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Suzanne Villalon-Hinojosa [email_address] http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786 NOSSCR October 2009 San Francisco, CA

1955 First list of disabling diseases 1968 Listings published in CFR 1977 Children published in CFR 1985 revised mental 1997 Children revised (interim final rules) 2001 Children revised (final rules) 2002 revised musculoskeletal 2004 revised skin, cancer 2005 revised genitourinary 2006 revised medical equivalence standard , revised cardiac 2007 revised digestive, special senses & speech 2008 revised immune system Alan L. Cowles, M.D., Ph.D. The History of the Disability Listings , March 2, 2005 http://www.ssa.gov/history/pdf/Listings_History.pdf svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

2009 Malignant Neoplastic Diseases 2010 Growth Impairment Respiratory System Hematological Disorders Endocrine System Neurological Mental Disorders 2011 Musculoskeletal System Cardiovascular System 2012 Digestive System Skin Disorders 2013 Genitourinary Impairments Impairments That Affect Multiple Body Systems 2015 Special Senses and Speech 2016 Immune System Disorders svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

SOURCE: Annual Statistical Report on the Social Security Disability Insurance Program, 2003 , Table 36. NOTES: Unknown diagnoses are excluded from the series. There was a change in the data series in 1995. Before 1995, the diagnostic data for awards at the appeals level were estimated from the diagnoses of cases allowed at the initial level. Beginning in 1995, all levels of decisions were included in the diagnostic data. svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

1.05C BEFORE 11/19/01 (e.g., herniated nucleus pulposus, spinal stenosis) with the following persisting for at least 3 months despite prescribed therapy and expected to last 12 months. With Pain, muscle spasm, and significant limitation of motion in the spine, and appropriate radicular distribution of significant motor loss with muscle weakness, and sensory, and reflex loss. 1.04A AFTER 11/19/01 (e.g., herniated nucleus pulposus, spinal arachnoiditis, spinal stenosis, osteoarthritis, degenerative disc disease, facet arthritis, vertebral fracture), resulting in compromise of a nerve root (including the cauda equina) or the spinal cord. With Evidence of nerve root compression characterized by neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss (atrophy with associated muscle weakness or muscle weakness) accompanied by sensory or reflex loss and, If there is involvement of the lower back, positive straight- leg raising test (sitting and supine) svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

We no longer require anatomic or radicular distribution of both sensory and reflex abnormalities…but require only that one or the other be present. This is because sensory and reflex abnormalities are not concurrent in all cases of nerve root compression that would nonetheless be disabling at the listing level. Depending on the level of the compression, both sensory and reflex abnormalities may not occur anatomically. The listing does require a “neuro-anatomic distribution” of pain to make clear that the nerve root compression would have to be reasonably expected to cause the pain . 66 Fed Reg. 58018 AHCPR Archived Quick Reference Guide http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.34420#34422 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

Bechterew Sign Bonnets Phenomena Bragard’s Sign Drop Test Ely’s Sign Fajersztajn Test Flip Test Gaenslen Test Goldthwait’s Test Kernig Sign Lasegue Sign Linder Sign Nachlas Test Neri Bowing Sign Ober Sign Patrick Test Sicards Sign Smith Peterson Test Spurlings Sign Yeomans Test AHCPR Archived Quick Reference Guide http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.34420#34422 Straight and Bent Leg Raising Tests , Jesse N. Borden, M.D., FACS, Diplomate American Board of Orthopedic Surgery svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

The straight leg raising (SLR) test can detect tension on the L5 and/or S1 nerve root. SLR may reproduce leg pain by stretching nerve roots irritated by a disc herniation. Pain below the knee at less than 70 degrees of straight leg raising, aggravated by dorsiflexion of the ankle and relieved by ankle plantar flexion or external limb rotation, is most suggestive of tension on the L5 or S1 nerve root related to disc herniation. Reproducing back pain alone with SLR testing does not indicate significant nerve root tension. Crossover pain occurs when straight raising of the patient's well limb elicits pain in the leg with sciatica. Crossover pain is a stronger indication of nerve root compression than pain elicited from raising the straight painful limb. Sitting knee extension can also test sciatic tension. The patient with significant nerve root irritation tends to complain or lean backward to reduce tension on the nerve. svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786 http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.34313

SSA will not re-contact the clinician and will accept the positive test unless: SLR is positive in one position but negative in the other position The pain elicited is not in the appropriate neuro-anatomical distribution The positive SLR findings are not consistently reproducible (that does not mean present at every exam), or Back pain is noted as a positive SLR test (not a true positive result). svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

Number of deaths for leading causes of death: Heart disease: 631,636 Cancer: 559,888 Stroke (cerebrovascular diseases): 137,119 Chronic lower respiratory diseases: 124,583 Accidents (unintentional injuries): 121,599 Diabetes: 72,449 Alzheimer's disease: 72,432 Influenza and Pneumonia: 56,326 Nephritis, nephrotic syndrome, and nephrosis: 45,344 Septicemia: 34,234 Source: Deaths: Final Data for 2006, Tables B, D, 7, 30 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

9.08 BEFORE 11/19/01 A. Neuropathy Demonstrated by significant and persistent disorganization of motor function in two extremities resulting in sustained disturbance of gross and dexterous movements, or gait and station (see 11.00C); or B. Acidosis Occurring at least on the average of once every 2 months documented by appropriate blood chemical tests (pH or pCO2 or bicarbonate levels); or C. Amputation at, or above, the tarsal region Due to diabetic necrosis or peripheral arterial disease; or D. Retinitis proliferans; Evaluate the visual impairment under the criteria in 2.02, 2.03, or 2.04 9.08 AFTER 11/19/01 A. Neuropathy Demonstrated by significant and persistent disorganization of motor function in two extremities resulting in sustained disturbance of gross and dexterous movements, or gait and station (see 11.00C); or B. Acidosis Occurring at least on the average of once every 2 months documented by appropriate blood chemical tests (pH or pCO2 or bicarbonate levels); or C. Retinitis proliferans; Evaluate the visual impairment under the criteria in 2.02, 2.03, or 2.04 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

1.05B One or both lower extremities at or above the tarsal region, with stump complications resulting in medical inability to use a prosthetic device to ambulate effectively, as defined in 1.00B2b, which have lasted or are expected to last for at least 12 months. Engineering advances have produced prosthetic devices which minimize and distribute stress so that some individuals wearing artificial limbs after amputation above the tarsal level for any reason (including diabetes mellitus, and vascular and arterial disease ) are able to work. 66 Fed. Reg. 58018 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

4 out of 5 patients undergoing an amputation will do well. But diabetics who have had one lower limb amputated have a 50 percent mortality rate in the five years following the amputation, and a 50 percent risk of developing a serious lesion in the second limb within two years. http://www.reversegangrene.com/foot_gangrene_bk_amputation_home.htm svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

… we recognize that individuals with the type of lower extremity amputation described in final listing 1.05B, will have an inability to ambulate effectively, as defined in 1.00B2b, when they are not using a prosthesis. This would be true whether they do not use a prosthesis because: they cannot afford one, a prosthesis has not been prescribed for them, or for other reasons. 66 Fed.Reg. 58015 An individual’s inability to afford treatment and/or inaccessibility in the local community is a justifiable cause for failing to follow treatment. SSR 82-59 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

Meet a listing All the criteria of the listing is found in the evidence Any relevant criteria in the introduction is also found in the evidence, and The duration requirement is met. 20 CFR §§ 404.1525(c)(3) and 415.925(c)(3) Equal a listing You have a listed impairment without the requisite findings (or you have them all but one is not severe enough) but you also have other findings that are of equal medical significance to the required criteria. You have an unlisted impairment but you also have findings closely analogous to listed impairments. You have a combination of impairments which don’t meet a listing but you also have findings which are of at least equal medical significance to the required criteria. 20 CFR §§ 404.1526 and 416.926 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

20 CFR § 404.1528 Symptoms are outside the medical evidence of record. SSR 96-3p Symptoms cannot be the basis of severity if not supported by “objective medical evidence.” SSR 96-7p Symptoms cannot be the basis of a finding of disability unless medical signs & lab findings establish the impairment which could reasonably be expected to produce the symptoms. Symptoms are not enough to equal a listing svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

All evidence (except vocational factors) is relevant to a determination of equivalence. 404.1526(c) Symptoms are considered when consistent with impairments. 404.1529(b) Evaluate symptoms by comparing objective evidence to other evidence. Other evidence includes statements from you, treating, non-treating sources about: what may precipitate or aggravate your symptoms, treatments or other methods you use to alleviate them, and how the symptoms may affect your pattern of daily living) 404.1529(c)(3) If the symptoms, signs, and laboratory findings of your impairment(s) are equivalent in severity to those of a listed impairment, we will find you disabled. 404.1529(d)(3) Evidentiary Requirements for Making Findings About Medical Equivalence , 71 Fed. Reg. 10424, March 1, 2006 But equivalence “happens” when: other findings=listed findings svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

A dysthymic disorder (an unlisted impairment) that medically equals listing 12.04A1, major depressive disorder is by definition as medically severe as a major depressive disorder. 71 Fed. Reg. 10427 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

However, a different functional limitation could substitute for a required finding if equally severe. 1 extreme=2 marked (mental impairments) 2 moderates=1 marked (immune system disorders) 20 CFR § 404.1529(d)(3) svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

In conditions which are episodic in character, c0nsideration should be given to frequency and duration of exacerbations, length of remissions, and permanent residuals. 11.00D Episodic nature acknowledged and frequency specified in the listing: seizures, asthma, recurrent arrhythmias, sickle cell crises, ischemic heart disease, mental impairments, autoimmune disorders Episodic nature acknowledged and frequency not specified meniere’s, multiple sclerosis, myasthenia gravis, skin Episodic nature not acknowledged nor frequency specified: diabetes Unlisted but episodic: migraines, narcolepsy, pancreatitis svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

An individual’s migraine headaches (an unlisted impairment) are medically equivalent in severity to listing 11.03, a seizure disorder listing that is the most closely analogous listing we have for comparison. 71 Fed. Reg. 10426 svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

Arachnoiditis is chronic inflammation inside the dura, whereas epidural fibrosis is scarring outside the dural sac. Many doctors appear to regard epidural fibrosis as less clinically significant than arachnoiditis, but in essence the nerve root compression arising from epidural fibrosis may cause similar clinical problems in terms of lower limb pain, sensory disturbance and weakness. In cases of arachnoiditis, there is often associated epidural fibrosis, but the reverse is not generally acknowledged, so that patients may be left with a diagnosis of epidural fibrosis and are unable to get a diagnosis of arachnoiditis even when the clinical picture fits. Arachnoiditis is an underdiagnosed condition. The Adhesive Arachnoiditis Syndrome , Dr. Sara Smith, http://www.arachnoiditis.info/content/the_adhesive_arachnoiditis_syndrome/the_adhesive_arachnoiditis_syndrome_3.html svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

RSD http://rsdrx.com/what_is_rsd.htm Kidney disease http://www.emedicinehealth.com/chronic_kidney_disease/article_em.htm Liver disease http://www.liverfoundation.org/education/info/progression/ Cardiac http://www.americanheart.org/presenter.jhtml?identifier=4569 Cancer http://www.cancer.gov/cancertopics/factsheet/Detection/staging Multiple Sclerosis http://www.mssociety.org.uk/about_ms/types_of_ms/index.html Gout http://www.niams.nih.gov/Health_Info/Gout/default.asp svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

longstanding policy requires that the judgment of a physician (or psychologist) designated by the Commissioner on the issue of equivalence on the evidence before the administrative law judge or the Appeals Council must be received into the record as expert opinion evidence and given appropriate weight. svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786

Old 404.1526: medical evidence only We will also consider the medical opinion given by one or more medical or psychological consultants designated by the Commissioner in deciding medical equivalence New 404.1526: all evidence We also consider the opinion given by one or more medical or psychological consultants designated by the Commissioner. svhatty@heardandsmith.com http://www.linkedin.com/pub/suzanne-villalon-hinojosa/9/199/786 Administrative law judges may also ask for and consider opinions from medical experts on whether your impairment(s) equals the requirements of any impairment listed in appendix 1 to this subpart. 404.1527(f)(2)(iii) Although we consider opinions from medical sources on issues such as whether your impairment(s) meets or equals the requirements of any impairment(s) in the Listing of Impairments, your residual functional capacity… the final responsibility for deciding these issues is reserved to the Commissioner. 404.1527(e)(2)

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