Source: https://www.federalregister.gov/documents/2014/02/25/2014-02659/revised-medical-criteria-for-evaluating-neurological-disorders
Timestamp: 2018-03-22 03:25:33
Document Index: 457401316

Matched Legal Cases: ['§\u2009404', '§\u2009404', '§\u2009404', '§\u2009404', '§\u2009404', '§\u2009404', '§\u2009404', '§\u2009416', '§\u2009404', '§\u2009416', '§\u2009416', '§\u2009416']

A Proposed Rule by the Social Security Administration on 02/25/2014
10635-10654 (20 pages)
11.00 Neurological Disorders.
https://www.federalregister.gov/d/2014-02659 https://www.federalregister.gov/d/2014-02659
We propose these revisions to reflect our program experience and advances in medical knowledge, treatment, and methods of evaluating neurological disorders. We last published final rules making comprehensive revisions to section 11.00—the neurological listings for adults (people who are at least 18 years old)—and section 111.00—the neurological listings for children (people under age 18)—on December 6, 1985.[1] Although we have made some changes since then, we have not comprehensively revised the rules since 1985.[2]
In developing these proposed rules, we considered the public comments we received in response to an ANPRM that we published in the Federal Register on April 13, 2005.[3] In the ANPRM, we announced our plans to update and revise this body system, and we invited the public to send us written comments and suggestions. We also considered the public comments we received at an outreach policy conference on “Neurological Disorders in the Disability Programs” that we hosted in New York, New York, on July 28, 2005.[4] In addition, we considered comments about neuropathy that we received when we revised the medical criteria for evaluating endocrine disorders.[5]
We propose to change the name of this body system from Neurological to Neurological Disorders to make it consistent with our naming of other body systems. We have been renaming all of the other body systems to include the word “disorders” as we revise them, and the name change we are proposing in this notice of proposed rulemaking (NPRM) is consistent with that approach.Start Printed Page 10637
11.00A Epilepsy 11.00A Which neurological disorders do we evaluate under these listings?
11.00B Brain tumors 11.00B What evidence do we need to document your neurological disorder?
11.00C Persistent disorganization of motor function 11.00C How do we consider adherence to prescribed treatment in neurological disorders?
11.00D In conditions which are episodic in character 11.00D What do we mean by disorganization of motor function?
11.00E Multiple sclerosis 11.00E How do we evaluate communication impairments under these listings?
11.00F Traumatic brain injury (TBI) 11.00F What do we mean by bulbar and neuromuscular dysfunction?
11.00G Amyotrophic Lateral Sclerosis (ALS) 11.00G How do we evaluate a combination of functional limitations under these listings?
In this new section, we describe the kinds of information that we use to establish the existence and severity of your neurological disorder. We also clarify our policy that we will not purchase imaging or laboratory tests that are complex, costly, or invasive.[6]
In this new section, we define the phrase “disorganization of motor function”. In proposed 11.00D2, we explain the addition of a severity standard for disorganized motor function, which we refer to as “extreme limitation.” We propose to define an extreme limitation as the inability to stand up from a seated position, or the inability to maintain balance in a standing position and while walking, or the inability to use your upper extremities. We then explain what each of these limitations means.Start Printed Page 10638
Although we do not propose to revise the requirements for evaluating communication impairments that are currently in listings 11.04A, 11.07C, and 11.11B, we propose to define the terms “ineffective speech or communication” and “significant interference” in 11.00E1 and 11.00E2. Guidance for evaluating speech and language impairments will be addressed in future regulations, as discussed in ANPRMs published in the Federal Register on April 13, 2005, and February 6, 2012.[7]
In proposed 11.00G2, we use essentially the same definition of “marked” as in 14.00I5, but we would not include the description of “marked” as “more than moderate but less than extreme.” Instead, we include an explanation based on the language describing the rating scale for mental disorders in current §§ 404.1520a(c)(4) and 416.920a(c)(4). This rating scale describes “marked” as the fourth point on a five-point rating scale. We explain that we would not require our adjudicators to use such a scale, but that “marked” would be the fourth point on a scale of “no limitation, mild limitation, moderate limitation, marked limitation, and extreme limitation.” With this guideline, we would not need to state that “marked” falls between “moderate” and “extreme.”
We propose to expand guidance to our adjudicators on evaluating multiple sclerosis (MS) by explaining that the disorder affects several aspects of functioning. In proposed 11.00N2, we explain how we evaluate the effects of MS using proposed criteria for disorganization of motor functioning or a combination of functional limitations.Start Printed Page 10639
11.02 Epilepsy—convulsive epilepsy 11.02 Epilepsy.
11.03 Epilepsy—nonconvulsive epilepsy 11.03 [Reserved].
11.04 Central nervous system vascular accident 11.04 Vascular insult to the brain.
11.05 Benign brain tumors 11.05 Benign brain tumors.
11.06 Parkinsonian syndrome 11.06 Parkinsonian syndrome.
11.07 Cerebral palsy 11.07 Cerebral palsy.
11.08 Spinal cord or nerve root lesions, due to any cause 11.08 Spinal cord insults.
11.09 Multiple sclerosis 11.09 Multiple sclerosis.
11.10 Amyotrophic lateral sclerosis 11.10 Amyotrophic lateral sclerosis.
11.11 Anterior poliomyelitis 11.11 Post-polio syndrome.
11.12 Myasthenia gravis 11.12 Myasthenia gravis.
11.13 Muscular dystrophy 11.13 Muscular dystrophy.
11.14 Peripheral neuropathies 11.14 Peripheral neuropathy.
11.15 [Reserved] 11.15 [Reserved].
11.16 Subacute combined cord degeneration (pernicious anemia) 11.16 [Reserved]
11.17 Degenerative disease not listed elsewhere, such as Huntington's chorea, Friedreich's ataxia, and spino-cerebellar degeneration 11.17 Neurodegenerative disorders of the central nervous system, such as Huntington disease, Friedreich ataxia, and spinocerebellar degeneration.
11.18 Cerebral trauma 11.18 Traumatic brain injury.
11.19 Syringomyelia 11.19 [Reserved].
11.21 [Reserved].
We propose to use the criterion disorganization of motor function in all listings, except proposed 11.02 for Epilepsy and 11.20 for coma or PVS. This criterion is analogous to the “disorganization of motor function” criterion that we have in most of the current neurological disorders listings. Our proposed criterion focuses on specific limitations in the ability to stand up, balance, walk, and use fingers, hands, and arms to perform fine and gross motor movements, rather than on Start Printed Page 10640specific neurological signs and the measureable degree of limitation demonstrated by those signs. This clarification to disorganization of motor function provides more consistency to our determinations of disorganization of motor function under the listings.
We propose to add a criterion for adherence to prescribed treatment. We believe that a specific period of time needs to pass during which you are adhering to prescribed treatment before Start Printed Page 10641considering the severity of the condition.
We are not proposing to include criteria for evaluating a combination of functional limitations in the childhood listings because we already evaluate functioning in children using the rules for determining the functional equivalence of an impairment(s) to the listings.[8] Except for minor editorial changes to make the text specific to children, we propose to repeat most of the introductory text of proposed 11.00 in the introductory text of proposed 111.00. Since we have already described these proposed revisions in the explanation to the introductory text of proposed 11.00, we describe here only sections of the proposed rules that are unique to children or that require further explanation.
The following chart provides a comparison of the current childhood listings and the proposed childhood listings.Start Printed Page 10642
111.02 Major motor seizure disorder 111.02 Epilepsy.
111.03 Nonconvulsive epilepsy 111.03 [Reserved].
111.04 Vascular insult to the brain.
111.05 Benign brain tumors 111.05 Benign brain tumors.
111.06 Motor dysfunction (due to any neurological disorder) 111.06 [Reserved].
111.07 Cerebral Palsy 111.07 Cerebral palsy.
111.08 Meningomyelocele (and related disorders) 111.08 Spinal cord insults.
111.09 Communication impairment, associated with documented neurological disorder 111.09 Communication impairments, associated with documented neurological disorder.
111.12 Myasthenia gravis.
111.13 Muscular dystrophy.
111.14 Peripheral neuropathy.
111.17 Neurodegenerative disorders of the central nervous system, such as Juvenile Huntington disease and Friedreich ataxia.
111.18 Traumatic brain injury.
111.20 Coma or persistent vegetative state.
111.21 Multiple sclerosis.
111.22 Motor neuron disorders other than ALS.
Under our current, long-standing policy, we do not require or purchase genetic testing to evaluate disability; however, we do consider all evidence in the record, including genetic testing, when we make a determination or decision of whether you are disabled (See, §§ 404.1520 and 416.920).
Barry, J.J. (2003). The recognition and management of mood disorders as a comorbidity of epilepsy. Epilepsia, 44, Start Printed Page 10643supplement s4, 30-40.doi:10.1046/j.1528-1157.44.s4.4.x
Carroll, L. (2006). War on the brain. Neurology Now, 2 (5), 12-16. Retrieved from http://journals.lww.com/​neurologynow/​Fulltext/​2006/​02050/​War_​on_​the_​Brain.13.aspx
Deutsch, P.M., Kendall, S.L., Daninhirsch, C., Cimino-Ferguson, S., & McCollom, P. (2006). Vocational outcomes after brain injury in a patient population evaluated for Life Care Plan reliability. NeuroRehabilitation, 21, 305-314. Retrieved from http://flcpr.org/​Documents/​Deutsch_​etal_​NR_​21_​305-314.pdf
Diedrich, A., & Robertson, D. (2010, March 4). Multiple system atrophy. Retrieved from http://emedicine.medscape.com/​article/​1154583-overview
Farbu, E. (2012). Post-polio syndrome. In J.Stone & M. Blouin (Eds.), International Encyclopedia of Rehabilitation. Retrieved from http://cirrie.buffalo.edu/​encyclopedia/​en/​article/​138/​
Hermanowicz, N., & Haske-Palomino, M. (2007). Parkinson disease: Essentials of diagnosis. Applied Neurology, 3 (2), 27-38. Retrieved from http://www.psychiatrictimes.com/​display/​article/​10168/​57546#
Karceski, S. (2007, March). Epilepsy essentials: Exploring the connection between epilepsy and migraine. Practical Neurology, 17-18. Retrieved from http://www.bmctoday.net/​practicalneurology/​
McCrory, D.C., Pompeii, L.A., Skeen, M.B., Moon, S.D., Gray, R.N., Kolimaga, J.T., & Matchar, D.B. (2004). Criteria to Determine Disability Related to Multiple Sclerosis. Evidence Report/Technology Assessment s, 100. (AHRQ Publication No. 04-E019-2). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://archive.ahrq.gov/​downloads/​pub/​evidence/​pdf/​msdis/​msdis.pdf
National Institute of Neurological Disorders and Stroke. (2011). NINDS Migraine Information Page. Retrieved from http://www.ninds.nih.gov/​disorders/​migraine/​migraine.htm
Rapposelli, D. (2007). Depression in epilepsy: Chipping away at obstacles to diagnosis and care. Psychiatric Times, 3 (1), 39-40. Retrieved from http://www.psychiatrictimes.com/​
Rodnitzky, R.L. (2007, March). Perchance to dream: How to minimize sleep disorders in Parkinson's disease. Practical Neurology, 58-67. Retrieved from http://bmctoday.net/​practicalneurology
Sahgal, V., & Reger, S. (2009, April 30). Physical medicine and rehabilitation for limb-girdle muscular dystrophy. Retrieved from http://emedicine.medscape.com/​article/​313515-overview
Sillanpää, M., & Shinnar, S. (2010). Long-term mortality in childhood-onset epilepsy. New England Journal of Medicine, 363, 2522-2529. doi:10.1056/NEJMoa0911610Start Printed Page 10644
Taber, K.H., Warden, D.L., & Hurley, R.A. (2006). Blast-related traumatic brain injury: What is known? Journal of Neuropsychiatry & Clinical Neurosciences, 18, 141-145. Retrieved from http://neuro.psychiatryonline.org/​issues.aspx?​journalid=​62
2. Amend appendix 1 by:
a. Revising item 12 of the introductory text before part A;
c. Inability to use your upper extremities means that you have an extreme loss of function of both upper extremities that interferes very seriously with your ability to perform fine and gross motor movements. Inability to perform fine and gross motor Start Printed Page 10645movements could include inability to feed oneself, inability to take care of personal hygiene, inability to sort and handle papers or files, or the inability to lift and carry items at or above waist level.
a. We will consider your symptoms and signs and how they affect your ability to function in work-related activities. When we evaluate your functioning, we will consider whether Start Printed Page 10646your symptoms and signs are persistent or intermittent, how frequently they occur and how long they last, their intensity, and whether you have periods of exacerbation and remission.
d. We do not count seizures that occur during a period when you are not adhering to prescribed treatment without good reason. When we determine that you had good reason for not adhering to prescribed treatment, we will consider your physical, mental, educational, and communicative limitations (including any lack of facility with the English language). We will consider you to have good reason for not following prescribed treatment if the treatment is very risky for you due to its magnitude or unusual nature, or if you are unable to afford prescribed treatment that you are willing to accept, but for which no free community resources are available. We will not follow guidelines in our policy that are not relevant to the number of seizures that you experience. For example, we will not consider amputation of an extremity or cataract surgery in one eye when there is a severe visual impairment not expected to improve with treatment in the other eye to be good reasons to not follow prescribed treatment for your seizures. We will follow guidelines found in our policy, such as §§ 404.1530(c) and 416.930(c) of this chapter, when we determine whether you have a good reason for not adhering to prescribed treatment.
1. Cerebral palsy (CP) is a term that describes a group of static, nonprogressive disorders caused by abnormalities within the brain that disrupt the brain's ability to control movement, muscle coordination, and posture. The resulting motor deficits manifest very early in a person's Start Printed Page 10647development, with delayed or abnormal progress in attaining developmental milestones; deficits may become more obvious as the person grows and matures over time.
S. What are motor neuron disorders, other than ALS, and how do we evaluate them under 11.22? Motor neuron disorders such as progressive bulbar palsy, primary lateral sclerosis (PLS), and spinal muscular atrophy (SMA) are progressive neurological disorders that Start Printed Page 10648destroy the cells that control voluntary muscle activity, such as walking, breathing, swallowing, and speaking. We evaluate the effects of these disorders on motor functioning, bulbar and neuromuscular functioning, oral communication, or a combination of functional limitations.
If you have a severe medically determinable impairment(s) that does not meet a listing, we will determine whether your impairment(s) medically equals a listing. See §§ 404.1526 and 416.926 of this chapter. If your impairment(s) does not meet or medically equal the criteria of a listing, you may or may not have the residual functional capacity to engage in substantial gainful activity, which we determine at the fourth, and if necessary, the fifth steps of the sequential evaluation process in §§ 404.1520 and 416.920 of this chapter. See also §§ 404.1545, 404.1560, 416.945, and 416.960 of this chapter. We use the rules in §§ 404.1594 and 416.994 of this chapter, as appropriate, when we decide whether you continue to be disabled.
Start Printed Page 10649
11.08 Spinal cord insults, characterized by A, B, or C:
11.10 Amyotrophic lateral sclerosis established by clinical and laboratory findings.
11.15 [Reserved]
11.16 [Reserved]
11.17 Neurodegenerative disorders of the central nervous system, such as Huntington disease, Friedreich ataxia, and spinocerebellar degeneration, characterized by A or B:
11.19 [Reserved]
11.20 Coma or persistent vegetative state, persisting for at least 1 month.Start Printed Page 10650
11.21 [Reserved]
11.22 Motor neuron disorders other than ALS, characterized by A, B, or C:
D. Documentation. * * *
12.09 Substance Addiction Disorders: * * *
111.00 Neurological Disorders.
1. General. * * * Impairments with neurological causes are to be evaluated under 111.00ff, as appropriate.
4. For children who are not yet able to balance, stand up, or walk independently, we consider their function based on assessments of limitations in the ability to perform comparable age-appropriate activities with the lower and upper extremities, given normal developmental expectations. For such children, an extreme level of limitation means developmental expectations at no more Start Printed Page 10651than one-half (1/2) of the child's chronological age.
d. We do not count seizures that occur during a period when you are not adhering to prescribed treatment without good reason. When we determine that you had a good reason for not adhering to prescribed treatment, we will consider your physical, mental, educational, and communicative limitations (including any lack of facility with the English language). We will consider you to have good reason for not following prescribed treatment if the treatment is very risky for you due to its magnitude or unusual nature, or if you are unable to afford prescribed treatment that you are willing to accept, but for which no free community resources are available. We will not follow guidelines in our policy that are not relevant to the number of seizures that you experience. For example, we will not consider amputation of an extremity or cataract surgery in one eye when there is a severe visual impairment not expected to improve with treatment in the other eye to be good reasons to not follow prescribed treatment for your seizures. We will follow guidelines found in our policy, such as § 416.930(c) of this chapter, when we determine whether you have a good reason for not adhering to prescribed treatment.
2. We evaluate your signs and symptoms, such as ataxia, spasticity, flaccidity, athetosis, chorea, and difficulty with precise movements when we determine your ability to stand up, Start Printed Page 10652balance, walk, or perform fine and gross motor movements. We will also evaluate your signs, such as dysarthria and apraxia of speech, and receptive and expressive language problems when we determine your ability to communicate. We will consider your other impairments or signs and symptoms that develop secondary to the disorder, such as post-impairment syndrome (a combination of pain, fatigue, and weakness due to muscle abnormalities); overuse syndromes (repetitive motion injuries); arthritis; abnormalities of proprioception (perception of the movements and position of the body); abnormalities of stereognosis (perception and identification of objects by touch); learning problems; anxiety; and depression.
2. We evaluate your signs and symptoms, such as flaccidity, spasticity, spasms, in-coordination, imbalance, tremor, physical fatigue, muscle weakness, dizziness, tingling, and numbness when we determine your ability to stand up, balance, walk, or perform fine and gross motor Start Printed Page 10653movements, such as using your arms, hands, and fingers.
If you have a severe medically determinable impairment(s) that does not meet a listing, we will determine whether your impairment(s) medically equals a listing. See §§ 404.1526 and 416.926 of this chapter. If your impairment(s) does not meet or medically equal a listing, we will consider whether your impairment(s) functionally equals the listings. See §§ 416.924(a) and 416.926(a) of this chapter. We use the rules in § 416.994(a) of this chapter when we decide whether you continue to be disabled.
111.03 [Reserved]
111.04 Vascular insult to the brain, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 111.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements, persisting for at least 3 consecutive months after the insult.
111.05 Benign brain tumors, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 111.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements.
111.06 [Reserved]
111.07 Cerebral palsy, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 111.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements.
111.08 Spinal cord insults, characterized by A or B:
111.09 Communication impairment, associated with documented neurological disorder. And one of the following:
111.10 [Reserved]
111.11 [Reserved]
111.13 Muscular dystrophy, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 111.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements.
111.14 Peripheral neuropathy, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 11.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements.
111.15 [Reserved]
111.16 [Reserved]
111.17 Neurodegenerative disorders of the central nervous system, such as Juvenile Huntington disease and Friedreich ataxia, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 111.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements.
111.18 Traumatic brain injury, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 111.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements, persisting for at least 3 consecutive months after the injury.
111.19 [Reserved]
111.21 Multiple sclerosis, characterized by disorganization of motor function (see 111.00D1), resulting in extreme limitation (see 111.00D2) in the ability to stand up, balance, walk, or perform fine and gross motor movements.
Start Printed Page 10654
4. Although we indicated in the ANPRM that we would not summarize or respond to the comments, we read and considered them carefully. You can read the ANPRM, the comments we received in response to the ANPRM, and a transcript of the policy conference at—http://www.regulations.gov/​#!documentDetail;​D=​SSA-2006-0140-0002 and http://www.regulations.gov/​#!documentDetail;​D=​SSA-2006-0140-0003.
8. See § 416.926(a) of this chapter.