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Social Security Administration Ruling on CFS
The Social Security Administration (SSA) issued a ruling on April 30, 1999 which paves
the way for severely afflicted persons with Chronic Fatigue Syndrome (CFS) to be
classified as having a medically determinable impairment. This ruling provides guidance
to disability claims processors for applying SSA policy to applications for Social
Security Disability Income (SSDI) benefits that result from disability due to CFS.
This does not imply that persons with CFS are automatically entitled to SSDI, but it
should make it easier for severely afflicted CFS patients to granted benefits.
Social Security Ruling, SSR 99-2p.; Titles II and XVI:
Evaluating Cases Involving Chronic Fatigue Syndrome (CFS)
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling.
SUMMARY:
In accordance with 20 CFR 402.35(b), the Commissioner of Social Security gives notice
of Social Security Ruling, SSR 99-2p. This Ruling clarifies disability policy for
the evaluation and adjudication of disability claims invo1ving Chronic Fatigue
Syndrome (CFS). This Ruling explains that, when it is accompanied by appropriate medical
signs or laboratory findings, CFS is a medically determinable impairment that can be the
basis for a finding of "disability." This Ruling ensures that all adjudicators will use
the same policies and procedures in evaluating disability claims involving CFS,
and provides a consolidated statement of these policies and procedures.
EFFECTIVE DATE:
April 30, 1999.
FOR FURTHER INFORMATION CONTACT:
Carolyn Kiefer
Office of Disability
Division of Medical and Vocational Policy
Social Security Administration
6401 Security Boulevard
Baltimore, MD 21235-6401
(410) 965-9104
SUPPLEMENTARY INFORMATION:
Although we are not required to do so pursuant to 5 U.S.C. 552(a) and (a), we are
publishing this Social Security Ruling in accordance with 20 CFR 402.35(b). Social
Security Rulings make available to the public precedential decisions relating to the
Federal old-age, survivors, disability, supplemental security income, and black lung
benefits programs. Social Security Rulings may be based on case decisions made at
all administrative levels of adjudication, Federal court decisions, Commissioner's
decisions, opinions of the Office of the General Counsel, and policy interpretations of
the law and regulations.
Although Social Security Rulings do not have the same force and effect as the statute
or regulations, they are binding on all components of the Social Security Administration,
in accordance with 20 CFR 402.35(b), and are to be relied upon as precedents in
judicating cases.
If this Social Security Ruling is later superseded, modified, or rescinded, we will
publish a notice in the Federal Register to that effect.
(Catalog of Federal Domestic Assistance, Programs 96.001 Social Security Disability
Insurance; 96.006 Supplemental Security Income)
Dated: April 23, 1999.
Kenneth S. Apfel,
Commissioner of Social Security.
Policy Interpretation Ruling Titles II and XVI: Evaluating Cases Involving
Chronic Fatigue Syndrome (CFS)
Purpose
To restate and clarify the policies of the Social Security Administration for developing
and evaluating title II and title XVI claims for disability on the basis of Chronic
Fatigue Syndrome (CFS), also frequently known as Chronic Fatigue and Immune
Dysfunction Syndrome.
Citations (Authority)
Sections 216(i), 223(d), 223(f), 1614(a)(3) and 1614(a)(4) of the Social Security Act,
as amended; Regulations No. 4, subpart P, sections 404.1505, 40404.1508-404.1513,
404.1520, 404.1520a, 404.1521, 404.1523, 404.1526-404.1529, 404.1560-404.1569a
and 404.1593-404.1594; and Regulations No. 16, subpart I, sections 416.905, 416.906,
416.908- 416.913, 416.920, 416.920a, 416.921, 416.923, 416.924, 416.924b, 416.924c,
416.926, 416.926a, 416.927-416.929, 416.960-416.969a, 416.987, 416.993, 416.994, and
416.994a.
Introduction
CFS is a systemic disorder consisting of a complex of symptoms that may vary in
incidence, duration, and severity. The current case criteria for CFS, developed by
an international group convened by the Centers for Disease Control and Prevention (CDC)
as an identification tool and research definition, include a requirement for four or more
of a specified list of symptoms. These constitute a patient's complaints as reported to a
provider of treatment.
However, the Social Security Act (the Act) and our implementing regulations require that
an individual establish disability based on the existence of a medically
determinable impairment; i.e., one that can be shown by medical evidence, consisting
of medical signs, symptoms and laboratory findings. Disability may not be established on
the basis of an individual's statement of symptoms alone.
This Ruling explains that CFS, when accompanied by appropriate medical signs or
laboratory findings, is a medically determinable impairment that can be the basis for
a finding of "disability." It also provides guidance for the evaluation of claims
involving CFS.
Policy Interpretation
CFS constitutes a medically determinable impairment when it is accompanied by medical
signs or laboratory findings, as discussed below. CFS may be a disabling impairment.
Definition of CFS
CFS is a systemic disorder consisting of a complex of symptoms that may vary in
incidence, duration, and severity. It is characterized in part by prolonged fatigue that
lasts 6 months or more and that results in substantial reduction in previous levels
of occupational, educational, social, or personal activities. In accordance with
criteria established by the CDC, a physician should make a diagnosis of CFS "only
after alternative medical and psychiatric causes of chronic fatiguing illness have
been excluded" (Annals of Internal Medicine, 121:953-9, 1994). CFS has been diagnosed
in children, particularly adolescents, as well as in adults.
Under the CDC definition, the hallmark of CFS is the presence of clinically
evaluated, persistent or relapsing chronic fatigue that is of new or definite onset
(i.e., has not been lifelong), cannot be explained by another physical or mental
disorder, is not the result of ongoing exertion, is not substantially alleviated by rest,
and results in substantial reduction in previous levels of occupational, educational,
social, or personal activities. Additionally, the current CDC definition of CFS requires
the concurrence of 4 or more of the following symptoms, all of which must have persisted
or recurred during 6 or more consecutive months of illness and must not have pre-dated
the fatigue:
- Self-reported impairment in short-term memory or concentration severe enough to
cause substantial reduction in previous levels of occupational, educational, social,
or personal activities
- Sore throat
- Tender cervical or axillary lymph nodes
- Muscle pain
- Multi-joint pain without joint swelling or redness
- Headaches of a new type, pattern, or severity
- Unrefreshing sleep
- Postexertional malaise lasting more than 24 hours
Within these parameters, an individual with CFS can also exhibit a wide range of
other manifestations such as:
- muscle weakness
- swollen underarm (axillary) glands
- sleep disturbances
- visual difficulties (trouble focusing or severe photosensitivity)
- orthostatic intolerance:
- lightheadedness
- increased fatigue with prolonged standing)
- other neurocognitive problems:
- difficulty comprehending and processing information)
- fainting
- dizziness
- mental problems (e.g., depression, irritability, anxiety)
Requirement for a Medically Determinable Impairment
Sections 216(i) and 1614(a) of the Act define "disability" as the inability to engage
in any substantial gainful activity (SGA) by reason of any medically determinable
physical or mental impairment (or combination of impairments) which can be expected to
result in death or which has lasted or can be expected to last for a continuous period
of not less than 12 months. Sections 223(d) and 1614(a) of the Act, and 20 CFR 404.1508
and 416.908 require that an impairment result from anatomical, physiological, or
psychological abnormalities that can be shown by medically acceptable clinical and
laboratory diagnostic techniques. The Act and regulations further require that an
impairment be established by medical evidence that consists of signs, symptoms, and
laboratory findings, and not only by an individual's statement of symptoms.
Under the CDC definition, the diagnosis of CFS can be made based on an individual's
reported symptoms alone once other possible causes for the symptoms have been ruled
out. However, the foregoing statutory and regulatory provisions require that, for
evaluation of claims of disability under the Act, there must also be medical signs
or laboratory findings before the existence of a medically determinable impairment may
be established.
Establishing the Existence of a Medically Determinable Impairment
The following medical signs and laboratory findings establish the existence of a
medically determinable impairment in individuals who have CFS. Although no specific
etiology or pathology has yet been established for CFS, many research initiatives
continue, and some progress has been made in ameliorating symptoms in selected
individuals. With continuing scientific research, new medical evidence may emerge that
will further clarify the nature of CFS and provide greater specificity regarding the
clinical and laboratory diagnostic techniques that should be used to document
this disorder.
Because of this, the medical criteria discussed below are only examples of signs
and laboratory findings that will establish the existence of a medically
determinable impairment; they are not all inclusive. As progress is made in medical
research into CFS, additional signs and laboratory findings may also be found that can be
used to establish that individuals with CFS have a medically determinable impairment.
The existence of CFS may be documented with medical signs or laboratory findings other
than those listed below, provided that such documentation is consistent with
medically accepted clinical practice and is consistent with the other evidence in the
case record.
Examples of Medical Signs That Establish the Existence of a Medically
Determinable Impairment
For purposes of Social Security disability evaluation, one or 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 with CFS:
- Palpably swollen or tender lymph nodes on physical examination
- Nonexudative pharyngitis
- Persistent, reproducible muscle tenderness on repeated examinations, including
the presence of positive tender points or, any other medical signs that are consistent
with medically accepted clinical practice and are consistent with the other evidence in
the case record
Examples of Laboratory Findings That Establish the Existence of a Medically
Determinable Impairment
At this time, there are no specific laboratory findings that are widely accepted as
being associated with CFS. However, the absence of a definitive test does not
preclude reliance upon certain laboratory findings to establish the existence of a
medically determinable impairment in persons with CFS. Therefore, the following
laboratory findings establish the existence of a medically determinable impairment
in individuals with CFS:
- An elevated antibody titer to Epstein-Barr virus (EBV) capsid antigen equal to or
greater than 1:5120, or early antigen equal to or greater than 1:640
- An abnormal magnetic resonance imaging (MRI) brain scan
- Neurally mediated hypotension as shown by tilt table testing or another
clinically accepted form of testing
- Any other laboratory findings that are consistent with medically accepted
clinical practice and are consistent with the other evidence in the case record; for
example, an abnormal exercise stress test or abnormal sleep studies, appropriately
evaluated and consistent with the other evidence in the case record
Mental Findings That Establish the Existence of a Medically Determinable Impairment
Some individuals with CFS report ongoing problems with the following:
- short-term memory
- information processing
- visual-spatial difficulties
- comprehension
- concentration
- speech
- word-finding
- calculation
- other symptoms suggesting persistent neurocognitive impairment
When ongoing deficits in these areas have been documented by mental status examination
or psychological testing, such findings constitute medical signs or (in the case
of psychological testing) laboratory findings that establish the presence of a
medically determinable impairment.
Individuals with CFS may also exhibit medical signs, such as anxiety or depression,
indicative of the existence of a mental disorder. When such medical signs are present
and appropriately documented, the existence of a medically determinable impairment
is established.
Evaluation
1. General
Claims involving CFS are adjudicated using the sequential evaluation process, just as for
any other impairment. Once a medically determinable impairment has been found to exist
(see discussion above), the severity of the impairment(s) must be established. The
severity of an individual's impairment(s) is determined based on the totality of medical
signs, symptoms, and laboratory findings, and the effects of the impairment(s), including
any related symptoms, on the individual's ability to function.
Also, several other disorders (including, but not limited to, FMS, multiple
chemical sensitivity, and Gulf War Syndrome, as well as various forms of depression, and
some neurological and psychological disorders) may share characteristics similar to those
of CFS. When there is evidence of the potential presence of another disorder that
may adequately explain the individual's symptoms, it may be necessary to pursue
additional medical or other development.
2. Step
When an adjudicator finds that an individual with CFS has a medically determinable
impairment, he or she must consider that the individual has an impairment that
could reasonably be expected to produce the individual's symptoms associated with CFS,
as required in 20 CFR 404.1529(b) and 416.929(b), and proceed to evaluate the intensity
and persistence of the symptoms. Thus, if an adjudicator concludes that an individual has
a medically determinable impairment, and the individual alleges fatigue, pain, symptoms
of neurocognitive problems, or other symptoms consistent with CFS, these symptoms must
be considered in deciding whether the individual's impairment is "severe" at step 2 of
the sequential evaluation process and at any later steps reached in the sequential
evaluation process. If fatigue, pain, neurocognitive symptoms, or other symptoms are
found to cause a limitation or restriction having more than a minimal effect on an
individual's ability to perform basic work activities, the adjudicator must find that
the individual has a "severe" impairment. See SSR 96-3p, "Titles II and XVI:
Considering Allegations of Pain and Other Symptoms in Determining Whether a
Medically Determinable Impairment is Severe."
3. Step
When an individual is found to have a severe impairment, the adjudicator must proceed
with the sequential evaluation process and must next consider whether the individual's
impairment is of the severity contemplated by the Listing of Impairments contained in
appendix 1, subpart P of 20 CFR 404. Inasmuch as CFS is not a listed impairment, an
individual with CFS alone cannot be found to have an impairment that meets the
requirements of a listed impairment; however, the specific findings in each case should
be compared to any pertinent listing to determine whether medical equivalence may exist.
Further, in cases in which individuals with CFS have psychological manifestations related
to CFS, consideration should always be given to whether the individual's impairment meets
or equals the severity of any impairment in the mental disorders listings in 20 CFR, part
404, subpart P, appendix 1, sections 12.00 ff. or 112.00 ff.
4. Steps
For those impairments that do not meet or equal the severity of a listing, an assessment
of residual functional capacity (RFC) must be made, and adjudication must proceed to
the fourth and, if necessary, the fifth step of the sequential evaluation process.
In assessing RFC, all of the individual's symptoms must be considered in deciding how
such symptoms may affect functional capacities. See SSR 96-7p, "Titles II and XVI:
Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an
Individual's Statements" and SSR 96-8p, "Titles II and XVI: Assessing Residual
Functional Capacity in Initial Claims."
If it is determined that the individual's impairment(s) precludes the performance of
past relevant work (or if there was no past relevant work), a finding must be made about
the individual's ability to perform other work. The usual vocational considerations (see
20 CFR 404.1560- 404.1569a and 416.960-416.969a) must be applied in determining
the individual's ability to perform other work.
Many individuals with CFS are "younger individuals," ages 18 through 49 (see 20 CFR
404.1563 and 416.963). Age, education, and work experience are not usually considered to
limit significantly the ability of individuals under age 50 to make an adjustment to
other work, including unskilled sedentary work. However, a finding of "disabled" is
not precluded for those individuals under age 50 who do not meet all of the criteria
of a specific rule and who do not have the ability to perform a full range of sedentary
work. The conclusion about whether such individuals are disabled will depend primarily on
the nature and extent of their functional limitations or restrictions. Thus, if it is
found that an individual is able to do less than the full range of sedentary work, refer
to SSR 96-9p, "Titles II and XVI: Determining Capability to Do Other Work - Implications
of a Residual Functional Capacity for Less Than a Full Range of Sedentary Work." As
explained in that Ruling, whether the individual will be able to make an adjustment to
other work requires adjudicative judgment regarding factors such as the type and extent
of the individual's limitations or restrictions and the extent of the erosion of the
occupational base for sedentary work.
5. Duration
The medical signs and symptoms of CFS fluctuate in frequency and severity and often
continue over a period of many months or years. Thus, appropriate documentation should
include a longitudinal clinical record of at least 12 months prior to the date of
application, unless the alleged onset of CFS occurred less than 12 months in the past,
or unless a fully favorable determination or decision can be made without
additional documentation. The record should contain detailed medical observations,
treatment, the individual's response to treatment, and a detailed description of how
the impairment limits the individual's ability to function over time.
When the alleged onset of disability secondary to CFS occurred less than 12 months
before adjudication, the adjudicator must evaluate the medical evidence and project the
degree of impairment severity that is likely to exist at the end of 12 months.
Information about treatment and response to treatment as well as any medical source
opinions about the individual's prognosis at the end of 12 months are helpful in
deciding whether the medically determinable impairment(s) is expected to be of
disabling severity for at least 12 consecutive months.
6. Continuing Disability Reviews
In those cases in which an individual is found to have a disability based on CFS but
medical improvement is anticipated, an appropriate continuing disability review should
be scheduled based on the probability of cessation under the Medical Improvement
Review Standard. This standard takes into account relevant individual case facts such as
the combined severity of other chronic or static impairments and the individual's
vocational factors.
Documentation
1. General
As with all claims for disability under both title II and title XVI, documentation of
medical signs or laboratory findings in cases involving CFS is critical to establishing
the presence of a medically determinable impairment. In cases in which CFS is
alleged, longitudinal clinical records reflecting ongoing medical evaluation and
treatment from the individual's medical sources, especially treating sources, are
extremely helpful in documenting the presence of any medical signs or laboratory
findings, as well as the individual's functional status over time. Every reasonable
effort should be made to secure all available, relevant evidence in cases involving
CFS to ensure appropriate and thorough evaluation.
Generally, evidence for the 12-month period preceding the month of application should
be requested unless there is reason to believe that development of an earlier period
is necessary, or unless the alleged onset of disability is less than 12 months before the
date of the application.
2. Recontacting Medical Sources/Consultative Examinations
If the adjudicator finds that the evidence is inadequate to determine whether the
individual is disabled, he or she must first recontact the individual's treating or
other medical source(s) to determine whether the additional information needed is
readily available, in accordance with 20 CFR 404.1512 and 416.912. Only after the
adjudicator determines that the information needed is not readily available from
the individual's health care provider(s), or that the necessary information or
clarification cannot be sought from the individual's health care provider(s), should
the adjudicator proceed to arrange for a consultative examination(s) in accordance with
20 CFR 404.1519a and 416.919a. The type of consultative examination(s) purchased will
depend on the nature of the individual's symptoms and the extent of the evidence already
in the case record.
3. Resolution of Conflicts
It should be noted that conflicting evidence in the medical record is not unusual in
cases of CFS due to the complicated diagnostic process involved in these cases.
Clarification of any such conflicts in the medical evidence should be sought first from
the individual's treating or other medical sources.
Medical opinions from treating sources about the nature and severity of an
individual's impairment(s) are entitled to deference and may be entitled to
controlling weight. If we find that a treating source's medical opinion on the issue(s)
of the nature and severity of an individual's impairment(s) is well-supported by
medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence in the case record, the adjudicator will
give it controlling weight. (See SSR 96-2p, "Titles II and XVI: Giving Controlling Weight
to Treating Source Medical Opinions," and SSR 96-5p, "Titles II and XVI: Medical
Source Opinions of Issues Reserved to the Commissioner".)
4. Assessing Credibility
In accordance with SSR 96-7p, if the existence of a medically determinable impairment
that could reasonably be expected to produce the symptoms has been established, as
outlined above, but an individual's statements about the intensity, persistence,
or functionally limiting effects of symptoms are not substantiated by objective
medical evidence, the adjudicator must consider all of the evidence in the case
record, including any statements by the individual and other persons concerning
the individual's symptoms. The adjudicator must then make a finding on the credibility of
the individual's statements about symptoms and their functional effects. When
additional information is needed to assess the credibility of the individual's
statements about symptoms and their effects, the adjudicator must make every reasonable
effort to obtain available information that could shed light on the credibility of
the individual's statements.
5. Treating and other medical sources
In evaluating credibility, the adjudicator should ask the treating or other medical
source(s) to provide information about the extent and duration of an
individual's impairment(s), including observations and opinions about how well the
individual is able to function, the effects of any treatment, including side effects, and
how long the impairment(s) is expected to limit the individual's ability to function.
Opinions from an individual's medical sources, especially treating sources, concerning
the effects of CFS on the individual's ability to function in a sustained manner in
performing work activities or in performing activities of daily living are important
in enabling adjudicators to draw conclusions about the severity of the impairment(s) and
the individual's RFC. In this regard, any information a medical source is able to
provide contrasting the individual's impairment(s) and functional capacities since the
alleged onset of CFS with the individual's status prior to the onset of CFS will be
helpful in evaluating the individual's impairment(s) and its functional consequences.
Third-party information, including evidence from medical sources who are not
"acceptable medical sources" for the purpose of establishing the existence of a
medically determinable impairment, but who have provided services to the individual, may
be very useful in deciding the individual's credibility. Information other than
an individual's allegations and reports from the individual's treating sources helps to
assess an individual's ability to function on a day- to-day basis and to depict
the individual's capacities over a period of time. Such evidence includes, but is not
limited to:
- Information from neighbors, friends, relatives, or clergy
- Statements from such individuals as past employers, rehabilitation counselors, or
school teachers about the individual's impairment(s) and the effects of the impairment(s)
on the individual's functioning in the work place, rehabilitation facility, or
educational institution
- Statements from other practitioners with knowledge of the individual,
e.g., nurse-practitioners, physicians' assistants, naturopaths, therapists, social
workers, and chiropractors
- Statements from other sources with knowledge of the individual's ability to function
in daily activities
- The individual's own record (such as a diary, journal, or notes) of his or her
own impairment(s) and its impact on function over time
The adjudicator should carefully consider this information when making findings about
the credibility of the individual's allegations regarding functional limitations
or restrictions.
EFFECTIVE DATE: This Ruling is effective on April 30, 1999.
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