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13.1 Definitions of General Terms

13.1.1 Occupational Disability

The Railroad Retirement Act identifies occupational disability as a permanent physical 

or mental condition that renders one unable to work in his or her regular railroad 

occupation in the railroad industry.

13.1.2 Regular Railroad Occupation

Regular railroad occupation is defined as the occupation in the railroad industry in which 

an employee: 

• Has engaged in service for hire in more calendar months than the calendar months 

in which he or she has been engaged in service for hire in any other occupation 

during the last preceding five calendar years, whether or not consecutive; or 

• Has engaged in service for hire in not less than one-half of all of the months in which 

he or she has been engaged in service for hire during the last preceding 15 

consecutive calendar years. 

If an employee last worked as an officer or employee of a railway labor organization and 

if continuance in such employment is no longer available to him or her, the regular 

railroad occupation shall be the position to which the employee holds seniority rights or 

the position which he or she left to work for a railway labor organization.

13.1.3 Impairment

An alteration to an individual's health status that is assessed by medical or functional 

means.

13.1.4 Permanent Impairment

Permanent impairment refers to a physical or mental impairment or combination of 

impairments that can be expected to result in death or has lasted on a continuous basis 

or can be expected to last for a continuous period of not less than 12 months. 

13.1.5 Disability

An alteration to an individual's capacity to meet personal, social, or occupational 

demands, or to meet statutory or regulatory requirements.

13.1.6 Treating Physician

A treating physician is a doctor to whom the claimant has been going for treatment on a 

continuing basis. The claimant may have more than one treating physician.
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13.1.7 Consultative Exam (CE)

An examination by a physician (often a specialist) performing a medical evaluation on a 

limited basis at the expense of the Railroad Retirement Board.

13.1.8 Consulting Physician

A consulting physician is a doctor (often a specialist) to whom the claimant's medical 

record may be referred for a review to provide opinions concerning a claimant's residual 

functional capacity and/or the sufficiency of the medical evidence in the file.

13.2 Initial Step In Occupational Disability Adjudication

The initial step in the adjudication of occupational disability is the review of the Disability 

Application filed with the Railroad Retirement Board (RRB) field office and forwarded to 

the Chicago headquarters for review. After receipt of the file at headquarters, a new 

claim folder is established and forwarded to the Disability Benefits Division (DBD) for 

adjudication. The file should contain information about employment and medical 

records pertaining to the nature of the claimant's disability. The initial step is to review 

the file for completeness, assess eligibility, and determine if there is sufficient medical 

evidence to adjudicate a claim.

The forms that should be included in the file are listed below:

13.2.1 Form AA-1 - Application For Employee Annuity

This form contains information needed for determining entitlement for an employee 

annuity under the Railroad Retirement Act. Information on this form includes data 

concerning the claimant's past railroad work. The data in this section should be used to 

ascertain the claimant's regular railroad occupation. 

13.2.2 Form AA-1d - Application For Determination Of Employee Disability

This form contains information about the claimant's disability and medical providers 

which have treated this condition.

13.2.3 Form G-3-EMP - Report Of Medical Condition By Employer/Form RL-11

Form G-3-EMP contains information concerning the claimant's ability to work including 

the ability to perform his or her regular railroad occupation, a description of the type of 

work that he or she can perform, work restrictions and disqualification information. The 

information on this form may be based upon the results of medical evaluations that have 

been conducted by medical examiners on behalf of the railroad. Form RL-11, Letter for 

G-3EMP Disqualification Request for Medical Evidence from Railroad Employers

requests that the employer complete the G-3-EMP form. (These forms should only be 

released in cases where the applicant meets the requirements for an occupational 
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disability annuity (see DCM 3.2.1) and claims to have been disqualified by the carrier.) 

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

must be included with all G-3EMP requests. The G-197 form must be signed by the 

applicant or authorized individual, authorizing the release of medical information to the 

RRB.

NOTE: If the applicant does not claim disqualification by the carrier or doesn’t qualify 

for an occupational disability annuity, then use Form RL-11D1 to request medical 

evidence by the employer. If the employer attaches 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.

13.2.4 Form G-250 - Request For Medical Records

The claimant's medical records from the treating physician(s) should accompany the 

submitted disability application. Copies of the claimant's medical records and a 

narrative summary should have been requested in the G-250 form from the claimant's 

treating physicians(s) by field office staff. The claims examiner should determine if 

information from all treating physicians is available for review. The claimant should 

have identified the physician(s) who has treated him for the condition on the AA-1d form 

and the claims examiner should ascertain if the reports from all physicians are present 

in the file. 

The Railroad Retirement Board regulations identify acceptable sources of medical 

evidence (Section 220.46). These sources include:

• Licensed Physicians

• Licensed Osteopaths

• Licensed Psychologists

• Licensed Optometrists (for measurement of visual fields and visual acuity)

13.2.5 Form G-250A - Medical Assessment Of Residual Functional Capacity

This form is provided to the claimant's treating physician(s) and contains information 

concerning the claimant's ability to perform work-related activities. It is to be completed 

along with the G-250 form.

13.2.6 Form G-251 - Vocational Report

This form contains specific information regarding the claimant's work history for the last 

15 years. Information concerning job demands and environmental factors are also 

included in this report. The claimant is requested to sign this form and acknowledge 

that civil and criminal penalties may be imposed if fraudulent statements are provided.
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13.2.7 Forms G-251A – Railroad Job Information

This form request job information regarding the claimant's job demands. The Field 

Office will release a Form G-251A to the employer. The Field Office will enter the 

regular railroad job position or occupation, location and date last worked. The employer 

must return the completed form within 30 calendar days from the date the form is 

released.

13.3 Determination Of Whether The Individual Is In Compensated 

Railroad Service

(See Figure 1 for Sect. 3-9)

The claims examiner must verify whether the claimant is currently in compensated 

railroad service. Persons who are in compensated railroad service are not eligible for 

benefits. 

13.4 Determination Of Whether Mental Or Physical Impairment Is 

Expected To Last 12 Months Or Result In Death

The claims examiner needs to evaluate whether the impairment(s) is expected to last 12 

or more months or result in death. If the impairment is not expected to last 12 months 

or result in death, the claim is denied. The claims examiner should obtain additional 

medical evidence if the information in the file is insufficient to make this determination. 

If the impairment(s) is expected to last 12 or more months, a determination needs to be 

made as to whether the information contained in the medical record is sufficient to 

perform an initial disability rating as identified in Section 5 of this document.

Documents which need to be reviewed to determine if the impairment is expected to last 

12 months or result in death include: 

13.4.1 Form AA-1d - Application For Determination Of Employee Disability

The nature of the claimant's medical condition is described in Section 3 of the AA-1d 

form along with information concerning the date that the claimant last worked. For 

persons who have chronic conditions that are not expected to improve and who are not 

working, it is reasonable for the claims examiner to assume for the purpose of a claim 

evaluation that the condition could be expected to last 12 months.

13.4.2 Form G-250 - Request For Medical Records

The claimant's medical records from the treating physician(s) should accompany the 

submitted disability application. Copies of the claimant's medical records and a 

narrative summary should have been requested by the field office (Form G-250) from 

the claimant's treating physician(s). This information should be reviewed to determine if 

the claimant has a chronic medical condition that is not expected to improve.
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13.4.3 Medical Evidence Of Record

Medical evidence of record includes hospital records, imaging studies, consultative 

examinations and ancillary tests. These types of documents provide objective evidence 

to confirm and evaluate an impairment and need to be reviewed to determine if an 

impairment will last 12 months or result in death.

13.5 Determination Of Whether The Information In The Medical 

Records Is Sufficient For Reaching An Initial Disability Decision

Information concerning the nature of the medical condition should be reviewed in 

conjunction with information concerning the date the claimant last worked as identified 

in Section 3 of the AA-1d form. Data concerning diagnosis, symptoms, objective 

findings, laboratory test results, X-ray and other imaging findings, treatment and 

prognosis should be in the medical record. Ideally, this information should be 

summarized in a narrative report. If a narrative report is not available, the claims 

examiner may have to review the individual medical records. Such information forms 

the medical basis for the preliminary adjudication of a disability claim. In addition, the 

Residual Functional Capacity Evaluation, as specified in Form G-250a, should have 

been completed by the physician and be available for review. If the claims examiner 

determines that the information is not sufficient to perform a disability adjudication, 

additional information should be requested from the claimant's physician(s) to continue 

the claims review process. 

If the information in the medical records is considered to be sufficient to reach a 

disability determination, then an assessment needs to be made as to whether the 

claimant's condition meets or equals the RRB's Listing of Impairments (20 CFR Part 

220).

13.6 Determination Of Whether The Condition Meets Or Equals The 

RRB Listing Of Impairments

13.6.1 Overview Of The Listing Of Impairments

The RRB's Listing of Impairments is a listing of conditions by the major body systems 

which are considered to generally prevent an individual from engaging in substantial 

gainful activity. 

The information contained in the claimant's medical records must be reviewed 

concerning whether the employee's medical condition is considered to meet or equal 

the standards identified in the Listing of Impairments. The purpose of the Listing of 

Impairments is to identify those individuals who unquestionably have disabling 

impairments.
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13.6.2 Determination Of Whether The Condition "Meets" The Listing Of 

Impairments

An impairment meets a listing only when it manifests the specific findings described in 

the medical criteria of that listed impairment. The determination that the condition 

meets the Listing of Impairments cannot be based on a diagnosis alone since other 

findings associated with the condition must also be present. These requirements can 

include confirmatory medical test findings to confirm the existence of the impairment 

and specific objective findings which indicate significant functional impairment. 

EXAMPLE: The mere diagnosis of active rheumatoid arthritis is not considered sufficient 

to meet the Listing of Impairments. The following factors must also be present:

A. History of persistent joint pain, swelling, and tenderness involving multiple major 

joints and with signs of joint inflammation (swelling and tenderness) and current 

physical examination despite prescribed therapy for at least 3 months, resulting 

in significant restriction of function of the affected joints, and clinical activity 

expected to last at least 12 months; and 

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

• Positive serologic test for rheumatoid factor; or

• Antinuclear antibodies; or

• Elevated sedimentation rate; or 

• Characteristic histologic changes in biopsy of synovial membrane or 

subcutaneous nodule (obtained independent of Social Security disability 

evaluation). 

13.6.3 Determination Of Whether The Condition "Equals" The Listing Of

Impairments

To determine if an impairment or combination of impairments equals the Listing of 

Impairments, a comparison must be made of the medical findings (the set of symptoms, 

signs and laboratory findings) in the claimant's medical record 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 and duration 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; or 
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B. Listed impairment where the signs, symptoms and laboratory findings are not 

identical to those specified for that impairment, but reflect equivalent severity; or 

C. Combined impairments where the signs, symptoms and laboratory findings 

reflect severity equal to the listed impairment most like the claimant's most 

severe impairment. 

If a claims examiner believes that a listing is equaled, the case may be sent to the 

consulting physician for review. 

13.6.4 Medical Condition Does Not "Meet" Or "Equal" The Listing Of Impairments

If the condition does not meet or equal the criteria identified in the Listing of 

Impairments, then the condition should be assessed in accordance with the criteria 

identified in Section 7.0.

13.7 Determination Of Whether The Employee Has Been Medically 

Disqualified From Regular Railroad Occupation By Railroad Employer

Information from the employer concerning the claimant's ability to perform the duties of 

the regular railroad occupation should be reviewed. Information concerning this matter 

should be present in Form G-3-EMP, which is generally completed by the railroad 

medical officer or other railroad representative in cases where the applicant claims to 

have been disqualified by the carrier. Form G-3-EMP provides information concerning 

the claimant's ability to perform his or her regular railroad occupation for medically 

documented reasons and has evidence that supports the conclusion that the applicant 

is unable to perform his or her occupation. If the employee is not allowed by his railroad 

employer to continue working in his or her regular railroad occupation, the claims 

examiner will consider the claimant disabled unless, based on the evidence in the Form 

G-3-EMP and elsewhere in the file, the claims examiner determines that no reasonable 

person could conclude that the employee can no longer perform his or her regular

railroad occupation for medical reasons.

In cases where a disqualification notice is received, it is not necessary to have medical 

evidence in file which details the severity of the disability. Rather, it is sufficient to make 

a rating with medical evidence in file that confirms the impairment. In these types of 

cases do not delay an occupational disability rating by developing medical evidence or 

scheduling medical examinations. 

EXAMPLE 1: A clerk has been disqualified by the railroad due to a history of 

degenerative arthritis. Medical evidence submitted consists of treating physician notes 

and chiropractic records. The records submitted did not include X-ray reports. The 

claimant also states on AA-1d that he/she takes medication for arthritis. The medical 

evidence submitted supports the claimed impairment for which the claimant was 

disqualified. There was no medical evidence submitted that contradicts or disputes the 

disqualification, therefore, the claimant can be rated occupationally disabled without 

further development.
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13.8 Determination To Ascertain If The Condition And Job Title Are 

Covered In The Occupational Disability Tables (A Tables)

Information in all of the medical records, the AA-1, and Form G-251, Vocational Report 

should be reviewed by the claims examiner to ascertain whether the claimant's 

condition and job title are included in the Tables. If the information indicates that the 

condition and the job title for the claimant's regular railroad occupation are included in 

the Tables, the claims examiner should evaluate the evidence in accordance with the 

procedures identified in Section 9. 

If either the condition or the job title is not included in the Tables, then the claimant's 

condition should be evaluated in accordance with the criteria identified in Section 10, 

Independent Case Evaluations.

Click this link to view the Occupational Tables.

13.9 Claims Evaluation For Conditions And Job Titles Covered In The 

Tables

13.9.1 Establish The Medical Diagnosis

Confirmatory tests can include information from medical records that document the 

presence of a condition, a surgical procedure, or the result of a specific diagnostic test. 

In some instances, confirmatory tests may also provide information on the claimant's 

functional capacity and are also listed as disability tests. Confirmatory test information 

is present in the initial section regarding each body part covered in the Tables. 

Appendix A contains information further detailing specific test criteria for the 

confirmatory test results or findings in the Tables.

If the information is incomplete, then further information should be obtained concerning 

the claimant's medical condition from other sources including consultative exam and/or 

functional evaluation tests. If some of the information is not in accordance with the rest 

of the medical information, it should be evaluated in accordance with the criteria 

identified in Section 10.

There are two types of confirmatory tests: highly recommended and recommended. 

These tests are discussed below.

13.9.1.1 Highly Recommended Tests

The designation of a confirmatory test as being highly recommended means that the 

test is almost always performed to establish a diagnosis. For many conditions, only one 

highly recommended test finding is suggested to establish a diagnosis. There may be 

times when that test is not available or is negative, but other detailed testing confirms 

the diagnosis.
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EXAMPLE A: For the condition of pulmonary hypertension, only one confirmatory test is 

considered to be highly recommended: the electrocardiogram. This condition is 

identified in the Tables as highly recommending an electrocardiogram with definite right 

ventricular hypertrophy to confirm the diagnosis. 

An electrocardiogram with evidence of right ventricular hypertrophy will confirm the 

diagnosis. However, it is reasonable to consider that a Swan-Ganz catheter may be 

inserted into the pulmonary artery to directly measure the pressure. This would also 

establish the diagnosis.

There may be some conditions for which several highly recommended tests are 

suggested to establish a diagnosis. In these circumstances, all highly recommended 

tests are suggested together to establish the diagnosis. 

EXAMPLE B: Three highly recommended criteria are identified for the diagnosis of 

chronic back pain, not otherwise specified. These criteria include:

• A history of back pain under medical treatment for at least one year, and

• A history of back pain unresponsive to therapy for at least one year, and

• A history of back pain with functional limitations for at least one year.

Sometimes the claimant may have undergone detailed testing which may provide more 

comprehensive information than one of the A highly recommended tests listed in the 

Tables, making the simpler test unnecessary. To illustrate, in Example A above, if the 

medical records contained direct measurement of elevated pulmonary artery pressure, 

an electrocardiogram would not be necessary to confirm the diagnosis. In cases where 

the highly recommended test is absent, there must be a logical, rational basis, based on 

the medical record, for accepting the diagnosis. The case summary rationale must 

support this decision.

13.9.1.2 Recommended Tests

The designation of a confirmatory test as recommended means that the test may not be 

performed, or be positive, to establish the diagnosis. However, a positive test provides 

significant support for confirming the diagnosis. If there are no highly recommended 

test(s) for the condition, at least one of the recommended tests should be positive. 

There are two categories of recommended tests which are described below.

A. Imaging Studies 

These studies can include MRI, CAT scan, myelogram, or plain film X-rays. For 

conditions where several of these imaging studies are identified as 

recommended tests, at least one of the test results should be positive and meet 

the confirmatory test criteria. For some conditions, such as degenerative disc 
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condition, there are several equivalent imaging methods that can be used to 

establish a diagnosis. 

B. Other Tests 

This category of tests refers to non-imaging studies. For some conditions, there 

is no single confirmatory test which can be used to establish a diagnosis since all 

available medical tests may have significant false negative or false positive rates. 

For example, electro-diagnostic tests, including electromyography and nerve 

conduction studies, are frequently abnormal in a person with a radiculopathy. 

However, some individuals with a radiculopathy can have normal electrodiagnostic test results. 

If there is no highly recommended confirmatory test requirement and the 

confirmatory tests only include non-imaging procedures, at least one of these 

tests should be positive. The greater the number of tests that are positive, the 

greater the confidence that the correct diagnosis has been established. 

EXAMPLE: The diagnostic confirmatory tests for ventricular ectopy, a cardiac 

arrhythmia, include the following recommended tests:

• Medical record review, i.e., a review of the claimant's medical records, or

• Holter monitoring, or

• Provocative testing producing a definite arrhythmia.

In this situation, only one of the recommended confirmatory tests should to be 

positive to reach a diagnosis. However, the more tests that are positive, the 

stronger the support for the diagnosis. 

If a diagnosis cannot be confirmed and all medical information is obtained, the 

claim is denied. 

In most circumstances, the claims examiner should not request that a 

confirmatory test be performed to establish the diagnosis at the expense of the 

RRB through a consultative examination (CE). In some situations where a CE is 

being planned and a simple test may be performed to establish a diagnosis, the 

claims examiner has the discretion to request a confirmatory test. 

In no circumstance should the claims examiner recommend that invasive testing 

be performed to confirm the diagnosis. Several of the confirmatory tests which 

are described in the Tables are invasive and it is not the intention of the Tables to 

suggest that invasive tests be performed. The inclusion of invasive tests in the 

Tables confirmatory test section is intended to help the claims examiner evaluate 

the significance of findings which may be part of the submitted medical record.
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13.9.1.3 Disability Determination

To reach a disability determination, disability test results need to be reviewed by the 

claims examiner. Disability tests measure the functional impact or impairment that a 

condition has on a person. The results of the test can classify a person as Disabled (D) 

or needing an Individual Case Evaluation (ICE). These terms are defined below: 

A. "D" - If the claimant has a "D" result, this signifies that the claimant is disabled. 

Only one D disability test finding is required to reach a determination of disability. 

B. "ICE" - If the claimant does not have any D results, the claim must be evaluated 

using the process described in Section 10. 

13.10 Independent Case Evaluations (ICE)

Independent Case Evaluation (ICE) is used for claims in which job titles and/or medical 

conditions are not covered by the Tables. The second situation in which cases are 

subject to ICE are claims where the job and medical condition are met, but there is no 

matching disability test. The third situation in which cases are subjected to ICE are 

claims which have not received a "D" rating because medical variations make it 

necessary to look at specific job information and/or specific medical information to make 

a determination. The fourth situation in which claims are reviewed using ICE are 

situations in which the job titles and the medical conditions may be covered, but the

information is not consistent or cannot be simply clarified. In this review, information in 

the Table regarding diagnosis and confirmation tests, as well as the tests judged to 

determine disability, may be a guide for the claims examiner in the decision process.

Independent Case Evaluation is a three step process:

The first step, medical information is reviewed to establish diagnosis and to establish an 

understanding of the condition by the claims examiner. Particular attention should be 

paid to the functional limitations of the condition. The impairments from the medical 

conditions relevant to claimant's regular occupation are determined.

The second step, the job information is evaluated to determine the job demands.

The third step, the medical information regarding relevant impairment is compared to 

the job demands.

13.10.1 Assessment Of Medical Information

13.10.1.1 Confirming The Diagnosis

The diagnosis will provide the claims examiner with the functional limitations that may 

be expected on a particular claim. The diagnosis is important for this reason to assess 

the other medical information. In some cases, the diagnosis is established through the 

initial review of the Tables.
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13.10.1.2 Assess Concordance Of Medical Findings In Entire Medical Record

The information in the medical record should be reviewed to determine whether the 

opinions among physicians regarding medical condition findings are consistent, 

including the claimant's history, physical examination findings, laboratory or other test 

results, and other information in the claimant's file. The claims examiner should review 

the AA-1d to ascertain if all relevant treating physician(s) medical records are available. 

If physicians have had a role in providing treatment or assessing the claimant's

condition and these records are not available for review, the disability examiner may 

use the most expeditious means available to obtain that medical evidence, if necessary. 

Once all relevant information has been secured, it should be reviewed and integrated 

into the disability determination process to decide if there is consistency of response 

among treating physicians. However, if the information available from one or more 

physicians contains clear and convincing evidence, especially if there is objective 

supporting information, the claims examiner may proceed without obtaining all records 

from all treating physicians.

13.10.1.3 Significant Difference In Medical Findings

If the medical records reveal that there are marked differences in the treating 

physicians' findings, then a CE and/or functional test should be obtained. 

EXAMPLE: A brakeman's medical records reveal conflicting evidence concerning the 

character and functional impact of an underlying low back condition. The claimant 

reported to his orthopedist a history of prolonged back pain of five years duration with 

severe symptoms for three years. The claimant reported in his history that his low back 

problems had kept him from participating in sports which he had participated in prior to 

the onset of his severe back problems three years ago. An MRI revealed degenerative 

disc changes.

The claims examiner reviews the claimant's entire medical record which includes 

medical treatment that he received from an osteopathic physician for the past three 

years just before he sought consultation with the orthopedic consultant. These medical 

records reveal a contradictory history from that provided to the orthopedist. The 

medical records reveal that the claimant had received medical therapy for a neck and 

later a low back strain following water-skiing and basketball injuries in the past two 

years. The claimant's stated medical history as provided to the orthopedist is not 

consistent with the history in his medical records with respect to the impact that the pain 

has had on his lifestyle. 

Since the RFC from the orthopedist could reasonably be expected to be based upon the 

claimant's medical history (rather than objective medical evidence), the quality of the 

RFC is jeopardized. In this type of situation, the claims examiner should request a 

consultative examination to resolve this matter and/or functional testing. 
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13.10.1.4 Significant Differences In Opinion Of RFC Among Treating Physicians 

And An Approach To RFC Quality Assessment

The RFC is a medical assessment and is based upon a review of the available medical 

evidence; it represents the judgment of the physician. The RFC should be based upon 

clear and convincing medical evidence demonstrating an impairment. In such 

circumstances where clear and convincing medical evidence is not present, a CE with 

authorization to perform functional capacity tests may be required.

EXAMPLE: A carman has a history of obstructive lung disease and has complaints of 

shortness of breath with exertion. The treating physician recommends no exertional 

activity. If the RFC is based primarily on symptoms of shortness of breath without 

consideration of the actual measurements of lung function or exercise performance, the 

finding is invalid. Shortness of breath can be caused by many factors including anxiety, 

psychological, and other factors. Lung function tests, such as Forced Expiratory 

Volume in one-second, are best predictors of exercise ability and should be used to 

establish performance limitations.

The following criteria should be assessed in determining the quality of an RFC:

A. Is the RFC largely based upon symptoms rather than objective evidence? 

If the RFC is not supported by objective evidence of a condition that will result in 

impairment, then the treating physician's RFC should not be considered as being 

sufficient. The claims examiner should request additional information or records, 

a CE, or functional testing where appropriate. 

EXAMPLE: The claimant, an engineer, reports a history of chronic low back pain. 

The physician's RFC opined that the claimant not lift over 35 pounds, bend, or 

stoop. No medical report is available, but a review of the medical records reveals 

that although the claimant sought medical attention on several occasions for low 

back pain, no specific abnormal physical findings have been documented. A 

plain film X-ray revealed that the claimant had some minor degenerative changes 

of the spine, but the radiologist reported these were normal for the claimant's 

age. No other definitive tests have been performed. The nature and extent of 

pain is not clearly documented in the medical records. 

In this case, the RFC is largely based upon subjective symptoms. The claims 

examiner can request that a consultative examination and/or functional test be 

performed. 

EXAMPLE: A general laborer works on maintenance of way for the past 10 

years. His work includes repetitive lifting of tie plates and spikes not removed by 

the automated spike puller. This job requires the claimant to stand most of the 

day, walk on uneven surface, lift and carry objects weighing up to 20 pounds. He 

presents with a 5 year history of low back pain that is worsening. He reports 

prolonged standing and lifting of objects over 20 pounds is painful. Attempts at 
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therapy have been unsuccessful. A report from his treating physician identifies 

that he has radicular pain in the L5 - S1 nerve distribution. An EMG reveals 

evidence of polyphasic wave activity in muscle innervated by L5 nerve. An MRI 

reveals diffuse degenerative disc changes more pronounced at L5-S1, but 

without definitive nerve impingement. A straight leg raise test is positive (both 

supine and sitting positions). 

A review of the medical records reveals that physical therapists, his primary 

physician, and orthopedist specialist all have reported similar complaints, 

consistent physical findings, and recommended that he avoid heavy work 

including frequent standing, repetitive lifting, bending and twisting. The 

recommended limitations include no lifting over 40 pounds, no repetitive lifting 

over 10 pounds, and no prolonged standing or walking. 

In this case, there is clear and convincing evidence that the RFC provided by the 

treating physician(s) is based upon valid medical evidence. The claimant's 

symptoms are consistent with the clinical findings including physical examination 

findings, imaging studies, and diagnostic tests. This medical history and the 

examination findings have been consistently reported by all of his medical care 

providers. 

B. Is the RFC based upon objective tests that have poor reliability or validity and 

are, therefore, poor predictors of functional capacity? 

If the objective tests have limited reliability and/or validity, then the claimant 

should be referred for a CE and/or functional tests to ascertain his or her 

functional capacity. 

EXAMPLE: A dispatcher with a degenerative lumbar disc disorder has a treating 

physician's RFC which opines that the claimant cannot lift any objects over 10 

pounds and is restricted from any activity involving repetitive bending or stooping. 

A review of medical records reveals that the dispatcher describes experiencing 

chronic low back pain for over one year that is aggravated by movement 

including lifting and bending. Physical examination is reported to reveal the 

presence of paravertebral muscle spasm and a diminished range of lumbar 

motion to 50% of what would be expected (method of measurement and 

reproducibility are not identified). Lumbar sacral X-rays reveal the presence of 

degenerative disc changes throughout the lumbar spine, but more pronounced in 

the L4-5 and L5-S1 regions. An MRI reveals the presence of a significant disc 

bulge at these same levels but there is no report of any spinal stenosis or disc 

herniation. 

In the Form G-250a the physician identifies several factors that support this RFC 

conclusion. These factors include the presence of degenerative disc changes in 

lumbar vertebrae seen with lumbar sacral spine X-ray, a disc bulge on an MRI, 

and the presence of back spasm and marked limited range of lumbar motion to 

<50% of the expected range. 
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This RFC is based upon medical evidence. However, as with many cases of 

chronic back pain, the evidence is of limited usefulness; see Table 1 for an 

example of significant findings related to the low back. Therefore, no one finding 

tells us that this man's back pain is significant and disabling. Together, they do 

support a physical basis for back pain, but are not diagnostic. 

The examiner can look for indications in the medical records that this dispatcher 

has had maximal therapy, including work conditioning and strengthening in 

physical therapy. The examiner should look for consistency of findings across 

different providers, and evidence of attempts to return to work. If that evidence is 

not clear and convincing, functional testing can be ordered. (see Section 11) 

13.10.1.5 Request For Consultations

Depending upon the amount of information in the file, the claims examiner may request 

that the claimant undergo functional tests in addition to, or in lieu of, other CEs. In such 

cases, if functional tests alone are recommended, the claims examiner should contact 

the claimant's treating physician(s) to ascertain whether there is any contraindication or 

physical limitations to obtaining a functional test. If a CE is going to be performed, the 

CE can provide authorization to conduct the testing. 

The protocols for functional capacity tests are described in Appendix C. The results of 

the examination and/or test(s) can be used to ascertain whether the claimant has an 

impairment that precludes the performance of the claimant's job functions. Additional 

review by a consulting physician may be required to resolve significant discrepancies 

between the treating physician's RFC opinion and that of the functional tests.

13.10.1.6 RFC Limitations Are Not Consistent With Functional Capacity Tests

Some claimants may have already undergone functional capacity tests, such as 

isometric strength tests, an FCE, or other tests. These results should be reviewed. If 

the treating physician concluded that the claimant's functional capacity is substantially 

below those that have been measured in functional tests, then the claimant should be 

referred for a CE evaluation and/or functional tests to ascertain the basis for this 

discrepancy. Alternatively, the treating physician may be requested to provide a 

rationale for the basis of his or her conclusions after reviewing the results of the 

functional testing.

13.10.1.7 Weight Of Evidence Determination

If there is consistency in the findings of the medical evidence, all medical information 

should be assessedequally. The medical evidence is assessed to determine if there is 

clear and convincing objective evidence that the claimant has a significant medical 

condition and that this condition prevents him or her from performing his regular job. 

Under this approach, the claims examiner would find a claimant to be occupationally 

disabled if the medical evidence demonstrates that it is more reasonable to conclude 

that the claimant is unable to perform his or her occupation than to reach a contrary 
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conclusion. The types of findings which support a determination that a condition has a 

significant functional impact, as well as factors which support a lesser impact, are found 

in the Occupational Disability Standards Manual. 

Information from the medical history should also be reviewed to ascertain whether the 

claimant's medical condition has been associated with any episodes of pain or other 

symptoms which have resulted in an inability to perform the critical tasks of his 

occupation. The significance of the pain episodes is strengthened in general if they are 

associated with objective findings. Medical records can provide an overall indication of 

the claimant's condition over time and may significantly reflect his or her ability to 

perform a task over a given time frame. Information pertaining to any continued job 

activity should be closely examined. 

The medical records should be reviewed to ascertain whether the claimant has been 

provided appropriate medical treatment and therapy for the condition(s) and whether the 

response to therapy has been (un)successful; this provides additional support to the 

physician's opinion that the claimant' s medical condition is permanent. The records 

should be examined to ascertain whether there is evidence of poor compliance with 

medical treatment, including failure to keep appointments, use of appropriate 

medication, or other factors. If the claims examiner determines that the claimant may 

not have had the opportunity to receive an adequate course of therapy, and therefore 

concludes the condition may not be permanent or expect to last 12 months, it is highly 

recommended that the case may be referred for a CE.

For further discussion of this topic, refer to L82-165, "Weight to be given testimony of 

treating physician."

13.10.1.8 Presence Of Substantial Objective Evidence Of Condition And 

Impairment

EXAMPLE: A carman has a history of degenerative lumbar disc disease. His medical 

findings include a history of chronic pain of several years duration, participation in a 

back exercise and rehabilitation program, use of anti-inflammatory medications, and 

participation in a weight loss program for obesity which resulted in a normalization of his 

weight and 25 pound weight loss. However, he continues to experience low back pain. 

Over the past six months, he has experienced shooting radicular leg pains affecting his 

right leg in the distribution of the L5 nerve. His physical examination revealed limitation 

of lumbar mobility and a positive right straight leg raised test. An MRI revealed 

evidence of significant disc degeneration in L4-5 and L5-S1 disc spaces with narrowing 

of the intervertebral foramen and spinal stenosis. The L4-5 disc appears to be 

impinging on the nerve root, but this is not clearly evident on the MRI. An EMG 

revealed evidence of muscle denervation affecting the muscles innervated by L5 nerve. 

Flexion and extension views of the back revealed no spinal instability.

In this case, the presence of multiple medical findings supports the conclusion that there 

is substantial objective evidence of a significant condition and impairment. Although any 

isolated finding might not be sufficient to conclude that the claimant is disabled, together 
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the findings support a diagnosis of a radiculopathy and spinal stenosis. The findings 

support a determination that the claimant is occupationally disabled since there is a high 

degree of clinical correlation of symptoms and the reported abnormal findings all 

support a common effect.

EXAMPLE: A trainman had a condition affecting his back and knee. He indicates that 

his ability to lift, carry, squat, and climb ladders is affected by both the conditions. The 

back condition is characterized by chronic back pain and he has been diagnosed with 

degenerative disc disease. The physical findings reveal nonspecific findings and an Xray reveals degenerative disc changes. 

The claimant also has arthritis of the right knee. X-rays of the knee revealed 

degenerative changes and the joint space is 2 - 3 mm. There is mild atrophy of the 

quadriceps muscles. His physician has completed an RFC stating that he cannot climb 

ladders more than occasionally, cannot squat more than occasionally, and cannot lift 

more than 20 pounds.

This trainman has atrophy of the quadriceps muscle, indicating disease in right knee 

significant enough that he has loss of muscle strength from disuse. This is clear and 

convincing evidence that the limitations set by the knee will be disabling for this job, 

which requires extensive climbing. Although the data on the back may not be sufficient 

at this point, the knee can be considered independently.

13.10.1.9 Limited Objective Evidence Of Significant Impairment

In this situation, although the claimant has one or more medical findings, the claims 

examiner determines that there is insufficient evidence upon which to reach a disability 

determination. There are several findings which could lead the claims examiner to 

reach the conclusion that the evidence is not sufficient to reach a "D" finding and that a 

CE and/or functional test should be performed.

13.10.1.10 Factors Supporting Lessening Impact

If the medical record reveals the presence of several factors supporting lessening 

impact identified as having a role in minimizing the impact of other findings, especially 

any factor that would suggest an inconsistency between examination findings and 

symptoms or exaggerated responses, the claims examiner should request a CE and/or 

functional tests. Figure 4 identifies the factors supporting lessening impact. The claims 

examiner needs to evaluate the entire medical record and determine if there is evidence 

of a significant number of negative mitigating factors which would make a determination 

solely on the basis of a review of the medical file valid. 

13.10.1.11 Additional Testing

If the claims examiner determines, based upon a review of the available medical 

evidence, that a final decision cannot be reached concerning disability for a claimant, 

the claims examiner should request a CE and/or functional tests. Factors that should 
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contribute to such a recommendation for additional testing include those identified in 

Figure 4. Factors which provide lessening support for a disability include differences 

between RFC assessments among physicians and limited objective evidence. In these 

circumstances, additional medical testing is recommended to resolve the matter of 

residual functional capacity. 

In general, a CE may be conducted in conjunction with the functional capacity test. 

Such an examination should especially be considered where:

• There is minimal objective evidence, and/or

• there is conflicting medical evidence in file, and/or

• the reliability/validity of the evidence is questionable, and/or 

• there are significant negative mitigating factors.

The claims examiner has the option to obtain a CE and/or functional capacity test. 

Section 11 contains an overview of the types of functional capacity tests that can be 

performed. The decision concerning the scope of additional testing that should be 

performed is based upon several factors. The claims examiner must exercise 

professional judgment in this matter depending on the needs of the case.

If the claims examiner finds that most of the evidence suggests that the person is not 

capable of performing the critical job demands but the evidence has some 

inconsistencies, limited functional tests may be requested to help confirm this 

assessment. In situations where the EPIC or PILE tests are not available, then 

isometric strength tests could be performed. However, it is important that limited testing 

not be used to assess disability for cases where there are potential multiple impairments 

or where there is minimal overall objective evidence. A more complete assessment of 

the claimant's overall effort and ability to perform tasks in a number of dimensions is 

recommended.

EXAMPLE: A shop laborer has a history of a radiculopathy and a herniated disc 

condition. He had an operation for this condition five years previously, underwent an 

L4-5 laminectomy, and had a subsequent back fusion. He returned to work and has 

been successfully performing his job for the past several years. However, over the past 

five years, he has experienced a recurrence of significant back pain.

Although there is evidence of back pathology and prior surgery, there is no evidence 

that new pathology or any other event has changed the claimant's clinical picture since 

his surgery and he was able to work after the surgery with no apparent problems. More 

comprehensive testing is indicated.
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13.10.2 Job Information

Determining the correct regular railroad occupation and associated job duties is 

required for occupational disability adjudication. Accurate job information is important 

for evaluating whether an applicant's impairment precludes performing his/her regular 

railroad occupation.

The regular railroad occupation is defined as follows:

• The occupation in which he/she has engaged in service for hire in more calendar 

months than calendar months in which he/she has been engaged in service for hire 

in any other occupation during the last preceding 5 calendar years, whether or not 

consecutive; or 

• The occupation in which he/she has engaged in service for hire in not less than onehalf of all of the months in which he/she has been engaged in service for hire during 

the last preceding 15 consecutive calendar years; or 

• If an employee last worked as an officer or employee of a railway labor organization 

and if continuance in such employment is no longer available to him/her, the "regular 

railroad occupation" shall be the position to which the employee holds seniority 

rights or the position which he/she left to work for a railway labor organization. 

13.10.2.1 Sources For Job Duty Information

Job duty information is required in the occupational disability process to compare with 

impairment-related restrictions. Relevant job duties are determined from several 

sources: 

A. Form G-251, Vocational Report - Form G-251 is completed by the applicant. The 

information on this form includes work history for determining the regular railroad 

occupation and a job description of tasks performed. The tasks include a 

narrative description, environmental hazards and physical activities involved in 

an 8-hour work day. 

B. Form G-251A, Railroad Job Information – Effective April 3, 2017, the Railroad 

Retirement Board (RRB) introduced a revised Form G-251A in accordance with 

the Disability Program Improvement Plan that will ask railroad employers to 

provide job information about applicants who apply for an occupational disability 

benefit under Section 2 (a)(1)(iv) of the Railroad Retirement Act (45 U.S.C. § 

231a(a)(1)(iv)). Collection of job information from the employers will assist the 

disability examiner with making an accurate disability determination. Prior to this 

date, the RRB used Form G-251a and G-251b Job Information reports to collect 

this information. Form G-251a was released to employers for employees with a 

generic job description attached. Generic job descriptions were used for a select 

number of railroad occupations and were some of the more common types of 

railroad jobs. The generic job description described how select occupations 
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were generally performed in the railroad industry for employees. Form G-251b 

was released to employers for employees who did not have a generic job 

description. 

The field office will be required to determine the employee's last regular railroad 

occupation and send the form to the employer The employer will then be given 

30 calendar days to respond. Do not trace this form with the field office or the 

railroad employer. If the employer does not respond within this time, use the job 

duty information on Form G-251 when evaluating the occupational disability 

determination.

If the G-251A is returned, ensure that the correct regular railroad occupation has 

been determined using the guidelines above.

13.10.2.2 Assessing The Employee's Regular Occupation Job Information

The file should be reviewed to determine whether the job information received by the 

employer and the applicant are consistent. When reviewing job information, all sources 

that submit information must be considered.

A. Assessing Job Information That is in Agreement 

In this scenario, the job information on Form G-251 and the job information 

received from the railroad employer is in agreement, or no job information is 

returned from the railroad employer. Since all information is in agreement, no 

further action is necessary for assessing job information. 

B. Assessing Job Information When Differences Exist 

Differences in job information must be reconciled only when they are material. 

A "material" difference is defined as job information that is received from different 

sources, a difference in job duties exists and the difference prevents the 

examiner from making a sound disability decision and therefore needs to be 

reconciled. For example: 

A carman has a history of low back pain. The objective medical evidence in file 

shows degenerative disc disease and he/she is restricted to lifting 50 pounds 

occasionally. The employee claims to lift 75 pounds frequently in his job duties. 

The railroad employer indicates that the employee lifts only 40 pounds 

occasionally. Because the actual disability determination depends on the correct 

amount of lifting the employee did, this difference is considered "material" and 

must be resolved. 

C. Assessing Non-material Differences 

There may be situations where differences exist in job information but they will 

not be material. When there are "non-material" differences, the occupational 
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disability rating should not be delayed for reconciliation. One scenario involves 

receiving information from an employee and an employer with discrepancies and 

areas of agreement. The areas of agreement (i.e., those job tasks common to 

both employee and employer job descriptions) may be precluded because of the 

medical condition. 

EXAMPLE: A switchman has a history of severe degenerative arthritis in both 

knees. Objective medical evidence shows he is precluded from walking along 

uneven terrain. The G-251 shows that the employee lifts 75 pounds daily, bends, 

crouches and kneels constantly and walks along the railroad tracks for 6 hours a 

day. The railroad employer submits job information that states the employee lifts 

40 pounds occasionally and sometimes bends, crouches and kneels. The 

employer does agree that the employee walks along uneven terrain for 6 hours 

per day. 

In this case there are differences in job information. However, since there is 

agreement between the railroad employer and employee on the amount of 

walking along uneven terrain, and such activity is precluded because of the 

medical condition, a favorable rating can be made without reconciling the 

differences. 

There may also be instances where there is discrepant job information and there 

are areas of agreement that are not precluded by the medical condition. 

EXAMPLE: A secretary suffers from chronic obstructive pulmonary disease. A 

spirometry shows the FEV1 to be 80 percent of normal and the only restriction 

placed on the employee is to avoid fumes, noxious gases and dust. The G-251 

indicates that the employee lifts 40 pound boxes of paper daily, sits 8 hours per 

day and sometimes bends, kneels and reaches. There is no indication that the 

secretary was exposed to fumes, noxious gases or dust. The railroad employer 

indicates the secretary had to lift 25 pound boxes of paper and was not exposed 

to any environmental hazards. 

Since there is no restriction on the amount of weight to be lifted, the discrepancy 

that involves the boxes of paper is non-material and does not have to be 

reconciled. The only restriction is based on environmental hazards, which are 

not found in the work place, and the claim should be denied. 

Another type of non-material discrepancy involves discrepant job descriptions, 

but the claimant's impairment would restrict him/her from performing the duties 

provided in either job description. 

EXAMPLE: A conductor has angina with exertion. A review of the medical 

evidence of record shows the claimant has chest pain which is suggestive of 

angina and is relieved with nitroglycerin. A review of the cardiologist's notes 

states that his patient is unstable and restricts him to lifting 20 pounds maximum. 

The employee's vocational reports states that he lifts 75 pound knuckles daily. 
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The railroad employer submits information that the employee lifts hoses that 

weigh 50 pounds maximum. 

here is a discrepancy in what was lifted and how much it weighed. In this 

situation, the employee would be precluded from lifting either amount. Therefore, 

these discrepancies do not need to be reconciled and the claim can be granted. 

13.10.2.3 Reconciling Material Differences

Material differences will usually result from an oversight by either the applicant or the 

employer. Request the field office to resolve the discrepancy by first calling the parties 

to clarify the job information in question. If material differences still exist, the examiner 

should utilize OccuBrowse and other sources of job information to resolve the 

differences.

13.10.3 Determination Of Disability Through The Use Of ICE

Once the medical information and the job information has been reviewed using the 

above process, the claims examiner shall make a disability decision based on his/her 

assessment and understanding of the information. If the medical and job information 

indicate that an individual is not capable of performing the duties of his/her regular 

occupation, then the claimant is disabled. If the medical and job information indicates 

that an individual is capable of performing the duties of his/her regular railroad 

occupation, then the claim is denied.

13.11 Functional Capacity Tests

Functional capacity tests provide objective measures of a claimant's maximal work 

ability. These tests range from simple measures of lifting capacity, such as an isometric 

strength test, to a functional capacity evaluation (FCE) which provides a systematic, 

comprehensive assessment of a claimant's overall strength, mobility, and endurance in 

addition to his or her functional capacity to perform physically demanding tasks, such as 

standing, walking, lifting, or kneeling. The tests should be performed to provide the 

claims examiner with evidence of how a claimant's condition affects his or her ability to 

perform a function.

13.11.1 Ordering a Functional Capacity Evaluation (FCE)

Disability examiners may not order a FCE without authorization from the RRB’s medical 

consultant, CEL. CEL will request a FCE when CEL’s doctors determine a FCE is 

necessary in order to make an occupational disability determination.

CEL will make their request for a FCE on Form G-137sup. In addition, they will contact 

the office of the Director of Disability Sickness and Unemployment Benefits Division 

(DSUBD) informing the Director of their request for an FCE The case will then be 

forwarded to the Director’s office.
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The Disability Initial Section Supervisor or the Disability Operations Analyst will be 

responsible for developing and ordering the FCE. The FCE report will be returned to 

the Initial Supervisor or Operations Analyst who will forward the file to the medical 

consultant, CEL, for the final RFC. CEL will then return the case with an RFC 

assessment to the Supervisor or Analyst who will enter the payment for the FCE and 

the consultant opinion. The file will be forwarded to the disability examiner for rating. 

If a case is returned to a disability examiner by CEL requesting a FCE, and it has not 

been seen by the Director of DSUBD, the Initial Supervisor or the Operation Analyst, 

refer the case to one of them.

13.11.2 Functional Capacity Test Selection

Two categories of functional capacity tests can be used to assess the claimant's 

functional ability depending upon the nature of the condition(s). If the principle problem 

is related to lifting, a limited testing approach utilizing progressive lift tests or an 

isometric lift test can be used to only assess this ability. For medical conditions 

involving multiple body systems that could affect task performance, an FCE should be 

performed. Similarly, if the results of lift testing provide indeterminate results, the 

claimant should receive an FCE.

13.11.3 Lifting Tests

Progressive lift tests measure a person's capacity to perform lifting by presenting 

increasing loads for the lifting. Two progressive lift tests are recommended, the EPIC 

lift capacity test and the PILE. In addition, an isometric strength test can be used to 

assess lifting ability, but this provides more limited and less specific information than the 

progressive lift tests. The EPIC and PILE tests are the preferred tests to assess lifting 

since they involve an assessment of the person's lifting capacity in several domains. 

The isometric strength test is useful as a screening evaluation to provide supplemental 

information and is primarily useful to provide confirmatory information for claimants who 

have other significant objective evidence of an underlying low back disorder.

13.11.4 Functional Capacity Evaluation

The FCE is an assessment tool that can be used to determine a person's maximal work 

ability. The components of an FCE include a questionnaire, interview, general 

musculoskeletal evaluation and physical demand tests such as lifting, squatting, 

walking, etc. An FCE is most useful for orthopedic conditions and not very useful for 

heart and lung conditions. This type of testing can also be performed for low back 

conditions if the results of lifting tests reveal intermediate test results where the loss is 

less than 50%, but greater than 25% or in cases involving multiple conditions.

13.11.5 Interpretation Of Functional Capacity Test Finding

The functional capacity tests should be integrated with other medical information from 

the claimant's disability evaluation. If the appropriate test criteria have been 
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established, the test results can be utilized in the occupational disability claims 

evaluation process. The claimant may have received an FCE or other functional test at 

the request of his or her treating physician which may be submitted as part of the 

medical documentation. It is important that the functional capacity test criteria meet the 

quality control provisions for the relevant tests. Progressive lift tests will identify the 

percentage of loss of lifting capacity that the claimant has compared with population 

norms. In addition, the testing will identify the claimant's ability to lift a specific load.

The claimant's absolute ability to lift should also be compared with the agreed upon job 

demands. If the claimant has received an EPIC test, the assessment includes a 

determination concerning the ability of the person to perform sedentary, light, medium, 

heavy, or very heavy work in accordance with the lifting demands identified in the 

Department of Labor's, Dictionary of Occupational Titles (DOT). If the claimant has 

received an FCE, the evaluation should include an assessment of the claimant's ability 

to perform work in accordance with the demand levels identified in the DOT as well as 

other specific demands unique to the claimant's occupation which may involve hand 

dexterity, stair climbing, or other physically demanding tasks not specifically addressed 

in the DOT classification. These other demands are not specifically assessed in 

progressive lift tests.

The claims examiner should assess whether the claimant's work abilities and any 

limitations identified by the treating physician are consistent with the findings from 

functional capacity tests. If the treating physician(s) RFC evaluation is not consistent 

with the ability objectively measured in a functional capacity test, the claims examiner 

may send the results of the functional capacity test to the treating physician and request 

an opinion from the treating physician concerning the basis for the RFC limitations. 

Alternatively, the claims examiner may request a CE and provide this information as 

part of the medical record for review. A functional capacity test may also be scheduled 

concurrently with a CE.

13.11.6 Quality Test Criteria

The performance of a claimant during functional capacity tests is dependent on several 

factors including instruction, effort, and the claimant's underlying clinical condition.

For a claims examiner to use information from a functional capacity test for an 

evaluation of a claimant, the test should meet the criteria identified. These criteria 

require that the test be performed by a qualified professional and that the claimant's 

effort is determined to be adequate by a trained examiner. For some tests, such as the 

EPIC test or an FCE, the heart rate of the claimant is required to be monitored to assure 

proper effort in performing the test.

Figures

Figures 1 through 5 and Table 1 can be referenced in the Occupational Disability 

Standards training packet.
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Appendices

See 20 CFR Part, 220, Appendix 1

The following appendices contain Confirmatory Test descriptions, Disability Test 

descriptions, and Testing Protocols. These supplements help in evaluating medical 

evidence for occupational disability claims.

Many of the test results and protocols are referred to in the Tables of the Occupational 

Disability Standards. However, the appendices also contain information that is not 

included in the Tables. The information that does not relate to the Tables is useful for 

claims that require an Independent Case Evaluation (ICE). For example, thyroid 

disorder is not covered in the Tables, but if an employee claims this condition as an 

impairment the confirmatory test description in Appendix A, Confirmatory Test 

Descriptions, is available as a guide to confirm the diagnosis.

Appendix C, consists of the protocols for numerous examinations. There are some 

tests, however, that should not be requested. These tests are:

Thallium studies

CT scan and myelogram

Electromyography

Nerve conduction velocity studies

HLA-B27 assay

Tuberculosis cultures

Holter monitors

These tests are either invasive (thallium studies), have acceptable substitutes (X-ray 

rather than CT scan) or should be part of the medical evidence of record (tuberculosis 

cultures). These procotols are available as an aide to examiners when these tests are 

submitted as medical evidence of recor

Appendix A - Confirmatory Test Descriptions

1.0 Cancer

Confirmation: The confirmation of cancer requires that the diagnosis be confirmed by 

histological examination of tissue obtained from a biopsy. It is rare for a diagnosis to be 

confirmed without a biopsy. The examiner should evaluate the medical records and 

confirm the presence of a pathology report to confirm the presence of the condition. 

Typically the claimant will have consulted with an oncologist and an examination of the 
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medical records from the oncologist should provide confirmatory information. A very 

high degree of reliance should be given to any diagnosis of cancer by an oncologist. 

Distant disease: This diagnosis refers to metastatic cancer or cancer that has spread 

to a site distant from the original tumor. In most circumstances the prognosis for distant 

or metastatic cancer is very poor. 

Localized disease: This diagnosis refers to cancer that is confined to the organ 

involved. Sometimes cancer may be localized to a small portion of the involved organ 

or be limited to single tissue within the organ. Persons with in situ cancer often have life 

spans equivalent to the general population and have no functional impairment after the 

removal of the tumor. 

Regional disease: This diagnosis refers to cancer that is confined to the organ and 

surrounding lymph nodes. 

2.0 Endocrine

Medical record review - Confirmation of condition and need for insulin use. This term 

refers to insulin dependent diabetes mellitus (IDDM). There are two principle types of 

diabetes mellitus: insulin requiring or insulin-dependent (IDDM) and non-insulin 

dependent diabetes mellitus (NIDDM). Persons with IDDM must use insulin to control 

their blood sugar. In persons with IDDM their diabetes is due to a lack of insulin. These 

persons are prone to developing ketoacidosis and small changes in their insulin dose 

can produce dramatic changes in blood sugar control. To confirm the presence of 

IDDM the medical records must contain evidence of an episode of ketoacidosis or 

absent or low blood insulin levels.

Persons with NIDDM have diabetes due to the development of a resistance to insulin. 

Many of these persons are obese and their glucose metabolism can be improved with 

weight reduction. Some of these persons may be treated with insulin to control their 

blood sugar but do not require insulin for control and are not prone to developing 

ketoacidosis or ketoacidotic coma. These persons should not be considered to have 

insulin-dependent diabetes mellitus even though they may take insulin at some time to 

control their diabetes. 

Medical record review - Confirmation of condition by blood test. This result pertains to 

thyroid disease (hyperthyroidism, hypothyroidism and thyroiditis) controlled or 

uncontrolled. The confirmation of the overall condition should be accomplished by 

verifying the presence of an abnormal blood test (thyroid hormone level or thyroid 

stimulating hormone level) and possible abnormal imaging studies (thyroid scan). 

Most persons with thyroid disorders can readily control their condition with appropriate 

replacement hormone therapy or other medical treatment. The designation that a 

thyroid condition is uncontrolled should be made by an endocrinologist and a specific 

reason(s) for the lack of control should be designated. Complications of thyroid 

conditions can include muscle weakness, tremors, cardiac rhythm disorders and other 
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problems. If complications remain after a course of adequate therapy, are verified by 

objective findings, and an endocrinologist judges the condition to be not controllable, 

then the thyroid condition should be considered as being uncontrolled. 

3.0 Cardiac

Angiography - Definite occlusion >60% of one vessel. The minimum requirement is 

considered to be greater than 60% occlusion of one major coronary artery. 

Cardiac catheterization - Poor global function and not coronary artery disease. This 

term refers to a result which shows poor global functioning of the heart that cannot be 

attributable to underlying coronary artery disease. This type of finding is seen with 

cardiomyopathy conditions. 

Infarction - Proven by history. This term refers to a documented myocardial infarction 

or heart attack. The medical records must be reviewed for evidence of hospitalization 

for a myocardial infarction or heart attack. The initial medical records should be 

reviewed and there should be a confirmatory test finding that documents the heart 

attack such as elevations of cardiac enzymes on blood testing. 

4.0 Respiratory

Methacholine challenge - Positive FEV1 decrease >20% at PC ≤8 mg/ml. This term 

refers to a drop of 20% in FEV1 with the administration of a dose of methacholine of 8 

mg/ml or other equivalent method such as a histamine challenge. 

Spirometry - FEV1/FVC ratio. This is a marker of obstruction that is seen in persons 

with underlying asthma when they are symptomatic. Asthmatics can have normal lung 

function when they are asymptomatic. If they are symptomatic at the time of testing, 

then this finding or a diminished FEV1 should be observed. This test result finding is not 

required if the person has medical records documenting the occurrence of previous 

episodes of asthma. This would include a medical record demonstrating wheezing or 

airway obstruction that reverses with the administration of a bronchodilator. 

5.0 Lumbar Sacral Spine

Electromyography - Definite denervation. Positive signs of denervation can include 

multiple positive sharp waves or fibrillation potentials. These findings are consistent 

with acute nerve root compression. Changes associated with chronic denervation 

include polyphasic waves. EMG changes should be correlated with distribution of 

symptoms and imaging study abnormalities. The presence of EMG findings in muscles 

unrelated to pain, symptoms in affected parts, or imaging studies abnormalities, can 

have minimal functional impact. 

Medical record review - Documentation of failure of implant following surgical 

procedure. This term refers to the failure of a device implanted for correction of an 

underlying problem. 
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MRI, CAT or myelogram - Neural impingement of spinal nerves below L1. This term 

refers to the occurrence of central disc herniation or other pathology that causes direct 

pressure on the sacral cauda equina nerve roots. Cauda equina syndrome is the result. 

This condition can be demonstrated by either MRI, CAT or myelogram

MRI, CAT or myelogram - Significant degenerative disc changes. Degenerative 

changes are common in the general population and some studies report that up to 70% 

of asymptomatic persons over the age of 50 have degenerative back changes. 

Osteophytes and disc space narrowing and degeneration are common, especially in the 

lower lumbar spine. There are no absolute criteria representing a clear delineation 

between findings that are responsible for pain and those seen in asymptomatic persons. 

Since degenerative changes can be seen in asymptomatic persons, imaging findings 

should correlate with clinical findings if the findings are going to be used for evaluating 

impairment and disability status. 

Findings that have been reported to have essentially no relevance include tropism or 

misorientation of the facet joints, increased lumbar lordosis, spina bifida occulta, 

transitional vertebra, Schmorl's nodes, and lumbosacral tilt. 

MRI, CAT or myelogram - Evidence of neural compression. This term refers to 

evidence of degenerative disc or joint changes that result in nerve root compression. 

The disc or joint pathology should involve the nerve root and correlate with the person's 

radicular symptoms including pain, numbness, tingling, or weakness. In the lumbar 

spine, the exiting nerve root is named for the vertebrae about which it exists. Thus, a 

L5-S1 disc herniation causes impingement of an S1 nerve root. Symptoms should be 

checked to see if they match the nerve root distribution. 

MRI, CAT or myelogram - Significant narrowing: spinal cord canal or intervertebral 

foramen. This term refers to significant narrowing of the spinal canal, nerve root canals, 

or intervertebral foramina. This condition is also known as spinal stenosis. There 

should be evidence that narrowing of the canal or other structures results in 

compression of neurological structures and correlates with symptoms. A narrow spinal 

canal can be congenital or relate to degenerative changes which can result in 

entrapment of the spinal canal or nerve roots. Stenosis can also be classified as the 

basis of which segments of the spinal canal are affected (central canal, the subreticular, 

lateral recess or the neural foramina). Symptoms must be correlated with imaging study 

findings since it is possible to have findings of spinal stenosis in an asymptomatic 

person. 

There are differences of opinion regarding the precise dimensions or size that 

differentiate a normal spinal canal from a canal with significant narrowing. In general 

when using a CAT scan to evaluate the spinal column, an anterior posterior diameter of 

less than 11. 5 mm (distance from the posterior surface of the vertebral body to the 

superior portion of the corresponding spinous process); or an interpedicular distance of 

less than 16 mm (transverse diameter); or a canal cross section of less than 1.45 cm 

are considered small. These dimensions are often provided on imaging study results. 

With reference to the lateral recess area, a measurement of less than 3 mm is 
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considered small. There are no widely accepted criteria for normal dimensions of the 

nerve root foramina. A small spinal canal favors the occurrence of compression of 

intraspinal neurological structures from degenerative spinal changes. 

Nerve conduction testing - Definite slowing. Confirmation of the condition requires 

evidence of definite slowing. This can be manifested by the absence of the H wave or 

by delay of 3mm/seconds. Nerve conduction slowing must be correlated with the 

distribution of symptoms and imaging study abnormalities. The presence of nerve 

conduction slowing unrelated to the pattern of pain distribution or other relevant 

symptoms or imaging study abnormalities can have minimal functional impact. 

Physical examination - Atrophy of affected limb greater than 2 cm. The presence of 

muscle atrophy can be observed in the lower extremity secondary to chronic 

denervation or disuse because of neurologic compromise. The circumference of the 

involved leg should be compared to the non involved leg (above knee). Atrophy should 

not be able to be explained by the presence of nonspine-related problems such as 

contralateral hypertrophy that might occur with a dominant limb or with increased use of 

a limb. Atrophy should be correlated with electrodiagnostic findings (electromyography - 

or nerve conduction testing) where possible. 

Physical examination - Straight leg raise. This is a physical examination finding that 

provides evidence of compression of the lumbosacral nerve roots and provides 

supportive evidence of a radiculopathy. The test involves raising the leg to determine if 

this produces symptoms of pain in distribution of the nerve root in the affected leg. 

There can be false positive results with this physical examination test. There are certain 

physical examination findings that can be performed by an examiner to determine if the 

claimant's response in a straight leg test is valid. Not all examiners perform a validity 

check on this physical examination finding. If the medical report contains information on 

tests for validity of the claimant response, then a positive finding is to be judged as more 

significant. 

The validity criteria can include:

• Crossed opposite straight leg raise - if lifting of the leg without pain produces sciatic 

pain in the contralateral leg, the result is to be judged as more valid (positive 

contralateral straight leg raising test). 

• Consistent repose to equivalent sciatic tension (stretching) - claimant response to 

raising leg while in the sitting position is compared to the response while supine 

(lying down). 

• Response of claimant while supine to dorsiflexion and plantar flexion of the anklenormally ankle dorsiflexion will relieve the pain and plantar flexion will increase the 

pain. 
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• Response of claimant while supine to hip internal and external rotation when the leg 

is straight - normally external rotation will decrease the complaints. 

Sensory examination - Loss of sensation in affected dermatomes. This term refers 

to the loss of sensation in areas of the lower limb corresponding to the distribution of 

the affected nerve. 

6.0 Cervical Spine

Electromyography - Definite denervation. A diagnosis is established by positive signs 

of denervation which can include multiple positive sharp waves or fibrillation potentials. 

These findings are consistent with acute nerve root compromise. Changes associated 

with chronic denervation include polyphasic waves. EMG changes should be correlated 

with distribution of symptoms and imaging study abnormalities. The presence of EMG 

findings in muscles unrelated to pain, other relevant symptoms, or imaging studies 

abnormalities, can have minimal functional significance. 

MRI, CAT or myelogram - Neural compression of spinal nerves. A diagnosis is 

established when clinical findings demonstrate evidence of a spinal curve or 

compromise of spinal nerves through the intervertebral foramina. 

MRI, CAT or myelogram - Significant neurogenic compression. This term refers to 

findings that produce significant spinal cord pressure including anterior compression of 

the spinal cord from posterior osteophytes, posterior compression from the ligamentum 

flavum, especially with extension of the cervical spine, or evidence of vascular 

compromise of the spine by effects on spinal arteries, or from a degenerated or torn 

disc that has encroached on the spinal cord. Significant encroachment of the spinal 

canal is more prominent when there is a narrow (10 mm or less sagittal diameter) spinal 

canal. 

MRI, CAT or myelogram - Significant disc degeneration. There are no definite criteria 

to define what degree of significant disc degeneration is associated with pain or 

impairment. It is not uncommon for asymptomatic persons to exhibit degenerative 

changes of the disc. 

MRI, CAT or myelogram - Significant joint degeneration. There are no definite criteria 

to define what degree of significant joint degeneration is associated with pain or 

impairment. It is not uncommon for asymptomatic persons to exhibit degenerative 

changes of the joints. 

Medical records review cervical - rheumatoid arthritis. Confirmation requires 

evaluation by a rheumatologist. 

Medical records - Continued pain post-surgery. The claimant should have continued 

pain after surgery that interferes with the ability to perform occupational activities. The 

claimant is not responsive to conservative therapy including medications or physical 

therapy for at least one year after surgery. 
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Medical records - Radicular pain. This term refers to pain in the distribution of the 

affected nerve root. Radicular pain should be correlated with imaging study findings. 

Nerve conduction testing - Definite slowing. Confirmation of the diagnosis requires 

evidence of definite slowing. Slowing is manifested by the absence of the H wave or by 

delay of 3mm/seconds. Nerve conduction slowing should be correlated with the 

distribution of symptoms and imaging study abnormalities. The presence of nerve 

conduction slowing of nerves unrelated to the pattern of pain distribution, other relevant 

symptoms, or imaging study abnormalities, have minimal functional significance. 

Physical examination - Atrophy of affected arm greater than 2 cm. A diagnosis is 

established by the presence of muscle atrophy that can be observed in the upper 

extremity secondary to chronic denervation or disuse because of neurologic 

compromise. The circumference of the involved arm should be compared to the non 

involved arm (above elbow). Atrophy should not be able to be explained by the 

presence of non spine-related problems such as contralateral hypertrophy that might 

occur with a dominant limb or with greatly increased use of a limb. Atrophy should be 

correlated with an electrodiagnostic finding (electromyography -or nerve conduction 

testing) when possible. 

Physical examination - Evidence of myelopathy. Myelopathy is a condition caused by 

compression of the spinal cord which can involve both upper and lower motor neurons. 

Compression can be due to several factors including both disc herniation and/or 

compression from degenerative bony changes involving the cervical spinal joints and 

surrounding structures. The diagnosis requires confirmation by imaging studies 

including CAT, MRI or myelogram. 

Upper motor neuron findings involve lower extremities and can produce symptoms of 

spasticity, increased deep tendon reflexes, and a positive Babinski test (not all may be 

present at same time). These are also called long tract signs. Some persons can also 

exhibit a stooped wide-based gait or jerky gait. 

Lower motor neuron involvement affects the upper extremity and results in weakness of 

the upper extremity. The distribution of weakness is dependent upon which nerve root 

is affected. Lesions at the C4-5 disc level involve the C5 nerve root and can produce 

deltoid weakness, shoulder abduction problems, and a loss of the biceps reflex. Lesions 

at the C5-6 disc level affect the C6 nerve root can cause weakness of the biceps, elbow 

flexion and forearm supination, and wrist extension. A C6-7 disc lesion affecting the C7 

nerve can produce weakness of elbow extension, as well as finger and wrist extension. 

A lesion at the C7-T1 disc can involve the C8 nerve and produce both weakness of 

elbow extension and finger flexion. 

7.0 Shoulder

Medical record review - Condition with permanent functional limitations. This term 

refers to the presence of an underlying medical condition that has produced a 

permanent impairment of the elbow, e.g., a permanent angular deformity of the elbow 
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following a fracture, or limitation of range of motion following a traumatic injury involving 

the joint. This abnormality should be confirmed with an imaging study. 

8.0 Hand And Arm

Medical record review - Documentation of medical condition for permanent limitation. 

This term refers to the presence of an underlying medical condition that has produced a 

permanent impairment of the wrist, hand or thumb. This condition should be confirmed 

with an imaging study. 

Nerve conduction studies - Definite median nerve conduction slowing at wrist. 

Physical examination - Definite reproducible evidence of limitation. This term refers to 

the presence of a physical finding that is measured consistently (or reliably) by different 

qualified medical examiners. 

9.0 Hip

Alkaline phosphatase - Increased up to 50 times. This term refers to a blood test 

finding.

10.0 Knee

The terms are self-explanatory. 

11.0 Ankle And Foot

The terms are self-explanatory. All reports should include the name and signature of 

the physician reading the test.

• The name of the technician administering the test should appear on the report.

Appendix B - Disability Test Descriptions

1.0 Cancer

Category 1. Conditions which are identified as Category 1 are classified as being 

disabling. These conditions either have a poor prognosis (in general < 50% 5-year 

survival rate) or the treatment required for the condition is associated with significant 

impairments which would make it impossible for the railroad employee to perform the 

job. 

Category 2. Category 2 conditions represent an intermediate group for which an 

individual determination is required. In general, conditions that have extensive local 

spread or more aggressive histopathology are more likely to be considered as disabling 

while those with more differentiated tumors (in general, less aggressive growth 

potential) and minimal local extension are more likely to be classified as a nondisabling. 
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Category 3. Category 3 conditions are considered as being nondisabling. Persons with 

these conditions generally have a life span that is similar to that of the general 

population with minimal impact on daily activities or ability to perform occupational 

tasks. 

2.0 Endocrine

The terms are self-explanatory.

3.0 Cardiac

The terms are self-explanatory. 

4.0 Respiratory

PO2 - arterial. No specific cut-off level is provided for PO2 which would result in a "D" 

classification since other measures are thought to better represent an indication of 

disability status. Other factors can also affect the arterial PO2 including altitude, breath 

holding, and obesity. Exercise capability is thought to correlate better with FEV1 than 

PO2. However, an arterial PO2 of <60 mm Hg in an claimant breathing room air (at sea 

level) with a confirmed lung condition provides strong evidence of severe pulmonary 

impairment. Such a claimant would be unlikely to be able to perform physically 

demanding work. 

5.0 Lumbar Sacral Spine

Lifting capacity diminished by 50%. This term refers to a decrease in lifting capacity 

by 50% using a valid measure of lifting capacity. 

No specific test or "gold standard" is available for measuring lifting capacity. Several 

tests can be used for this type of assessment and each method has its own particular 

limitations. Several factors can affect the lifting capacity of the worker other than 

musculoskeletal capacity or strength. Limiting factors may include fear or anxiety about 

the test or unclear instructions. For a test to be a valid predictor of lifting capacity, these 

factors need to be assessed as part of the quality control procedure. These tests have 

been selected based upon the following criteria:

MRI, CAT, myelogram - Significant narrowing of the spinal canal. This term refers to 

spinal stenosis which has been defined as narrowing of the spinal canal, nerve root 

canals, or intervertebral foramina. For a diagnosis to be confirmed, there should be 

evidence that the narrowing of the canal results in compression of neurological 

structures and is correlated with symptoms of the affected dermatomes. A narrow 

spinal canal can be congenital or be related to degenerative changes resulting in 

entrapment of the spinal canal or nerve roots. Stenosis can also be classified on the 

basis of which segments of the spinal canal are affected (central canal, the subreticular, 

lateral recess or the neural foramina). 
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There are differences of opinion regarding the precise dimensions or size that 

differentiate a normal spinal canal and a canal with significant narrowing. When using a 

CAT scan to evaluate the spinal column, an anterior posterior diameter of less than 11.5 

mm (distance from the posterior surface of the vertebral body to the superior portion of 

the corresponding spinous process) an interpedicular distance of less than 16 mm 

(transverse diameter), or a canal cross section of less than 1.45 cm are considered 

small. With reference to the lateral recess area, a measurement of less than 3 mm is 

considered small. There are no widely accepted criteria for normal dimensions of the 

nerve root foramina. A small spinal canal favors the occurrence of compression of 

intraspinal neurological structures from degenerative spinal changes. 

Symptoms should be correlated with imaging study findings since it is possible to have 

findings of stenosis in asymptomatic persons. 

MRI, CAT, myelogram - Significant compression of the dural sac. This term refers to 

the presence of a compression of the dural sac which results in spinal cord or nerve root 

compression. There must be correlating symptoms in the appropriate distribution of the 

nerve root. The presence of correlating electrodiagnostic findings (EMG or NCV) 

provides strong supportive evidence in establishing the diagnosis. This finding in the 

presence of a narrow spinal canal can also be considered as significant narrowing - 

spinal canal. 

MRI, CAT, myelogram - Significant narrowing of the intervertebral foramen. This 

condition is the presence of a narrow intervertebral foramen that could produce 

impingement of a nerve root. There must be correlating symptoms in the appropriate 

distribution of the nerve root. The presence of correlating electrodiagnostic findings 

(EMG or NCV) provide strong supportive evidence of confirmation of the diagnosis. This 

finding in the presence of a narrow spinal canal can also be considered as significant 

narrowing - spinal canal. 

MRI, CAT, myelogram - Disc extrusion with neural impingement. This condition is the 

presence of a disrupted disc that has resulted in direct impingement of a nerve root. To 

confirm the diagnosis and result in a "D" determination, there must be correlating 

symptoms in the appropriate distribution of the nerve root. The presence of correlating 

electrodiagnostic findings (EMG or NCV) provides strong supportive evidence of the 

diagnosis. This finding, in the presence of a narrow spinal canal, could also be 

considered to be classified as significant narrowing - spinal canal. 

Medical record review - Frequent flare-ups with objective findings. This term refers to 

evidence of repeated infections over the past three years with corresponding blood 

findings demonstrating chronic infection, abnormal bone scan findings showing 

increased uptake consistent with active infection, and/or positive bacterial cultures 

requiring antibiotic therapy (usually intravenous and requiring hospitalization). 

Physical examination - Lower extremity weakness. This term refers to the presence of 

lower extremity weakness due to neurogenic compression of spinal canal or nerves that 

significantly interferes with gait or ability to use lower limb. To establish a diagnosis, 
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there should be correlating imaging study findings demonstrating pathological 

correlation in the spinal canal to account for the weakness and the underlying 

electrodiagnostic findings. There should be demonstrated atrophy in the affected limb. 

X-ray flexion/extension - Segmental instability. This term means the flexion and 

extension comparison roentgenograms showing significant injury-related anterior-toposterior translation of two adjacent vertebral bodies of 5 mm or more. 

6.0 Cervical Spine

MRI, CAT, or myelogram - Significant spinal cord pressure. Imaging findings that can 

account for significant spinal cord pressure include anterior compression of the spinal 

cord from posterior osteophytes, posterior compression from the ligamentum flavum, 

especially with extension of the cervical spine, evidence of vascular compromise of the 

spine by effects on spinal arteries, or from a degenerated or torn disc that has 

encroached on the spinal cord. Significant encroachment of the spinal canal is more 

prominent when there is a narrow spinal canal (10 mm or less sagittal diameter). 

Multilevel - Neurologic compromise. This condition is muscle weakness involving 

more than one nerve segment. Muscle weakness should be confirmed with appropriate 

imaging study findings (the presence of radiological evidence of confirming lesion, i.e., 

disc spur, etc. involving appropriate nerve segment innervating the muscle group 

responsible for the weakness). Ideally,

electromyographic or nerve conduction study findings should provide confirmatory 

electrodiagnostic evidence. Isolated radiological findings have little significance. 

Physical examination - Lower extremity weakness and/or significant spasticity. The 

examiner should demonstrate the presence of weakness or spasticity in a claimant with 

confirmed compression of the spinal cord. The presence of associated gait problems 

makes these findings more disabling. These findings should be correlated with imaging 

study findings of significant spinal cord pressure. Without confirmatory findings on 

imaging studies, the presence of these physical findings should not be considered 

disabling. 

7.0 Shoulder

The terms are self-explanatory.

8.0 Hand And Arm

The terms are self-explanatory. 

9.0 Hip

The terms are self-explanatory. 
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10.0 Knee

Physical examination - Valgus deformity, 16-20 degrees. Deformity measured by 

femoral-tibial angle; 3 degrees to 10 degrees valgus is considered normal. 

Physical examination - Valgus deformity, 8-12 degrees. Deformity measured by 

femoral-tibial angle; 3 degrees to 10 degrees valgus is considered normal. 

X-ray of knee. X-rays of the knee should be taken in the standing position. 

11.0 Ankle And Foot

X-ray - Ankle 0 mm. This term refers to absence of joint space from degenerative 

changes. The normal cartilage interval is 4 mm. 

X-ray - Talonavicular joint 0 mm or 1 mm. This term refers to the joint space of the 

talonavicular joint. This joint space is typically between 2 - 3 mm. The ankle should 

demonstrate some associated degenerative changes. 

Appendix C - Test Protocols

Protocol For Progressive Lift Tests

Two progressive lift tests are recommended for the RRB disability assessment: EPIC 

and PILE. The following procedures should be followed with respect to the 

administration of these tests:

The person undergoing testing should have medical authorization prior to performing 

the test.

The health professional administering the test should have completed an approved 

course of training for the test and demonstrate an acceptable level of proficiency.

The facility must have the appropriate equipment to administer the test.

The written test protocol contained in the examiner or administration manual for 

the test must be followed. 

The examiner must assess and report the examinee’s test results using the criteria 

specified by the test designed and the test-specific protocols.

Written reports must follow the procedures described in the test-specific 

protocols.

The final report should include a ranking of the subject against population norms 

and must include a statement concerning the evaluator’s assessment of the 

subject’s efforts in performing the test. 
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Isometric Strength Lift Test Protocol

The RRB recommends an isometric strength lift test as part of a protocol to assess the 

functional capacity of an individual. There are several recommended test protocols that 

have been published in the peer-reviewed literature for this type of test. The RRB 

recommends that the Zeh test protocol be used for assessing isometric strength lifting 

capacity (Zeh J, Hansson T, Bigos S, Spengler D, Battie M, Wortley M. (1986) Isometric 

strength testing: recommendations based on a statistical analysis of procedure. Spine. 

11(1): 43-46).

The Zeh protocol limits the number of exertions or lifts that the subject must perform 

and minimizes the risk of injury associated with lifting. An isometric lift test is less 

comprehensive and specific than a complete Functional Capacity Evaluation (FCE). If 

there are minimal findings or there is an impairment of other body parts or systems, 

then the FCE should be considered as the initial test requirement.

The following parameters should be followed for all isometric strength tests performed 

by the RRB:

The University of Michigan strength test system or equivalent should be used. (Chaffin 

D, Herrin GD, Keyserling WM. (1978) Preemployment strength testing: An updated 

position. J. Occu Med. 20: 403-408).

Lift should be measured in arm, leg or squat, and torso. One lift maneuver should be 

performed for each position.

Instructions to the claimant should be objective, with no emotional appeal.

Subjects should be asked to increase exertion during the first 2 seconds, then hold 

steady for 3 more seconds. 

Subjects should not be given specific test results to compare with norms or with other 

volunteers’ performances.

Other influences on performance (e.g., noise, spectators) should be minimized.

The final report should include a ranking of the subject against population norms and 

must include a statement concerning the evaluator’s assessment of the subject’s effort 

in performing the test. 

Subjects should be instructed to discontinue the test in case of any physical discomfort.

Authorization from a treating or board-appointed examining physician should be 

obtained prior to the testing procedure.

The value of the isometric lift test can be increased by increasing the numbers of lifts. 

The number of lifts can be increased to two lifts for each position upon recommendation 

of the board-appointed examining physician or with approval of the treating physician(s).
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Instructions For Thallium Studies

Thallium study (nuclear myocardial perfusion) is a nuclear medicine technique used to 

measure the viability of heart muscle. It is usually done in conjunction with an exercise 

protocol to stress the heart muscle (medications can also be used to stress the heart 

muscle without physical exercise.)

The following guidelines should be adhered to when conducting and reporting on the 

thallium (myocardial perfusion) imaging study:

Provide the date of testing

An exercise protocol should be indicated on the report (e.g. Bruce protocol) and the 

percent of maximum heart rate should be reported.

The thallium should be injected at peak exercise (usually 1 minute prior to cessation of 

exercise). 

The dose of the thallium injected should be reported.

Imaging studies should be done immediately to assess the “exercise” portion of the 

study. A “redistribution” imaging study should be obtained 3-4 hours later, anterior, left 

anterior oblique (45 degrees) and left lateral views should be obtained for each imaging 

study. 

The results should be interpreted by a board certified nuclear medicine physician and 

include comments on lung activity, distribution and if any abnormalities are reversible or 

non-reversible.

The physician's name and signature should appear on the report.

Instructions For Holter Monitoring (Ambulatory Electrocardiograph)

The Holter monitor records the heart’s electrical activity through electrodes placed on 

the chest over a 24 to 48 hour period. The electrical impulses are then transmitted to 

an amplifier, which records them on a small magnetic tape recorder for later review by 

the physician.

The following guidelines must be adhered to when conducting and reporting on Holter 

monitoring:

Ambulatory electrocardiographs use a bipolar lead system. Generally, the leads of a 

two-channel system approximate lead V1, and V2. The lead configuration should be 

indicated on the report.

The patient should be required to complete a diary card for the duration of the test. On 

this card the patient should record his/her activities and symptoms during the monitoring 

period. 
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The technician will then correlate the electrical activity with the symptoms and activities 

reported on the card.

The date of recording must be provided.

The date of analysis must be provided.

The length of the recording must be reported and must be for at least a 24 hour period.

A comment on the quality of the scan should be included with the report.

Any abnormal findings (e.g., abnormal rhythm, ectopic beats, etc.) should be indicated 

as well as any associated symptoms experienced by the patient.

If any abnormalities are noted on the 24-hour Holter monitor, correlation to existing 

disease should be commented on.

The name of the technician scanning the initial readings should be indicated.

All reports should be signed and dated by the physician.

The physician interpreting the results should be a board certified cardiologist.

Instructions For CT And Myelograms

CT and myelograms are common imaging studies used to assess the anatomy of the 

lumbar spinal canal, the knee, shoulder and wrist.

The following guidelines must be adhered to when conducting and reporting on CT and 

myelograms: 

Provide date of exam.

All CT scans and myelograms should be read by a board certified radiologist. The 

radiologist’s name and signature should appear on the dictated report.

CT cuts should be made no wider than 0.5 cm. When evaluating low back pain, the 

cuts should be made parallel to the vertebral endplates.

Myelography and CT-myelography should use a water-based contrast media, not oil 

based.

The technical protocols for these imaging tests should be described on the radiologist 

reports.
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Instructions For Spinal Instability X-Rays

Spinal instability X-rays are X-rays of the cervical, thoracic and lumbar spine done in full 

flexion and extension views. These are functional studies which are designed to 

demonstrate motion or lack of motion of the spinal vertebrae.

The following guidelines should be adhered to when conducting and reporting on spinal 

instability X-rays: 

Provide date of examination.

A description of the vertebral bodies should be included with the report. Particularly, the 

report should comment on any disk space narrowing and alignment of the vertebral 

canal. 

The physician's name and signature should appear on the report. 

Instructions For Electromyography (EMG)

Electromyography is used to assess neurologic dysfunction. The overall diagnostic 

objectives of this test is to assess suspected myelopathy (dysfunction of the spinal 

cord), radiculopathy (dysfunction of a spinal nerve root), neuropathy (dysfunction of a 

peripheral nerve at a distance the nerve root), and myopathy (muscle abnormalities).

The following guidelines should be adhered to when reporting on EMG studies:

Provide the date of testing.

• The muscles being tested should be included in the report.

• Electrical activity of the muscle(s) being tested at rest, on needle insertion and 

during contraction should be reported.

• Recruitment patterns and drop-outs of motor unit potentials should be reported. 

• The physician’s name and signature should appear on the report.

Instruction For Nerve Conduction Velocity Studies

Nerve conduction studies are tests of peripheral nerves performed by stimulating the 

nerve at one point and measuring the action potential either at another point along the 

nerve (sensory conduction) or of the muscle innervated by the nerve (motor 

conduction).

The following guidelines should be adhered to when conducting and reporting on nerve 

conduction velocity studies:

Provide the date of testing.
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The nerve being tested should be indicated as well a any latency in the conduction 

times (in milliseconds). Normal values should be included for comparison.

An assessment by the reviewing neurologist should be included in the report.

The neurologist's name and signature should appear on the report.

Instructions For HLA-B27 Assay

HLA-B27 is a serologically defined allele of the human HLA-B locus. The presence of 

the HLA-B27 antigen strongly suggests ankylosing spondylitis and related disorders.

The following guidelines must be adhered to when conducting and reporting on HLAB27 assays:

Samples must be received within 48 hours of collection.

Prior to analyzing any samples, instrument quality control should be performed using 

negative control samples. Positive controls should also be used. Any quality control 

results that indicate a failure should be recorded and action taken.

Results should be reported as negative or positive.

The name of the technical supervisor or medical director should appear on the report.

Instructions For Tuberculosis Cultures

Many laboratories have adopted the recommendations to use rapid acid-fast bacilli 

(AFB) smears, growth detection (i.e., primary culture), identification, and drugsusceptibility testing for M tuberculosis.

The following guidelines must be adhered to when conducting and reporting on AFB 

smears and primary tuberculosis cultures: 

The regulations implementing the 1988 Clinical Laboratory Improvement Amendments 

(CLIA) require all laboratories that perform any mycobacteriology testing to enroll in 

federally approved proficient testing (PT) programs.

It is important to identify which category the laboratory reporting the results falls into:

AFB smears performed and all specimens for primary culture referred to another 

laboratory.

AFB smears and primary cultures for M tuberculosis performed, but all AFB positive 

culture isolates referred for organism identification and drug-suspectibility tests.

AFB smears and primary culture with identification of M tuberculosis isolates performed 

but referred to drug-susceptibility testing.
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AFB smears, primary culture, identification and drug susceptibility testing for M 

tuberculosis performed.

Rapid laboratory testing to identify and determine the drug susceptibility of M 

tuberculosis isolates is vital to effective diagnosis, treatment and control of TB.

Liquid culture method should be used in order to decrease the time required to detect 

and solate mycobacterium, as well as increase the sensitivity of the culture to M 

tuberculosis.

Results should be reported as negative or positive. If result is positive, sensitivities of 

the culture to certain antibiotics should also be reported.

Name of supervising microbiologist should be on the report.

Instructions For Multiple Sleep Latency Testing (MSLT)

MSLT is the only scientifically validated objective test of excessive sleepiness. The 

MSLT is used to establish a diagnosis of specific sleep disorders or to determine the 

severity of sleepiness.

For correct interpretation, the MSLT must be performed under appropriate conditions 

and requires accurate technique. The following guidelines must be adhered to when 

conducting and reporting on multiple sleep latency tests. The following protocols are 

accepted by the American Sleep Disorders Association.

For correct interpretation, the MSLT must be performed following an all night 

polysomnogram to provide accurate documentation of the proceeding nights sleep.

MSLT are routinely performed at 2 hour intervals, beginning 1.5 to 3 hours after the end 

of the nocturnal recording.

The testing bedrooms should be quiet and dark and intermitted noises (e.g. elevator, 

toilet, sirens) that are likely to abort sleep onset should be avoided. If such noises are 

unavoidable, the noise should be documented on the polysomnographic chart 

recording.

The light level in the bedroom should be very low and should not vary with the time of 

day. 

Room temperature should be kept constant.

• The patient/subject should be prohibited from ingesting alcohol or caffeine on the 

day of the test.

• Since the study may be influenced by sleep for up to 7 nights beforehand, the 

patient should have completed sleep diary forms for 1-2 weeks prior to the sleep 

study. 
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• The MSLT should consist of five nap opportunities in order to determine both 

severity of sleepiness and presence of two or more sleep onset rapid eye movement 

(REM) period for the diagnosis of narcolepsy.

• A 4-hour nap test may be performed for determination of excessive sleepiness, but 

this test is not reliable for the diagnosis of narcolepsy unless at least two sleep onset 

REM periods have occurred.

• Sleep onset should be determined by the first epoch of any stage of sleep, including 

stage 1 sleep.

• The absence of sleep on any nap opportunity should be recorded as a sleep latency 

of 20 minutes.

• The MSLT report should include the onset and offset time of each nap, latency from 

lights out to the first epoch of sleep, amount of each sleep stage, total sleep time, 

mean lateness to sleep of all naps and number of sleep onset REM periods.

• All reports should include the name and signature of the physician reading the test.

• The name of the technician administering the test should appear on the report.