner when the medical records are not sufficient to provide a 

RFC and to recommend what medical records to obtain. 

Note to File: A completed, signed, and dated note to file of the medical opinion 

from the onsite medical consultant during the bi-weekly visit between the 

consultant and DBD examiner staff. 
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See DCM 11.2 instructions on the use, access, and completion of the Forms G137, G-137a and G-137SUP.

Form SSA-2506-BK, Psychiatric Review Technique (used for psychological 

medical opinions only), and/or,

Form SSA-4734-F4-SUP, Mental Residual Functional Capacity Assessment

4.11.3 Advice Concerning Examination To Be Scheduled Or Interpretation Of 

Medical Evidence

Complete Form G-137; file on right side of folder, and route to the medical consultant. If 

the medical opinion is being requested on an urgent basis, write the word “URGENT” in 

the top margin of the G-137 and in the top margin of the route slip. 

4.11.4 Conflicting Medical Reports

When conflicting medical reports are contained in the evidence secured, the disability 

examiner should resolve the conflict by requesting a medical consultant opinion. (See 

DCM 13.10.1.3) For example: Examiner should seek additional information to resolve 

conflicting medical reports between independent medical examinations and the 

claimant’s treating physician, i.e. health care professional. The disability examiner 

should complete Form G-137, Medical Consultant Opinion. The medical consultant will 

respond by completing Form G-137SUP, Medical Consultant Determination Worksheet. 

4.11.5 Residual Functional Capacity (RFC)

The claimant's impairment(s) may cause physical and mental limitations that affect what 

the claimant can do in a work setting. RFC is what the claimant can do despite his or 

her limitations. If the claimant has more than one impairment, DBD will consider all of 

his or her impairments of which DBD is aware.

DBD considers the claimant's capacity for various functions such as physical and 

mental abilities. RFC is a medical assessment. However, it may include descriptions of 

the limitations that go beyond the symptoms that are important in diagnosis and 

treatment of the claimant's medical impairment(s) and may include observations of the 

claimant's work limitations in addition to those usually made during formal medical 

examinations.

The descriptions and observations of the limitations, when used, must be considered 

along with the rest of the claimant's medical records to enable the disability examiner to 

decide to what extent the claimant's impairment(s) keeps him or her from performing 

particular work activities.
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The assessment of the claimant's RFC for work is not a decision on whether the 

claimant is disabled, but is used as the basis for determining the particular types of work 

the claimant may be able to do despite his or her impairment(s). A claimant's vocational 

background is considered along with his or her residual functional capacity in arriving at 

a disability decision.

When DBD assesses the claimant's physical abilities, DBD assesses the severity of his 

or her impairment(s) and determines his or her RFC for work activity on a regular and 

continuing basis. DBD considers the claimant's ability to do physical activities such as 

walking, standing, lifting, carrying, pushing, pulling, reaching, handling, and the 

evaluation of other physical functions. A limited ability to do these things may reduce 

the claimant's ability to do work.

When DBD assesses a claimant's mental impairment(s), DBD considers factors, such 

as:

• his or her ability to understand, to carry out, and remember instruction; and

• his or her ability to respond appropriately to supervision, co-workers, and work 

pressures in a work setting.

Some medically determinable impairments, such as skin impairments, epilepsy, and 

impairments of vision, hearing or other senses, postural and manipulative limitations, 

and environmental restrictions do not limit physical exertion. If the claimant has this 

type of impairment in addition to one that affects physical exertion, DBD considers both 

in deciding his or her RFC.

If the limiting effects of the applicant's impairments are not specifically or completely 

addressed in the medical reports secured, the disability examiner should request a 

medical decision by completing Form G-137 and forwarding it with the folder to the 

medical consultant.

The medical consultant will complete Form G-137 SUP.

4.11.6 Protest Of Denial Or Request For Reconsideration

When a protest of a denial or a request for reconsideration is received, a disability 

examiner, other than the disability examiner who initially handled the case, must review 

the case as follows:

A. No New Information or Evidence Received - If no additional information or 

evidence has been presented and a doctor's opinion concerning the evidence is 

already in file and the disability examiner reviewing the case is in full agreement 

with the previous decision of denial, it is not necessary to refer the case for 

medical opinion again;
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B. New Information or Evidence - When the applicant has presented new 

information or evidence, the case must be referred with Form G-137 for a 

medical opinion. The claims specialist will place this category of case in the 

consultant's "special tray" because of the time limits related to these actions.

4.11.7 Termination Of Benefits

When the disability examiner determines that termination of benefits is appropriate 

based on medical recovery of the annuitant, the case must be referred to the medical 

consultant.

This type of case is referred to the medical consultant to document the file in case of 

protest or appeal.

4.11.8 Finding Of Disability Is Based On SS Listing Of Impairments

To determine if the impairments equal the level of severity in the SS Listing of 

Impairments, refer the case to the medical consultant.

4.12 Use Of RR and SS Listing Of Impairments

4.12.1 Information Contained In The RR and SS Listing Of Impairments

The SS Listing of Impairments is a listing which contains examples of medical 

conditions which generally prevent an individual from engaging in substantial gainful 

activity. This is the basic guide used by the Social Security Administration for medical 

evaluation of all disability claims. Its purpose is to identify those individuals who clearly 

have disabling impairments.

If an applicant for social security benefits has a medical condition with the specific 

medical findings described in the listing or one that is the medical equivalent of any 

listed set of findings, a finding of disability is made on medical grounds alone. This is 

true provided the duration requirement is met, or is expected to be met, and there is no 

evidence to refute the finding (i.e., performance of substantial gainful activity or failure, 

without good reason, to follow prescribed treatment which could be expected to restore 

the ability to work.

The Railroad Retirement Board also uses the SS Listing of Impairments as the basis for 

the Listings of Impairments found in the Regulations [20 CFR Part 220 (Appendix 1 of 

Part 220)] under the Railroad Retirement Act. The majority of these Listings are 

essentially the same; however there are instances when the SS Listing of Impairments 

will differ from the Listings in the RRB Regulations. This occurs when SSA enacts new 

legislation changing their Listing of Impairments, before the RRB has the opportunity to 

update the Listing of Impairments found in the RRB Regulations. 
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4.12.2 Applying The RR and SS Listing Of Impairments To RRB Disability 

Decisions

A. Using the RRB Listing Of Impairments in a RRB Disability Decision

Disability claims examiners must use the Listings of Impairments found in the 

Regulations under the RR Act (Appendix 1 of Part 220) when making an initial 

disability annuity rating (decisions made on page 2 of OLDDS) under the RR Act. 

This would encompass any employee (either occupational or total and permanent), 

child, widow(er), remarried widow(er) or surviving divorced spouse disability 

decision.

B. Using the SS Listing Of Impairments in a RRB Disability Decision

Disability claims examiners must use the Listing of Impairments found in the 

Regulations under the SS Act (Appendix 1 to Subpart P of Part 404) when making a 

period of disability (Disability Freeze) rating (decisions made on page 3 of OLDDS) 

under the SS Act. This would encompass any employee (either single or joint), 

child, widow(er), remarried widow(er) or surviving divorced spouse disability 

decision.

When a RRB disability claims examiner is making a disability decision in which a Listing 

is met or equaled, it is necessary for the examiner to review each Listing of Impairments 

(RRB and SSA) and cite the proper Listing under each Act. 

For example, it is common practice that when an applicant indicates (s)he is receiving 

or has filed for disability at SSA, the RRB will make an effort to obtain any medical 

evidence and disability decision that has been made by SSA. In these cases when a 

decision from SSA is received and an allowance has been made by SSA that cites a 

Listing as the reason for the grant, the RRB examiner will need to review the RRB 

Listing of Impairment to determine if it corresponds with the SSA Listing of Impairments. 

When the Listings match, the examiner can proceed as usual. However, in cases in 

which the Listing cited by SSA does not exist in the RRB Listing it will be necessary for 

the RRB disability claims examiner to review the RR Listing to determine if another RR 

Listing may be met. If not, then the case should be sent to the RRB medical opinion 

provider to determine if another Listing can be met or equaled. In these cases, the 

applicant will still be found disabled, but the decision will need to cite the correct Listing 

citation under each Act. 

4.12.3 Impairments Which Meet The Listing

An impairment "meets" a listing only when it manifests the specific findings described in 

the set of medical criteria for that listed impairment. Such a finding cannot be based on 

diagnosis alone.

The "level of severity" in the Listing is not defined in terms of residual functional 

capacity. When certain functional limitations are specified for a listed impairment, they 
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relate only to the degree of dysfunction for that particular listing section and only to the 

specific function identified.

4.12.4 Impairments Which Equal The Listing

To determine if an impairment or combination of impairments "equals" the Listing a 

comparison must be made of the medical findings (the set of symptoms, signs and 

laboratory findings) in the claimant's medical evidence and the medical findings 

specified for the listed impairment most like the claimant's impairment(s). The 

claimant's impairment(s) can be considered "equal" to the Listing only if the medical 

findings are at least equivalent in severity to those specified in the Listing. A decision of 

equivalence can never be made based solely on symptoms.

Equivalence is established under the following three circumstances:

A. an unlisted impairment where signs, symptoms and laboratory findings describe 

severity equal to the most closely related listed impairment;

B. a listed impairment where the signs, symptoms and laboratory findings are not 

identical to those specified for that impairment, but reflect equivalent severity;

C. combined impairments where the signs, symptoms and laboratory findings reflect 

severity equal to the listed impairment most like the claimant's most sever 

impairment.

As in determining whether a Listing is met, it is incorrect to consider whether the Listing 

equaled is on the basis of an assessment of overall functional impairment. If a disability 

examiner believes that a Listing is equaled, the case must be sent to the medical 

consultant.

4.12.5 Evaluation Of Symptoms

Symptoms (e.g., pain, shortness of breath) are individual's own perception of the effect 

of a physical or mental impairment. Symptoms do not have a significant effect on a 

disability decision unless clinical and laboratory data and the medical history establish 

findings which can reasonably be expected to account for the symptoms. There must 

be objective evidence to justify the overall evaluation of severity.

When symptoms are alleged as a significant aspect of the impairment, but the criteria 

for a listed impairment are not met or equaled and severe impairment exists, the 

symptoms must be considered in evaluating disability. The following guide can be used 

in the consideration of symptoms.

A. Is there a medically determinable severe impairment? A finding of disability can 

only be based on a medically determinable severe impairment. "Medically 

determinable" means that the impairment has demonstrable anatomical, 
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physiological or psychological abnormalities which manifest themselves through 

medical evidence consisting of symptoms, signs and laboratory findings.

If no medically determinable severe physical impairment can be found which 

would produce a symptom the claimant alleges limits the ability to work, it is 

possible that the symptom may be the result of a medically determinable severe 

mental impairment. If a severe impairment, either physical or mental, cannot be 

established based on clinical and laboratory findings, the claimant cannot be 

considered to be disabled, regardless of the intensity of, or limitations allegedly 

imposed by, the symptom. Symptoms alone cannot justify the findings of a 

medically determinable severe impairment.

B. Is the Listing met or equaled? Once a medically determinable severe impairment 

has been established, determine whether the impairment meets or equals an SS 

Listing. When determining whether the impairment meets a Listing which 

includes a symptom as one criterion, it is generally required only that the 

symptom be present in addition to the required clinical and laboratory findings. 

This is true unless the Listing specifically states that the symptom must be of a 

certain intensity or must cause certain functional limitations.

If a Listing is not met, consider whether the medically determinable severe 

impairment equals a Listing. The clinical and laboratory findings must be equal 

to or greater in severity than the requirements specified in the Listing, even 

though the intensity of the symptoms may exceed the Listing. The intensity of 

symptoms can never compensate for a missing clinical or laboratory finding.

C. What is the impact of the symptoms on residual functional capacity?

If there is a medically determinable severe impairment, but the SS Listing is not 

met or equaled, a RFC assessment should be made. In an RFC assessment, 

symptoms are considered in terms of any additional functional limitations they 

impose beyond those clearly demonstrated by the objective medical finding 

alone. Since symptoms are subjective in nature and not reliably quantifiable, 

functional limitations imposed by symptoms must generally be inferred from the 

medical history, the objective (clinical and laboratory) physical findings, and a 

knowledge as to what symptom - related effects on functional capacity can 

reasonably be expected.

Conclusions about the presence and persistence of a symptom, its effects and 

any resulting reduction in RFC should be based on consideration of: alleged 

frequency and duration of the symptom, precipitating or aggravating factors; 

effect on daily activities; dosage effectiveness and side-effects of medication; 

recorded physician observations of the symptoms. Where pain is the symptom, 

its location and radiation must also be considered.
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4.13 Death After Denial Or Cessation

4.13.1 Evidence Required

If a claimant dies within a year after denial of a disability claim or termination due to 

cessation of disability, secure a death certificate and examine the medical portion. The 

medical portion should show the cause of death and the underlying conditions which 

gave rise to the direct cause. The underlying cause (the disease or injury which 

initiated the train of events leading to death) is shown last. If the direct cause of death 

adequately describes the sequence of events, no underlying conditions need to be 

shown.

If the death certificate is not sufficient to determine whether the denial or cessation 

decision was correct, secure a copy of the hospital records if the claim died in a 

hospital. If hospital records are not available, obtain a medical report from the physician 

attending at death and any other available pertinent evidence.

4.13.2 Evaluating Evidence In Death Cases

If the evidence indicates that death resulted from violence or accident, the previous 

disability determination need not be re-examined. If the evidence submitted after the 

claimant's death established that the impairment was more severe than shown by the 

evidence previously developed, or if an additional impairment existed which was not 

previously disclosed, reopen the case to consider the new evidence.

If the case was denied because the duration requirement was not met and the new 

evidence indicates that the impairment resulted in death and was continuously severe 

enough to prevent substantial gainful activity, reopen the case to make a finding of 

disability. (See RCM 6.2).

Appendices

Appendix A Body Systems Evaluation Guide 

A. GENERAL USE OF APPENDIX

This appendix is based on the "Audit Review Guide" that was prepared by 

Consultative Examination, Inc. It provides general medical data to aid the disability 

examiner in reaching a determination of "disabled" or "not disabled."

The listing of examinations to schedule are contained in Appendix C.

B. MUSCULOSKELETAL IMPAIRMENTS

1. BASIC CONSIDERATIONS
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Consideration of impairments of the Musculoskeletal System in general is 

somewhat unique in that pain is considered to be part of the origin of the 

impairment and allowance is made for such consideration.

Nonpainful but disabling conditions are found in this impairment category as 

well.

As with other conditions, the impairment must be a medically verifiable 

condition wherein applicable instances pain is generally considered as a 

substantial and serious problem.

Nevertheless, where pain is considered to be a factor, allegation of pain alone 

is never a sufficient criteria for finding disability. The basic diagnosis of 

medically determinable condition must be documented and some accepted 

objective finding that correlates closely with pain must be present on physical 

examination.

Proper documentation requires a medical history (a description of events to 

date from a medical source; M.D. or D.O.)

Objective findings of the alleged disorder on physical examination along with 

laboratory and x-ray findings in support of the basic diagnosis are all part of 

adequate documentation.

Statements or quotations from the records of an M.D. or D.O. by an 

acceptable source (medical records technician, medical librarian, nurse, etc.) 

are considered sufficient medical evidence. On the other hand, statements 

from a nurse’s examination, nursing practitioner's examination, chiropractic 

examinations and treatment, observations by a psychologist and social 

worker may be helpful but are NOT considered medical evidence.

Most conditions in this impairment category carry a durational requirement 

(the expectation that the impairment will last at least 12 months or longer.)

Only reasonable expectations are required, NOT actual duration as a 

condition of finding of disability.

Some conditions also require that claimant be under medical care and the 

condition be unresponsive to treatment.

medical care is defined as professional care rendered by a licensed M.D. or 

D.O.

2. INFLAMMATORY ARTHRITIS

This diagnosis category includes impairments due to forms of arthritis that 

cause joint inflammation.
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Documentation of disability requires the history of joint pain, swelling and 

tenderness. Outlining of applied therapy, medication taken and response to 

such therapy should also be included.

Physical examination must include signs of joint inflammation (swelling, 

redness, tenderness) and range of motion of the affected joint in degrees.

Proper documentation of the inflammatory arthritis should include laboratory 

tests indicating that the arthritis is active. Such a test is the erythrocyte 

sedimentation rate. Some other tests are also used to improve the accuracy 

and specificity of these non-specific tests. Rheumatoid factor test and 

antinuclear antibody test are the most widely used and acceptable ones for 

disability determination purposes.

3. OSTEOARTHRITIS

Arthritis affecting the major joints of the upper and lower extremities are 

referred to by this diagnostic category. Major joints are: hip, knee, ankle, 

shoulder, elbow, and wrist.

Documentation should include the history indicating the onset of joint pain, 

the accompanying symptoms (such as stiffness), history of any surgeries 

done on the joint (such as surgical arthrodesis, joint replacement, etc.) The 

postsurgical status should be described, as well.

Physical examination of the affected joint should document signs of swelling 

or effusion, the range of motion in degrees, and the description of anatomical 

deformities in detail (subluxation, contracture, ankylosis, instability, etc.) If

ankylosis is found, the position and degrees of the ankylosed joint must be 

described. Knee instabilities must be discussed in detail.

Laboratory findings should include x-ray evidence of joint space narrowing, 

osteophyte formation and/or bony destruction. 

4. DISORDERS OF THE SPINE

The history should include: exact location of the pain (usually it is neck or low 

back pain.) Any symptoms of nerve root compression should be listed in the 

history (i.e. sneezing or coughing will aggravate the pain) along with 

accompanying bladder or bowel incontinence.

History of fractures and clarification whether these fractures were traumatic or 

spontaneous are also important parts of documentation.

If surgery was done, the date and type of surgery should be elicited along 

with discussion of therapeutic results.
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Physical examination should include: the presence of surgical scars, 

abnormal curvatures (such as kyphosis, scoliosis or lordosis) upon inspection. 

Visible muscle spasms and deformities of the spine should be noted, as well.

Other components of adequate documentation are muscle tenderness or 

paravertebral tenderness on palpation and range of motion (expressed in 

degrees) of both cervical and lumbosacral spine.

Neurological examination must include: a description of the claimant's gait 

and posture along with the ambulatory device if used. Discussion should be 

present as to the distance the claimant is capable of walking with and without 

the device.

Motor examination includes: muscle strength, size of muscle and 

abnormalities (such as atrophy or hypertrophy.) The muscle strength should 

be quantitated; the atrophy or hypertrophy should be documented by 

appropriate circumferential measurements expressed in inches or 

centimeters.

Sensory examination: should also be described in detail as to distribution. 

Reflexes (especially that of the Achilles and knee jerk) should be in file.

The straight leg raising test is helpful in determining the overall severity but it 

is to be correlated with other clinical findings particularly due to the fact that 

this test includes a great measure of subjectivity.

Laboratory examinations should include x-ray examinations. Calcified 

ligaments, ankylosis, compression fractures, osteoporosis, signs of arthritis, 

etc. are important findings in substantiating the presence of a musculoskeletal 

disorder.

5. FRACTURES

Documentation of fractures: should include the date of injury to determine the 

duration of disability, if present. The treating physician's advice as to weight 

bearing should also be included in the history.

Physical examination findings should evidence complications if they are 

present (i.e., ulcers or nonunion) as well as findings as to whether any motion 

can be manually induced at the fracture site. The latter is direct evidence of 

clinical solidity versus nonunion.

If the fracture affects the upper extremity: a description of the claimant's 

ability to use the arms and hands for grasping, pinching, reaching, pushing, 

pulling and reaching overhead is required.

If the lower extremity is affected: a description of gait and posture should be 

included along with a description of ambulatory devices, if they are used.
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6. AMPUTATION

History of amputation should describe: which extremity is amputated, and the 

level of amputation must be specified. The reason for amputation must be 

clarified as the amputation might not be found disabling but the cause for the 

amputation (i.e., diabetes mellitus with gangrene) might reveal an additional 

underlying impairment.

In most cases of amputation, the history should also detail the potential use of 

prosthesis and its effectiveness.

Physical examination should describe the exact level of amputation (i.e., 

below the knee, above the knee, midthigh, etc.) The prosthesis should be 

described and how well the claimant uses it. The condition of the stump 

should be described with respect to erosions, ulcers and/or neurological 

complications.

In overall assessment of disability, the condition of the other extremity should 

also be taken into consideration.

7. OSTEOMYELITIS

Documentation of the history of this bone infection should include: the onset 

date, location, symptoms along with other local (i.e., drainage) or systemic 

(i.e., fever) manifestations. Evidence should be developed relative to therapy 

applied (i.e. surgery, antibiotics, etc.) and the response to therapy.

Physical examination should describe local findings, such as heat, redness or 

drainage as well as systemic findings such as fever.

Laboratory examinations needed to confirm the diagnosis include x-ray 

evidence of osteomyelitis, leukocytosis and elevated erythrocyte 

sedimentation rate.

8. GLOSSARY OF MUSCULOSKELETAL TERMS, SYNONYMS, 

ABBREVIATIONS

A/E Above the elbow amputation

A/K Above the knee amputation

Amb Ambulatory

Amp Amputation

ANA Antinuclear antibody test
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AP and Lat. Antero-posterior and lateral

B/E Below the elbow amputation

B/K Below the knee amputation

DIP Distal interphalangeal joint

DJD Degenerative joint disease

ESR Erythrocyte sedimentation rate

Fx Fracture

GSW Gun shot wound

HNP Herniated nucleus pulposus

I & D Incision and drainage

jt. Joint

JRA Juvenile rheumatoid arthritis

LLE Left lower extremity

LUE Left upper extremity

MCP Metacarpophalangeal joint

MTP Metatarsophalangeal joint

ORIF Open reduction and internal fixation

Ortho Orthopedics

OT Occupational therapy

PA Posterior-anterior

PIP Proximal interphalangeal joint

PT Physical therapy

RA Rheumatoid arthritis

RF Rheumatoid factor test

RLE Right lower extremity
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RUE Right upper extremity

ROM Range of motion

Trx Traction

THR Total hip replacement

S/P Status post

C. CARDIOVASCULAR IMPAIRMENTS

1. BASIC CONSIDERATIONS - Appropriate documentation of impairments 

of the circulatory system generally requires three-dimensional structure 

which is found in many other body systems as well.

This three-pronged approach begins with a detailed medical history of the 

claimant's complaints, allegations, and description of symptoms.

This history is followed by a physical examination pertinent to the 

complaints and history supported by one or more ancillary objective tests 

to verify and quantitate, when possible, the severity of the impairment.

Objective tests, often called laboratory findings, are comprised of various 

impersonal modalities such as ordinary x-rays, electrocardiograms (ECG, 

EKG), or more sophisticated techniques such as those based on the 

Doppler effect.

Some of these procedures or tests may be ordered by the Railroad 

Retirement Board. Other invasive types of objective evidence, for 

instance the ones obtained through catheterization of the heart, may not 

be ordered as a consultative examination. The latter procedures carry a 

measure of risk and are ordered only by the treating physician. Objective 

evidence of this type is, of course, very valuable and should be obtained 

when they are available as evidence of record.

In disability claims, the primary emphasis is not on diagnostic 

classification, but, rather, identifying the functional disturbance which may 

interfere with substantial gainful activity.

Cardiac disability generally results from one of four types of heart disease:

1. Congestive heart failure,

2. Ischemic heart disease,

3. Conduction disturbances,
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4. Miscellaneous other heart conditions.

2. CONGESTIVE HEART FAILURE

A. In concert with the principles mentioned above, this circulatory system 

condition should be addressed with limited concern for the etiology (the 

cause of the disease-producing impairment of the heart function.) This will 

again be apparent when subsequent impairments refer back to this 

condition.

The first and usually the most obvious state of heart failure which causes 

significant functional interference is simply the persistent congestive heart 

failure which has been uncorrected by treatment. Documentary 

requirements for this condition consist primarily of proper medical history, 

physical examination, and clinical findings.

Evidence of physical examination, which is usually sought to establish the 

diagnosis of congestive heart failure, includes: signs of vascular 

congestion (such as hepatomegaly), peripheral or pulmonary edema, 

shortness of breath, enlargement of the heart, abnormalities of the jugular 

venous pulse, orthopnea etc.

Notice that proper documentation of this condition does not require any 

specific laboratory tests. The fact of prescribed treatment, however, must 

be documented in the evidence. The congestive heart failure must be 

found present in a relatively recent clinical examination.

There are situations in which there has been an improvement to the extent 

that congestive heart failure is not currently present, yet, the condition is of 

disabling severity because of advanced and persistent left ventricular 

enlargement and hypertrophy. In these instances, the claimant's history 

failure in spite of prescribed therapy at some point in the past and 

advanced and persistent left ventricular hypertrophy and enlargement is to 

be demonstrated by two objective tests:

1. Electrocardiogram, and

2. Chest x-ray.

The electrocardiogram must indicate ventricular enlargement and 

hypertrophy.

The chest x-ray must indicate significant extension of the cardiac shadow 

(left ventricle).

Certain valvular conditions and other types of cardiac disease along with 

congestive heart failure resultant of diseases of the lungs or the blood 

vessel can cause congestive heart failure as well. The required 
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electrocardiographic and x-ray evidence should correspond with the 

underlying condition.

Whatever is the cause factor of congestive heart failure, if it is not 

currently present on clinical examination, it is an absolute requirement to 

have a history indicating the unquestionable presence of congestive heart 

failure at some point in the past in-spite of prescribed therapy. Current 

EKG findings and x-ray findings should be presently consistent with 

ventricular enlargement, hypertrophy, or other underlying cardiac (or 

pulmonary) conditions corresponding with the etiology of the heart failure.

3. ISCHEMIC HEART DISEASE

The establishment of this very complex and important heart condition is 

based upon a careful and detailed history. The cardinal symptom of this 

condition is chest pain. Multiple features of the alleged chest pain must 

conform to generally established criteria in order to attribute it to cardiac 

origin.

Since the possibility of chest pain arising from structures other than the 

heart muscle must be closely considered, a thorough description of the 

chest pain is an essential portion of the documentation. Documentation of 

the chest pain should cover nine characteristics:

1. Precipitating factors,

2. Location,

3. Character, 

4. Duration,

5. Relieving factors,

6. Radiation,

7. Frequency,

8. Associated symptoms,

9. Ancillary tests and medications.

Medical reports lacking one or more of these characteristics are not 

necessarily deficient or incomplete; however, an optimally documented 

claim should contain information as to all of these characteristics.

In order to consider chest pain to be of cardiac origin, the precipitating 

factor should be primarily effort that is a physical exertion. At times after 
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meals, or due to extremes of emotional upset, chest pain of cardiac origin 

may arise. In the case of preinfarction or unstable angina, chest pain of 

cardiac origin can arise with little provocation or even at rest. When the 

diagnosis is Prinzmetal angina the pain is experienced usually at rest, 

often at night, at times during usual activity.

The location of the pain is always substernal.

The character of the pain is pressure-like, heavy, constrictive or 

oppressive, aching, or burning sensation.

The duration of the pain is somewhat unreliable, yet, it is most often 

between several and 15 minutes.

The pain might radiate in the arms and hands or the neck, lower jaw, 

epigastrium, or the back.

The pain is generally relieved by nitroglycerin, often times by rest.

The frequency of the pain is always intermittent and it is often associated 

by diaphoresis, apprehension, and fear of death.

On tests and medications the claimant is likely to report that he is 

receiving various nitroglycerin preparations, beta-blocker, calcium 

antagonists. The claimant is also likely to report to have undergone 

resting EKG, treadmill exercise test, various blood tests (enzyme tests), 

and possibly coronary arteriogram (angiogram).

For disability purposes, the preferred assessment of ischemic heart 

disease is a functional evaluation. The technique is that of a treadmill 

exercise test which combines constant electrocardiographic monitoring of 

the claimant while he is progressing from the resting state through a 

gradually increasing exercise load by walking on a treadmill. This is a 

non-invasive and reasonably safe way of quantitating the functional state 

of the coronary arteries with a relative high degree of accuracy. The 

workload on the treadmill is defined in units called METS. Depending on 

the speed of the treadmill, the grade of the slope against which the patient 

walks, and the duration of the exercise, various protocols have been 

developed which are correlated with various levels of workload (various 

MET levels). One of the most widely used protocols is the Bruce Protocol.

BRUCE PROTOCOL

STAGE SPEED (MPH) GRADE (%) MINUTES METS

I 1.7 10 3 4.9
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II 2.5 12 6 7.1

III 3.4 14 9 9.7

IV 4.2 16 12 12.6

V 5.0 18 15 16*

* Permits heavy labor

A positive test at the level of 5 METS or less is generally considered to 

indicate impairment severity precluding any substantial gainful activity on 

a sustained basis. Positive tests at higher MET levels may be used ot 

define the claimant's residual functional capacity, that is the type of work 

which the claimant might be able to do.

Since the graded treadmill exercise test is a reasonably safe procedure, it 

can be ordered by the Railroad Retirement Board to be performed at a 

competent facility as a consultative examination. It is essential to leave 

the judgment as to indication or contraindication of the treadmill exercise 

test to the consulting physician.

NOTE: A decision as to the possible contraindication to the test should 

never be made by the Railroad Retirement Board, the Board's medical 

staff or any other individual who is not directly examining the patient 

immediately prior to the scheduled test.

There are alternative types of documentation which may be applicable in 

the absence of acceptable treadmill exercise test, or if the treadmill test is 

contraindicated. In fact, if the treadmill test is not available as evidence of 

record the examiner should not order treadmill test as a consultative 

examination if the claim can be adjudicated on some other basis. Such 

basis could be EKG abnormalities which establish that the claimant any 

time in the past experienced a transmural myocardial infarction. To 

document this fact, acute tracings of the infarction from the time when it 

occurred (as evidence of record) is the preferred evidence. Considering 

that most myocardial infarctions are treated in hospitals, as a rule these 

records should be available. In case the acute tracings are not available, 

remote tracings should be secured which are consistent with a history of 

past myocardial infarction. These remote tracings are EKG signs present 

on a current resting EKG consistent with past myocardial injury.

The resting EKG findings may show ischemic type changes which would 

constitute alternative documentation to graded exercise treadmill testing.

1. Master's two step exercise testing constitutes an alternative to 

graded exercise treadmill test. This test is less accurately 
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standardized than the treadmill; therefore, clinicians prefer the 

latter. Before treadmill technology became widely available in the 

United States (in the 1970's) the Master's test was the test of 

choice.

2. If angiographic evidence (coronary arteriogram) is available as 

evidence of record indicating severe narrowing of main coronary 

arteries, this evidence constitutes an alternative to graded exercise 

treadmill test, as well.

A left bundle branch block generally prevents application of the graded 

exercise treadmill testing and the block itself commonly results from 

coronary artery disease. Accordingly, the presence of left bundle branch 

block may be considered indicative of coronary artery disease, per se, 

unless it is negated by a negative coronary arteriogram available as 

evidence of record.

Ejection fraction studies, if available as evidence of record, could also 

constitute an alternative to graded exercise treadmill test in documenting 

coronary artery disease.

4. CONDUCTION DISTURBANCES, ARRHYTHMIAS

Generally, the irregular heart beat must be objectively confirmed by 

Electrocardiogram either by ordinary resting EKG or the ambulatory tape 

recording (Holter monitoring), which device will monitor the rhythm of the 

heart over a multi-hour time span during customary activities.

Particular caution is to be used in assessing arrhythmias of the claimants 

who take digitalis because the medicine itself commonly produces 

arrhythmias.

Many arrhythmias are treated with pacemakers. The examiner should be 

conscious of the fact that the implantation of a pacemaker in not

considered a major heart surgery and it does not automatically mean that 

the claimant is completely disabled. The degree of severity is to be 

assessed by documentation of the underlying condition and the extent of 

control achieved by the pacemaker and/or medication. Nevertheless, the 

presence of permanent pacemakers will restrict an individual's functional 

capacity to a considerable degree.

5. MISCELLANEOUS OTHER CARDIOVASCULAR CONDITIONS

A. Hypertensive Vascular Disease - High blood pressure produces 

impairment by its damaging action on major organs such as the

heart. If symptoms are generated due to high blood pressure they 

should be evaluated according t the nature of the symptoms. In 
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evaluating these symptoms the examiner should be conscious of 

the fact that some of these symptoms are subject to significant

improvement once the high blood pressure has been brought under 

control.

B. Aneurysms - This bulging out of the blood vessel generally arises 

from either the aorta or one of its major branches. The presence of 

the condition is to be documented by x-ray studies as objective 

evidence. Severity evaluation then is base on various 

complications caused by the aneurysm. These complications 

maybe unique to the condition or may fall under previously 

described categories, such as congestive heart failure. 

Occasionally, the aneurysm causes recurrent attacks of sudden 

temporary loss of consciousness. The claims of recurrent syncopal 

attacks due to aneurysm should be documented by x-ray findings of 

the presence of the aneurysm. Also, documentation should include 

a description of the interference these syncopal episodes represent 

with respect to normal daily activities.

C. Chronic Venous Insufficiency of the Lower Extremity

1. Arteriosclerosis Obliterans and Thrombo-angiitis - The first of 

these two entities is the common chronic arterio occlusive 

disease of the extremities, usually the lower extremities. 

The second condition in this group is a rare affliction call 

Buerger's disease. Unlike arteriosclerosis obliterans this 

condition is an inflammatory disorder involving both the 

arteries and the veins. It is peculiar to young male smokers.

There must be a detailed history and physical examination 

demonstrating two key points:

a. Malfunction of the deep venous return of the limb, and

b. Persistent or recurrent ulceration of the skin which is 

resistant to therapy. Laboratory evidence of record 

such as Doppler studies or venograms are useful in 

assisting the adjudication.

The cardinal requirement of documentation of these 

conditions is the clinical presence of intermittent claudication 

which must be established by history. The symptom 

complex is characterized by pain in the muscles f the 

extremity which is brought on by use of the limb and relieved 

by rest. Objective documentation may be provided by 

arteriography showing obstruction of the common femoral or 

the deep femoral artery.
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As in other situations of invasive procedures it is to be noted 

that the Railroad Retirement Board must not order such 

arteriograms as consultative examination but when it is 

available as evidence of record it is always to be secured.

An alternate form of documentation which is absolutely 

noninvasive, (thus, it could be ordered as consultative 

examination) is the Doppler's ultrasound blood flow study. 

This noninvasive technique offers confirmation of arterial 

obstruction by showing impaired pulsation. This study is a 

simple means of measuring the blood pressure in specified 

arteries with great precision thus demonstrating obstruction.

Plethysmography is a more cumbersome means toward the 

same end utilizing an electrical impedance technique.

2. Transient Ischemic Attacks - Transient ischemic attack are 

transient episodes of ischemia of the brain, the area of 

involvement in turn producing symptoms depending on the 

function of the involved area. Symptoms range from 

weakness of one extremity through unilateral blindness 

homonymous hemianopsia, weakness in face, arms, or legs, 

or simply a sensation of numbness or tingling in certain 

areas of the body. Recent studies indicate that these 

attacks are linked almost exclusively to arteriosclerotic 

thrombosis. This is the first stage of developing stroke which 

may progress to a completed stroke or regress without any 

permanent damage.

In documenting transient ischemic attacks, arteriograms are 

of great value. As in other invasive techniques, such 

arteriograms are to be obtained if they are available as 

evidence of record but never ordered as a consultative 

examination by the Railroad Retirement Board. In assessing 

impairment severity resultant of transient ischemic attacks, 

one should document the actual functional impairment 

caused by the condition. Because of the variety of 

symptoms produced by this condition, a highly individualized 

approach is recommended. In addition to the nature of the 

symptoms, their precipitating factors and frequency, 

longitudinal evidence relative to their progression is also to 

be developed.

6. GLOSSARY OF CARDIOVASCULAR TERMS, SYNONYMS, 

ABBREVIATIONS
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AG Angiogram

AI Aortic insufficiency

AMI Acute myocardial infarction

A/S Aortic stenosis

ASCVD Arteriosclerotic cardiovascular disease

ASD Atrio-septal defect

ASHD Arteriosclerotic heart disease

AF Atrial fibrillation

A/V Atrioventricular

BBB Bundle branch block

CAD Coronary artery disease

CHF Congestive heart failure

CV Cardiovascular

ECG Electrocardiogram

EKG Electrocardiogram

HCM Hypertrophic cardiomyopathy

HCVD Hypertensive cardiovascular disease

HHD Hypertensive heart disease

HOCM Hypertrophic obstructive cardiomyopathy

IHD Ischemic heart disease

IHSS Idiopathic hypertrophic subaortic stenosis

LBBB Left bundle branch block

LVH Left ventricular hypertrophy

MI Myocardial infarction

NSR Normal sinus rhythm
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NTG Nitroglycerine

PAC Premature atrial contraction

PAT Paroxysmal atrial tachycardia

PSVT Paroxysmal supraventricular tachycardia

SVT Supraventricular tachycardia

TIA Transient ischemic attack

V.FIB Ventricular fibrillation

VSD Ventricular septal defect

D. SENSORY SYSTEM IMPAIRMENTS

1. BASIC CONSIDERATIONS

In determining impairment severity of visual or hearing deficit, remaining 

vision or hearing in the better eye or ear after best correction is taken into 

consideration.

2. VISUAL DISORDERS

History should include the onset of visual loss, the cause and diagnosis, if 

known, the treatment received and the therapeutic response. If surgery 

has been done, date of surgery and therapeutic results are all parts of 

adequate documentation.

Physical examination should describe the eye findings in detail, including 

funduscopic examination.

Central visual acuity is measured by a Snellen's test for far vision and by a 

Jaeger's test for near vision. In assessing impairment severity, one should 

always utilize the best corrected vision (with eye glasses or contact 

lenses) in the better eye.

Visual field examinations should be carried out via a parametric device 

utilizing a 3 millimeter white objective disc target at a distance of 330 

millimeter. The illumination during the examinations should not be less 

than 7 foot candles. The hand held arc perimeter and the Goldmann 

perimeter are also acceptable as an alternative to the preferred arc 

perimeter.
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Tangent screen perimeters and various automated perimeters while 

helpful in clinical practice are not desirable instruments for disability 

determination purposes. This is mainly due to the fact that many of these 

devices record an erroneously more constricted visual field than the arc 

perimeter or the Goldmann perimeter.

In cases where visual field loss is a component of the impairment severity 

assessment, a copy of the appropriately labeled visual field chart must be 

included in file.

3. HEARING DISORDERS

Generally, in clinical practices, a distinction is made between conductive 

and sensori-neural hearing loss.

When the hearing loss is due to external canal or middle ear 

abnormalities, it is conductive. Hearings loss due to the inner ear and/or 

the eighth cranial nerve is classified as sensori-neural.

Conductive hearing loss in the majority of cases is not expected to last for 

12 months, as opposed to sensori-neural losses which, as a rule, fulfill 

durational criteria.

A special condition relative to hearing impairments is Meniere's disease. It 

is characterized by recurrent, severe vertigo, sensori-neural hearing loss 

and tinnitus. These attacks are associated with nausea and vomiting. 

Occasionally, recurrent feelings of fullness or pressure in the affected ear 

is part of the clinical picture. The hearing loss is usually progressive 

although in the initial stages it is often fluctuating.

History should include the cause of the hearing loss if it is known, along 

with the diagnosis and the development of symptoms. If Meniere's 

disease is the working diagnosis, detailed history as to vertigo, tinnitus 

and fluctuating hearing loss should be elicited.

Physical examination of the ear should be done and results recorded in 

file. The standard tuning fork tests (Rinne and Weber's) are often helpful 

in documentation of a hearing impairment. The presence of an 

audiometric examination by an audiologist does not eliminate the need for 

a physical examination, as the audiometry concerns itself with 

measurements of hearing but not with etiological abnormalities which are 

necessary to document in order to establish a medically determinable 

impairment along with data relative to durational requirements. In sensorineural hearing loss, often a detailed neurological examination is 

necessary.
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Audiometry is the standard measurement used to document the degree of 

hearing loss. As it is primarily a measurement, the audiometer used must 

meet the standards of the American National Standards Institute.

The hearing in the better ear is the value used for proper determination of 

impairment severity. 

If medical evidence suggests hearing is restorable by hearing aid, the pure 

tone testing and speech discrimination testing are to be done with 

simultaneous use of a hearing aid.

Results of the audiometric examination along with a copy of the actual 

chart should be included in the file for adequate documentation. A 

complete audiometric exam should include the results of:

a. Air conduction test,

b. Bone conduction test,

c. Speech discrimination test.

In vestibular-labyrinthine disorders (i.e. Meniere's disease), additional 

special studies (such as caloric test, electronystagmography, 

polytomograms and x-rays of the skull and temporal bone) are needed for 

proper documentation.

4. GLOSSARY OF SENSORY TERMS, SYNONYMS, ABBREVIATIONS 

AD Right ear

AS Left ear

AU Both ears

Aur Ear auricle

bilat. Bilateral

DB Decibels

EENT Eye, ear, nose and throat

OD Right eye

OPH Ophthalmology

OS Left eye
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OU Both eyes

PERLA Pupils equally reactive to light and accommodation

SRT Speech reception threshold

VA Visual acuity

E. RESPIRATORY IMPAIRMENTS

1. BASIC CONSIDERATIONS

Generally, documentation of respiratory impairments of any kind consists 

of medical evidence relative to:

a. Adequate history,

b. Physical examination,

c. X-ray findings,

d. Other special studies of the respiratory system.

In the presence of chronic respiratory failure, claimants invariably 

complain of shortness of breath. This allegation alone is not sufficient for 

documenting a respiratory impairment, but it is essential as the initial step 

toward establishing the diagnosis of chronic pulmonary disease. In 

evaluating respiratory impairments, a distinction generally is made 

between obstructive and restrictive pulmonary conditions.

2. OBSTRUCTIVE DISORDERS

Obstructive disorders are characterized by an increased resistance in the 

airways (blockage) which results in a prolongation of air passage during 

expiration (exhaling). This condition often includes the loss of lung 

elasticity, bronchospasm, edema of the bronchial mucosa and thick 

bronchial secretion.

A mechanical example illustrating the condition is a balloon pump with the 

function of pumping air in and out a tube system. Bronchospasm would 

be corresponding with sudden narrowing of the tubing system permitting 

less room for air to pass through. Edema and bronchial secretion further 

aggravates the same problem. The loss of lung elasticity would be 

analogous with the pump's inability to pump out all the air it sucked in with 

a resultant residual of air. The end result is that the absolute efficiency of 

the pump decreased while resistance of the tubing increased. These two 

factors in combination result in a grossly deficient air exchange.
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Accordingly, the major symptom of all obstructive disorders is dyspnea 

(shortness of breath), even at rest. The term obstructive lung disease is 

often combined with the term "chronic" denoting long term disorder, 

largely involving irreversible changes in the respiratory system's structure 

and function, ultimately producing a clinical picture called chronic 

respiratory failure.

The most frequently occurring chronic obstructive pulmonary diseases 

are:

a. Emphysema,

b. Bronchial asthma.

Since many asthmatics at a later stage of their condition develop 

emphysema as well, the distinction between the two conditions is not 

always easy or clear. Both conditions have the common characteristic of 

episodic nature and, in the end stage, they both can lead to chronic 

respiratory failure.

Claimants with these conditions usually present a history of dyspnea 

(shortness of breath), which is the number one item in the required 

documentation. In addition, a common complaint is chronic coughing with 

or without expectoration (sputum).

Upon physical examination, the physician is likely to find an increased AP 

(anteroposterior) diameter of the chest wall, often referred to as "barrel 

chest" in case of emphysema. The same finding is somewhat unreliable 

and it is not present at the early stages of bronchial asthma, only at the 

stage where chronic respiratory failure and sequential emphysema 

complicates the clinical picture. Use of the accessory muscles of 

respiration with ordinary breathing might be noted as well as flaring of the 

nostrils. When the patient is in chronic respiratory failure, signs of 

cyanosis may be observed.

On percussion, the examining physician may find increased resonance or 

tympanitic chest. Again, these findings are present in emphysema only 

and early stages of asthma may present with a completely normal physical 

examinations with the exception of an examination performed during an 

acute asthmatic attack when the findings are primarily present on 

auscultation.

During an acute asthmatic attack, prolonged expiration (exhaling), coarse 

rhonchi, rales and expiratory wheezing can be present.

In emphysema, the auscultation is of limited value. If any findings are 

mentioned, they are likely to be decreased breath sounds.
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These are some general system findings relative to chronic obstructive 

pulmonary disease such as clubbing of the fingernails, cyanosis and 

dyspnea.

It is to be emphasized that not all these findings are present at the same

time in all patients. Individual judgment is to be used, but the 

preponderance of these findings should be present in order to establish 

the presence of a chronic obstructive pulmonary disease.

On chest x-ray the most common findings are:

a. Hyperaeration of the lungs (increased transparency of the lung 

tissue to x-ray),

b. Flattening of the diaphragm or tenting of the diaphragm at it's rib 

insertion,

c. Occasionally, large bullae may be seen.

Pulmonary function studies measure the lung's capacity for moving and 

containing air, that is, ventilation. With some exceptions, generally, 

pulmonary function studies are used in the evaluation of obstructive 

disorders whereas in the evaluation of restrictive disorders, arterial blood 

gas studies are of greater value.

Pulmonary function studies are to be obtained only when clinically a 

pulmonary impairment is clearly established based upon history, physical 

examination and chest x-ray findings. A mere complaint of dyspnea 

without corroborating objective evidence is not sufficient indication to 

purchase a pulmonary function study.

The documentation requirements for pulmonary function studies are as 

follows:

a. Identification of the spirometer by manufacturer and model number,

b. Properly labeled spirogram showing distance per second on the 

abscissa and distance per liter on the ordinate,

c. Calibration of volume units through mechanical means if the 

spirogram is generated by means other than direct pen linkage to a 

mechanical displacement type spirometer (giant syringe),

d. FVC (FEV-1) recorded at a paper speed of at least 20 mm. per 

second.

3. RESTRICTIVE DISORDERS
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Restrictive disorders are another group of respiratory tract diseases which 

are also characterized by limitation or reduction of the volume of air which 

can be moved in and out of the lungs. As opposed to obstructive 

disorders, the problem here appears to be that our example pump is 

quasi-encapsulated in a hard shell, not permitting the pump to expand 

adequately, that is, the lung's capacity to expand and to contact is 

reduced. The result is again inadequate air exchange. The shortness of 

breath is more prominent on exertion.

Two conditions are particularly known to produce such a restrictive 

disorder:

a. Mechanical restrictions - This involves the loss of ventilatory 

volume due rib cage, thoracic skeletal abnormalities such as 

kyphosis and scoliosis as well as paralysis of the diaphragm.

b. Fibrotic degeneration of the lungs (pulmonary fibrosis) - This 

involves decreasing lung tissue elasticity.

Frequently, both obstructive and restrictive pulmonary diseases are 

present in the same individual.

History should establish the complaint of dyspnea, (that is, shortness of 

breath) particularly on exertion.

On physical examination, various findings might be present. If the 

restrictive condition is a result of mechanical restrictions, physical 

examination should reveal the reason for the disruption of the anatomical 

mechanisms of ventilation (such as the fixation of the rib cage, paralysis of 

the diaphragm, thoracic or other skeletal abnormalities such as kyphosis

or scoliosis.)

If the restrictive condition is a result of fibrotic lung conditions, the only 

physical finding might be markedly diminished breath sounds or some 

dullness on percussion.

The chest x-ray in fibrotic conditions may be normal, or might e 

characteristic of conditions known to cause fibrotic restriction (such as, 

sarcoidosis, diffuse pulmonary fibrosis, etc.)

Arterial blood gas studies are used to analyze the concentration and 

percentage of oxygen and carbon dioxide in the arterial blood coming from 

the lungs (that is, to measure respiration.)

The testing procedure is somewhat invasive and painful. It involves an 

arterial puncture, often times combined with exercise testing of the 

claimant. The technique is to determine the acid base balance in the 
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blood, the arterial carbon dioxide and the oxygen partial pressure in the 

blood, drawn from arteries leaving the lungs.

These test are reflective of the efficiency of oxygen/carbon dioxide transfer 

in the lungs and are most useful in the evaluation of pulmonary disorders 

in which there is lung tissue damage, scarring or fibrosis.

The diagnosis of fibrotic pulmonary condition may be established by 

biopsy. A biopsy should never be purchased as a consultative 

examination. If it is available as evidence of record it establishes the 

diagnosis but does not establish the degree of impairment severity.

s evidence of record, carbon dioxide diffusion capacity may be available. 

This test is subject to a high degree of technical error and should not be 

purchased as a consultative examination but if available it should be 

considered as any other medical evidence.

In the usual case, arterial blood gas studies would not be substituted for 

pulmonary function studies in chronic obstructive pulmonary diseases. 

The ideal documentation of the severity of chronic obstructive lung 

disease is, as discussed previously, the pulmonary function study.

However, there are some chronic obstructive pulmonary conditions in 

which the main process involved is shunting. Such impairment could be 

reflected by blood gas studies establish a disabling pulmonary condition in 

the wake of a chronic primarily obstructive pulmonary disease, the blood 

gas values are acceptable in lieu of pulmonary function studies only if the 

claimant is clinically clearly in chronic respiratory failure.

For instance, an individual who has chronic obstructive pulmonary disease 

which is now acutely superimposed by bronchitis or pneumonia, may be 

producing blood gas values of disabling severity. This is due to the fact 

that his or her ability to compensate for the obstruction is temporarily 

compromised. However, after resolution of the acute superimposition, 

(recovery from bronchitis or pneumonia) the ventilatory function may 

significantly improve. Accordingly, when the pulmonary disease is 

primarily obstructive in nature and evidence of record blood gas studies 

are available indicating a disabling pulmonary condition, particular 

attention is to be paid to determine that the claimant is indeed in chronic 

and not acute (temporary) respiratory failure.

Less often the converse might occur when a claimant has a condition 

which is primarily restrictive in nature and pulmonary function studies are 

indicating a disabling degree of restrictive pulmonary condition. If chronic

respiratory failure is clinically established, the pulmonary function study 

results could suffice in documenting primarily restrictive pulmonary 

disorder.
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If pulmonary function studies are used in evaluating restrictive pulmonary 

diseases, the value to be considered is the vital capacity.

Lung scan results may be available in file. As with lung biopsy it should 

not be purchased as a consultative examination. If it is available, it should 

be used in the establishment of diagnosis and overall assessment.

4. PULMONARY TUBERCULOSIS

The reason for pulmonary tuberculosis not having been given as an 

example or categorized under obstructive or restrictive conditions, is that it 

may produce various clinical pictures depending on the stage of the 

disease and the extent of the lung involvement. It is very rare, in this day 

and age, that treated tuberculosis per se would reach disabling severity. 

However, in certain cases when the disease involves an extensive area of 

lung parenchyma, significant loss of respiratory function may result. In 

such case, documentation with either a pulmonary function study and/or 

arterial blood gas studies could be used for determining severity. In the 

usual case, the presence of an active lesion as documented by a positive 

sputum test would not be a determinant of severity.

5. PULMONARY MALIGNANCY

This condition will be discussed under MALIGNANCIES.

6. AUTOIMMUNE DISEASES

These diseases involving the lungs will be discussed under MULTIPLE 

BODY SYSTEMS.

7. COR PULMONALE

This condition involves both the lungs and the heart. The causative factor 

is the heart condition. It will be discussed under CARDIOVASCULAR 

IMPAIRMENTS.

8. DISEASES OF THE LARYNX

Since the larynx is part of the respiratory system it will be discussed here.

The most common potentially disabling condition affecting the larynx is 

cancer. In most cases, a laryngectomy is performed resulting in partial or 

total loss of ability to speak. The degree of speech loss would determine 

the claimant's ability to perform work related activities. Impairment 

severity would be determined by two factors:

a. The degree to which the claimant's natural ability to speak is 

compromised, and
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b. The degree to which the patient's speech is restored by using 

various electronic assisting devices.

In evaluating speech one should consider it's:

a. Intelligibility,

b. Volume

c. Sustainability,

d. Speech structure.

9. OTHER INFECTIOUS DISEASES OF THE LUNGS (MYCOTIC 

INFECTION, ETC.)

These types of lung disorders are usually both obstructive and restrictive. 

They can be evaluated either on the basis of the impairing impact on the 

claimant's pulmonary function or in some cases, on the basis of other 

systemic involvements (brain, heart, etc.).

When pulmonary function is the determinant of severity, pulmonary 

function studies or arterial blood gas studies may be used for evaluation.

10. OCCUPATIONAL LUNG DISEASES (SILICOSIS, ASBESTOSIS, 

PNEUMOCONIOSIS, BERYLLOSIS, ETC.)

These diseases can cause nodular or diffuse fibrous degeneration, as well 

as generalized granulomatous disease with resultant impairment of

pulmonary function. For determination of the impairment's severity, both 

pulmonary function studies (vital capacity) and/or arterial blood gas 

studies can be useful.

11. GLOSSARY OF RESPIRATORY TERMS, SYNONYMS, 

ABBREVIATIONS

COPD Chronic obstructive pulmonary disease

COLD Chronic obstructive lung disease emphysema

CDAL Workers pneumoconiosis

CWP Black lung disease

FEV-1 Forced expiratory volume in one second

FVC Force vital capacity
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MVV Maximal voluntary ventilation

PA Co2 Arterial partial pressure of Co2 (mm Hg.)

PAL, Chest x-ray (Postero-anterior and Lateral)

PA 02 Arterial partial pressure of 02 (mm Hg.)

Pulmonary In- sufficiency Respiratory failure

SOB Shortness of breath, dyspnea

TB Tuberculosis

WNL Within normal limits

F. GASTROINTESTINAL IMPAIRMENTS

1. BASIC CONSIDERATIONS

Disorders of the gastrointestinal system that are found to be disabling, are 

disabling either because of resultant malnutrition or due to complications 

of the impairment. Since therapeutic response is considered in the overall 

severity assessment, documentation of therapy and response is often 

essential for adequate documentation of the claim.

The more common gastrointestinal problems include recurrent upper 

gastrointestinal hemorrhage, stricture, stenosis or obstruction of the 

esophagus, peptic ulcer disease, chronic liver disease, chronic ulcerative 

or granulomatous colitis and regional enteritis. Significant weight loss due 

to miscellaneous gastrointestinal disorders also often occurs.

Most of these, as well as other less common gastrointestinal disorders, 

require documentation in terms of the claimant's past medical history, 

physical examination findings, as well as findings by means of special 

studies (e.g. x-ray examination, endoscopic examination, biochemistry 

findings, etc.)

2. RECURRENT UPPER GASTROINTESTINAL HEMORRHAGE

Documentation of this condition requires that the claimant's past history 

evidence hematemesis, preferably confirmed by medical personnel. The 

latter is desirable because lay observers tend to mistake any bleeding 

through the mouth for hematemesis. Bona fide hematemesis involves a 

large amount of bright or dark red material proven to be blood on chemical 

testing.
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Generally massive hematemesis results in immediate hospitalization, thus 

on physical examination aided by special studies it is easily confirmed. By 

use of nasogastric tube placed in claimant's stomach and suctioning, 

generally a large amount of blood is obtained.

An alternative means of documentation consists of use of esophagigastroscopy through which the hemorrhage can be directly observed. In 

order to consider upper gastrointestinal bleeding as "recurrent", by 

definition, it has to occur at least twice sufficiently far apart to assure the 

reviewer that indeed the bleeding is recurrent and not one occurrence 

being interrupted by temporary remission. Exact time frame cannot be 

given but it is desirable that at least several weeks elapse between the 

episodes to qualify for the term "recurrent."

"Hemorrhage" refers to brisk bleeding, not simply oozing. Accordingly 

systemic symptoms are expected to accompany through hemorrhage. 

These systemic findings include decreased hemoglobin level, faintness, 

dizziness, tachycardia, in more severe cases loss of consciousness. 

Documentation should be secured whenever possible relative to the 

source of bleeding since many of the causative conditions are correctable 

by surgery.

Optimal documentation also includes evidence to the fact that claimant's 

coagulation system is intact.

3. STRICTURE, STENOSIS OR OBSTRUCTION OF THE ESOPHAGUS

Documentation of these disorders must evidence substantial weight loss 

caused by the disorder.

Documentation of the specific disorder requires demonstration of the 

condition by both esophagoscope and x-ray studies.

Biopsy and cytology studies of the strictured area are often valuable to 

determine the etiology and the stricture. The most frequent causative 

conditions are neoplasm and fungal diseases. While neoplastic diseases 

are rarely reversible, fungal diseases are often treatable and reversible. 

Accordingly, whenever these studies are available as evidence of record 

they should be secured.

NOTE: Cytology studies or biopsies should never be ordered as 

consultative examinations by the Railroad Retirement Board.

If stricture is not neoplastic in origin, it is desirable that documentation 

evidence that dilations of esophagus has been tried, since the majority of 

benign esophageal strictures are treatable enabling claimant to maintain 

adequate nutritional status.
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4. PEPTIC ULCER DISEASE

Claimant's medical history includes epigastric pain, at times accompanied 

by vomiting.

In bleeding ulcers, history of hematemesis may be obtained.

If the claimant underwent surgery for the ulcer, recurrence of the disease 

is significant information. Documentation of recurrence goes beyond 

history; it is to be demonstrated by special studies.

X-ray evidence of recurrent ulcer is often difficult following definitive 

surgery, due to the fact that typically there is a great deal of distortion of 

the area of previous ulcer by the surgery. As a result, recurrence of ulcer 

is more often suspected than actually proven by x-ray. Consequently, 

unless the recurring ulcer is unusually large, proper documentation relies 

upon gastroscopic findings.

An infrequent but potentially disabling complication of peptic ulcer disease 

is fistula formation.

Inoperable fistulas are usually complications of ulcer surgery. As a result 

of the fistula, a large volume of fluid is being continuously lost. The 

claimant who is unable to compensate for the loss of a large amount of 

fluid gradually becomes malnourished.

Documentation of fistula formation should demonstrate accordingly:

a. X-ray evidence of fistula,

b. Measurement of daily fluid loss,

c. Signs of malnutrition.

Physical examination findings are not characteristic in uncomplicated 

ulcer. There may be vague abdominal tenderness and/or distention. If 

obstruction occurred, severe abdominal distention is a common finding. 

Because of the impact peptic ulcer disease might have on the claimant's 

nutritional status, a report of the claimant's height and weight is always an 

inherent part of the physical examination report. Whenever the claimant's 

poor nutritional status is considered as a significant factor in finding of 

disability, documentation should be secured to evidence that the claimant 

has none of the remedial causes of peptic ulcer complications (such as 

obstruction.)

To satisfy this aspect of documentation repeat upper GI x-ray series are 

desirable along with statement from the treating physician regarding 

claimant's compliance in following diet and medication.
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5. CHRONIC LIVER DISEASE

Symptoms vary depending on the stage of the disease. Anorexia, fatigue, 

nausea and weakness are common elements of history which also might 

be positive for habitual excessive drinking and/or hepatitis.

During history taking, special attention is being paid to previous episodes 

of hematemesis to elicit the possibility of esophageal varices. It is to be 

noted that past history of hematemesis is not tantamount to having 

esophageal varices, as a host of other conditions can cause 

hematemesis.

History of massive hematemesis, supported by direct endoscopic 

observation by a physician of bleeding varices, is considered sufficient 

documentation of the severity of chronic liver disease.

An alternative to this direct endoscopic observation is x-ray evidence of 

varices enabling the professional reviewer to attribute the hematemesis to 

the varices.

A palliative therapy performed to alleviate the problems caused by 

esophageal varices is shunt operation. Documentation of this operation 

requires the operative report describing the procedure. The term "shunt 

operation" refers to porto-caval shunting procedures. Shunt procedures 

performed to manage otherwise intractable ascites (Le Veen shunt) are 

not to be considered as a shunt operation for esophageal varices.

Physical examinations findings in chronic liver insufficiency are varied and 

numerous. Jaundice, hepatomegaly, ascites are the most common 

findings. When the claimant's consciousness is impaired due to hepatic 

insufficiency in the wake of established chronic liver disease, the 

diagnosis of hepatic encephalopathy should be considered. The initial 

symptoms include drowsiness, sluggish movements and speech 

disturbances, which symptoms eventually progress to confusion, stupor 

and frank coma.

Some claimants with chronic liver disease develop skin and/or endocrine 

abnormalities. Spider nevi, palmar erythema and gynecomastia are some 

examples.

Routine laboratory evaluation of claimants with chronic liver disease 

shows several significant abnormalities.

Blood chemistry studies will demonstrate low serum albumin and elevated 

serum globulin values. One of the most widely used blood chemistry 

studies in documenting chronic liver disease is serum bilirubin. In order to 

utilize serum bilirubin values as evidence of chronic liver disease, they 
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must be fractionated. Fractionated bilirubin studies divide the bilirubin by 

chemical means into total and direct bilirubin. Claimants with hemolytic 

jaundice will have constant elevated bilirubin without liver disease but the 

bilirubin is almost all total bilirubin. This is in contract with claimants with 

genuine liver disease whose bilirubin values are elevated in the total and 

the direct fraction.

Several serum enzyme values, if significantly elevated, are indicative of 

hepatic dysfunction. It is to be noted that the abnormal enzyme value 

must be at least three to four times greater than normal to document 

significant functional impairment. Enzymes most often elevated are 

SGOT, SGPT, LDH and alkaline phosphatase.

The most valuable special study in establishing the presence and severity 

of chronic liver disease is liver biopsy. Documentation requires a detailed 

pathological report of liver biopsy, for the term "cirrhosis" is used too 

liberally in clinical practice. Fibrosis and disorganization of the liver 

structure must be reported to substantiate the diagnosis of cirrhosis of the 

liver.

If ascites is present, it has to be documented not only as a physical finding 

but also needle aspiration of abnormal cavity should evidence the 

presence of fluid. Ultrasound examination of the abdominal cavity 

constitutes an acceptable alternative documentation to needle aspiration.

6. CHRONIC ULCERATIVE COLITIS

Usual history of these claimants consists of a series of episodes of bloody 

diarrhea with minimal or no symptoms between attacks. Recurrent bloody 

stools should be demonstrated by proctoscopic or colonoscopic evidence 

of active colitis by direct visualization. X-ray evidence is not a requirement 

and it is frequently not done; however, if barium enema results are 

available as evidence of record substantiating the condition, they should 

be secured.

Occasional blood in passed stool is not evidence that colitis has recurred 

or that it is active.

One of the most significant complications of this condition is anemia due 

to blood loss as a result of recurrent bloody stools. Anemia, when 

present, should be documented by repeated hematocrit determinations.

Since another potential sequela of this disease is significant weight loss, 

height and weight values are an inherent part of the documentation of 

chronic ulcerative colitis.
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In some cases, chronic ulcerative colitis is not limited to the 

gastrointestinal system, but it may involve other organs or body systems. 

The most often affected areas include the joints (arthritis), the eyes (iritis) 

and the liver. Proper documentation of systemic manifestations requires 

an accurate clinical description of the organ involved.

When the condition is complicated by fistula formation, intractable abscess 

or stenosis, intermittent obstruction might be the result. Proper 

documentation of intermittent obstruction requires not only an accurate 

description of clinical findings of obstruction, but also corroboration by 

abdominal x-rays. 

7. REGIONAL ENTERITIS

Due to the vagueness of symptoms, this condition is not only difficult to 

diagnose but it is equally difficult to identify past history and/or chief 

complaints characteristic of regional enteritis. Systemic symptoms such 

as anorexia and weight loss, often accompany the initial episodes of 

diarrhea. Visual complaints due to iritis and joint pains due to arthritis are 

found as complications of this condition.

On physical examination, elevated temperature might be found. 

Abdominal pain, distention or mass on palpation, perianal fistula and/or 

abscess formation, are not infrequently present. Abnormal funduscopic 

findings, joint swelling and jaundice indicate systemic manifestations.

Laboratory findings are not specific, thus the presence of the condition can 

only be proven by x-ray description of findings or macroscopic observation 

during surgery. In the latter instance, detailed and specific description of 

macroscopic findings is required. It is to be noted that biopsy of the lesion 

is not diagnostic of regional enteritis.

Persistent or recurrent intestinal obstruction must be documented by 

repeated x-ray finding of obstruction. Physical findings of abdomen are 

important, but x-ray evidence takes precedence.

Although, in general documenting the presence and severity of an 

impairment, by accurate description of findings is more important than 

establishment of an exact diagnosis, it is important for proper 

documentation of gastrointestinal disorders that an exact gastrointestinal 

diagnosis be made to account for the gastrointestinal findings. This is a 

requirement because many emotional conditions can cause 

gastrointestinal symptoms such as loss of appetite, nausea, vomiting, 

diarrhea and weight loss.

8. GLOSSARY OF GASTROINTESTINAL TERMS, SYNONYMS, 

ABBREVIATIONS
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BILI T&D bilirubin total and direct

BS Bowel sounds

G Gastrointestinal

HAA Hepatitis associated antigen

IJ BYPASS Ileo-jejunal bypass

JAUND Jaundice

LGI Lower gastrointestinal

NG Nasogastric

PR Per rectum

RDA Recommended dietary allowance

RECT. Rectal

RLQ Right lower quadrant, abdomen

RUQ Right upper quadrant, abdomen

SGOT Serum glutamic oxaloacetic transaminase

SGPT Serum glutamic pyruvic transaminase

SMB Small intestine

TPN Total parenteral nutrition

TWE Tap water enema

UGI Upper gastrointestinal

WN Well nourished

G. GENITO-URINARY IMPAIRMENTS

1. BASIC CONSIDERATIONS
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Impairments of this body system include various conditions, involving 

organs of the genito-urinary apparatus. As with other body systems 

documentation includes adequate history physical examination and 

special studies confirming the presence of a genito-urinary system 

disease. With few exceptions, disability resulting from these disorders is 

determined by the resultant renal failure. In addition, treatments for renal 

failure (such as hemodialysis, peritoneal dialysis, kidney transplantation) 

may also have an impact on the impairment severity.

One of the conditions representing an exception from the previously 

described group of genito-urinary disorders is nephrotic syndrome. This 

condition can cause disability even if bone fide renal failure is not present. 

Nephrotic syndrome is a collection of low serum albumin, increased fats 

(cholesterol and triglycerides) and edema. These manifestations reflect 

the essence of the syndrome, that is, excessive protein loss due to kidney 

damage.

Documentation requirements of genito-urinary disorders are similar in all 

cases, regardless of the underlying condition if chronic renal failure 

ensued. They will be outlined next. The somewhat different 

documentation standards of the nephrotic syndrome will follow.

2. CHRONIC RENAL FAILURE

Since the long-term prognosis of chronic renal failure is principally 

different from that of acute renal failure, documentation of the chronic 

nature of claimant's renal disorder and the subsequent renal failure is an 

essential part of claims development. Medical evidence fulfilling this 

requirement (that is, providing longitudinal perspective over claimant's 

condition) include hospital records and/or outpatient records. Considering 

the debilitating nature of chronic renal failure, patients are almost 

invariably under continuous medical care, thus ample medical evidence 

should be available as evidence of record in most cases.

Systemic manifestations (such as anorexia, weight loss, weakness, 

fatigue and lassitude of chronic renal failure) along with symptoms of 

associated anemia, glucose intolerance, peripheral neuropathy or 

osteodystrophy are all non-specific. They are results of retention of 

various metabolic by-products under normal circumstances excreted by 

the kidneys (urea, creatinine, potassium, etc.).

Physical examination findings vary, as well. Neuromuscular 

manifestations seen on physical examination include muscular twitching 

as well as peripheral neuropathy affecting sensory or motor functions or 

both.
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Malnutrition, leading to severe weight loss and muscular wasting, is 

common. Accordingly, documentation of the claimant's height and weight 

in the physical examination report are always desirable.

Further complications of chronic renal failure have to be documented. For 

instance, the common and uncomfortable symptom of intractable pruritus 

can reach disabling proportions. Hypertension, edema and heart failure 

are frequent sequelae of persistent fluid overload. Pericardial irritation or 

inflammation (pericarditis) may be the cause of substernal chest pain 

which is often confirmed by ECG or echocardiograph findings.

Documentation of the need for chronic dialysis (either peritoneal or 

hemodialysis) is essential in the determination of the severity of chronic 

renal failure.

In case of renal transplant, documentation should secure medical 

evidence pertaining not only to the fact that is has been performed but 

also relative to the period of convalescence (that is, adequacy of renal 

function twelve months following surgery.)

Complications, if any, should be documented, as well. Renal infections, 

rejection, systemic complications and side effects of steroid and/or 

immunal suppressive therapy are not uncommon postsurgically.

Primary diagnostic confirmation of chronic renal failure is by special 

studies. Laboratory testing of blood and urine (that is, serum creatinine 

and creatinine clearance in a pooled 24-hour urine collection) are the most 

basic studies.

In addition to these primary studies, adjunct laboratory results are often 

desirable. Results of blood gases, electrolytes, serum calcium and 

phosphorous are often available as evidence of record. Complete blood 

count often documents low hematocrit indicating anemia. A bone x-ray 

may show osteoporosis, osteitis fibrosa and/or pathological fractures. A 

chest x-ray and ECG will show congestive heart failure, when present.

3. NEPHROTIC SYNDROME

Abnormalities in serum and urinary protein characterize this genito-urinary 

system impairment.

Documentation of this condition relies heavily upon evidence of record as 

these claimants are invariably under continuous medical supervision. 

History is best obtained from hospital or outpatient records.

Confirmation of the impairment is obtained through serum albumin 

determination and urinary protein determination in a 24-hour interval. 
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Serum cholesterol is another adjunctive laboratory evidence in 

establishing the presence of this renal disorder.

In addition to these special studies, adequate documentation should 

reveal appropriate physical findings.

Physical findings should include descriptions of the extent and location of 

tissue edema, the presence of absence of ascites, pleural and/or 

pericardial effusion, hydrarthrosis, etc.

If renal biopsy was performed, results of the biopsy should be secured.

NOTE: Due to the invasive nature of the procedure a renal biopsy should 

never be ordered as consultative examination by the Railroad Retirement 

Board.

The determination of impairment severity of the nephrotic syndrome 

depends on the level of serum albumin and urinary protein. These 

parameters should be viewed in light of the claimant's therapeutic 

response.

4. GLOSSARY OF GENITO-URINARY TERMS, SYNONYMS, 

ABBREVIATIONS

A/G Albumin globulin ratio

Alb Albumin

BUN Blood urea nitrogen

Ca Calcium

Creat Creatinine

GFR Glomerular filtration rate

GU Genito-urinary

IVP Intravenous pyelography

KUB Kidney, ureter and bladder x-ray

Retro Pyelo Retrograde Pyelography

Sod Bicarb Sodium bicarbonate

TP Total protein
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TUR Transurethral resection

UA Routine urinalysis

UTI Urinary tract infection

H. HEMIC-LYMPHATIC IMPAIRMENTS

1. BASIC CONSIDERATIONS

This group of disorders include disorders of the different blood cells (red 

blood cells, white blood cells and platelets), as well as the factors involved 

in the coagulation process.

Red blood cell disorders are often manifested by anemia which results in 

pallor and weakness. Diseases affecting white blood cells are usually 

characterized by frequent bacterial infections since these cells play a 

predominant role in the body's immune defense mechanism. Platelet 

disorders, along with vascular disorders and clotting factor deficiencies, 

result in hemorrhagic tendencies.

The more common red cell disorders are due to deficient red blood cells. 

However, polycythemia vera is characterized by an increase in red blood 

cells. As a result of this increase in the red blood cells, the blood 

becomes thick (hyperviscosity) and the resultant impaired blood flow is 

responsible for most of the clinical signs and symptoms.

The most common red blood cell disorders result in anemia. There are 

varied causes of anemia, due to deficient red cell production because of 

lack of component substances (e.g. iron deficiency, folic acid deficiency) 

or because of bone marrow failure (hypoplastic and aplastic anemia). 

Some anemias are due to excessive red cell destruction (e.g. hemolytic 

anemias, such as sickle cell anemia), and some are a result of a 

combination of both decreased production and increased destruction 

(chronic disease malignancy, renal disease.)

The white blood cell disorders are also characterized by either reduction in 

their number (granulocytopenia) or an abnormal accumulation of abnormal 

white cells (leukemia).

Plasma cell disorders are characterized by the proliferation of a group of 

cells normally involved in immunoglobulin synthesis. Multiple myeloma is 

a neoplastic disease characterized by the over-production of abnormal 

immunoglobulins. The presence of abnormal cells results in pathologic 

fractures, bone pain and recurrent infections.
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MACROGLOBULINEMIA is another plasma cell disorder which involves 

IgM synthesis and results in hyperviscosity (thickening of the blood) 

symptoms and recurrent bacterial infections. Diagnosis is made by serum 

or urine protein electrophoresis and/or immunoelectrophoresis.

A finding of disability due to these disorders is based on the recurrent 

systemic infections and/or bone abnormalities. They should be 

documented accordingly.

Coagulation disorders may be classified into three groups based on the 

stages of clotting:

a. Vascular phase (e.g. anaphylactoid purpura, hereditary 

telangiectasia,)

b. Platelet phase (e.g. idiopathic thrombocytopenic purpura, 

congenital platelet defects such as wiskott-aldrich syndrome,) and, 

c. Coagulation phase (e.g. Hemophilia.)

These groups of disorders may result in a finding of disability, because of 

the recurrent bleeding tendencies requiring frequent blood transfusions. 

In addition, bleeding into major organs (e.g. the brain) can cause 

irreversible resultant changes.

Many of the hemiolymphatic disorders are classified as neoplasms 

because of the presence of abnormal cells that tend to proliferate and take 

over the normal cells in the blood and the bone marrow. The most 

common of these are the lymphomas, foremost of which is Hodgkin's 

disease. A finding of disability occurs when the disease is uncontrolled by 

prescribed therapy or if there is a metastasis, to distant organs.

The documentation of hemic-lymphatic disorders preferably include more 

than a one-time consultative examination (internist) and appropriate 

laboratory test. Hospitalization and/or out-patient records to document the 

longitudinal course of the alleged disorder is also always desirable.

Since these conditions require ongoing medical monitoring, as a rule 

hospital records should be available.

2. DISORDERS OF THE RED BLOOD CELLS

These diseases are characterized by the anemia caused by either 

excessive blood loss, deficient red cell production and/or excessive red 

cell destruction.
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Regardless of the cause, the documentation should include a history of 

the symptoms (e.g. weakness, lassitude, excessive bleeding, etc.) and the 

diagnosis, if already established.

Physical examination findings should include pallor, noted not only on the 

skin but also in the mucous membranes (e.g. conjunctiva, buccal 

mucosa). In some cases where there is excessive red cell destruction, 

splenomegaly may be noted.

Laboratory findings to establish the diagnosis include, the red blood cell 

count, hemoglobin and/or hematocrit.

The following discussion of sickle cell anemia reflects the special features 

of this disease not seen in other anemias. History should include the 

episodes of sickle cell crisis, its frequency, severity and the type of therapy 

received (i.e. blood transfusions, prolonged hospitalizations, etc.) Inquiry 

as to the involvement of major organs (such as the lungs, brain and heart) 

is needed since it is not uncommon for sickle cell disease to cause organ 

damage. Frequent hospitalizations due to repeated sickle cell crisis may 

be significant in the process of finding the degree of severity of disability. 

Medical records from previous hospitalizations generally provide optional 

documentation of this order.

Physical examination findings in sickle cell disease include joint swelling 

and/or deformity, which may be marked, especially during a crisis. 

Splenomegaly is also a common finding.

Laboratory examination to document the diagnosis of sickle cell anemia 

include hemoglobin electrophoresis, red blood cell count (decreased and a 

peripheral smear (typically showing sickle cells).

3. DISORDERS OF THE WHITE BLOOD CELLS

The most common disease of this group is leukemia, acute and chronic.

History usually consists of an apparently infectious process with acute 

onset, although it may have an insidious onset with progressive weakness 

and pallor.

The less common, granulocytopenia (a reduction in white cells) may 

present with the same history. 

Leukemia is usually treated with chemotherapy. It is important to elicit a 

history of drug side effects since these may cause symptoms, affecting the 

impairment severity assessment.

Physical examination findings seen in this group of disorders include, 

pallor, splenomegaly and lymphadenopathy.
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Special studies confirming the diagnosis are complete blood count, 

peripheral blood smear examination and/or bone marrow puncture 

examination showing the abnormal white blood cells. The latter test (bone 

marrow puncture) is an invasive and painful procedure and should not be 

ordered as a consultative examination by the Railroad Retirement Board.

4. HEMORRHAGIC DISORDERS

These are diseases which are characterized in hemorrhagic tendencies. 

This may be due to a defect in the vascular system, the platelets or 

coagulation factors.

Regardless of etiology, bleeding tendency is the predominant symptom 

elicited in the history. Many of these disorders (e.g. hemophilia) are 

hereditary; thus, the family history is an important aspect of 

documentation.

There are no characteristic findings in this group of disorders, on physical 

examination, however, hematomas and ecchymoses are common 

findings. In addition, in hemophiliacs with repeated bleeding in their joints 

(hemarthrosis) there may be joint swelling and effusion which, if chronic, 

may result in permanent joint deformity. Hospital records usually include 

all the required documentation.

Special studies to document the diagnosis include coagulation studies 

(platelet count, bleeding time, prothrombin time, specific assays for factors 

V-XIII, etc.)

5. LYMPHOMAS

The two major types are Hodgkin's disease and non-Hodgkin lymphoma.

History consists of varied systemic symptoms ranging from fever, nights 

sweats, weight loss to bone pain.

Physical findings include lymphadenopathy which should be differentiated 

from other diseases causing lymph node enlargement.

Special studies include lymph node biopsy and/or bone marrow 

examination documenting the characteristic cells. Because they are 

invasive, they should not be purchased as a consultative exam.

6. PLASMA CELL DISORDER

The most common of these disorders is multiple myeloma which is a 

progressive and neoplastic disease.
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History includes persistent, bone pain and/or pathologic fracture. 

Recurrent bacterial infection is also common. It is not unusual for renal 

failure to be the presenting symptom.

Physical examination findings are usually not characteristic or prominent 

except for pallor.

Special studies include laboratory findings (such as anemia seen in a 

complete blood count, proteinuria and an abnormal serum protein 

electrophoresis.) Occasionally, x-ray of the bones may show 

characteristic punched-out lesions or osteoporosis.

Another plasma cell disorder is macroglobulinemia. History should include 

fatigue, weakness, bleeding, visual disturbances and headache. Physical 

examination reveals generalized lymphadenopathy and 

hepatosplenomegaly. The confirmatory special studies include laboratory 

diagnosis made by serum protein electrophoresis and/or 

immunoelectrophoresis.

7. GLOSSARY OF HEMIC-LYMPHATIC TERMS, SYNONYMS, 

ABBREVIATIONS

ALL Acute Lymphocytic leukemia

Aniso Anisocytosis

CBC Complete blood count

CLL Chronic lymphocytic leukemia

CML Chronic myelocytic leukemia

CGL Chronic granulocytic leukemia

Coag Coagulation

EBL Estimated blood loss

Fe Iron

G-6-PD Glucose-6-phosphate dehydrogenase

HB or Hgb Hemoglobin

Hct Hematocrit

ITP Idiopathic thrombocytopenic purpura
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PTT Partial thromboplastin purpura

PT/Quick

Time One stage prothrombin time

RBC Red blood cell

Retic Reticulocyte

Rh Rhesus factor

SS or SC Sickle cell

T & C Type and cross match

TIBC Total iron binding capacity

WBC White blood cell

I SKIN IMPAIRMENTS

1. BASIC CONSIDERATIONS

Finding of disability on the basis of a skin disorder may result when the 

skin lesion involve extensive body surface or areas (such as the hands 

and feet) which are crucial for job-related activities and/or normal daily 

functioning. In many instances, the response of the disease to therapy is 

taken into consideration, as certain skin disorders resist therapy.

As with other impairments, skin impairments must be shown to have 

persisted or to be expected to persist at disabling severity for at least 12 

months following onset.

Certain systemic diseases may include skin abnormalities as one of the 

systemic manifestations (systemic lupus erythematosus, dermatomyositis, 

scleroderma). In these cases, along with other body systems involved, the 

extent of the skin lesion and resultant functional restriction must be 

documented.

Malignant tumors of the skin require documentation, as outlined in the 

chapter for malignant tumors.

Some skin disorders result in severe physical disfigurement. 

Documentation of impairment of this nature is done separately below.
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Certain diseases (such as psoriasis) manifest not only skin involvement 

but also joint swelling (arthritis). Documentation of the body system 

involved is an inherent part of claims development in these cases. 

Standards for documentation are outlined in the chapter for 

musculoskeletal impairments.

3. DOCUMENTATION STANDARDS OF COMMON SKIN DISORDERS

History of the skin condition has to be sufficiently detailed to assist 

determination of diagnosis as well as prognosis. Onset date of the 

disorder, description of the symptoms, their location and severity are all 

elements of adequate documentation. This type of data is usually part of 

outpatient follow-up records. The same medical evidence also often 

contains data as to the nature of therapy as well as the therapeutic 

response. Adverse side effects of therapy should be documented if they 

occurred.

Physical examination findings are varied however, the majority of skin 

diseases are diagnosed by characteristic skin lesions. The findings vary 

from papules, nodules and vesicles to scales, crusts and ulcers. The oral 

mucosa, the axillary area, the anogenital areas, scalp and nails may be 

involved in the disease process, thus findings in these areas should be 

noted.

In cases where contractures occur secondary to burns, it is important to 

document the areas affected since they may cause significant limitation of 

motion (i.e. burns involving the chest and the axilla may restrict abduction 

and/or elevation of the shoulder).

There are no specific laboratory diagnostic tests for skin disorders, 

however, skin biopsy results may give an indication of the exact nature 

and etiology of the condition.

NOTE: Biopsy should never be ordered as a consultative examination by 

the Railroad Retirement Board, but when available as evidence of record it 

is always desirable to obtain this valuable medical evidence.

If the skin disease is a manifestation of a systemic disorder, the 

appropriate laboratory tests to document the underlying condition are a 

relevant part of the required medical evidence.

3. PHYSICAL DISFIGUREMENT

Although physical disfigurement without functional loss is rarely a basis for 

finding of disability, severe disfigurement due to any cause (skin disease, 

burns, etc.) may preclude the claimant from job activities requiring 

extensive person to person contact or dealing with the public in general.
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When disfigurement is found to be a significant factor in impairment 

severity assessment, the following documentation is necessary:

a. Detailed physical examination results, describing the physical 

defect and therapy received along with the side effects of therapy 

and the therapeutic response.

b. Description of claimant's daily activities, potential constriction of 

interest, reclusiveness and relationship with others, in general. 

This data is necessary to determine the functional limitations the 

claimant's disfigurement causes not only in a physical but also in a 

psychosocial sense. Information relative to repeated denial of 

employment due to claimant's appearance may be considered as 

adjunctive evidence of a non-medical nature.

c. Current photographs of the claimant along with close up view of the 

affected areas are often helpful evidence aiding the impairment

severity assessment process. If use of prosthesis has been 

recommended pictures should be taken while prosthesis is in use.

Frequently, claimants with disfiguring impairments develop secondary 

psychiatric conditions (e.g. depression) which should be documented and 

evaluated in addition to the disfigurement caused by the skin lesion itself. 

Documentation standards for the additional psychiatric impairment, if 

present, are outlined in chapter for mental impairments.

4. GLOSSARY OF TERMS, SYNONYMS, ABBREVIATIONS

derm Dermatology, dermis

epith Epithelium (skin)

SC Subcutaneous

SMR Submucous resection

STSG Split thickness skin graft

UVL Ultraviolet light

J. ENDOCRINE SYSTEM IMPAIRMENTS

1. BASIC CONSIDERATIONS
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Disability resulting from endocrine disorders is caused by either an excess 

or deficiency of hormones secreted by endocrine glands. Since hormones 

enter the blood, rather than ducts, they can impact upon any or all organs 

through the circulatory system. Accordingly, abnormalities in endocrine 

function may affect other body systems. Hormones play a major role in 

metabolism and are crucial for normal physical and mental development, 

reproduction and homeostasis. If endocrine disorders occur during the 

early stages in life affecting development, permanent pathological 

conditions may be the result.

2. THYROID DISORDERS

This group of diseases is a result of either excessive or underproduction of 

hormone. The diagnosis is established by characteristic symptomatology 

resulting from the hormonal imbalance. Laboratory findings substantiate 

the level of glandular functioning; thus, thyroid function tests are an 

inherent part of adequate documentation.

Complete physical examination findings should document any other organ 

involvement resulting from the thyroid disorder. It is common to find 

exophthalmos (protrusion of the eyeballs) along with goiter. Chronic 

exposure of the eyeballs can result in the drying out of membranes 

covering the eyes. Significant impairment severity can be found on that 

basis alone. Establishment of severity depends on the ophthalmological 

findings; specifically, that of exophthalmometry.

In summary, documentation of thyroid disorders should include:

a. History of the disorder, corresponding symptoms,

b. Physical examination findings describing involvement of other body 

systems, if any;

c. Laboratory tests should include thyroid function studies and,

d. If exophthalmos is present an ophthalmological examination to 

document the extent of exophthalmos.

3. DIABETES MELLITUS

The diagnosis of diabetes mellitus is customarily established by findings of 

persistently elevated blood sugar, family history and symptomatology 

initially characterized by a triad of polyuria, polydipsia and polyphagia.

The degree of elevation of blood sugar level, per se, does not determine 

the severity of the condition. Complications (that is, end-organ damage 

resulting from diabetes) are the determining factor of severity.
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Acidosis occurring frequently, requiring repeated hospitalizations, should 

be factored into the impairment severity assessment. Records of 

repeated hospitalizations are to be secured for review.

Documentation of end-organ damage consists of careful history to identify 

the organs involved. Commonly, complaints of blurred vision indicate 

involvement of the retinal blood vessels. Numbness and tingling in the 

extremities may reflect peripheral neuropathy. In cases where peripheral 

vascular disease complicates the clinical picture history may vary from 

intermittent claudication to amputation due to non-healing wound which 

eventually resulted in gangrene. In cases with ocular (retinal) involvement 

ophthalmological examination results should be included in file. If renal 

complications are at issue, signs and symptoms of the renal involvement 

along with renal function tests are necessary for adequate documentation.

Documentation of diabetes mellitus includes not only a comprehensive 

history and system review documenting symptomatology, but also a 

comprehensive physical examination to explore potential end-organ 

damages. Hospitalization and outpatient records are valuable evidence in 

determining the course of the disease and the resultant complications.

4. DIABETES INSIPIDUS

Abnormalities of the posterior pituitary gland may cause this condition. 

Diagnosis is usually easily established by history, which also includes the 

course of the disease.

Laboratory documentation includes an urinalysis indicating low specific 

gravity. Hospital records generally indicate electrolyte abnormalities upon 

admission due to recurrent dehydration, a frequent complication of this 

condition.

5. HYPERPARATHYROIDISM

In addition to history describing the claimant's symptoms, laboratory 

evidence establishing this condition is elevated parathyroid hormone level. 

Other laboratory findings include serum calcium and serum phosphorous 

level. The former is pathologically elevated while the latter is depressed.

Finding of severity is generally commensurate with the manifest bone 

disorder that is secondary to generalized decalcification of bones.

The x-ray of the bones indicates various abnormalities ranging from signs 

of decalcification to pathological fractures.

If other body systems are involved physical examination and systems 

review should document the severity of impairment of corresponding body 
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system. For documentation standards of each body system, the reviewer 

is cross-referred to the appropriate chapter of this appendix.

6. HYPOPARATHYROIDISM

This condition is the opposite of the pathological condition described 

above.

Documentation standards for the condition are similar to those of 

hyperparathyroidism; of course, the findings will be different. Generally, 

the characteristic mineral abnormality (that is, pathologically low serum 

calcium level supported by parathyroid hormone assay) is sufficient to 

establish the diagnosis.

As a sequelae to the hormone and mineral imbalance, neuromuscular 

irritability is found in these claimants. Clinically, this irritability is 

manifested in severe and recurrent episodes of tetany. The same 

underlying pathology can expand to the extent that generalized seizures 

occur. The history of episodes of tetany and/or convulsions are best 

obtained from hospitalization or outpatient records. A one-time 

consultative examination is usually inadequate to establish this particular 

facet of the disorder.

Parathyroid hormone deficiency is known to cause cataracts. If visual 

complications accompany Hypoparathyroidism, apply the documentation 

standards outlined in the chapter for visual impairments in this appendix.

7. GLOSSARY OF ENDOCRINE TERMS, SYNONYMS, ABBREVIATIONS

ACTH Adrenocorticotrophic hormone

ADH Anti-diuretic hormone

DM Diabetes mellitus

DI Diabetes insipidus

DOCA Deoxycorticosterone acetate

FBS Fasting blood sugar

FTI Free thyroxine index

Glu Glucose

GTT Glucose tolerance test
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17-OH 17 hydroxysteroids

I131 Iodine 131 (radioactive iodine)

17-KS 17 ketosteroid

PBI Protein binding iodine

PPBS Post-prandial blood sugar

PTH Parathyroid hormone

PZI Protamine zinc insulin

RIA Radio-immuno assay

TSH Thyroid stimulating hormone

T3 Uptake Triiodothyronine uptake

K. NEUROLOGICAL IMPAIRMENTS

1. BASIC CONSIDERATIONS

A neurological examination usually includes the following:

a. Mental Status Examination - This part of the neurological 

examination provides documentation relative to the claimant's level 

of consciousness (alert, comatose, stuporous, confused, etc.); 

orientation to time, person, and place and intellectual deterioration. 

Memory is tested along with the claimant's reality testing. 

Abnormal behavior patterns, if present, should also be noted here.

b. Speech - Claimant's ability to communicate by verbal means should 

be documented. The presence of aphasia, or other speech 

impairment, along with any other significant interference of 

communication should be noted.

c. Cranial Nerve Examination - This should include findings of the 

testing of cranial nerves, such as ability to swallow, etc. Any 

hearing or visual defects should be noted as well in this portion of 

the neurological examination.

d. Cerebellar Function Tests - This portion of the neurological 

examination is concerned with the claimant's stand or station, gait 
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and coordination in the upper and lower extremities. If ataxia, 

hemiparesis, limping, or abnormal ambulation is present, a 

description of the claimant's ability to walk and stand with and 

without ambulatory devices should be included in the report. 

Common tests used in this area are: Romberg's test, finger to nose 

test, rapid alternating movements, etc.

e. Motor Function Examination - This essential portion of the 

examination includes the presence or absence of rigidity, tremors, 

weakness, etc. Any abnormalities of muscle groups should be 

quantified (that is, graded from normal to complete paralysis.)

f. Sensory System Examination - The senses of touch, pain, 

temperature (hot or cold), vibration and muscle joint position sense 

are tested. Sensation may be normal, decreased, absent or 

heightened. Stereognosis (recognition of shapes by touch with 

eyes closed) is also tested.

g. Reflex Examination - A reflex, by definition, is a response evoked 

by a stimulus; it may or may not be conscious. A set of reflexes is 

usually tested. Examples of the upper extremity reflexes are, the 

biceps and triceps reflex. Examples of superficial reflexes in the 

face include the corneal reflex. In the lower extremities, the knee 

jerk or patellar reflex and the ankle jerk or Achille's reflex is tested 

as well as some pathological ones (such as the Babinski reflex). 

Superficial reflex in the abdomen is the abdominal reflex and the 

cremasteric reflex.

2. EPILEPSY (SEIZURES)

Epilepsy is a syndrome as opposed to uniform disease entity. The 

epilepsy syndrome may be divided into two general categories of its 

clinical manifestations.

a. Major Motor Seizures (Grand Mal or Generalized) - This type of 

seizure is characterized by momentary feeling of strangeness 

(aura) followed by unconsciousness and convulsive movements of 

the arms and the legs. These events are followed by complete 

relaxation of the muscles to such an extent that there might be 

incontinence of urine and sometimes feces. This phase is often 

followed by sleep or gradual regaining of consciousness.

1) Documentation Requirements

a) History - Include the following essential items:

Onset of seizures,
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Description of seizures.

This portion of the documentation can be obtained 

several ways, emergency room and/or hospitalization 

records may have a detailed description of the 

seizures observed by a doctor, a nurse, or hospital 

personnel. If these are not available, the claimant's 

attending physician could be contacted for 

description, if he himself has observed an alleged 

seizure. More frequently, the friends or relatives of 

the claimant have observed a seizure. Therefore, in 

the absence of medical evidence documenting a 

detailed seizure description, lay evidence may be 

used to document an alleged seizure. The claimant's 

description of his own seizure, is however, 

unacceptable, since he is supposed to be 

unconscious during a seizure and thus would not be 

aware of what actually happens during an episode. 

This portion of the documentation is crucial for 

documentation of a seizure disorder since the 

objective findings are usually negative. A seizure 

patient commonly has a normal neurological 

examination and many seizure disorders will manifest 

with a normal EEG.

b) Frequency of Seizures - This information may be 

obtained from the claimant's treating physician and/or 

relatives who live with the claimant. This information 

may also be found in out-patient progress notes 

and/or follow-up notes (clinic records).

If the claimant alleges daytime and/or nighttime 

seizures, the frequency of each one must be clearly 

documented. In addition, if seizures occur only at 

night, information as to the presence of any residuals 

occurring the day after a seizure, is essential. This is 

to provide information as to how these residuals 

would affect the claimant's ability to function during 

the day. The frequency of seizures usually imposes 

considerable difficulty in verification.

Actual frequency is subject to a great deal of 

variability. Certain patients may experience no 

seizures for many months, then suddenly may have 

several attacks within a brief period of time.
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The following information in c), d), and e) must be 

obtained in detail when seizures occur in such a 

manner.

c) Prescribed Therapy - This should include the names 

and dosages of the medications the claimant is taking 

to control his seizures. Statements relative to the 

claimant's compliance to prescribed therapy is 

needed, since most seizures are controlled by anticonvulsive therapy. The determination of blood levels 

of Dilantin or other anticonvulsive drugs are useful in 

determining whether treatment is being followed. On 

cases adjudicated after 1980, this type of evidence is 

desirable to secure.

d) Physical Examination - Physical examination findings 

should include the complete neurologic examination. 

While a completely normal neurological examination 

is often present in a substantial number of claimants 

with genuine seizure disorder, this portion of the 

documentation is an indispensable part of the 

documentary process. If the examination is not 

normal, the abnormal findings may include injury 

secondary to a seizure episode (such as bruises, 

lacerations, tongue bite, etc.).

e) Laboratory - An EEG (Electroencephalogram) should 

also be in the record substantiating the presence of 

convulsive disorder. A positive EEG does not 

necessarily mean that the impairment is severe; 

however, it serves to confirm the diagnosis of 

epilepsy. On the other hand, a normal EEG does not 

necessarily rule out a seizure disorder or imply that 

the impairment is not severe. Fifteen percent of 

epileptics have a normal EEG. Due to the statistically 

significant number of individuals who have a genuine 

seizure disorder with concomitant normal EEG, an 

allowance can be made in the presence of normal 

EEG if the preponderance of evidence indicates a 

disabling seizure disorder. Nevertheless, this 

provision is not intended to eliminate the need for 

documentation of EEG as when it is present and it is 

positive it increases the likelihood significantly as to 

the presence of a genuine seizure disorder.

The anticonvulsant serum level is an essential 

documentation requirement in seizure disorders, 
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since the most important factor in determining the 

severity of seizure disorders is the response to 

therapy (that is, whether frequency and intensity of 

the seizures will occur in spite of adherence to 

prescribed therapy). The serum level of each 

prescribed medication should be obtained.

An acceptability of an EEG is unlimited, except when 

secondary changes occurred in the clinical 

manifestations of the seizure disorder.

b. Minor Motor Seizures - This category may be further divided into:

1) Petit Mal - This consists of a brief interruption of 

consciousness, sometimes accompanied by rhythmical 

blinking of the eyelids. Recovery usually immediately follows 

and the entire episode usually occurs within seconds. A 

classic petit mal may be developed by getting a detailed 

description of a seizure in the same manner as obtained in a 

seizure description in major motor seizures. A petite mal 

seizure is usually very brief in its episode. The seizure 

episode itself is not determinant of severity. It is the 

postictum manifestation, if any, which interferes with the 

claimant's ability to perform work related functions; therefore, 

the documentation of postictal manifestations in petite mal 

(as well as the other less common types of minor motor 

seizures) is essential in the documentation of these types of 

seizure disorders. Such postictal manifestations, which are 

usually behavioral, as well as their duration, should be 

documented in the file. Unlike the previously described 

major motor seizure disorder which does not have a 

characteristic EEG pattern or doesn't necessarily have 

positive EEG finding whatsoever, this type of seizure 

disorder has a very specific EEG abnormality without which 

pattern the diagnosis of petite mal is considered 

unsubstantiated and undocumented. This absolutely 

necessary positive EEG finding is 3 per second, spike and a 

wave EEG pattern.

There are two less common types of minor motor seizures 

that are sometimes classified as petit mal. The EEG findings 

for classic petit mal are not necessarily characteristic of the 

two less common types of minor motor seizures.

The first one is myoclonic jerks. This is sudden and 

involuntary contraction of the muscles of the trunk or 

extremities. They may e slight, or they may become so 
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violent that the claimant may drop an object held in the hand. 

The seizure should be adjudicated under the minor motor 

seizure disorder.

The other type of minor motor seizure is akinetic seizure 

(drop attacks). This is characterized by a sudden loss of 

tone in all the muscles resulting in the patient's fall to the 

ground. If there is any loss of consciousness, it is usually 

very brief. Again the documentation of this is the same as 

the documentation of petit mal and the adjudication would 

also be done under minor motor seizures.

2) Focal Seizures - During an attack of focal seizure, the 

claimant remains conscious. The seizure itself consists of 

clonic movements in localized groups of muscles such as 

the hand or the forearm. There may be momentary 

weakness of the muscles involved (Todd's paralysis). These 

are classified under minor motor seizures. Focal seizures 

very rarely have postictal manifestations.

Certain focal seizures may cause a spread of epilepsy 

discharge causing clonic movement throughout the body 

(Jacksonian seizure). In such cases, consciousness is lost. 

Further manifestation of the Jacksonian seizures are similar 

to those of a Grand Mal type. Documentation of this type of 

seizure disorder should involve very careful detailed 

description of the seizure to enable an independent reviewer 

to determine whether adjudication should be done under 

major motor seizures or minor motor seizures. The 

predominant manifestations should be the guide to be used 

in this determination. Nevertheless, previously outlined 

documentation requirements apply to whichever type of 

seizure is more predominant, whether it be the major motor 

seizure or the minor motor seizure.

A special type of focal (or partial) seizure is the psychomotor 

or temporal lobe seizure. This is the complex disorder of 

sensation ranging from sensory hallucination (sight, sound, 

taste or smell) to highly organized psychic disturbances. 

Occasional chewing movement and smacking of the lips are 

accompanying symptoms. Frequently, this type of seizure 

disorder results in the alteration of consciousness (dreamy 

and confused state) as opposed to loss of consciousness. 

These phenomenon are followed by repetitive, usually 

stereotype, automatism which involve only partially 

purposeful or totally inappropriate bizarre behavior. There is 

complete amnesia of these events after the attack. In these 
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types of seizure disorders, documentation should include, as 

in other seizures, a detailed description of the seizures.

3. CEREBROVASCULAR ACCIDENT (STROKE) - This 

condition often occurs without any forewarning signs, but 

even if some forewarning signs have been present for some 

time the event is usually dramatic. In a matter of several 

minutes, the claimant develops a wide scale of neurological 

symptoms, the specifics of which depend on the area 

affected by the accident. Functional loss directly after the 

occurrence of the CVA tends to be much greater than the 

residuals after the stormy, dramatic event settles. 

Accordingly, the functional loss observed immediately after 

the stroke, tends to be much more exaggerated and affects 

greater neurological functions than the residuals will be once 

the accident takes a more chronic and less precipitous 

course.

Proper documentation of this condition consists of 

documentation of the time the cerebrovascular accident 

occurred, possible forewarning signs (transient ischemic 

attacks), description of the functional loss (symptoms, signs 

and findings), as well as documentation of a waiting period 

of approximately three months to permit the individual to 

regain all the functions that were only temporary lost and to 

assess the residual symptoms which are unlikely to improve 

with time. Results of detailed neurological examinations, 

three months after the alleged episode of CVA, are crucial to 

the determination of severity. This should include the same 

detailed findings as detailed under basic considerations of 

the complete neurological examination. If any motor 

dysfunction is present due to the episode, this should be 

documented by detailed description of the motor system 

(that is, if there is any weakness, spasticity and/or cerebellar 

abnormalities such as ataxia, incoordination, tremor). The 

neurologic findings should be completed and detailed to 

enable an independent reviewer to determine the degree of 

interference the neurologic abnormalities would impose on 

the claimant's remaining ability do fine and/or gross 

movements as well as the degree of interference that it could 

impose on the patient's ability to stand and walk.

4. CEREBRAL PALSY - The term cerebral palsy embraces s 

group of disorders of the motor system present at birth. This 

is true even if at times all signs of the disease may not be 

immediately apparent at birth. The most common clinical 

feature is spastic paraplegia with brisk tendon reflexes and 
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extensor plantar responses. There is a spasm of the 

muscles at that time. Sometimes, only the upper extremities 

are involved, but, more commonly, one upper and one lower 

extremity is involved. Accompanying intellectual disability

and epilepsy are often present in cerebral palsy. As with any 

other neurologic disorders, the diagnosis of cerebral palsy 

should be established and this can be made by obtaining 

records from the claimant's attending physician or past 

medical records of hospitalization documenting the 

neurologic dysfunctions which led to the diagnosis of 

cerebral palsy. If the claimant is seen as an adult, it is more 

difficult to obtain birth records which document the possible 

cause or the cerebral palsy. However, previous medical 

records, hospital records or outpatient follow-up would also 

document the neurologic dysfunctions which would have 

been the basis for documenting cerebral palsy.

By definition, cerebral palsy is a static condition, that is, 

progression or improvement of the condition is not expected 

throughout life. When the diagnosis of cerebral palsy is 

definitely established, the neurologic findings need not be 

very recent. Nevertheless, they should contain a complete 

documentation of the neurologic findings (that is, including 

the motor, sensory and reflex findings as well as cerebellar 

examination).

In cerebral palsy, there are various degrees of severity of the 

neurologic dysfunction. In many cases, cerebral palsy may 

result in motor dysfunction that would be so severe as to 

interfere with the claimant's ability to walk, stand and/or to 

perform fine and gross motor manipulations. However, in 

certain cases where there is less severe neurologic 

dysfunction, a finding of severity may be made when it is 

combined with other disorders (such as seizure disorder, 

Intellectual Disability, significant behavioral or emotional 

disorder and/or significant speech, hearing or visual 

problems). In the latter type of cases, documentation should 

include not only the establishment of the diagnosis of 

cerebral palsy and the corresponding neurologic findings, 

but should also include an IQ testing; when Intellectual 

Disability is present, or if any mental impairment is present 

such as autism and/or emotional disorders, a detailed 

psychiatric examination report should be in the file. When 

there is evidence of a significant defect in speech, hearing or 

vision, the documentation of this additional impairment 

should also be made accordingly.
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5. HEAD INJURY - Compound fractures and depressed 

fractures of the skull often result in cerebral trauma. The 

most severe forms of brain damage with gross 

traumatization usually result in unconsciousness and there is 

a danger of intercranial bleeding. Persistent eurologic 

deficits after recovery are often found. The resulting 

neurologic manifestations of head injuries are similar to that 

seen in cerebrovascular accidents; therefore, the 

documentation of head injury is the establishment of the 

diagnosis, the chronology of events leading to the head 

injury and the resulting neurologic residuals.

In addition to normal neurologic findings, a head injury may 

also result in a seizure disorder which should then be 

documented just like any seizure case. Likewise, the head 

injury may result in chronic organic brain syndrome which 

would be documented as outlined under mental impairment.

6. INTRACRANIAL TUMOR - The usual symptoms of 

intracranial tumors are caused by irritation and destruction of 

the nerve tissue as well as intracranial pressure. Deficits 

arising as a result of a brain tumor depend on which area of 

the brain is affected. Brain tumors vary from the most 

common (which is the benign gliomas) to the malignant brain 

tumors. It is crucial in the documentation of brain tumors to 

obtain the pathology report documenting what type of brain 

tumor is present since there are certain forms of malignant 

gliomas (such as glioblastoma multiform). Other types of 

brain tumors should be documented not only by the 

pathological classification of type of brain tumor present, but 

also the resulting neurologic dysfunction. Therefore, the 

crucial evidence needed for these types of tumors is the 

neurologic examination findings. It is also crucial to 

establish if there is any evidence of metastasis anywhere 

else secondary to the brain tumor.

7. PARKINSONISM - Parkinsonism is a syndrome which 

includes generalized poverty of movement, tremor and 

rigidity. It is a progressive degenerative disorder affecting the 

basal ganglia. Documentation needed in Parkinsonism is 

the history of the disease (that is, the signs and symptoms) 

which must support the diagnosis. Disease is fairly 

characteristic (that is, the first and most prominent symptom 

is tremor). Rigidity usually follows the same distribution as 

the tremor. Eventually, bradykinesia may also be noted. With 

progression of symptoms, there is significant neurologic 

dysfunction resulting in disturbance in the patient's ability to 
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perform fine and gross as well as dexterous movements and 

his ability to walk and stand is also markedly affected. The 

crucial documentation for parkinsonism includes not only the 

characteristic history and the course of the disease, but also 

the response to therapy as well as the detailed neurologic 

examination findings.

8. CHOREA - This condition is characterized by sudden jerking 

movement of the limbs which, although not fully coordinated, 

may have the appearance of poor manners. The two most 

common types are the Huntington's chorea and sydenham

chorea. Sydenham chorea is a benign disorder of childhood 

and is usually one of the manifestations of rheumatic fever. 

On the other hand Huntington's chorea is a progressive 

disorder consisting of dementia and bizarre involuntary 

movements. It is a hereditary disorder and mental 

deterioration usually occurs sooner or later. The latter type 

of chorea (Huntington's) is the most serious one, since it is a 

degenerative disease and usually results in very severe 

neurologic dysfunction. Documentation of the resulting motor 

dysfunction could be done with a comprehensive neurologic 

examination. In addition, there is mental deterioration, and 

possibility of development of chronic brain syndrome occurs 

eventually. Documentation of this resulting impairment could 

be done as in the documentation for chronic brain syndrome 

outlined under the mental impairments category (that is, with 

detailed mental status as well as the description of daily 

activities).

9. MULTIPLE SCLEROSIS - This is a chronic disease which is 

caused by the absence of the covering of the nerve cells and 

is clinically manifested by a variety of neurologic symptoms 

and signs which have a tendency toward remission and 

exacerbation. The chief character of the symptoms is the 

multiplicity and the tendency to varied nature as well as 

severity with passage of time. Documentation of this 

disorder includes the history, which is crucial to determine 

the course of the disease and the response to therapy. 

Change of the symptoms occurs frequently; therefore, it is 

important that current neurological findings be in the file to 

allow determination of current severity. There are no 

characteristic laboratory findings of multiple sclerosis, 

therefore, laboratory evidence may be helpful when positive 

but does not negate the presence of the disease when it is 

negative (example CAT scan).
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10. DISEASES OF THE SPINAL CORD - This includes diseases 

such as compression of the spinal cord by tumor or cervical 

spondylosis, subacute combined degeneration of the cord 

and syringomyelia. The careful establishment of the 

diagnosis and the history, the course of the disease, the 

supporting laboratory findings (such as the results from a 

myelogram, a CAT scan and/or EMG) should be secured if 

available. When the diagnosis is established, the resulting 

neurologic dysfunction should be documented with a 

comprehensive neurologic examination. If there is any 

persistent disorganization of motor function that would result 

in the inability of the patient to use his upper extremities for 

manual manipulation or the use of his lower extremities for 

standing and/or walking, such a finding should be described 

in detail as it can limit the claimant's residual functional 

capacity. In certain spinal cord disorders where there is 

involvement of the cranial nerves, the cranial nerve 

examination (part of the comprehensive neurologic 

examination) should allow the evaluation of the presence of 

significant bulbar signs, if any. In certain cases (such as 

poliomyelitis), certain residuals result, in addition to 

significant motor dysfunction involving one or two 

extremities. There may be difficulty with swallowing or 

breathing or with the patient's ability to speak intelligibly; 

therefore, in addition to the complete neurologic 

examination, comprehensive physical examination with 

general observations should document if any of the above 

abnormalities are present.

11. DISORDERS OF MUSCLES - This includes the classic 

muscular dystrophy and myasthenia gravis. Types of these 

disorders involve not only the muscle itself but the 

innervation of these muscles. Significant muscle weakness 

with resulting atrophy is a common finding. In myasthenia 

gravis there may also be difficulty with speaking, breathing, 

and swallowing, which findings should be taken into 

consideration when evaluating the overall physical 

examination findings.

Response to therapy should also be documented in the file. 

Overall, however, disorders of muscles would result in 

finding of severity when there is significant motor dysfunction 

resulting from muscular weakness. The comprehensive 

neurologic examination which should be in file would include, 

among other things, the description of the muscles, and the 

presence or absence of atrophy. The muscle strength of the 

affected muscle group should be quantitated. It is not 
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sufficient that the report would only say mild, moderate, or 

severe weakness, but this should be illustrated in more detail 

by a description of how the muscle group would respond to 

resistance and gravity.

12. PERIPHERAL NEUROPATHY - This type of impairment 

may be the result of end-organ damage by diseases such as 

diabetes mellitus. The diagnosis is established by the 

symptoms (that is, numbness and tingling of extremities) and 

by the neurologic findings (that is sensory deficits). In severe 

cases, there are motor deficits documented by muscle 

weakness and/or atrophy. Again, documentation of this type 

of disorder is adequate with a comprehensive neurologic 

examination.

13. GLOSSARY OF NEUROLOGICAL TERMS, SYNONYMS, 

ABBREVIATIONS 

ALS Amyotrophic lateral sclerosis

ANS Autonomic nervous system

CAT scan Computerized axial tomography

CNS Central nervous system

CP Cerebral palsy

CSF Cerebro-spinal fluid

CVA Cerebro-vascular accident

DT Delirium tremens

DTR Deep tendon reflex

EEG Electroencephalogram

EMG Electromyography

EOM Extraocular movements

GM Grand mal

HNP Herniated nucleus pulposus

KJ Knee jerk
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LP Lumbar puncture

MS Multiple sclerosis

MD Muscular dystrophy

Phenobarb Phenobarbital

TIA Transient ischemic attack

L. MENTAL IMPAIRMENTS

1. BASIC CONSIDERATIONS

For disability evaluation purposes, four different categories of mental 

impairments should be distinguished:

a. Intellectual Disability, 

b. Chronic organic brain syndrome,

c. Functional psychotic disorders,

d. Functional nonpsychotic disorders.

2. INTELLECTUAL DISABILITY

Among these four types of mental impairments, Intellectual Disability is the 

most objectively, numerically assessed. Intellectual Disability is a lifelong 

condition characterized by below-average intelligence with resultant 

impairment in learning, maturity, and social adjustment. This assessment 

is carried out by the use of standardized measurements of intelligence 

often referred to as psychometric testing. Psychometric testing is 

professionally administered by psychologists. Accordingly, while organic 

brain syndromes, functional psychotic disorders, and functional nonpsychotic disorders are best assessed by physicians, the optimal 

assessment of Intellectual Disability lies in the field of psychology. In some 

instances of organic brain syndrome, where the impairment primarily 

affects the intelligence, psychometric testing is also useful to establish an 

objective measure of intellectual deterioration.

There are several types of psychometric testing that yield a numerical 

measurement of intelligence (IQ). It is generally agreed that the Wechsler 

Intelligence Scale (revised) is the most reliable intelligence testing. This 

scale provides three different IQ values: the full scale IQ (computed by 
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utilizing two subtest scores); the performance score (performance IQ); 

and, the verbal score (verbal IQ).

NOTE: In assessing the impairment severity of the claimant the lowest of 

the three subtest scores always prevails.

The second most popular psychometric testing provides only one IQ 

score. This test is the Stanford-Binet Intelligence Test. There are several 

other acceptable intelligence tests, (Leiter, McCarthy, Cattel, Raven); 

however, either the Wechsler or the Stanford-Binet is always desirable.

Several tests are often erroneously used for assessment of intelligence 

and they are unacceptable as they either measure something other than 

intelligence or they are not well standardized. The most often mistakenly 

used tests are:

a. Peabody Picture Vocabulary Test,

b. Vineland Social Maturity Test,

c. The Denver Developmental Achievement Test,

d. The Slosson Intelligence Test.

Intellectual Disability is a lifelong condition which is not subject to 

significant improvement once the intelligence level has reached its final 

plateau. Nevertheless, during the early years of development, it is subject 

to change, particularly depending on the degree of Intellectual Disability. 

Accordingly, when assessing the acceptability of psychological testing one 

should consider the claimant's age at the time of the testing as well as the 

date of testing as it relates to the date adjudication.

TIMELINESS OF PSYCHOMETRIC TEST RESULTS

IQ Score Age at testing Time Limit

Below 40 Before 7 Years 2 Years

Over 40 Before 7 Years 1 Year

Below 40 Before 7 Years 4 Years

Over 40 Before 7 Years 2 Years

Any IQ At 16 or Older No Limit
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Medical evidence is always desirable to verify that the claimant's IQ is 

consistent with his daily activities, scope of interest, ability to relate to 

others, and general behavior. 

In assessing the medical evidence one should be conscious of the fact 

that an IQ of 59 or below is characteristic of the lowest two percent of the 

general population.

There are some special circumstances, particularly in the profoundly 

intellectually disabled range, where, due to the claimant's condition, a well 

standardized IQ testing cannot be performed. In these instances, 

psychological or medical reports (specifically describing the claimant's 

behavior with attention to the obvious intellectual, social, and physical 

impairment) should be secured.

3. ORGANIC BRAIN SYNDROME, FUNCTIONAL NONPSYCHOTIC 

DISORDERS, AND FUNCTIONAL PSYCHOTIC DISORDERS

These disorders are best evidenced by a psychiatrist's report.

Psychiatric judgment in clinical practice relies heavily on observations of 

the interviewer (that is, the psychiatrist draws inference from what he sees 

as the patient's behavior) as to the nature of the patient's mental functions.

Two salient features of this have particular significance for disability 

assessments: 

The clinician observes and describes behavior. This is the type of 

objective evidence required for independent assessment.

Although there are varied schools of thought in the field of psychiatry 

which may affect the diagnosis, treatment, approach, etc., in a clinical 

setting, these variances have little impact on the required documentation. 

It is so, because it is the actual observation and descriptions which are 

central to the disability assessment. The definition of disability requires 

that the individual have a medically determinable impairment 

substantiated by signs, symptoms, and ancillary findings.

The evidence should contain three basic characteristics: it should be 

current, complete, and objective, requiring a minimum amount of 

extrapolation relative to the claimant's functioning. The timeliness of this 

evidence is required for both determining current severity and duration.

Obtaining detailed objective evidence (as opposed to subjective 

judgments) is very important and often difficult.

For example, if the psychiatrist just sates that the claimant "appears 

paranoid," this is inadequate documentation as it represents a conclusion 
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only and does not relay how that conclusion was reached. On the other 

hand, if the physician states that "the claimant appears paranoid as he 

glanced around the room after entering, stating that he just wants to make 

sure the office is not electronically bugged", then we have objective data. 

In the latter example, the psychiatrist clearly demonstrated why he 

concluded that the person was paranoid.

Another example concerns cognitive functioning. The psychiatrist might 

state "the memory and concentration are o.k." This is inadequate 

evidence, as the data used to come to this conclusion is not presented. 

Instead, the report should disclose the procedure and response (such as, 

"the claimant's immediate memory is good as measured by his ability to 

repeat five items after two minutes waiting").

Proper documentation should include medical evidence relative to the 

following four elements of claimant's condition.

a. Medical History - Every well documented file should contain a 

medical history. In Mental disorder claims, longitudinal information 

is often more important than it is in other body systems. A report of 

past psychiatric hospitalizations might be helpful in documenting 

the continuing nature of the mental disorder. It can also aid in 

determining whether a particular behavior is in response to an 

acute stress or is part of a long-term process.

For example, sudden severe paranoia may be a newly emerged 

problem but it might have been present in low grade form for a 

number of years. It might also be an acute response to drug 

ingestion from the streets (such as, PCP, LSD, etc.) or prescribed 

medications (such as, corticosteroid). The first instances would be 

more consistent with a psychosis such as schizophrenia, while the 

latter are limited to the duration of the affect of the drug with only a 

few or no postpsychotic residuals. Historical data can also be used 

to determine whether longitudinally significant deterioration has 

taken place.

The perspective that a well-documented psychiatric history 

provides is especially useful when the only current medical data in 

file for the mental disorder is a one-time evaluation by a 

consultative examination. This may or may not be representative of 

the claimant's usual functioning. A medical history provides the 

background with which the current medical information can be 

correlated. This is similar to a strip of movie film comprised of many 

individual still pictures none of which alone portrays the whole 

story. Only by observing each still picture in a series and in proper 

sequence does a coherent progression of events emerge. More 

than one individual piece of medical evidence is needed in order to 
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portray the development, current status, and potential duration of a 

mental disorder. 

b. Mental Status - A vital part of psychiatric evidence is the mental 

status examination. This can be defined as a systematized 

description of the psychiatrist's observations and impressions of the 

claimant. There are several parts of the mental status examination 

and each one is an important component in assembling the total 

picture of claimant's functioning. The following are several 

important sections:

1) There should be a description of the claimant's appearance 

noting areas such as dressing, personal hygiene, type of 

distress and motor activity.

2) A description of the claimant's attitude toward the interviewer 

is helpful in trying to draw conclusions about the claimant's 

behavior in a work situation. For example, if the claimant 

establishes a profile of hostility when facing questions posed 

to him, difficulty might be anticipated in the person's 

relationship to coworkers and supervisors.

3) The manner in which the claimant expresses himself gives 

an indication of possible underlying psychopathology. Such 

phenomena is pressured speech, loosened associations, 

disturbances in perception (hallucinations), disturbances in 

content of thought (delusions), or disturbances in form of 

thought (loosening of associations, incoherence, flight of 

ideas, ideas of reference, etc.), along with some "soft signs" 

of thought disturbances (poverty of thought, thought 

blocking, circumstantiality, tangentiality), are potentially 

incapacitating. Being aware of these disorders is important 

because they influence work and school behavior.

4) Speech content gives us an idea of what the claimant's main 

concerns are. The previously mentioned perceptual 

disturbances, disturbances in content and form of thought, 

somatic preoccupations, suicidal and homicidal ideations, 

phobias and obsessions are examples of significant findings.

5) A description of claimant's emotional state, both from the 

interviewer's and the claimant's point of view, is valuable 

information about the claimant's mental life. Mood disorders 

(such as, mania and depression) can be impairing; 

especially, as they affect energy level and concentration. 

Thus, it is necessary to see if they are present.
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6) An assessment of the claimant's appropriate level of 

cognitive functioning is important in determining the extent 

that the claimant can learn new tasks and cope with the 

changing requirements of a work situation. A person's 

orientation, memory, attention, concentration, ability to 

abstract, fund of general information and level of judgment 

need to be tested.

Assessment of the claimant's insight into his mental 

condition will permit better prognostication regarding 

treatment compliance.

c. POST MORBID FUNCTIONING - Residuals of a psychiatric illness 

affect post morbid functioning and, therefore, it is necessary to 

have an account of the individual's daily activities after some of the 

acute symptoms have subsided. For example, after an acute 

schizophrenic episode there often is a prolonged postpsychotic 

depression during which the psychotic symptoms (delusions, 

hallucinations, incoherence) are no longer evident. Nevertheless, 

there might be a series of residuals present (such as, pronounced 

lack of energy, disturbance in eating or sleeping, feeling of 

hopelessness and helplessness, at times suicidal ideations, suicidal 

attempts, etc.). Although these symptoms might not be described 

as schizophrenic by nature they do interfere with normal 

functioning.

A contrasting example would be manic depressive illness where the 

person's behavior can e quite disturbed during the manic episode 

but with treatment, his ability to function may be remarkably good 

after a few weeks. Due to the fluctuations of symptoms of 

psychiatric conditions, a single current examination may not always 

sufficiently describe an individual's sustained ability to function. The 

claimant's level of functioning may vary considerably over a period 

to time depending on the claimant's ego strength, stability of 

condition, regression potential, stress tolerance and other factors. 

The level of functioning at any particular point in time may appear 

relatively efficient or very poor. Proper evaluation the claimant's 

sustained customary functioning is best obtained by longitudinal 

evidence.

d. DAILY ACTIVITIES - The task of disability documentation does not 

end by simply confirming the claimant's allegations by clinical 

findings. The process involves a second step of documenting the 

impact the verified psychiatric impairment has on the individual's 

ability to function. Documentation of the claimant's activities, which 

is representative of the individual's customary daily psychological 

functioning, is a vital part of the documentation of mental claims. 
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The documentation should cover the description of the claimant's 

typical daily activities, scope of interest and ability to relate to 

others. In cases where the claimant's condition is not psychotic, his 

ability to attend to personal hygiene should be documented as well. 

Often, it is necessary to obtain documentation relative to the 

claimant's sleep pattern, appetite, energy level, relationships with 

others, nature of these relationships, ability to engage in hobbies 

and other discretional activities and to take care of household 

chores.

A description of these activities can be deceptively optimistic, 

particularly in cases of psychiatric claimants with supporting 

families or claimants who live in various highly structured settings 

such as halfway houses, day care centers, nursing homes, etc. In 

assessing the claimant's daily activities, scope of interest and ability 

to relate to others (that is, the claimant's quality of life) one should 

be cognizant of the independence with which the claimant 

participates in these described activities, the frequency and 

appropriateness of the activities and the general quality of the 

claimant's daily living.

For instance, if it is stated that the claimant watches television all 

day it should not be automatically assumed that the claimant 

watches television as a choice as opposed to other recreational 

activities, that claimant selects the programs that he enjoys, or 

even that the program, per se, registers while the claimant is sitting 

in front of the television set. In some instances the family puts the 

claimant in front of the television set, turns it on, and the claimant, 

removed from reality, sits in front of the television not as a result of 

free choice but rather as a sign of withdrawal, indecisiveness, and 

diminished motivations

Similar individual judgment should be applied in assessing each 

and every aspect of the claimant's daily activities, scope of interest, 

ability to relate to others and (in nonpsychotic disorders) ability to 

attend to person hygiene.

Many mental disorders have a common feature; that is, the disorder 

is characterized by one or more psychotic episodes interrupted by 

intervals with different degrees of recovery. This recovery is 

typically varied and uncertain. Documentation of the claimant's daily 

functioning should be comprehensive, pertaining to as large a 

portion of the claimant's daily living as possible. Certainly, the 

documentation should describe usual daily functioning for a greater 

length of time than, for instance, a period of acute hospitalization.
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It should be clear that the documentation must enable the examiner 

to form an objective opinion, free of assumptions and predictions 

about claimant's current functioning.

Due to the nature of mental impairments, it is often desirable to 

obtain a statement from the examining physician/psychologist 

regarding the claimant's ability to handle his own finances.

In summary, the medical documentation of psychiatric claims is 

multiple. The first step is to substantiate the presence of a 

medically determinable impairment; the second is to document the 

historical background and longitudinal aspect of the mental 

disorder. This is followed by the description of a comprehensive 

mental status. The fourth element is to secure documentation 

relative to the claimant's customary daily living, which should be 

current, typical, and representative of the claimant's usual daily 

functioning. This documentation should be thorough and detailed to 

enable the independent reviewer to assess the claimant's 

impairment severity, residual functional capacity, and competence 

to manage their own affairs.

4. GLOSSARY OF MENTAL TERMS, SYNONYMS, ABBREVIATIONS

CBS Chronic organic brain syndrome

CPZ Chlorpromazine (a type of neuroleptic medication)

CNS Central nervous system

CVA Cerebrovascular accident

DT Delirium therapy

ECT Electroconvulsive Tremens

EST Electrosh ck therapy

FSIQ Full scale IQ

IQ Intelligence quotient

MAIO Monoamine oxidase inhibitor (A type of antidepressant 

medication)

MSW Master of Social Work
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OBS Organic brain syndrome

OT Occupational therapy

PIQ Performance IQ

SH Social history

VIQ Verbal IQ

The following section briefly defines the specific behavior manifested in 

frequently seen psychiatric symptoms. This indicates the kind of 

information needed to determine how the disease process is manifesting 

itself, possibly causing disability.

Agitation

This is a manifestation of restlessness with hyperactivity (such as, 

handwriting, pacing, etc.) and general perturbation. In essence, the 

behavior can't keep up with the thought processes and results in 

inappropriate behavior.

Autistic or Other Regressive Behavior

Regression refers to the act of returning to some earlier level of adaption 

(e.g., a shift from mature behavior to less mature behavior, either mental 

or physical).

Autistic behavior is manifested by the individual's total absorption with 

himself. He responds only to internal stimuli, daydreams, fantasies, 

delusions, hallucinations, etc. External stimuli is either ignored or

interpreted only in terms of the individual.1/

Delusions

"A belief engendered without appropriate external stimuli and maintained 

by one in spite of what to normal beings constitutes incontrovertible and 

'plain-as-day' proof or evidence to the contrary. Further, the belief held is 

not one which is ordinarily accepted by other members of the patient's 

culture or subculture....Delusions are misjudgment of reality based on 

projection."2/

1/ Psychiatric Dictionary Fourth Edition; Leland E. Hinsie, M.D. and Robert 

Jean Campbell, M.D.; Oxford University Press, New York, London, 

Toronto, 1974, p.78.
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2/ Ibid, p. 191.

A delusion is a belief that is obviously contrary to demonstrable facts 3/ as 

opposed to a hallucination which is a sense perception to which there is

no external stimulus.

Phantasy/fantasy is a conscious or unconscious product of imagination, 

consisting of a group of symbols synthesized into a unified story by a 

secondary process. 4/ Phantasies are not psychotic symptoms and are 

not necessarily pathological, either.

Depression

"A pathological state of conscious psychic suffering and guilt, 

accompanied by a marked reduction in the sense of personal values, and 

a diminution of mental, psycho-motor, and even organic activity, unrelated 

to actual deficiency....."5/

Depression is generally thought of as a lowering of mood-tone, 

synonymous with dejection, sadness, gloominess, despair, despondency, 

etc. Claimants with depression will also exhibit a change in their activity 

levels, usually with a marked reduction, although there may be a 

restlessness and increased psycho-motor activity. There will also be 

demonstrated difficulty in thinking (e.g., forgetfulness, obsessive thinking, 

anxieties, worries, inability to complete thoughts, etc.).

3/ Ibid, p. 333.

4/ Ibid, p. 564.

5/ Ibid, p. 200.

Elation

"An affect consisting of feelings of euphoria, triumph, intense selfsatisfaction, optimism, etc." 6/

Hallucinations

"An apparent audio-visual perception of an external object when no such 

object is present. The auditory and visual stimuli have no source in the 

environment; rather, they are sensations arising within the individual 

himself." 7/

Illogical Association of Ideas

Associations are the innumerable related threads which guide thinking. In 

some psychotic conditions, the associations are interrupted and lose their 
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continuity. As a result, thinking becomes haphazard, seemingly 

purposeless, illogical, confused, incoherent, abrupt and bizarre. Among 

the many possible association disturbances are clang associations 

association based on similarity of sound, without regard for differences in 

(meaning), indirect associations, thought-deprivation (blocking), 

inappropriate application of cliches, impoverishment of thought, 

replacement of thinking proper by a senseless compulsion to associate 8/

and ideas of reference (a morbid impression that the conversation, 

smiling, or other actions of other persons have reference to oneself.). 9/

6/ Ibid, p. 258-9.

7/ Ibid, p. 333.

8/ Ibid, p. 69.

9/ Ibid, p. 372.

Inappropriateness of Affect

Affect is the nonverbal aspect of communication or qualification of the 

verbal communication. It is the feeling-tone, emotion, or mood 

accompaniment of an idea or mental representation. To some extent, it is 

culturally/sub-culturally determined. Typical disturbances include 

indifference, blunted affect, shallowness, flatness and constriction of the 

affect.

Mood is often inconsistent or exaggerated with a lack of adaptability and 

capacity for appropriate modulation of mood tone. There may be an 

incongruity between the affect displayed at the verbal productions of the 

individual. 8/ Affect may be behavior manifestations of intrapsychic 

pathology (e.g., response to hallucinations or delusions.)

Psycho-motor Disturbances

Normal activity is controlled or disturbed by movement which is psychically 

determined. This could be manifested by either a reduction or an increase 

in psycho-motor activity (such as, psycho-motor retardation; stereotypes, 

(which are constant repetitions of any motion, catatonia; dysarthria, which 

is difficulty with articulation; stammering and tremors).

M. MALIGNANT TUMORS

1. BASIC CONSIDERATIONS

Although medical science has taken giant steps in treating many 

malignancies, the diagnosis of cancer is still an ominous one which is 

recognized by most physicians. Accordingly, malignant tumors represent a 
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special group of impairments. The special nature of these impairments is 

manifested in the fact that while impairment severity assessment in other 

categories of impairments is primarily an evaluation of function (with only 

secondary emphasis on diagnosis) with respect to malignancies the 

opposite is true.

The well established diagnosis of malignancy, with very few exceptions, 

represents at least a significant impairment. Most malignancies are not 

only considered significant but, if some other provisions are met, they are 

also considered for a time period automatically disabling.

These provisions can be divided into three categories:

a. Some malignancies are considered disabling by simply establishing 

the diagnosis, (e.g., oatcell carcinoma of the lung). This group of 

malignancies carry the worst prognosis; that is, an individual having 

been diagnosed as such would have an extremely short life 

expectancy.

b. The second group of malignancies is less invasive; thus, in order to 

find a claimant disabled with these malignancies, usually the 

presence of a metastasis is required (e.g., carcinoma of the 

kidneys). In some instances the required metastasis qualifies for 

the finding of disability only if it is located beyond the region of the 

primary tumor, indicating wide spread neoplastic pathology (e.g., 

arcinoma or sarcoma of the large intestine).

c. The third group of malignancies will be found disabling if they show 

resistance to therapy; either surgery (unrespectable tumors) or 

chemotherapy (e.g., inoperable carcinoma of the stomach or 

carcinoma of the prostate gland not controlled by prescribed 

therapy).

Whichever classification a given claimant's malignancy falls under, if the 

medical criteria are fulfilled the finding of disability is warranted for a time 

period regardless of the momentary functional impairment manifested by 

the claimant.

Again, the underlying principle is that if an individual meets the specified 

criteria, death is expected to follow in a short period of time, even if 

momentarily the individual is in remission.

The logical question follows: How long is the assumption valid? At what 

point in time should the reviewer concern himself with the actual functional 

limitations caused by the malignancy? At what point should residual 

functional capacity be assessed, thus focus be shifted from diagnosis to 

function?
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Although the answer to this question is somewhat arbitrary, most 

physicians agree that three years after onset usually a more or less stable 

functional assessment of impairment severity can be carried out.

Accordingly, as a rule, documentation of malignancies needs to develop 

specific diagnostic and in some instances therapy-resistance criteria only 

for three years, after which period documentation should be secured as to 

current impairment severity and resultant residual functional capacity. The 

only exception is acute leukemia where, the time limit is two and a half 

years after the diagnosis was established.

2. DOCUMENTATION

The operative report and the pathological report are generally the most 

desirable evidence supporting the diagnosis of malignancies. As a rule, 

efforts should be made to secure this valuable evidence. Because of the 

nature of malignancies claimants require hospitalization during the 

diagnostic work-up and often during therapy as well. Accordingly, the 

desired documentation should be available as evidence of record. The 

reports and/or summaries should contain sufficient details establishing the 

diagnosis with which clinical signs and symptoms of the disease, along 

with other available laboratory evidence, should be consistent.

The site of primary lesion and any recurrence of metastasis must be 

specified in all malignancy claims.

The operative report should be comprehensive. Detailed and definitive 

findings of gross and microscopic examination of available surgical 

specimen should be in file.

The presence of local or regional recurrences, if any, should be included 

in the report along with a description of metastases.

Post-therapeutic residuals must be described in detail, as well as the side 

effects of therapy. Frequently, the therapy applied to control the 

malignancy causes functional limitations due to its side effects.

Chemotherapy, radiation therapy and surgery are the most common forms 

of treatment for malignancies. Often times, these modalities are used in 

combination. Therapeutic regimen and therapeutic response to 

chemotherapy vary widely. Hence, a description of therapy as well as the 

long-term therapeutic plan is always desirable evidence. Side effects of 

therapy may change in the course of administration. Effectiveness of 

therapy can be adequately assessed only if sufficient time (usually several 

months) elapsed since initiation of therapy to allow full therapeutic effects 

and side effects show significant individual differences. The most 

frequently encountered side effects of chemotherapy include: 
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gastrointestinal side effects, skin reactions and central nervous system 

symptoms. It is not uncommon for individuals not to experience any 

significant side effects at all or only a mild degree in the course of 

chemotherapy.

Chemotherapy is frequently administered in 6 to 12 month cycles and the 

response to therapy usually can be determined during this period. Severe 

reactions to therapy may last 5 to 7 days following administration. Severe 

reactions may occur as often as once a month. Documentation during this 

period should include signs and/or symptoms indicating recurrence or 

metastasis, if present.

Radiation therapy can cause skin or other soft tissue damage (e.g. 

scarring) as a side effect. Not infrequently, the radiation affects the bone 

marrow as well, with a resultant decrease in the cellular elements of the 

blood manifesting as anemia, leukopenia and/or thrombocytopenia. In the 

presence of these side effects adequate documentation should include 

evidence relative to these findings.

Radical surgery as a therapeutic modality frequently causes functional 

limitations. Most often these limitations are appropriately evaluated under 

the musculosketal system, and at times under other corresponding body 

systems. When the musculosketal system is most affected, documentation 

should include description of range of motion in degrees, status of 

musculature as well as a description of abilities to perform fine and gross 

manipulations.

In general, a good functional description of the affected body system is 

always desirable and often essential. The following is an example of the 

diverse descriptions necessary for adequate documentation:

1. Cancer of the larynx often/requires laryngectomy. Documentation 

should include the effects of surgery on claimant's speech, such as:

a. Intelligibility,

b. Volume,

c. Sustainability,

d. Speech structure.

In addition, documentation should be developed regarding the 

claimant's ability to lift and carry, since the ability to close the glottis 

is lost.

2. Cancer of the tongue and/or mandible often affects the claimant's 

abilities to speak as well. Adequate documentation should cover 
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not only this function but facial disfigurements should be 

documented as well.

3. GLOSSARY OF MALIGNANT TUMOR TERMS, SYNONYMS, 

ABBREVIATIONS

Alk Phos Alkaline phosphatase

Bx Biopsy

BSO Bilateral salphingo-oophorectomy

Ca or CA Carcinoma

D & C Dilatation and curretage

DUB Dysfunctional uterine bleeding

FS Frozen section

Metas. Metastases

TAH Total abdominal hysterectomy

TUR Transurethral resection

N. MULTIPLE ORGAN SYSTEM IMPAIRMENTS

1. BASIC CONSIDERATIONS

This section includes diseases manifested by abnormalities involving more 

than one body system. This may be a result of their nature; that is, they 

are not confined to one single organ. In some other instances, the disorder 

may start out in one body system but later may affect other organs. 

Foremost of this type of disorder are the so-called rheumatic diseases 

which are manifested mainly by involvement of the joints.

Further examples are the connective tissue disorders (such as, systemic 

lupus erythematosus; scleroderma, dermatomyositis, polyarteritis nodosa, 

sarcoidosis, ulcerative colitis and regional enteritis). Sarcoidosis is 

discussed more at length under pulmonary Impairments. Ulcerative colitis 

and regional enteritis are discussed under gastrointestinal impairments.

2. SYSTEMIC LUPUS ERYTHEMATOSUS
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This inflammatory disorder of unknown origin affects the connective 

tissues. The majority of cases occur in females; symptoms may affect any 

organ system.

The diagnosis is made by the clinical findings which are varied. 

Characteristic butterfly rash in the face is often present. In some 

instances, alopecia (loss of hair) may occur. Some patients complain of

photosensitivity. Lung involvement is manifested as recurrent pleurisy or 

pneumonia. The covering membrane of the heart may also be affected 

(pericarditis).

Since the small blood vessels may be involved, purpura (small 

hemorrhages under the skin) is a common finding. Kidney involvement 

occurs in many patients, although this may be asymptomatic for a long 

time. A nephrotic syndrome-like clinical picture may be the initial 

manifestation of the disease.

When the central nervous system is involved, manifestations range from 

mild personality changes to frank psychosis, organic brain syndrome and 

epilepsy. Permanent joint deformity (such as, ankylosis or subluxation) 

may occur, when joints are chronically swollen after extended duration of 

the condition.

The LE cell test is most correlated with SLE but it is not pathognonmic.

The antinuclear antibody test (ANA) is also useful for establishing the 

diagnosis, although this is usually done by correlating all available medical 

evidence including history, physical findings and other laboratory tests.

The course of systemic lupus erythematosus is commonly chronic. 

Relapses and long periods of remission are also seen. Those patients with 

heart and kidney involvement have a less favorable prognosis than those 

with only skin and joint involvements.

Documentation of systemic lupus erythematosus claims require obtaining 

hospital and/or outpatient records which usually contain either positive 

ANA test or positive LE preparations test. In some instances, as evidence 

of record, results of skin and/or other organ biopsy are available 

documenting the diagnosis.

NOTE: Biopsy should never be ordered as a consultative examination by 

the Railroad Retirement Board, but when available as evidence of record, 

this valuable medical evidence is always desirable.

Since a significant component in the assessment of the impairment 

severity is the resultant end organ damage, adequate documentation 

includes evidence relative to organ/system involvement and damage. 
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Documentation standards for various systemic involvements are crossreferred to the corresponding organs or systems.

3. OBESITY

Chronic obesity is associated with problems affecting musculosketal, 

cardiovascular, pulmonary and vascular systems. Impairments resulting 

from this end organ involvement is the determining factor for findings of 

severity in massive obesity.

Documentation of the body system involved is crucial in addition to 

documenting the severity of obesity. Documentation of obesity itself 

includes measurements of height and weight. The height and weight of the 

claimant should be measured without shoes.

In obese patients with hypertension, it is important to document the blood 

pressure measured with the appropriate size cuff since blood pressures of 

obese patients taken with the regular cuff may show falsely high readings.

When the claimant alleges a past history of heart disease with the 

possibility of congestive heart failure, reasonable efforts should be exerted 

to document such episodes by obtaining hospital and/or outpatient records 

to determine if the claimant indeed has signs and symptoms of congestive 

heart failure.

If musculosketal impairment (i.e. osteoarthritis) is alleged in addition to 

obesity, the appropriate documentation will include the condition of the 

alleged joint problems (range of motion of the affected joint as well as the 

corresponding x-ray evidence).

In claims involving obesity, the limitations of functions must be determined 

by objective medical evidence documenting the individual's ability to 

perform functions of everyday living, such as walking, sitting, bending, 

arising and standing. Documentation of this is important, since an obese 

individual may be found disabled on the basis of obesity alone due to 

resultant gross reduction of function.

It is also necessary to document, if possible, the etiology of obesity to 

determine if the condition may be expected to improve within twelve 

months following alleged onset date.

4. GLOSSARY OF MULTIPLE ORGAN SYSTEM TERMS, SYNONYMS, 

ABBREVIATIONS

BP Blood pressure
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CHF Congestive heart failure

Ht. Height

HPN Hypertension

LE Lupus erythematosus

SLE Systemic lupus erythematosus

Wt. Weight

Appendix B Field Guide

MEDICAL EVIDENCE DEVELOPMENT AND EVALUATION

See FOM1 Article 13, Appendix B

Appendix C Medical Exam Reference Chart 

See FOM1 Article 13, Appendix C