Health professionals play a vital role in the disability determination
process and participate in the process in a variety of ways:
- As treating sources or other medical sources who provide medical evidence on behalf of their patients;
- As CE sources to perform, for a fee, examinations and/or tests that are needed;
- As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of
SSAs regional offices, or in SSA central office; or
- As medical experts who testify at administrative law judge hearings.
A medically determinable physical or mental
impairment is an impairment that results from anatomical, physiological, or psychological abnormalities which can be shown
by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established
by medical evidence consisting of signs, symptoms, and laboratory findings-not only by the individual's statement of symptoms.
Most disability claims are initially processed through a network of local Social Security field offices
and State agencies (usually called disability deter-mination services, or DDSs). Subsequent appeals of unfavorable determinations
may be decided in the DDSs or by administrative law judges in SSA's Office of Hearings and Appeals.
How is the disability determination made?
A. SSAs regulations provide for disability evaluation under a procedure known as the "sequential evaluation
process." For adults, this process requires sequential review of the claimant's current work activity, the severity of his
or her impairment(s), the claimant's residual functional capacity, his or her past work, and his or her age, education, and
work experience.
When do disability benefits start?
A. The law provides that, under the Social Security disability program, disability benefits
for workers and widows usually cannot begin for 5 months after the established onset of the disability. The 5 month waiting
period does not apply to individuals filing as children of workers. Under SSI, disability payments may begin
as early as the date the individual files an application.
In addition, under the SSI disability program, an applicant may be found
"presumptively disabled," and receive cash payments for up to 6 months while the formal disability determination is made.
The presumptive payment is designed to allow a needy individual to meet his or her basic living expenses during the time it
takes to process the application. If it is finally determined that the individual is not disabled, he or she is not required
to refund the payments. There is no provision for a finding of presumptive disability under the title II program.
Information
from other sources may also help show the extent to which a person's impairment(s) affects his or her ability to function.
Other sources include public and private social welfare agencies, non-medical sources such as teachers, day care providers,
social workers and employers, and other practitioners such as naturopaths, chiropractors, and audiologists.
Listing of Impairments
Adult Listings
1.00 Musculoskeletal System-The inability to ambulate effectively or the inability to perform fine and gross
movements effectively must have lasted, or be expected to last, for at least 12 months.
2.00 Special Senses and Speech-Loss of Speech. In evaluating the loss of speech, the ability to produce speech by
any means includes the use of mechanical or electronic devices that improve voice or articulation. Impairments of speech may
also be evaluated under the body system for the underlying disorder, such as neurological disorders, 11.00ff.
11.00 Neurological-Persistent disorganization
of motor function in the form of paresis or paralysis, tremor or other involuntary movements, ataxia and sensory disturbances
(any or all of which may be due to cerebral, cerebellar, brain stem, spinal cord, or peripheral nerve dysfunction) which occur
singly or in various combinations, frequently provides the sole or partial basis for decision in cases of neurological impairment.
The assessment of impairment depends on the degree of interference with locomotion and/or interference with the use of fingers,
hands and arms.
12.00 Mental Disorders-The
evaluation of disability on the basis of mental disorders requires documentation of a medically determinable impairment(s),
consideration of the degree of limitation such impairment(s) may impose on the individual's ability to work, and consideration
of whether these limitations have lasted or are expected to last for a continuous period of at least 12 months. The listings
for mental disorders are arranged in nine diagnostic categories: Organic mental disorders (12.02); schizophrenic, paranoid
and other psychotic disorders (12.03); affective disorders (12.04); mental retardation (12.05); anxiety-related disorders
(12.06); somatoform disorders (12.07); personality disorders (12.08); substance addiction disorders (12.09);
and autistic disorder and other pervasive developmental disorders (12.10).
Children
Disability in Children-Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable
physical or mental impair-ment or combination of impairments that causes marked and severe functional limitations, and that
can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
How is the disability determination made?
For children applying for SSI, the process requires sequential review of
the child's current work activity (if any), the severity of his or her impairment(s), and an assessment of whether his or
her impairment(s) results in marked and severe functional limitations. If an adult or child is found disabled or not disabled
at any point in the evaluation, the evaluation does not continue. |
B. Nonconvulsive epilepsy. Classical petit mal seizures must be documented by characteristic EEG pattern,
plus infor-mation as to age at onset and frequency of clinical seizures. Myoclonic seizures, whether of the typical infantile
or Lennox
-gastaut variety after infancy, must also be documented by the characteristic EEG pattern plus information as to age
at onset and frequency of seizures.
C. Motor dysfunction. As described in 111.06, motor dysfunction may be due to any neurological disorder.
It may be due to static or progressive conditions involving any area of the nervous system and producing any type of neurological
impairment. This may include weakness, spasticity, lack of coordination, ataxia, tremor, athetosis, or sensory loss.
Documentation of motor dysfunction must include neurologic findings and description of type of neurologic abnormality
(e.g., spasticity, weakness), as well as a description of the child's functional impairment (i.e., what the child is unable
to do because of the abnormality).
Where a diagnosis has been made, evidence should be included for substantiation of the diagnosis (e.g., blood chemistries
and muscle biopsy reports), wherever applicable.
D. Impairment of communication. The documentation should include a description of a recent comprehensive
evaluation including all areas of affective and effective communication, performed by a qualified professional.
A. Persistent motor dysfunction as a result of hypotonia and/or
musculoskeletal weakness, postural reaction deficit, abnormal primitive reflexes, or other neurological impairment as described
in 111.00C, and with significant interference with age-appropriate major daily or personal care activities, which in an infant
or young child include such activities as head control, swallowing, following, reaching, grasping, turning, sitting, crawling,
walking, taking solids, feeding self; or
B. Mental
impairment as described under the criteria in 112.05 or 112.12; or . Significant interference with commun-ication
due to speech, hearing, or visual impairments as described under the criteria in 102.00 and 111.09; or
F. Other impairments such as, but not limited to malnutrition,
hypothyroidism, or seizures should be evaluated under the criteria in 105.08, 109.02 or 111.02 and 111.03, or the criteria
for the affected body system.
The structure of the mental disorders listings for children under age 18 parallels the structure for the mental disorders
listings for adults but is modified to reflect the presentation of mental disorders in children.
The listings for mental disorders in children are arranged in 11 diagnostic categories: Organic mental disorders (112.02);
schizophrenic, delusional (paranoid), schizoaffective, and other psychotic disorders (112.03); mood disorders (112.04); mental
retardation (112.05); anxiety disorders (112.06); somatoform, eating, and tic disorders (112.07); personality disorders (112.08);
psychoactive substance dependence disorders (112.09); autistic disorder and other pervasive developmental disorders (112.10);
attention deficit hyperactivity disorder (112.11); and developmental and emotional disorders of newborn and younger infants
(112.12).
Appeals
What can an individual do if he or she disagrees with
the determination?
A. If an individual disagrees with the initial determination in the case, he or she may appeal it. The first administra-tive
appeal is a reconsideration, which is generally a case review at the State level by an adjudicative team that was not involved
in the original determination.
If dissatisfied with the reconsideration determination, the individual may request a hearing before an administrative
law judge. If he or she is dissatisfied with the hearing decision, the final administrative appeal is for review by the Appeals
Council. In general, a claimant has 60 days to appeal an unfavorable determination or decision.
Appeals must be filed in writing and may be submitted by mail or in person to any Social Security office. If the individual
exhausts all administrative appeals, but wishes to continue pursuing the case, he or she may file a civil suit in Federal
District Court and eventually appeal all the way to the United States Supreme Court.
Other Information
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