Medical Equivalence

  • SSA's policy is that the regulations on medical equivalence already require the consideration of all relevant evidence, not just the medical findings.
    • This interpretation is articulated in AR 00-2(7) .
      • Adjudicators in the Seventh Circuit (Illinois, Indiana and Wisconsin) have to follow AR 00-2(7) for the Hickman case.
    • SSA interprets “medical evidence” in the medical equivalence regulations, 20 C.F.R. §§ 404.1526(b) , 416.926(b), broadly so as to include not just objective test results or other findings reported by medical sources, but other information about a claimant's medical conditions and their effects, including the claimant's own description of his or her impairments."
    • The regulations at 20 C.F.R. §§ 404.1525 (f), 416.925(f) state “some listed impairments include symptoms usually associated with those impairments as criteria.”
      • Symptoms are routinely reported in the medical evidence of record and have always been used to document listing level severity.
    • The medical equivalence regulations, 20 C.F.R. §§ 404.1526(a) , 416.926(a), state that "we will compare the symptoms, signs, and laboratory findings about your impairments as shown in the medical evidence . . . with the medical criteria shown with the listed impairment.”
    • SSA intends that "medical evidence" in 20 C.F.R. §§ 404.1526(b) and 416.926(b) includes reported symptoms, as well as signs and laboratory findings.
      • It doesn't matter if the symptoms are reported in the medical evidence or elsewhere, they must still be given appropriate consideration.
    • The credibility of symptoms at Step 3 is addressed at 20 C.F.R. §§ 404.1525(f) and 416.926(f) of the regulations, which state "It is not necessary, unless the listing specifically states otherwise, to provide information about the intensity, persistence or limiting effects of the symptom as long as all other findings required by the specific listing are present.”
    • Section 1.00B2d of the revised musculoskeletal listings (66 FR 58010, 58038 (2001)) explains that an individual's pain or other symptoms may be an important factor contributing to functional loss.
      • As a result, if an individual has an impairment that could reasonably be expected to produce the pain or other symptoms, it is important to evaluate the intensity and persistence of the pain or other symptoms carefully in order to determine their impact on the individual's functioning under the listings.
      • Since many of the new musculoskeletal listings specifically require a determination of the functionally limiting effects of the impairment, considering the credibility of symptoms at Step 3 would be appropriate.
      • The new musculoskeletal listings, including listing 1.04B for spinal arachnoiditis, contain both medical and functional criteria.
        • In order to equal these listings, you must have equivalent medical findings (signs, symptoms and laboratory findings), not just equivalent functional findings.
        • The regulations at 20 C.F.R. §§ 404.1526(a), 416.926 (a) require that medical findings are at least equal in severity and duration to the listed findings before SSA will make a determination or decision that a listing is medically equaled.
        • It is the interrelationship of the set of medical findings, not just the individual criteria, that establishes listing-level severity.
          • New listing 1.04B for spinal arachnoiditis requires medical findings.
            • An operative note or pathology report of tissue biopsy, or appropriate medically acceptable imaging to confirm the diagnosis.
            • Severe burning or painful dysesthesia must also be documented.
          • Equivalent medical findings resulting from other medically determinable impairments could be substituted for the required medical findings; and along with the required deficits in function, could establish medical equivalence to listing 1.04B.
            • Functional deficits alone would never support a decision of medical equivalence.
          • To further clarify the issue, sections 20 C.F.R. 404.1529(d)(3) and 416.929(d)(3) of the regulations state “we will not substitute your allegations of pain or other symptoms for a missing or deficient sign or laboratory finding to raise the severity of your impairment(s) to that of a listed impairment.”
            • Subjective complaints or testimony alone cannot be used to medically equal a listing.
            • Medical findings establishing the appropriate level of severity and duration are required.
          • SSA opines that these new listings do not create a new medical equivalency standard; and it follows that a medical expert should not be needed to address equivalency unless there are medical findings, not just testimony, to consider in establishing equivalency.