Transcript Equaling the Listings - National Association of Disability Examiners

Equaling: the three-fold way
Jeff Vasiloff, MD, MPH: [email protected]
Note: these are my personal opinions and interpretations of SSA policy; that
is, they are not policy statements of SSA, and they and should not be used as
such. Each case needs to be looked at on a case-by-case basis following all
SSA policies and guidelines.
“Equal rights for all, special
privileges for none.”
Thomas Jefferson
Useful POMS references for equaling
• DI 28090.040 Discussion of Meets or Equals
– General overview (big picture) of equaling
• DI 24505.015 Finding Disability Based on the
Listing of Impairments
– Detailed explanations on how to equal, including
examples
• DI 24515.061 How We Evaluate Symptoms,
Including Pain
– Very important about how to “factor in” pain and other
symptoms like shortness of breath
Highlights of DI 24505.015 B. Medical
equivalence
• 1. What is medical equivalence?
• An impairment(s) is medically equivalent to a listed
impairment…if it is at least equal in severity and
duration to the criteria of any listed impairment.
Highlights of DI 24505.015 B. Medical
equivalence (continued)
• 2. How do we determine medical equivalence?
• We can determine medical equivalence in the
following three
ways:
Medical Equivalence: first of three ways
(“Type 1”)
• 1. If the claimant has an impairment that is
described in the listing, BUT
– The claimant’s impairment does not exhibit 1 or more of
the specified findings, OR
• the claimant’s impairment does exhibit all of the
findings, BUT
– 1 or more of the findings is not as severe as
specified,
»THEN the claimant’s impairment is medically
equivalent IF other findings related to the
impairment is of at least equal medical
significance to the (missing) criteria
Medical Equivalence: second of three ways
(“Type 2”)
• 2. If the claimant has an impairment that is not
described in the listings, THEN
– The claimant’s impairment and findings will be
compared with those of a closely analogous listing.
THEN IF
• the findings are of at least equal medical
equivalence to those of a listed impairment,
THEN
– the claimant’s impairment is medically
equivalent to the analogous listed impairment.
Medical Equivalence: third of three ways
(“Type 3”)
• 3. If the claimant has a combination of
impairments, but none of them meets a listing,
THEN
– the claimant’s findings from the combination of
impairments will be compared to the findings of
related listings. THEN IF
• the claimant’s findings are of at least equal
medical significance to the findings of a related
listing, THEN
– the claimant’s combination of impairments is
medically equivalent to the selected related
listing.
“Writing up” an equals per POMS
1. (Always) discuss the claimant’s symptoms,
findings, and test results (in, for example, the
FOFAE)
– This is always the first step of all equals (as well
as other claims)
“Writing up” an equals per POMS: TYPE 1
Equals (missing finding in a listing)
1. Mention the findings of the pertinent listing
2. Mention the missing finding(s)
3. Identify a “substitute” finding or several “substitute”
findings that “make up for” or “equal” the missing
finding(s) in terms of severity or “seriousness”
4. Explain why the substitute finding(s) “make up for”
or “equal” the “intention” of the missing finding(s)
“Writing up” an equals per POMS: TYPE 2
Equals (only an analogous listing exists)
1. Mention the listing that most closely resembles the
claimant’s condition/impairment; that is, the
analogous listing
2. Mention the findings or criteria of the analogous
listing
3. Identify the specific findings of the claimant’s
condition/impairment that are analogous to (or
closely correspond) to the findings of the listing
4. Explain how the claimant’s findings rise to the level
of producing a level of impairment that is equivalent
to that of the analogous listing
“Writing up” an equals per POMS: TYPE 3
Equals (combinations of impairments)
1. Mention the listing that pertains to the claimant’s
worst (or most severe) condition/impairment
2. Mention the findings of that listing
3. Explain how the claimant does have a severe
impairment in a (listing) area, but not so severe as
to completely meet the listing
“Writing up” an equals per POMS: TYPE 3
Equals (combinations of impairments)
[continued]
4. Mention all the claimant’s other
conditions/impairments and findings
5. Explain the severity of each of the other
conditions/impairments and the “seriousness” of
the findings
6. Explain how the effects--added together—of the
combination of impairments and findings are
equivalent in severity to the “intent” of the selected
listing
A fact about impairments and function
• It is often true that having to function with 2
impairments is more difficult than having to function
with 1 impairment
• It is often true that having to function with 3
impairments is more difficult than having to function
with 2 impairments
• Having 4 or more impairments likely poses a
severe challenge to function
• Some impairment “combinations” are, in general,
especially limiting or “disabling”
Frequent SSA adult claimant
impairment/conditions
Respiratory
• COPD
• Obesityhypoventilation
• Asthma
•Pulm . hypertension
Cardiac
•
•
•
•
Orthopedic
• Osteoarthritis:
• Spine
• Knee
• Hip
• Antalgic gait
• Rotator cuff disease
Gastrointestinal
• Cirrhosis
Heart failure
Angina
Claudication
Venous insufficiency
Metabolic
•
•
•
•
Morbid obesity
Diabetes
Diabetic foot ulcers
Charcot foot
Neurologic
•
•
•
•
•
Neuropathy
Hemiparesis
Multiple sclerosis
Unstable gait
Carpal tunnel
Kidney
• Chronic kidney
Idiopathic
• Myofascial pain
• Fibromyalgia
• Inflammatory arthritis
•Rheumatoid arthritis
•Lupus, etc.
Hematologic
• Anemia
Some serious combinations of
impairments
• Obesity + weightbearing arthritis
• Obesity + lung disease
• Weight-bearing arthritis
+ claudication
• Weight-bearing arthritis
+ neuropathy
• Visual impairment +
neuropathy
• Visual impairment +
hearing impairment
•
•
•
•
Heart + lung disease
Heart failure + angina
Claudication + angina
Hemiparesis + weighbearing arhritis
• Hemiparesis + lung
disease
• Amputation on one side
+ neuropathy on the
other
• Amputation + an
arm/hand problem
Highlights of DI 24515.061 How We Evaluate
Symptoms, Including Pain
• A. […], we consider all your symptoms, including
pain, and the extent to which your symptoms can
reasonably be accepted as consistent with the
objective medical evidence, and other evidence…
• However, statements about your pain or other
symptoms will not alone establish that you are
disabled; there must be medical signs and
laboratory findings which show that you have a
medical impairment(s) which could reasonably be
expected to produce the pain or other symptoms
alleged…
Highlights of DI 24515.061 How We Evaluate
Symptoms, Including Pain (continued)
B. Your symptoms, such as pain, fatigue, shortness
of breath, weakness, or nervousness, will not be
found to affect your ability to do basic work
activities unless medical signs or laboratory
findings show that a medically determinable
impairment(s) is present…
Now for some…
…FUN!
Mini-cases…
…That are GIGANTIC in importance!
And remember, when you hear hoof beats, do
not think of zebras, think of what is common:
Respiratory
• COPD
• Obesityhypoventilation
• Asthma
•Pulm . hypertension
Cardiac
•
•
•
•
Orthopedic
• Osteoarthritis:
• Spine
• Knee
• Hip
• Antalgic gait
• Rotator cuff disease
Gastrointestinal
• Cirrhosis
Heart failure
Angina
Claudication
Venous insufficiency
Metabolic
•
•
•
•
Morbid obesity
Diabetes
Diabetic foot ulcers
Charcot foot
Neurologic
•
•
•
•
•
Neuropathy
Hemiparesis
Multiple sclerosis
Unstable gait
Carpal tunnel
Kidney
• Chronic kidney
Idiopathic
• Myofascial pain
• Fibromyalgia
• Inflammatory arthritis
•Rheumatoid arthritis
•Lupus, etc.
Hematologic
• Anemia
Mini-case 1
• Long history of progressively worsening
shortness of breath with exertion
• Hyperinflation by CXR; emphysema by CT
• Taking 2 prescribed bronchodilators, and has
wheezes on several examinations
• FEV1 a year and a half ago was 47% predicted
(40% is usually listing level)
• Stable state oxygen saturation at rest in the
outpatient clinic was 85%; he was then
prescribed oxygen
What listing might we consider?
What listing might we consider?
• 4.02?
• 3.02?
• 15.02?
What listing might we consider?
• 4.02?
• 3.02?
• 15.02?
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
What listing requirement of 3.02C2 is
MISSING?
What listing requirement of 3.02C2 is
MISSING?
• No stable-state blood gases (for which to find a
listing level degree of hypoxemia, that is, a
listing level of PO2)
What are you going to REPLACE the
missing requirement WITH?
•
•
•
•
Hemoglobin of 15
Creatinine of 1.1
Oxygen saturation of 85%
Ejection fraction of 0.6
What are you going to REPLACE the
missing requirement WITH?
•
•
•
•
Hemoglobin of 15
Creatinine of 1.1
Oxygen saturation of 85%
Ejection fraction of 0.6
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
√Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
How would you “write up” the equals?
Writing up the equals of Mini-case 1
• The claimant has classic COPD by history,
symptoms, physical signs, imaging (chest-xray and
CT), and PFS that are just above listing level. He is
significantly impaired by exertional dyspnea. While
no stable-state blood gases have been drawn to
assess PO2 level, he did undergo oxygen saturation
testing to reveal a resting saturation of only 85%,
which correlates to a PO2 of less than 55 mmHg (the
listing level for 3.02C2). He was placed on 24/7
oxygen due to this. He has also been receiving
prescribed treatment. Taking everything together, his
impairment equals 3.02C2.
Mini-case 2
• Consider the SAME claimant as in Mini-case 1 but
instead of having a stable-state resting oxygen
saturation of 85%, he had a resting saturation of
92% (Normal? Above listings? Below listings?)
• But in addition, the T/S conducted a “6 minute walk
test” which showed that the oxygen saturation was
85% at the end of the walk.
• Would this claimant ‘s impairment equal one of the
3.02 listings?
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
Mini-case 2
• In THIS case, therefore, we would equal 3.02C3
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
√Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
Mini-case 3 (an example from POMS)
• Difficulty walking, chronic pain and stiffness of the
left leg, especially the knee
• X-ray of the left knee: moderate tricompartmental
osteoarthritis
• X-ray of left ankle: moderate osteoarthritis
• Antalgic gait with an obligatory cane
• Decreased range of motion of both left knee and
left ankle--otherwise no abnormal joint findings
What listing might we consider?
• 1.04
• 1.02
• 11.04
• 17.09
What listing might we consider?
• 1.04
• 1.02
• 11.04
• 17.09
Does this claimant meet all of the (many)
criteria in 1.02?
• 1.02 Major dysfunction of a joint or joints WITH:
– i) gross anatomical deformity (e.g., subluxation,
contracture, bony ankylosis, fibrous ankylosis, instability,
etc.), AND
– ii) chronic pain and stiffness, WITH
– iii) signs of limitation of motion, OR other abnormal
motion of the affected joint, AND
– iv) findings on medical imaging of joint space narrowing,
bony destruction, or ankylosis, WITH
– A. Involvement of one major peripheral weight-bearing
joint (hip, knee, ankle), RESULTING IN
• inability to ambulate effectively
Answer: almost but not quite
• 1.02 Major dysfunction of a joint or joints WITH:
– i) gross anatomical deformity (e.g., subluxation,
contracture, bony ankylosis, fibrous ankylosis, instability,
etc.), AND
√chronic pain and stiffness, WITH
iii) √signs of limitation of motion, OR other abnormal
ii)
motion of the affected joint AND
iv) √findings on medical imaging of joint space narrowing,
bony destruction, or ankylosis, WITH
– A. √ Involvement of one major peripheral weight-bearing
joint (hip, knee, ankle), RESULTING IN
– √inability to ambulate effectively
So what is missing is a …
• i) gross anatomical deformity (e.g.,
subluxation, contracture, bony ankylosis,
fibrous ankylosis, instability…)
This is missing because the claimant has:
• No subluxation (abnormal movement of a bone
out of its normal joint position)
• No contracture (fixed limited mobility of a joint)
• No fibrous ankylosis (usually a total immobility of
the bones within a joint due to the growth of
abnormal fibrous tissue)
• No bony ankylosis (usually a total immobility of the
bones within a joint due to the growth of abnormal
bone)
• No instability (excessive movement or laxity or
floppiness of the bones within a joint)
•
What are you going to REPLACE the
missing requirement WITH?
What are you going to REPLACE the
missing requirement WITH?
• The listing calls for impairment of one joint.
BUT
• The claimant, in fact, has two joints in which
function is impaired. THEREFORE,
• Let us substitute the second joint with
impaired function for the lack of having a
gross anatomic deformity of the first joint
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
√Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
How would you “write up” the equals?
Writing up the equals of Mini-case 3
• The claimant has ineffective ambulation due to significant,
well-documented tricompartmental osteoarthritis of the left
knee (by x-ray). There is chronic pain, stiffness, and
decreased range of motion. While she does not have a
gross anatomical deformity as defined in the listing, she
has a second weight-bearing joint that is impaired by xray-documented osteoarthritis. Further, the left ankle
impairment is severe, interferes with ambulation, and
contributes to his cane-dependence. The additional ankle
impairment indicates as much severity as if she did have
a gross anatomical deformity such as a knee flexion
contracture. Thus, her impairment equals the intent of
1.02A.
Mini-case 4 (another example from POMS)
• Recurrent migraine headaches for years despite
regular physician contact and prescribed treatment
• Has aura, gets “spaced out,” and then has an
intense headache with severe throbbing pain
• Associated with nausea and photophobia
• Must lie down in a dark and quiet room for 4 to 72
hours—at these times has difficulty with ADLs
• Has 2 or more of such headaches per week
• No compliance concerns
Is there a listing for migraine headaches?
Is there a listing for migraine headaches?
• No—that would be too EASY!
What listing is most closely related to this
claimant’s impairment?
• 11.02
• 11.03
• 11.04
• 11.99
What listing is most closely related to this
claimant’s impairment?
• 11.02
• 11.03
• 11.04
• 11.99
11.03 is most closely related to this
claimant’s impairment
• 11.03: Epilepsy—nonconvulsive WITH detailed
description of a typical seizure including all
associated phenomena, OCCURRING more than 1
time per week IN SPITE OF 3 or more months of
prescribed treatment, WITH
–
–
–
–
Alteration of awareness, OR
Loss of consciousness [but without convulsions], AND
Transient postictal (“after-seizure”) manifestations OF
Unconventional behavior OR significant interference
with activities during the day
Why is 11.03 appropriate to use with
migraine headaches?
Why is 11.03 appropriate to use with
migraine headaches?
• Because both nonconvulsive seizures and
migraines:
– “Come and go”; that is, they are intermittent or
“paroxysmal”
– Have a sudden, unexpected onset
– Can recur rarely or frequently
– Commonly affect impair or “cloud” consciousness
– Can cause significant inability to function during the
occurrence or “spell” and as well as for several hours
afterward
– Require medications that can cause side effects
Thus, migraines can impair function in a
similar or “analogous” way as do some
seizures
• Therefore, because no migraine listing exists, it is
appropriate to use a listing that deals with an
analogous disease or condition
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
– Type 1 (missing finding in a listing)?
–√ Type 2 (only an analogous listing
exists)?
– Type 3 (combination of impairments)?
How would you “write up” the equals?
Writing up the equals of Mini-case 4
• While not having epilepsy, the claimant has recurrent
episodes of well-documented and well-described,
classic migraine headaches characterized by an aura
(as is often true with seizures), a feeling of being
“spaced out” (which is an alteration of consciousness),
followed by an incapacitating headache requiring
several hours or days to recover. These headaches
have occurred despite prescribed treatment, and occur
2 or more times per week. Thus, her episodic clinical
manifestations, while not due to epilepsy, produce a
very similar incapacity as to that produced by
uncontrolled seizures. Thus, her impairment equals the
intent of 11.03.
Mini-case 5
• This claimant has a rare disease called cystinuria,
so a little bit needs to be said about this:
• It is an inherited defect of kidney and small bowel
transport of certain amino acids (like cysteine)
• It is the most common cause of kidney stones in
children (but only causes 2% of stones in adults)
• The problem is: frequent stones form, causing
recurrent flank pain, hematuria, recurrent urinary
tract infections, urinary tract obstruction, and
ultimately, in some cases, end stage kidney
disease
Mini-case 5 (continued)
• The claimant complains of recurrent severe flank
pain due to kidney stones (before they are passed
or removed), recurrent pyelonephritis (kidney and
sometimes bloodstream infections), chronic flank
pain (from kidney stones that remain in the kidney),
and vomiting and drowsiness due to narcotics for
the pain
• She has had more than 40 lithotripsies (a
procedure to breakup kidney stones so they will
pass) by age 33 in 2007
Mini-case 5 (continued)
• More than 20 imaging studies confirm multiple and
recurrent stones
• She has had many hospitalizations (more than 3
per year since AOD) for surgical stone extractions
because they were obstructing the ureters
• She has scarring and moderate atrophy (loss of
kidney tissue) of right kidney
Is there a listing for kidney stones or
cystinuria?
Is there a listing for kidney stones or
cystinuria?
• No
What listing(s) is/are most closely related to
this claimant’s impairment?
• 12.04
• 12.05
• 3.03
• 5.06
• Both 3.03 and 5.06
What listing(s) is/are most closely related to
this claimant’s impairment?
• 12.04
• 12.05
• 3.03
• 5.06
• Both 3.03 and 5.06
3.03B is closely related to this claimant’s
impairment
• 3.03 Asthma WITH
• A. Based on FEV1
• B. Asthmatic attacks, IN SPITE OF
– prescribed treatment, AND
– requiring physician intervention, OCCURRING
– 1 or more times every 2 months, OR (really) 6 or more
times in a year
• But 24+ hour hospitalizations count as 2 attacks
Why is 3.03B closely related to this
claimant’s impairment?
Why is 3.03B closely related to this
claimant’s impairment?
• Because 3.03B deals with frequent flare-ups or
exacerbations of a disease, exacerbations that are
so severe that timely physician intervention in the
emergency department or hospital is needed
Thus, recurrent kidney stones--causing obstruction
(blockage) of the urinary tract and resultant pain and
kidney infection--can impair function in a similar or
“analogous” way as do exacerbations of asthma
• Therefore, because no kidney stone or cystinuria
listings existing, it is appropriate to use a listing that
deals with an analogous disease or condition
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
– Type 1 (missing finding in a listing)?
–√ Type 2 (only an analogous listing
exists)?
– Type 3 (combination of impairments)?
How would you “write up” the equals?
• The claimant does not have asthma with frequent and
significant exacerbations, but has a genetically-based
disease, cystinuria, which, due to uncontrollable stone
formation, causes frequent and significant obstruction of the
ureters, sometimes leading to infection, but each time,
requiring aggressive outpatient or inpatient surgery to
relieve the obstructions. Since AOD, the claimant has never
had a year where she has had less than 3 hospitalizations,
each > 24 hours. Thus, while she does not have asthma
with frequent attacks, she has frequent “attacks” of kidney
stones that require even more intense physician-directed
interventions than in the usual case of asthma. She is
compliant and there is no effective treatment to prevent
continuing new stone formation. Thus, her impairment
equals the intent of 3.03B.
But what about using 5.06?
• 5.06 Inflammatory bowel disease WITH
documentation by imaging, endoscopy, or direct
visualization at open surgery, WITH
– A. Obstruction of stenotic (“narrowed”) areas in the small
intestine or colon, WITH
• dilation of the bowel before the obstruction,
CONFIRMED BY
• imaging or direct visualization at open surgery,
REQUIRING
• hospitalization to relieve the obstruction, AND
• occurring 2 or more times within a 6 month period,
each episode at least 60 days from each other
Why is 5.06A closely related to this
claimant’s impairment?
• Because the claimant’s recurrent kidney stones
result in recurrent obstruction (and dilation) of the
hollow urinary tract--just like inflammatory bowel
disease results in stenoses (partial obstruction or
complete obstruction) of the hollow gastrointestinal
tract
• Also, in both the claimant and those with severe
inflammatory bowel disease, the recurrent
obstruction requires hospitalization and invasive
procedures to relieve the obstruction
Thus, recurrent kidney stones--causing obstruction
(blockage) of the urinary tract and resultant pain and
requiring hospitalization to relieve the obstruction can impair
function in a similar or “analogous” way as do obstructions
of the gastrointestinal tract in inflammatory bowel disease
• Therefore, because no kidney stone or cystinuria
listings existing, it is appropriate to use a listing that
deals with an analogous disease or condition
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
– Type 1 (missing finding in a listing)?
–√ Type 2 (only an analogous listing
exists)?
– Type 3 (combination of impairments)?
How would you “write up” the equals?
• The claimant does not have inflammatory bowel disease but
does have a chronic, genetically-based condition (cystinuria)
that affects the small bowel as well as the kidneys. While
she does not have recurrent bowel obstructions, she has
formed multiple kidney stones that do obstruct the ureters.
Not only are these obstructions documented by imaging, but
require either outpatient or inpatient surgeries to relieve
them. Because the formation of new stones cannot be
prevented, obstructions have continued and will continue.
Further, the obstructions have been so frequent and severe
that she has had recurrent kidney infections, which along
with the high urinary tract pressures from obstruction, have
damaged her kidneys, as evidenced by scarring and
atrophy of the right kidney. Thus, her impairment equals the
intent of 5.06A.
Mini-case 6
• The claimant’s major problem is exertional fatigue
and shortness of breath with minimal activity
• PFS (in the stable state and valid, per CE) reveal
an FEV1 of 46% predicted (but this is above the
listing level for his height)
• She had a myocardial infarction in the distant past
which has caused persistent systolic dysfunction
with an ejection fraction (in the stable state) of 0.32
(or 32%) [recall the listing level is 0.3 or less, or
30% or less]
What listings might we consider?
• 3.02
• 4.02
• 5.02
• 7.02
• 3.02 and 4.02
What listings might we consider?
• 3.02
• 4.02
• 5.02
• 7.02
• 3.02 and 4.02
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
What is the problem with 3.02A in this
case?
What is the problem with 3.02A in this
case?
• The claimant’s FEV1 is above listings, BUT he
appears quite limited despite this, probably
because he has not only “lung failure” but “heart
failure” which are synergistic in limiting exertion due
to fatigue and dyspnea
So perhaps he meets 4.02--let us look at the
many criteria for this complicated listing
Remember 4.02 has an A part and a B part
• 4.02 Chronic heart failure IN SPITE OF
prescribed treatment WITH symptoms AND signs
of heart failure (dyspnea, fatigue, jugular venous
distension, pulmonary rales or crackles,
hepatojugular reflux, or edema) PLUS one severity
indicator from list A, and one severity indicator
from list B
List A criteria (two options)
1. Ejection fraction of 0.3 or less (30% or less)
WITH left ventricular diameter of 6 or more
centimeters
OR
2. Echocardiography results that confirm
significant diastolic dysfunction (intraventricular
septal thickness + left ventricular posterior wall
thickness = 2.5 cm or more, WITH left atrial
diameter of 4.5 cm or more)
List B criteria (this is the first of three
options)
• 1. Persistent symptoms of heart failure
which seriously limit ADLs, PLUS cardiac
stress testing is contraindicated
List B criteria (this is the second of three
options)
• 2. Three (3) or more separate episodes of acute
heart failure THAT ARE > 2 weeks apart, DURING
WHICH stability was attained, WITH
– Fluid overload BY SIGNS (edema, jugular venous
distension, hepatojugular reflux, pulmonary edema), OR
– IMAGING (cardiac chamber enlargement, pleural
effusions, pulmonary edema by x-ray, ascites), AND
REQUIRING
• Intensive physician intervention in a
hospital/emergency department LASTING 12 or more
hours
List B criteria (this is the third of three
options)
• 3. Inability to sustain an aerobic exercise intensity
of 5 metabolic equivalents of oxygen consumption
(METs) DUE TO:
–
–
–
–
Cardiopulmonary symptoms (dyspnea, fatigue), OR
Abnormal EKG or rhythm changes, OR
Low blood pressure, OR
Lightheadedness, confusion, or ataxic (unstable and
uncoordinated gait)
What is the problem with the 4.02 listings in
this case?
What is the problem with the 4.02 listings in
this case?
• Neither the A nor B criteria are met, but, despite
this, he has severe systolic dysfunction (EF 0.32;
normal is 0.55 or above). However, he appears
quite limited despite this, probably because he has
not only “heart failure” but “lung failure” which are
synergistic in limiting exertion due to fatigue and
dyspnea
So what does common sense (and SSA
policy!) tell us to do in cases such as
these?
So what does common sense (and SSA
policy!) tell us to do in cases such as
these?
• “ADD” or “SUMMATE” the effects of both
impairments to see if the overall effect of the
combination of impairments rises to the level of
being equivalent to or “equaling” a listing
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
–√ Type 3 (combination of impairments)?
How would you “write up” the equals?
Writing up the equals of Mini-case 6
• The claimant has significant heart failure with stable
state systolic dysfunction of just above listing level
(EF = 0.32). She also has significant COPD with an
FEV1 that is just above listing level (46% predicted).
She has credible symptoms of fatigue and shortness
of breath with minimal exertion. Both her heart failure
and COPD are synergistic (“combine together in an
enhancing or especially additive way”) in limiting
exertion. While both her heart disease alone and her
lung disease alone do not meet a listing, when the
effects of each are added to one another, the effect
on her total functioning equals the intent of either
4.02 or 3.02A.
Mini-case 7
• Type 2 diabetes, tingling and numbness of the feet,
fatigue, shortness of breath with exertion, knee pain
and a limp
• BMI of 52
• Moderate right knee osteoarthritis on x-ray;
probable osteoarthritis of the left knee by physical
examination
• Mild to moderate antalgic gait with limp on right
• No ambulatory used
• Decreased sensation in both legs below the knees
• FEV1 of 51% predicted
What listings might we consider?
• 3.02
• 11.14
• 1.02
• Both 3.02 and 1.02
• 3.02 and 11.14 and 1.02
What listings might we consider?
• 3.02
• 11.14
• 1.02
• Both 3.02 and 1.02
• 3.02 and 11.14 and 1.02
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
Which part of 3.02 is the most relevant?
•
•
•
•
•
3.02 Chronic pulmonary insufficiency
A. Based on FEV1?
B. Based on FVC?
C. 1. Based on DLCO?
C 2. Based on resting stable state hypoxemia
(PO2)?
• C 3. Based on stable state hypoxemia (PO2)
with exercise?
What is the problem with 3.02A in this
case?
What is the problem with 3.02A in this
case?
• The recent, stable-state measurement of FEV1 is
above listing level
So let us look at 11.14
• 11.14 Peripheral neuropathies WITH
disorganization of motor function as described in
11.04B despite prescribed treatment, WHERE
11.04 is:
– Significant and persistent disorganization of motor
function in two extremities, resulting in EITHER
sustained disturbance of gross and dexterous
movements OR gait and station
What is the problem with 11.14 in this case?
What is the problem with 11.14 in this case?
• He does have evidence of a neuropathy, but
looking at his ADLs, he can walk about three
blocks; the first two at just a little slower than
normal for him
• He doesn’t appear to meet the criteria for
ineffective ambulation (but he is close)
So let us look at 1.02 again
• 1.02 Major dysfunction of a joint or joints WITH:
– i) gross anatomical deformity (e.g., subluxation,
contracture, bony ankylosis, fibrous ankylosis, instability,
etc.), AND
– ii) chronic pain and stiffness, WITH
– iii) signs of limitation of motion, OR
– iv) other abnormal motion of the affected joint (?), AND
– v) findings on medical imaging of joint space narrowing,
bony destruction, or ankylosis, WITH
– A. Involvement of one major peripheral weight-bearing
joint (hip, knee, ankle), RESULTING IN
• inability to ambulate effectively
What is the problem with 1.02A in this
case?
• Two things: he doesn’t meet ineffective ambulation
(but he is close), and also, he has no gross
anatomical deformity
So what does common sense (and SSA
policy!) tell us to do in cases such as
these?
So what does common sense (and SSA
policy!) tell us to do in cases such as
these?
• “ADD” or “SUMMATE” the effects of all
impairments (including, in this case, his obesity with
a BMI of 52) to see if the overall effect of the
combination of impairments rises to the level of
being equivalent to or “equaling” a listing
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
– Type 3 (combination of impairments)?
So what type of equals is this?
– Type 1 (missing finding in a listing)?
– Type 2 (only an analogous listing exists)?
–√ Type 3 (combination of impairments)?
How would you “write up” the equals?
Writing up the equals of Mini-case 7
• The claimant has four severe impairments: extreme morbid
obesity, lung disease, osteoarthritis in one (if not both
knees), and diabetic neuropathy. The morbid obesity is
synergistic with his lung disease to limit exertion
dramatically. Similarly, his knee arthritis is synergistic with
his diabetic neuropathy (with its loss of tactile sensation and
proprioception) in limiting the ability to ambulate for even
short distances safely. Finally, his obesity is synergistic also
with his neuropathy and osteoarthritis in affecting
ambulation. While there is no listing for morbid obesity, and
while he does not meet a pulmonary listings like 3.02A or a
musculoskeletal listing like 1.02A or a peripheral neuropathy
listing like 11.14, when the effects of each are added to one
another, the effect on total functioning equals the intent of
1.02A or 11.14.
Take home message:
• When approaching claims in which there are one or
more severe impairments that do not meet a listing,
remember that you can support an equals by:
– Substituting an equivalent clinical finding or test
result for one that is missing from a listing
– Picking an analogous listing, and explaining how
your claimant’s impairment or condition is closelycorrelated to, and therefore, equivalent to the listing
– Taking note of all of the claimant’s nonlisting-level
impairments, and explaining how--often through
synergy—the combined effects of the impairments
are equal to the incapacity produced by a listed
impairment that is fully met
And remember, when you hear hoof beats, do
not think of zebras, think of what is common:
Respiratory
• COPD
• Obesityhypoventilation
• Asthma
•Pulm . hypertension
Cardiac
•
•
•
•
Orthopedic
• Osteoarthritis:
• Spine
• Knee
• Hip
• Antalgic gait
• Rotator cuff disease
Gastrointestinal
• Cirrhosis
Heart failure
Angina
Claudication
Venous insufficiency
Metabolic
•
•
•
•
Morbid obesity
Diabetes
Diabetic foot ulcers
Charcot foot
Neurologic
•
•
•
•
•
Neuropathy
Hemiparesis
Multiple sclerosis
Unstable gait
Carpal tunnel
Kidney
• Chronic kidney
Idiopathic
• Myofascial pain
• Fibromyalgia
• Inflammatory arthritis
•Rheumatoid arthritis
•Lupus, etc.
Hematologic
• Anemia
Questions and comments?
• Thank you for having me NADE and
OADE!