Objective Medical Evidence Requirements
for Disability Adjudication
(Your Memo 01/30/98) --REPLY
Commissioner Apfel has asked me to
respond to the issues raised in your memorandum dated January 30,
1998. I also have copies of your memoranda addressed to Administrative
Appeals Judge Andrew E. Wakshul and General Counsel Arthur Fried,
which raise essentially the same issue. This memorandum is also a
response to your letters to the General Counsel and Judge Wakshul.
Your letter indicates that the Social
Security Administration (SSA) needs to take a definitive position with
respect to whether fibromyalgia and chronic fatigue syndrome (CFS)
constitute medically determinable impairments. You requested an
opinion from OGC on this issue and suggested that the Appeals Council
meet en banc or schedule oral argument to resolve the issue.
Although the regulations authorize the
Appeals Council to hear oral argument in a case raising an important
question of law or policy, the Appeals Council does not establish
agency policy with respect to issues related to the evaluation of
specific medical conditions. Rather, the office of Disability
establishes agency policy is such cases.
Your letter states that fibromyalgia
and CFS do not constitute medically determinable impairments within
the meaning of section 223(d) (3) of the Social Security Act because
there are no acceptable medical criteria by which these impairments
can be diagnosed. Your letter further states that " 'symptoms'
only become 'signs' when a medically determinable impairment has been
established, and subjective 'signs' on examination are therefore not
'objective' evidence in the absence of other objective evidence for
providing a predicate for a diagnosis."
However, SSA
has taken a definitive position that fibromyalgia and CFS can
constitute medically determinable impairments within the meaning of
the statute. As you noted in your letter, CFS was discussed
in the process unification training in 1996-1997.
[Page 2]
Although we regret that you found this discussion inadequate, the
training did state clearly and unequivocally that individuals alleging
CFS can be found to have a medically determinable impairment under the
disability program given the presence of certain specified signs and
findings. This position is consistent with the instructions in Program
Operations Manual System (POMS) DI 24515.075, Disability Digest No.
93-5, and Social Security Rulings (SSRs) 98-3p, 96-4p. and 96-7p,
issued on July 2, 1996, which detail our policies as to how symptoms
effect determinations of the presence of a medically determinable
impairment, impairment severity, and the ability to engage in
sustainable work activity.
Establishing the existence of a
medically determinable impairment does not necessarily require that
the claimant or the medical evidence establish a specific diagnosis.
This is especially true when the medical community has not reached
agreement on a single set of diagnostic criteria. All the Act and
regulations require is that some physical or mental impairment be
established through medically acceptable clinical and laboratory
diagnostic techniques. In some cases, the record may not establish the
diagnosis, but there will be medical signs established by medically
acceptable clinical techniques that show that there is an impairment,
and that there is a relationship between the findings and the symptoms
alleged; i.e., that the existence of a medically determinable
impairment that could reasonably be expected to produce the symptoms
has been established.
As you indicated in your letter, with
the publication of SSRs 96-4p and 96-7p in July 1996, we intended to
emphasize the statutory standard requiring the establishment of a
medically determinable impairment as a predicate to the evaluation of
symptoms. However, we did not mean to imply that it is first necessary
to establish a fixed diagnosis in order to find the presence of a
medically determinable impairment. Rather, the medically determinable
impairment is established in the presence of anatomical,
physiological. or psychological abnormalities that can be objectively
observed and reported apart from the individual's perceptions even in
the absence of a definitive diagnosis.
Your argument based on the Rulings
seems to misinterpret the explanation in Footnote 2 to SSR 96-4p,
which explains our longstanding policy consistent with 20 CFR §§.
404.1528(b) and 416.928(b), that some symptoms, when appropriately
reported by a physician or psychologist in a clinical setting, can
also be considered "signs" because sometimes these
observations constitute "medically acceptable clinical diagnostic
techniques." This is true for mental impairments in general and
for such widely accepted and recognizable disorders as migraine
headaches.
[Page 3]
CFS is a systemic disorder consisting of a complex of symptoms and
signs that may vary in incidence, duration, and severity. The hallmark
of CFS is the presence of clinically evaluated, persistent or
relapsing chronic fatigue that is of slow or definite onset which
cannot be explained by another diagnosed physical or mental disorder,
or the result of ongoing exertion. It is not substantially alleviated
by rest and results in substantial reduction in previous levels of
occupational, educational, social, or personal activities. Within
these parameters, CFS can exhibit a variety of symptoms and signs.
As with all claims for disability,
documentation of objective physical and/or mental findings in cases
involving CFS is critical to establish the presence of a medically
determinable impairment. In cases in which CFS is alleged,
longitudinal clinical records reflecting ongoing medical assessment
and treatment from the individual's medical sources, especially
treating sources, are imperative to document objective physical and/or
mental findings. Every reasonable effort should be made to secure all
relevant evidence in cases involving CFS to ensure appropriate and
thorough disability evaluation
For purposes of Social Security
disability evaluation, one or the more of the following medical signs
clinically documented over a period of at least 6 consecutive months
establishes the existence of a medically determinable impairment for
individuals alleging disability on the basis of CFS:
- episodes of clinically documented
low-grade fever;
- palpably swollen and tender lymph
nodes on physical examination;
- nonexudative pharyngitis; and
- muscle wasting with no other
direct cause identified.
At this time, there are no specific
laboratory findings that definitively document the presence of CFS.
The results of tilt- table testing to evaluate neurally mediated
hypotension may be abnormal in individuals with CFS. Nonspecific
laboratory findings indicative of chronic immune system activation
(e.g., slight elevations in immune complexes, depressed natural killer
cell activity, or atypical lymphocytes) may he included in the
evidentiary record of individuals alleging CFS, but such findings are
not definitive of CFS nor are they necessarily evidence of a medically
determinable impairment.
Some individuals with CFS report
problems with neurocognitive functioning, including problems with
short-term memory, comprehension, concentration, speech, and/or
calculation. Other individuals with CFS may exhibit signs of a mental
or emotional disorder, such as anxiety or depression. When deficits in
these areas have been documented by mental status examination and/or
Page 4
psychological testing, such findings constitute medical signs that
establish the presence of a medically determinable impairment
If an adjudicator concludes that an
individual has a medically determinable impairment, and the individual
alleges severe fatigue on a recurring basis consistent with CFS, such
fatigue must be considered in deciding whether the individual's
impairment is severe. If chronic fatigue is found to significantly
limit an individual's ability to perform basic work activities, a
"severe" impairment must be found to exist at step 2 of the
sequential evaluation process. Although symptoms alone cannot be the
basis for finding a medically determinable impairment, an individual's
symptoms and the effects of those symptoms on the individual's
functional abilities must be considered both in determining impairment
severity and in assessing the individual's residual functional
capacity.
Fibromyalgia is a disorder defined by
the American College of Rheumatology (ACR) and we recognize it as
medically determinable if there are signs that are clinically
established by the medical record. The signs are primarily the tender
points. The ACR defines the disorder in patients as "widespread
pain in all four quadrants of the body for a minimum duration of 3
months and at least 11 of the 18 specified tender points which cluster
around the neck and shoulder, chest, hip, knee, and elbow
regions." Other typical symptoms, some of which can be signs if
they have been clinically documented over time, are irritable bowel
syndrome, chronic headaches, temporomandibular joint dysfunction,
sleep disorder, severe fatigue, and cognitive dysfunction.
I agree with your observation that we
need to do a better job of explaining our policy with respect to the
adjudication of claims involving impairments like fibromyalgia and CFS.
Toward that end, we have been drafting policy guidance to help
adjudicators evaluate these impairments.
I trust that this explanation and
clarification will assist you in applying the regulations and rulings
to cases involving fibromyalgia and CFS.
(Signed)
Susan M. Daniels, Ph. D.
