Social Security Ruling, SSR 12-2p; Titles II and XVI: Evaluation of Fibromyalgia, 43640-43644 [2012-17936]

Download as PDF 43640 Federal Register / Vol. 77, No. 143 / Wednesday, July 25, 2012 / Notices Federal benefits. Section 7201 of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101–508) further amended the Privacy Act regarding protections for such persons. The Privacy Act, as amended, regulates the use of computer matching by Federal agencies when records in a system of records are matched with other Federal, State, or local government records. It requires Federal agencies involved in computer matching programs to: (1) Negotiate written agreements with the other agency or agencies participating in the matching programs; (2) Obtain approval of the matching agreement by the Data Integrity Boards of the participating Federal agencies; (3) Publish notice of the computer matching program in the Federal Register; (4) Furnish detailed reports about matching programs to Congress and OMB; (5) Notify applicants and beneficiaries that their records are subject to matching; and (6) Verify match findings before reducing, suspending, terminating, or denying a person’s benefits or payments. B. SSA Computer Matches Subject to the Privacy Act We have taken action to ensure that all of our computer matching programs comply with the requirements of the Privacy Act, as amended. Dawn S. Wiggins, Acting Executive Director, Office of Privacy and Disclosure, Office of the General Counsel. Notice of Computer Matching Program, SSA With the Department of Veterans Affairs (VA), Veterans Benefits Administration (VBA) A. Participating Agencies SSA and VA/VBA. srobinson on DSK4SPTVN1PROD with NOTICES B. Purpose of the Matching Program The purpose of this matching program is to establish the conditions under which VA will disclose VA compensation and pension payment data to us for the purpose of identifying certain Supplemental Security Income (SSI) and Special Veterans Benefit (SVB) recipients under titles XVI and VIII of the Social Security Act (Act), respectively, who receive VAadministered benefits. This disclosure will also enable us to identify income limits of certain individuals in order to determine their potential eligibility for the Medicare Savings Program to implement a Medicare outreach VerDate Mar<15>2010 17:49 Jul 24, 2012 Jkt 226001 program mandated by section 1144 of title XI of the Act. C. Authority for Conducting the Matching Program The legal authorities for us to conduct this computer matching are sections 806(b), 1144, and 1631(e)(1)(B) and (f) of the Act (42 U.S.C. 1006(b), 1320b–14, and 1383(e)(1)(B) and (f)). The legal authority for VA to disclose information under this agreement is section 1631(f) of the Act (42 U.S.C. 1383(f)), which requires Federal agencies to provide such information as our Commissioner needs for purposes of determining eligibility for or amount of benefits, or verifying other information with respect thereto. D. Categories of Records and Persons Covered by the Matching Program 1. Systems of Records VA will provide us with electronic files containing compensation and pension payment data from its system of records (SOR) entitled the ‘‘Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records—VA’’ (58VA21/ 22/28), first published at 74 FR 14865 (April 1, 2009). We will match the VA data with SSI/ SVB payment information maintained in our SOR entitled ‘‘Supplemental Security Income Record and Special Veterans Benefits (SSA/OASSIS 60– 0103).’’ 2. Number of Records During the 12-month period from April 2010 through March 2011, we received 14.3 million records from VA, of which 524,470 matched supplemental security records (SSR). We expect the volume of records received from VA to increase in the future. We estimate receiving 84 million records annually from VA in the coming years. 3. Specified Data Elements We will conduct the match using the Social Security number, name, date of birth, and VA claim number on both the VA file and the SSR. 4. Frequency of Matching VA will furnish us with an electronic file containing VA compensation and pension payment data monthly. The actual match will take place approximately during the first week of every month. E. Inclusive Dates of the Matching Program The effective date of this matching program is May 11, 2012; provided that PO 00000 Frm 00070 Fmt 4703 Sfmt 4703 the following notice periods have lapsed: 30 days after publication of this notice in the Federal Register and 40 days after notice of the matching program is sent to Congress and OMB. The matching program will continue for 18 months from the effective date and may be extended for an additional 12 months thereafter, if certain conditions are met. [FR Doc. 2012–18109 Filed 7–24–12; 8:45 am] BILLING CODE 4191–02–P SOCIAL SECURITY ADMINISTRATION [Docket No. SSA–2011–0021] Social Security Ruling, SSR 12–2p; Titles II and XVI: Evaluation of Fibromyalgia Social Security Administration. Notice of Social Security Ruling AGENCY: ACTION: (SSR). In accordance with 20 CFR 402.35(b)(1), the Commissioner of Social Security gives notice of Social Security Ruling, SSR 12–2p. This ruling provides guidance on how we develop evidence to establish that a person has a medically determinable impairment of fibromyalgia, and how we evaluate fibromyalgia in disability claims and continuing disability reviews under titles II and XVI of the Social Security Act. DATES: Effective Date: July 25, 2012. FOR FURTHER INFORMATION CONTACT: Cheryl Williams, Office of Disability Programs, Social Security Administration, 6401 Security Boulevard, Baltimore, Maryland 21235– 6401, (410) 965–1020. SUPPLEMENTARY INFORMATION: Although we are not required to do so pursuant to 5 U.S.C. 552(a)(1) and (a)(2), we are publishing this SSR in accordance with 20 CFR 402.35(b)(1). Through SSRs, we make available to the public precedential decisions relating to the Federal old-age, survivors, disability, supplemental security income, special veterans benefits, and black lung benefits programs. We may base SSRs on determinations or decisions made at all levels of administrative adjudication, Federal court decisions, Commissioner’s decisions, opinions of the Office of the General Counsel, or other interpretations of the law and regulations. Although SSRs do not have the same force and effect as statutes or regulations, they are binding on all components of the Social Security Administration. 20 CFR 402.35(b)(1). SUMMARY: E:\FR\FM\25JYN1.SGM 25JYN1 Federal Register / Vol. 77, No. 143 / Wednesday, July 25, 2012 / Notices This SSR will be in effect until we publish a notice in the Federal Register that rescinds it, or publish a new SSR that replaces or modifies it. (Catalog of Federal Domestic Assistance, Program Nos. 96.001, Social Security— Disability Insurance; 96.002, Social Security—Retirement Insurance; 96.004— Social Security—Survivors Insurance; 96.006—Supplemental Security Income) Michael J. Astrue, Commissioner of Social Security. Policy Interpretation Ruling Titles II and XVI: Evaluation of Fibromyalgia Purpose: This Social Security Ruling (SSR) provides guidance on how we develop evidence to establish that a person has a medically determinable impairment (MDI) of fibromyalgia (FM), and how we evaluate FM in disability claims and continuing disability reviews under titles II and XVI of the Social Security Act (Act).1 Citations: Sections 216(i), 223(d), 223(f), 1614(a)(3), and 1614(a)(4) of the Act, as amended; Regulations No. 4, subpart P, sections 404.1505, 404.1508– 404.1513, 404.1519a, 404.1520, 404.1520a, 404.1521, 404.1523, 404.1526, 404.1527–404.1529, 404.1545, 404.1560–404.1569a, 404.1593, 404.1594, appendix 1, and appendix 2; and Regulations No. 16, subpart I, sections 416.905, 416.906, 416.908– 416.913, 416.919a, 416.920, 416.920a, 416.921, 416.923, 416.924, 416.924a, 416.926, 416.926a, 416.927–416.929, 416.945, 416.960–416.969a, 416.987, 416.993, 416.994, and 416.994a. srobinson on DSK4SPTVN1PROD with NOTICES Introduction FM is a complex medical condition characterized primarily by widespread pain in the joints, muscles, tendons, or nearby soft tissues that has persisted for at least 3 months. FM is a common syndrome.2 When a person seeks disability benefits due in whole or in part to FM, we must properly consider 1 For simplicity, we refer in this SSR only to initial claims for benefits made by adults (individuals who are at least age 18). However, the policy interpretations in this SSR also apply to claims for benefits made by children (individuals under age 18) under title XVI of the Act and to claims above the initial level. FM can affect children, and the signs and symptoms are essentially the same in children as adults. The policy interpretations in this SSR also apply to continuing disability reviews of adults and children under sections 223(f) and 1614(a)(4) of the Act, and to redeterminations of eligibility for benefits we make in accordance with section 1614(a)(3)(H) of the Act when a child who is receiving title XVI childhood disability benefits attains age 18. 2 See National Center for Biotechnology Information, U.S. National Library of Medicine, Fibromyalgia, https://www.ncbi.nlm.nih.gov/ pubmedhealth/PMH0001463. VerDate Mar<15>2010 17:49 Jul 24, 2012 Jkt 226001 43641 (the criteria in section II.B.). If we cannot find that the person has an MDI of FM but there is evidence of another MDI, we will not evaluate the impairment under this Ruling. Instead, we will evaluate it under the rules that apply for that impairment. A. The 1990 ACR Criteria for the Classification of Fibromyalgia. Based on these criteria, we may find that a person has an MDI of FM if he or she has all three of the following: 1. A history of widespread pain—that is, pain in all quadrants of the body (the right and left sides of the body, both above and below the waist) and axial skeletal pain (the cervical spine, Policy Interpretation anterior chest, thoracic spine, or low FM is an MDI when it is established back)—that has persisted (or that by appropriate medical evidence. FM persisted) for at least 3 months. The can be the basis for a finding of pain may fluctuate in intensity and may disability. not always be present. I. What general criteria can establish 2. At least 11 positive tender points that a person has an MDI of FM? on physical examination (see diagram Generally, a person can establish that he below). The positive tender points must or she has an MDI of FM by providing be found bilaterally (on the left and evidence from an acceptable medical right sides of the body) and both above source.3 A licensed physician (a and below the waist. medical or osteopathic doctor) is the a. The 18 tender point sites are only acceptable medical source who can located on each side of the body at the: provide such evidence. We cannot rely • Occiput (base of the skull); upon the physician’s diagnosis alone. • Low cervical spine (back and side The evidence must document that the of the neck); physician reviewed the person’s • Trapezius muscle (shoulder); medical history and conducted a • Supraspinatus muscle (near the physical exam. We will review the shoulder blade); physician’s treatment notes to see if • Second rib (top of the rib cage near they are consistent with the diagnosis of the sternum or breast bone); FM, determine whether the person’s • Lateral epicondyle (outer aspect of symptoms have improved, worsened, or the elbow); • Gluteal (top of the buttock); remained stable over time, and establish • Greater trochanter (below the hip); the physician’s assessment over time of and the person’s physical strength and • Inner aspect of the knee. functional abilities. b. In testing the tender-point sites,6 II. What specific criteria can establish the physician should perform digital that a person has an MDI of FM? We will find that a person has an MDI of FM palpation with an approximate force of 9 pounds (approximately the amount of if the physician diagnosed FM and pressure needed to blanch the provides the evidence we describe in thumbnail of the examiner). The section II.A. or section II. B., and the physician’s diagnosis is not inconsistent physician considers a tender point to be with the other evidence in the person’s positive if the person experiences any case record. These sections provide two pain when applying this amount of sets of criteria for diagnosing FM, which pressure to the site. 3. Evidence that other disorders that we generally base on the 1990 American College of Rheumatology (ACR) Criteria could cause the symptoms or signs were for the Classification of Fibromyalgia 4 excluded. Other physical and mental (the criteria in section II.A.), or the 2010 disorders may have symptoms or signs ACR Preliminary Diagnostic Criteria 5 that are the same or similar to those the person’s symptoms when we decide whether the person has an MDI of FM. As with any claim for disability benefits, before we find that a person with an MDI of FM is disabled, we must ensure there is sufficient objective evidence to support a finding that the person’s impairment(s) so limits the person’s functional abilities that it precludes him or her from performing any substantial gainful activity. In this Ruling, we describe the evidence we need to establish an MDI of FM and explain how we evaluate this impairment when we determine whether the person is disabled. 20 CFR 404.1513(a) and 416.913(a). Frederick Wolfe et al., The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report of the Multicenter Criteria Committee, 33 Arthritis and Rheumatism 160 (1990), available at https:// www.rheumatology.org/practice/clinical/ classification/fibromyalgia/ 1990_Criteria_for_Classification_Fibro.pdf. 5 See Frederick Wolfe et al., The American College of Rheumatology Preliminary Diagnostic PO 00000 3 See 4 See Frm 00071 Fmt 4703 Sfmt 4703 Criteria for Fibromyalgia and Measurement of Symptom Severity, 62 Arthritis Care & Research 600 (2010), available at https://www.rheumatology.org/ practice/clinical/classification/fibromyalgia/ 2010_Preliminary_Diagnostic_Criteria.pdf. 6 We may use the criteria in section II.B. of this SSR to determine an MDI of FM if the case record does not include a report of the results of tenderpoint testing, or the report does not describe the number and location on the body of the positive tender points. E:\FR\FM\25JYN1.SGM 25JYN1 43642 Federal Register / Vol. 77, No. 143 / Wednesday, July 25, 2012 / Notices erythrocyte sedimentation rate, antinuclear antibody, thyroid function, and rheumatoid factor). disorder, or irritable bowel syndrome; and 3. Evidence that other disorders that could cause these repeated manifestations of symptoms, signs, or co-occurring conditions were excluded (see section II.A.3.). 1. As in all claims for disability benefits, we need objective medical evidence to establish the presence of an MDI. When a person alleges FM, longitudinal records reflecting ongoing medical evaluation and treatment from acceptable medical sources are especially helpful in establishing both the existence and severity of the impairment. In cases involving FM, as in any case, we will make every reasonable effort to obtain all available, relevant evidence to ensure appropriate and thorough evaluation. 2. We will generally request evidence for the 12-month period before the date of application unless we have reason to believe that we need evidence from an 7 Some examples of other disorders that may have symptoms or signs that are the same or similar to those resulting from FM include rheumatologic disorders, myofacial pain syndrome, polymyalgia rheumatica, chronic Lyme disease, and cervical hyperextension-associated or hyperflexionassociated disorders. 8 We adapted the criteria from the 2010 ACR Preliminary Diagnostic Criteria because the Act and our regulations require a claimant for disability benefits to establish by objective medical evidence that he or she has a medically determinable impairment. See sections 223(d)(5)(A) and 1614(a)(3)(D) of the Act; 20 CFR 404.1508 and 416.908; SSR 96–4p: Titles II and XVI: Symptoms, Medically Determinable Physical and Mental Impairments, and Exertional and Nonexertional Limitations, 61 FR 34488 (July 2, 1996) (also available at: https://www.socialsecurity.gov/ OP_Home/rulings/di/01/SSR96–04-di-01.html). 9 Symptoms and signs that may be considered include the ‘‘(s)omatic symptoms’’ referred to in Table No. 4, ‘‘Fibromyalgia diagnostic criteria,’’ in the 2010 ACR Preliminary Diagnostic Criteria. We consider some of the ‘‘somatic symptoms’’ listed in Table No. 4 to be ‘‘signs’’ under 20 CFR 404.1528(b) and 416.928(b). These ‘‘somatic symptoms’’ include muscle pain, irritable bowel syndrome, fatigue or tiredness, thinking or remembering problems, muscle weakness, headache, pain or cramps in the abdomen, numbness or tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud’s phenomenon, hives or welts, ringing in the ears, vomiting, heartburn, oral ulcers, loss of taste, change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, or bladder spasms. 10 Some co-occurring conditions that may be considered are referred to in Table No. 4, ‘‘Fibromyalgia diagnostic criteria,’’ in the 2010 ACR Preliminary Diagnostic Criteria as ‘‘somatic symptoms,’’ such as irritable bowel syndrome or depression. Other co-occurring conditions, which are not listed in Table No. 4, may also be considered, such as anxiety disorder, chronic fatigue syndrome, irritable bladder syndrome, interstitial cystitis, temporomandibular joint disorder, gastroesophageal reflux disorder, migraine, or restless leg syndrome. 11 ‘‘Waking unrefreshed’’ may be indicated in the case record by the person’s statements describing a history of non-restorative sleep, such as statements about waking up tired or having difficulty remaining awake during the day, or other statements or evidence in the record reflecting that the person has a history of non-restorative sleep. VerDate Mar<15>2010 17:49 Jul 24, 2012 Jkt 226001 III. What documentation do we need? A. General PO 00000 Frm 00072 Fmt 4703 Sfmt 4703 E:\FR\FM\25JYN1.SGM 25JYN1 EN25JY12.000</GPH> account for the person’s symptoms and signs. Laboratory testing may include imaging and other laboratory tests (for example, complete blood counts, B. The 2010 ACR Preliminary Diagnostic Criteria. Based on these criteria, we may find that a person has an MDI of FM if he or she has all three of the following criteria 8: 1. A history of widespread pain (see section II.A.1.); 2. Repeated manifestations of six or more FM symptoms, signs,9 or cooccurring conditions,10 especially manifestations of fatigue, cognitive or memory problems (‘‘fibro fog’’), waking unrefreshed,11 depression, anxiety srobinson on DSK4SPTVN1PROD with NOTICES resulting from FM.7 Therefore, it is common in cases involving FM to find evidence of examinations and testing that rule out other disorders that could Federal Register / Vol. 77, No. 143 / Wednesday, July 25, 2012 / Notices earlier period, or unless the alleged onset of disability is less than 12 months before the date of application.12 In the latter case, we may still request evidence from before the alleged onset date if we have reason to believe that it could be relevant to a finding about the existence, severity, or duration of the disorder, or to establish the onset of disability. B. Other Sources of Evidence 1. In addition to obtaining evidence from a physician, we may request evidence from other acceptable medical sources, such as psychologists, both to determine whether the person has another MDI(s) and to evaluate the severity and functional effects of FM or any of the person’s other impairments. We also may consider evidence from medical sources who are not ‘‘acceptable medical sources’’ to evaluate the severity and functional effects of the impairment(s). 2. Under our regulations and SSR 06– 3p,13 information from nonmedical sources can also help us evaluate the severity and functional effects of a person’s FM. This information may help us to assess the person’s ability to function day-to-day and over time. It may also help us when we make findings about the credibility of the person’s allegations about symptoms and their effects.14 Examples of nonmedical sources include: a. Neighbors, friends, relatives, and clergy; and b. Past employers, rehabilitation counselors, and teachers; and c. Statements from SSA personnel who interviewed the person. C. When There Is Insufficient Evidence for Us To Determine Whether the Person Has an MDI of FM or Is Disabled srobinson on DSK4SPTVN1PROD with NOTICES 1. We may take one or more actions to try to resolve the insufficiency: 15 a. We may recontact the person’s treating or other source(s) to see if the information we need is available; b. We may request additional existing records; c. We may ask the person or others for more information; or d. If the evidence is still insufficient to determine whether the person has an MDI of FM or is disabled despite our 12 See 20 CFR 404.1512(d) and 416.912(d). 20 CFR 404.1513(d)(4), 416.913(d)(4); SSR 06–3p: Titles II and XVI: Considering Opinions and Other Evidence from Sources Who Are Not ‘‘Acceptable Medical Sources’’ in Disability Claims, 71 FR 45593 (August 9, 2006), (also available at: https://www.ssa.gov/OP_Home/rulings/di/01/ SSR2006-03-di-01.html). 14 See section IV below. 15 See 20 CFR 404.1520b(c) and 416.920b(c). 13 See VerDate Mar<15>2010 17:49 Jul 24, 2012 Jkt 226001 43643 efforts to obtain additional evidence, we may make a determination or decision based on the evidence we have. 2. We may purchase a consultative examination (CE) at our expense to determine if a person has an MDI of FM or is disabled when we need this information to adjudicate the case.16 a. We will not purchase a CE solely to determine if a person has FM in addition to another MDI that could account for his or her symptoms. b. We may purchase a CE to help us assess the severity and functional effects of medically determined FM or any other impairment(s). If necessary, we may purchase a CE to help us determine whether the impairment(s) meets the duration requirement. c. Because the symptoms and signs of FM may vary in severity over time and may even be absent on some days, it is important that the medical source who conducts the CE has access to longitudinal information about the person. However, we may rely on the CE report even if the person who conducts the CE did not have access to longitudinal evidence if we determine that the CE is the most probative evidence in the case record. IV. How do we evaluate a person’s statements about his or her symptoms and functional limitations? We follow the two-step process set forth in our regulations and in SSR 96–7p.17 A. First step of the symptom evaluation process. There must be medical signs and findings that show the person has an MDI(s) which could reasonably be expected to produce the pain or other symptoms alleged. FM which we determined to be an MDI satisfies the first step of our two-step process for evaluating symptoms. B. Second step of the symptom evaluation process. Once an MDI is established, we then evaluate the intensity and persistence of the person’s pain or any other symptoms and determine the extent to which the symptoms limit the person’s capacity for work. If objective medical evidence does not substantiate the person’s statements about the intensity, persistence, and functionally limiting effects of symptoms, we consider all of the evidence in the case record, including the person’s daily activities, medications or other treatments the person uses, or has used, to alleviate symptoms; the nature and frequency of the person’s attempts to obtain medical treatment for symptoms; and statements by other people about the person’s symptoms. As we explain in SSR 96–7p, we will make a finding about the credibility of the person’s statements regarding the effects of his or her symptoms on functioning. We will make every reasonable effort to obtain available information that could help us assess the credibility of the person’s statements. V. How do we find a person disabled based on an MDI of FM? Once we establish that a person has an MDI of FM, we will consider it in the sequential evaluation process to determine whether the person is disabled. As we explain in section VI. below, we consider the severity of the impairment, whether the impairment medically equals the requirements of a listed impairment, and whether the impairment prevents the person from doing his or her past relevant work or other work that exists in significant numbers in the national economy. VI. How do we consider FM in the sequential evaluation process? 18 As with any adult claim for disability benefits, we use a 5-step sequential evaluation process to determine whether an adult with an MDI of FM is disabled.19 A. At step 1, we consider the person’s work activity. If a person with FM is doing substantial gainful activity, we find that he or she is not disabled. B. At step 2, we consider whether the person has a ‘‘severe’’ MDI(s). If we find that the person has an MDI that could reasonably be expected to produce the pain or other symptoms the person alleges, we will consider those symptom(s) in deciding whether the person’s impairment(s) is severe. If the person’s pain or other symptoms cause a limitation or restriction that has more than a minimal effect on the ability to perform basic work activities, we will 16 See 20 CFR 404.1520b(c)(3), and 416.920b(c)(3). We may purchase a CE without recontacting a person’s treating or other sources if the source cannot provide the necessary information, or the information is not available from the source. See 20 CFR 404.1519a(b), and 416.919a(b). 17 See 20 CFR 404.1529(b) and (c) and 416.929(b) and (c); SSR 96–7p: Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual’s Statements, 61 FR 34483 (July 2, 1996) (also available at: https:// www.socialsecurity.gov/OP_Home/rulings/di/01/ SSR96-07-di-01.html). 18 As we have already noted, we refer in this SSR only to adult disability claims, but the guidance in the SSR applies to all disability cases under titles II and XVI involving FM. We use different sequential evaluation processes for claims of children under title XVI and in continuing disability reviews of adults and children under titles II and XVI. See 20 CFR 404.1594, 416.924, 416.994, and 416.994a. We also use a modification of the 5-step sequential evaluation process for adults in 20 CFR 416.920 when we do age-18 redeterminations under title XVI. See 20 CFR 416.987. 19 See 20 CFR 404.1520 and 416.920. PO 00000 Frm 00073 Fmt 4703 Sfmt 4703 E:\FR\FM\25JYN1.SGM 25JYN1 43644 Federal Register / Vol. 77, No. 143 / Wednesday, July 25, 2012 / Notices srobinson on DSK4SPTVN1PROD with NOTICES find that the person has a severe impairment(s).20 C. At step 3, we consider whether the person’s impairment(s) meets or medically equals the criteria of any of the listings in the Listing of Impairments in appendix 1, subpart P of 20 CFR part 404 (appendix 1). FM cannot meet a listing in appendix 1 because FM is not a listed impairment. At step 3, therefore, we determine whether FM medically equals a listing (for example, listing 14.09D in the listing for inflammatory arthritis), or whether it medically equals a listing in combination with at least one other medically determinable impairment. D. Residual Functional Capacity (RFC) assessment: In our regulations and SSR 96–8p,21 we explain that we assess a person’s RFC when the person’s impairment(s) does not meet or equal a listed impairment. We base our RFC assessment on all relevant evidence in the case record. We consider the effects of all of the person’s medically determinable impairments, including impairments that are ‘‘not severe.’’ For a person with FM, we will consider a longitudinal record whenever possible because the symptoms of FM can wax and wane so that a person may have ‘‘bad days and good days.’’ E. At steps 4 and 5, we use our RFC assessment to determine whether the person is capable of doing any past relevant work (step 4) or any other work that exists in significant numbers in the national economy (step 5). If the person is able to do any past relevant work, we find that he or she is not disabled. If the person is not able to do any past relevant work or does not have such work experience, we determine whether he or she can do any other work. The usual vocational considerations apply.22 1. Widespread pain and other symptoms associated with FM, such as fatigue, may result in exertional limitations that prevent a person from doing the full range of unskilled work in one or more of the exertional categories in appendix 2 of subpart P of part 404 (appendix 2).23 People with FM 20 See SSR 96–3p: Titles II and XVI: Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe, 61 FR 34468 (July 2, 1996) (also available at: https://www.ssa.gov/OP_Home/ rulings/di/01/SSR96-03-di-01.html). 21 See 20 CFR 404.1520(e), 416.920(e); SSR 96– 8p: Titles II and XVI: Assessing Residual Functional Capacity in Initial Claims, 61 FR 34474 (July 2, 1996) (also available at: https://www.socialsecurity. gov/OP_Home/rulings/di/01/SSR96–08-di-01.html). 22 See 20 CFR 404.1560–404.1569a and 416.960– 416.969a. 23 See SSR 83–12: Title II and XVI: Capability To Do Other Work—The Medical-Vocational Rules as a Framework for Evaluating Exertional Limitations VerDate Mar<15>2010 17:49 Jul 24, 2012 Jkt 226001 may also have nonexertional physical or mental limitations because of their pain or other symptoms.24 Some may have environmental restrictions, which are also nonexertional. 2. Adjudicators must be alert to the possibility that there may be exertional or nonexertional (for example, postural or environmental) limitations that erode a person’s occupational base sufficiently to preclude the use of a rule in appendix 2 to direct a decision. In such cases, adjudicators must use the rules in appendix 2 as a framework for decisionmaking and may need to consult a vocational resource.25 DATES: Effective Date: This SSR is effective on July 25, 2012. Cross-References: SSR 82–63: Titles II and XVI: Medical-Vocational Profiles Showing an Inability To Make an Adjustment to Other Work; SSR 83–12: Title II and XVI: Capability To Do Other Work—The Medical-Vocational Rules as a Framework for Evaluating Exertional Limitations Within a Range of Work or Between Ranges of Work; SSR 83–14: Titles II and XVI: Capability To Do Other Work—The Medical-Vocational Rules as a Framework for Evaluating a Combination of Exertional and Nonexertional Impairments; SSR 85–15: Titles II and XVI: Capability To Do Other Work—The Medical-Vocational Rules as a Framework for Evaluating Solely Nonexertional Impairments; SSR 96–3p: Titles II and XVI: Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe; SSR 96–4p: Policy Interpretation Ruling Titles II and XVI: Symptoms, Medically Determinable Physical and Mental Impairments, and Exertional and Nonexertional Limitations; SSR 96–7p: Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual’s Statements; SSR 96–8p: Titles II and XVI: Assessing Residual Within a Range of Work or Between Ranges of Work (available at https://www.socialsecurity.gov/ OP_Home/rulings/di/02/SSR83-12-di-02.html). 24 See SSR 85–15: Titles II and XVI: Capability To Do Other Work—The Medical-Vocational Rules as a Framework for Evaluating Solely Nonexertional Impairments (available at: https://www.social security.gov/OP_Home/rulings/di/02/SSR85-15-di02.html); and SSR 96–4p. 25 See SSR 83–12; SSR 83–14: Titles II and XVI: Capability To Do Other Work—The MedicalVocational Rules as a Framework for Evaluating a Combination of Exertional and Nonexertional Impairments (available at https://www.social security.gov/OP_Home/rulings/di/02/SSR83-14-di02.html); SSR 85–15; and 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, 61 FR 34478 (July 2, 1996) (also available at: https://www. socialsecurity.gov/OP_Home/rulings/di/01/SSR9609-di-01.html). PO 00000 Frm 00074 Fmt 4703 Sfmt 4703 Functional Capacity in Initial Claims; 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; SSR 99– 2p: Titles II and XVI: Evaluating Cases Involving Chronic Fatigue Syndrome (CFS); SSR 02–2p: Titles II and XVI: Evaluation of Interstitial Cystitis; and SSR 06–3p: Titles II and XVI: Considering Opinions and Other Evidence from Sources Who Are Not ‘‘Acceptable Medical Sources’’ in Disability Claims; Considering Decisions on Disability by Other Governmental and Nongovernmental Agencies; and Program Operations Manual System (POMS) DI 22505.001, DI 22505.003, DI 24510.057, DI 24515.012, DI 24515.061–DI 24515.063, DI 24515.075, DI 24555.001, DI 25010.001, and DI 25025.001. [FR Doc. 2012–17936 Filed 7–24–12; 8:45 am] BILLING CODE 4191–02–P DEPARTMENT OF STATE [Public Notice 7963] Culturally Significant Objects Imported for Exhibition Determinations: ‘‘Byzantine Art in the Mary and Michael Jaharis Galleries of Greek, Roman and Byzantine Art’’ Notice is hereby given of the following determinations: Pursuant to the authority vested in me by the Act of October 19, 1965 (79 Stat. 985; 22 U.S.C. 2459), Executive Order 12047 of March 27, 1978, the Foreign Affairs Reform and Restructuring Act of 1998 (112 Stat. 2681, et seq.; 22 U.S.C. 6501 note, et seq.), Delegation of Authority No. 234 of October 1, 1999, Delegation of Authority No. 236–3 of August 28, 2000 (and, as appropriate, Delegation of Authority No. 257 of April 15, 2003), I hereby determine that the objects to be included in the exhibition ‘‘Byzantine Art in the Mary and Michael Jaharis Galleries of Greek, Roman and Byzantine Art’’ imported from abroad for temporary exhibition within the United States, are of cultural significance. The objects are imported pursuant to loan agreements with the foreign owner or custodian. I also determine that the exhibition or display of the exhibit objects at the Art Institute of Chicago, Chicago, IL, from on or about November 10, 2012, until on or about November 8, 2015, and at possible additional exhibitions or venues yet to be determined, is in the national interest. I have ordered that Public SUMMARY: E:\FR\FM\25JYN1.SGM 25JYN1

Agencies

Social Security Administration

[Federal Register Volume 77, Number 143 (Wednesday, July 25, 2012)]
[Notices]
[Pages 43640-43644]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-17936]

-----------------------------------------------------------------------

SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2011-0021]

Social Security Ruling, SSR 12-2p; Titles II and XVI: Evaluation
of Fibromyalgia

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

-----------------------------------------------------------------------

SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of
Social Security gives notice of Social Security Ruling, SSR 12-2p. This
ruling provides guidance on how we develop evidence to establish that a
person has a medically determinable impairment of fibromyalgia, and how
we evaluate fibromyalgia in disability claims and continuing disability
reviews under titles II and XVI of the Social Security Act.

DATES: Effective Date: July 25, 2012.

FOR FURTHER INFORMATION CONTACT: Cheryl Williams, Office of Disability
Programs, Social Security Administration, 6401 Security Boulevard,
Baltimore, Maryland 21235-6401, (410) 965-1020.

SUPPLEMENTARY INFORMATION: Although we are not required to do so
pursuant to 5 U.S.C. 552(a)(1) and (a)(2), we are publishing this SSR
in accordance with 20 CFR 402.35(b)(1).
Through SSRs, we make available to the public precedential
decisions relating to the Federal old-age, survivors, disability,
supplemental security income, special veterans benefits, and black lung
benefits programs. We may base SSRs on determinations or decisions made
at all levels of administrative adjudication, Federal court decisions,
Commissioner's decisions, opinions of the Office of the General
Counsel, or other interpretations of the law and regulations.
Although SSRs do not have the same force and effect as statutes or
regulations, they are binding on all components of the Social Security
Administration. 20 CFR 402.35(b)(1).

[[Page 43641]]

This SSR will be in effect until we publish a notice in the Federal
Register that rescinds it, or publish a new SSR that replaces or
modifies it.

(Catalog of Federal Domestic Assistance, Program Nos. 96.001, Social
Security--Disability Insurance; 96.002, Social Security--Retirement
Insurance; 96.004--Social Security--Survivors Insurance; 96.006--
Supplemental Security Income)

Michael J. Astrue,
Commissioner of Social Security.

Policy Interpretation Ruling

Titles II and XVI: Evaluation of Fibromyalgia

Purpose: This Social Security Ruling (SSR) provides guidance on how
we develop evidence to establish that a person has a medically
determinable impairment (MDI) of fibromyalgia (FM), and how we evaluate
FM in disability claims and continuing disability reviews under titles
II and XVI of the Social Security Act (Act).\1\
---------------------------------------------------------------------------

\1\ For simplicity, we refer in this SSR only to initial claims
for benefits made by adults (individuals who are at least age 18).
However, the policy interpretations in this SSR also apply to claims
for benefits made by children (individuals under age 18) under title
XVI of the Act and to claims above the initial level. FM can affect
children, and the signs and symptoms are essentially the same in
children as adults. The policy interpretations in this SSR also
apply to continuing disability reviews of adults and children under
sections 223(f) and 1614(a)(4) of the Act, and to redeterminations
of eligibility for benefits we make in accordance with section
1614(a)(3)(H) of the Act when a child who is receiving title XVI
childhood disability benefits attains age 18.
---------------------------------------------------------------------------

Citations: Sections 216(i), 223(d), 223(f), 1614(a)(3), and
1614(a)(4) of the Act, as amended; Regulations No. 4, subpart P,
sections 404.1505, 404.1508-404.1513, 404.1519a, 404.1520, 404.1520a,
404.1521, 404.1523, 404.1526, 404.1527-404.1529, 404.1545, 404.1560-
404.1569a, 404.1593, 404.1594, appendix 1, and appendix 2; and
Regulations No. 16, subpart I, sections 416.905, 416.906, 416.908-
416.913, 416.919a, 416.920, 416.920a, 416.921, 416.923, 416.924,
416.924a, 416.926, 416.926a, 416.927-416.929, 416.945, 416.960-
416.969a, 416.987, 416.993, 416.994, and 416.994a.

Introduction

FM is a complex medical condition characterized primarily by
widespread pain in the joints, muscles, tendons, or nearby soft tissues
that has persisted for at least 3 months. FM is a common syndrome.\2\
When a person seeks disability benefits due in whole or in part to FM,
we must properly consider the person's symptoms when we decide whether
the person has an MDI of FM. As with any claim for disability benefits,
before we find that a person with an MDI of FM is disabled, we must
ensure there is sufficient objective evidence to support a finding that
the person's impairment(s) so limits the person's functional abilities
that it precludes him or her from performing any substantial gainful
activity. In this Ruling, we describe the evidence we need to establish
an MDI of FM and explain how we evaluate this impairment when we
determine whether the person is disabled.
---------------------------------------------------------------------------

\2\ See National Center for Biotechnology Information, U.S.
National Library of Medicine, Fibromyalgia, https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001463.
---------------------------------------------------------------------------

Policy Interpretation

FM is an MDI when it is established by appropriate medical
evidence. FM can be the basis for a finding of disability.
I. What general criteria can establish that a person has an MDI of
FM? Generally, a person can establish that he or she has an MDI of FM
by providing evidence from an acceptable medical source.\3\ A licensed
physician (a medical or osteopathic doctor) is the only acceptable
medical source who can provide such evidence. We cannot rely upon the
physician's diagnosis alone. The evidence must document that the
physician reviewed the person's medical history and conducted a
physical exam. We will review the physician's treatment notes to see if
they are consistent with the diagnosis of FM, determine whether the
person's symptoms have improved, worsened, or remained stable over
time, and establish the physician's assessment over time of the
person's physical strength and functional abilities.
---------------------------------------------------------------------------

\3\ See 20 CFR 404.1513(a) and 416.913(a).
---------------------------------------------------------------------------

II. What specific criteria can establish that a person has an MDI
of FM? We will find that a person has an MDI of FM if the physician
diagnosed FM and provides the evidence we describe in section II.A. or
section II. B., and the physician's diagnosis is not inconsistent with
the other evidence in the person's case record. These sections provide
two sets of criteria for diagnosing FM, which we generally base on the
1990 American College of Rheumatology (ACR) Criteria for the
Classification of Fibromyalgia \4\ (the criteria in section II.A.), or
the 2010 ACR Preliminary Diagnostic Criteria \5\ (the criteria in
section II.B.). If we cannot find that the person has an MDI of FM but
there is evidence of another MDI, we will not evaluate the impairment
under this Ruling. Instead, we will evaluate it under the rules that
apply for that impairment.
---------------------------------------------------------------------------

\4\ See Frederick Wolfe et al., The American College of
Rheumatology 1990 Criteria for the Classification of Fibromyalgia:
Report of the Multicenter Criteria Committee, 33 Arthritis and
Rheumatism 160 (1990), available at https://www.rheumatology.org/practice/clinical/classification/fibromyalgia/1990_Criteria_for_Classification_Fibro.pdf.
\5\ See Frederick Wolfe et al., The American College of
Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and
Measurement of Symptom Severity, 62 Arthritis Care & Research 600
(2010), available at https://www.rheumatology.org/practice/clinical/classification/fibromyalgia/2010_Preliminary_Diagnostic_Criteria.pdf.
---------------------------------------------------------------------------

A. The 1990 ACR Criteria for the Classification of Fibromyalgia.
Based on these criteria, we may find that a person has an MDI of FM if
he or she has all three of the following:
1. A history of widespread pain--that is, pain in all quadrants of
the body (the right and left sides of the body, both above and below
the waist) and axial skeletal pain (the cervical spine, anterior chest,
thoracic spine, or low back)--that has persisted (or that persisted)
for at least 3 months. The pain may fluctuate in intensity and may not
always be present.
2. At least 11 positive tender points on physical examination (see
diagram below). The positive tender points must be found bilaterally
(on the left and right sides of the body) and both above and below the
waist.
a. The 18 tender point sites are located on each side of the body
at the:
Occiput (base of the skull);
Low cervical spine (back and side of the neck);
Trapezius muscle (shoulder);
Supraspinatus muscle (near the shoulder blade);
Second rib (top of the rib cage near the sternum or breast
bone);
Lateral epicondyle (outer aspect of the elbow);
Gluteal (top of the buttock);
Greater trochanter (below the hip); and
Inner aspect of the knee.
b. In testing the tender-point sites,\6\ the physician should
perform digital palpation with an approximate force of 9 pounds
(approximately the amount of pressure needed to blanch the thumbnail of
the examiner). The physician considers a tender point to be positive if
the person experiences any pain when applying this amount of pressure
to the site.
---------------------------------------------------------------------------

\6\ We may use the criteria in section II.B. of this SSR to
determine an MDI of FM if the case record does not include a report
of the results of tender-point testing, or the report does not
describe the number and location on the body of the positive tender
points.
---------------------------------------------------------------------------

3. Evidence that other disorders that could cause the symptoms or
signs were excluded. Other physical and mental disorders may have
symptoms or signs that are the same or similar to those

[[Page 43642]]

resulting from FM.\7\ Therefore, it is common in cases involving FM to
find evidence of examinations and testing that rule out other disorders
that could account for the person's symptoms and signs. Laboratory
testing may include imaging and other laboratory tests (for example,
complete blood counts, erythrocyte sedimentation rate, anti-nuclear
antibody, thyroid function, and rheumatoid factor).
---------------------------------------------------------------------------

\7\ Some examples of other disorders that may have symptoms or
signs that are the same or similar to those resulting from FM
include rheumatologic disorders, myofacial pain syndrome,
polymyalgia rheumatica, chronic Lyme disease, and cervical
hyperextension-associated or hyperflexion-associated disorders.
[GRAPHIC] [TIFF OMITTED] TN25JY12.000

B. The 2010 ACR Preliminary Diagnostic Criteria. Based on these
criteria, we may find that a person has an MDI of FM if he or she has
all three of the following criteria \8\:
---------------------------------------------------------------------------

\8\ We adapted the criteria from the 2010 ACR Preliminary
Diagnostic Criteria because the Act and our regulations require a
claimant for disability benefits to establish by objective medical
evidence that he or she has a medically determinable impairment. See
sections 223(d)(5)(A) and 1614(a)(3)(D) of the Act; 20 CFR 404.1508
and 416.908; SSR 96-4p: Titles II and XVI: Symptoms, Medically
Determinable Physical and Mental Impairments, and Exertional and
Nonexertional Limitations, 61 FR 34488 (July 2, 1996) (also
available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-04-di-01.html).
---------------------------------------------------------------------------

1. A history of widespread pain (see section II.A.1.);
2. Repeated manifestations of six or more FM symptoms, signs,\9\ or
co-occurring conditions,\10\ especially manifestations of fatigue,
cognitive or memory problems (``fibro fog''), waking unrefreshed,\11\
depression, anxiety disorder, or irritable bowel syndrome; and
---------------------------------------------------------------------------

\9\ Symptoms and signs that may be considered include the
``(s)omatic symptoms'' referred to in Table No. 4, ``Fibromyalgia
diagnostic criteria,'' in the 2010 ACR Preliminary Diagnostic
Criteria. We consider some of the ``somatic symptoms'' listed in
Table No. 4 to be ``signs'' under 20 CFR 404.1528(b) and 416.928(b).
These ``somatic symptoms'' include muscle pain, irritable bowel
syndrome, fatigue or tiredness, thinking or remembering problems,
muscle weakness, headache, pain or cramps in the abdomen, numbness
or tingling, dizziness, insomnia, depression, constipation, pain in
the upper abdomen, nausea, nervousness, chest pain, blurred vision,
fever, diarrhea, dry mouth, itching, wheezing, Raynaud's phenomenon,
hives or welts, ringing in the ears, vomiting, heartburn, oral
ulcers, loss of taste, change in taste, seizures, dry eyes,
shortness of breath, loss of appetite, rash, sun sensitivity,
hearing difficulties, easy bruising, hair loss, frequent urination,
or bladder spasms.
\10\ Some co-occurring conditions that may be considered are
referred to in Table No. 4, ``Fibromyalgia diagnostic criteria,'' in
the 2010 ACR Preliminary Diagnostic Criteria as ``somatic
symptoms,'' such as irritable bowel syndrome or depression. Other
co-occurring conditions, which are not listed in Table No. 4, may
also be considered, such as anxiety disorder, chronic fatigue
syndrome, irritable bladder syndrome, interstitial cystitis,
temporomandibular joint disorder, gastroesophageal reflux disorder,
migraine, or restless leg syndrome.
\11\ ``Waking unrefreshed'' may be indicated in the case record
by the person's statements describing a history of non-restorative
sleep, such as statements about waking up tired or having difficulty
remaining awake during the day, or other statements or evidence in
the record reflecting that the person has a history of non-
restorative sleep.
---------------------------------------------------------------------------

3. Evidence that other disorders that could cause these repeated
manifestations of symptoms, signs, or co-occurring conditions were
excluded (see section II.A.3.).

III. What documentation do we need?

A. General

1. As in all claims for disability benefits, we need objective
medical evidence to establish the presence of an MDI. When a person
alleges FM, longitudinal records reflecting ongoing medical evaluation
and treatment from acceptable medical sources are especially helpful in
establishing both the existence and severity of the impairment. In
cases involving FM, as in any case, we will make every reasonable
effort to obtain all available, relevant evidence to ensure appropriate
and thorough evaluation.
2. We will generally request evidence for the 12-month period
before the date of application unless we have reason to believe that we
need evidence from an

[[Page 43643]]

earlier period, or unless the alleged onset of disability is less than
12 months before the date of application.\12\ In the latter case, we
may still request evidence from before the alleged onset date if we
have reason to believe that it could be relevant to a finding about the
existence, severity, or duration of the disorder, or to establish the
onset of disability.
---------------------------------------------------------------------------

\12\ See 20 CFR 404.1512(d) and 416.912(d).
---------------------------------------------------------------------------

B. Other Sources of Evidence

1. In addition to obtaining evidence from a physician, we may
request evidence from other acceptable medical sources, such as
psychologists, both to determine whether the person has another MDI(s)
and to evaluate the severity and functional effects of FM or any of the
person's other impairments. We also may consider evidence from medical
sources who are not ``acceptable medical sources'' to evaluate the
severity and functional effects of the impairment(s).
2. Under our regulations and SSR 06-3p,\13\ information from
nonmedical sources can also help us evaluate the severity and
functional effects of a person's FM. This information may help us to
assess the person's ability to function day-to-day and over time. It
may also help us when we make findings about the credibility of the
person's allegations about symptoms and their effects.\14\ Examples of
nonmedical sources include:
---------------------------------------------------------------------------

\13\ See 20 CFR 404.1513(d)(4), 416.913(d)(4); SSR 06-3p: Titles
II and XVI: Considering Opinions and Other Evidence from Sources Who
Are Not ``Acceptable Medical Sources'' in Disability Claims, 71 FR
45593 (August 9, 2006), (also available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03-di-01.html).
\14\ See section IV below.
---------------------------------------------------------------------------

a. Neighbors, friends, relatives, and clergy; and
b. Past employers, rehabilitation counselors, and teachers; and
c. Statements from SSA personnel who interviewed the person.

C. When There Is Insufficient Evidence for Us To Determine Whether the
Person Has an MDI of FM or Is Disabled

1. We may take one or more actions to try to resolve the
insufficiency: \15\
---------------------------------------------------------------------------

\15\ See 20 CFR 404.1520b(c) and 416.920b(c).
---------------------------------------------------------------------------

a. We may recontact the person's treating or other source(s) to see
if the information we need is available;
b. We may request additional existing records;
c. We may ask the person or others for more information; or
d. If the evidence is still insufficient to determine whether the
person has an MDI of FM or is disabled despite our efforts to obtain
additional evidence, we may make a determination or decision based on
the evidence we have.
2. We may purchase a consultative examination (CE) at our expense
to determine if a person has an MDI of FM or is disabled when we need
this information to adjudicate the case.\16\
---------------------------------------------------------------------------

\16\ See 20 CFR 404.1520b(c)(3), and 416.920b(c)(3). We may
purchase a CE without recontacting a person's treating or other
sources if the source cannot provide the necessary information, or
the information is not available from the source. See 20 CFR
404.1519a(b), and 416.919a(b).
---------------------------------------------------------------------------

a. We will not purchase a CE solely to determine if a person has FM
in addition to another MDI that could account for his or her symptoms.
b. We may purchase a CE to help us assess the severity and
functional effects of medically determined FM or any other
impairment(s). If necessary, we may purchase a CE to help us determine
whether the impairment(s) meets the duration requirement.
c. Because the symptoms and signs of FM may vary in severity over
time and may even be absent on some days, it is important that the
medical source who conducts the CE has access to longitudinal
information about the person. However, we may rely on the CE report
even if the person who conducts the CE did not have access to
longitudinal evidence if we determine that the CE is the most probative
evidence in the case record.
IV. How do we evaluate a person's statements about his or her
symptoms and functional limitations? We follow the two-step process set
forth in our regulations and in SSR 96-7p.\17\
---------------------------------------------------------------------------

\17\ See 20 CFR 404.1529(b) and (c) and 416.929(b) and (c); SSR
96-7p: Titles II and XVI: Evaluation of Symptoms in Disability
Claims: Assessing the Credibility of an Individual's Statements, 61
FR 34483 (July 2, 1996) (also available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-07-di-01.html).
---------------------------------------------------------------------------

A. First step of the symptom evaluation process. There must be
medical signs and findings that show the person has an MDI(s) which
could reasonably be expected to produce the pain or other symptoms
alleged. FM which we determined to be an MDI satisfies the first step
of our two-step process for evaluating symptoms.
B. Second step of the symptom evaluation process. Once an MDI is
established, we then evaluate the intensity and persistence of the
person's pain or any other symptoms and determine the extent to which
the symptoms limit the person's capacity for work. If objective medical
evidence does not substantiate the person's statements about the
intensity, persistence, and functionally limiting effects of symptoms,
we consider all of the evidence in the case record, including the
person's daily activities, medications or other treatments the person
uses, or has used, to alleviate symptoms; the nature and frequency of
the person's attempts to obtain medical treatment for symptoms; and
statements by other people about the person's symptoms. As we explain
in SSR 96-7p, we will make a finding about the credibility of the
person's statements regarding the effects of his or her symptoms on
functioning. We will make every reasonable effort to obtain available
information that could help us assess the credibility of the person's
statements.
V. How do we find a person disabled based on an MDI of FM? Once we
establish that a person has an MDI of FM, we will consider it in the
sequential evaluation process to determine whether the person is
disabled. As we explain in section VI. below, we consider the severity
of the impairment, whether the impairment medically equals the
requirements of a listed impairment, and whether the impairment
prevents the person from doing his or her past relevant work or other
work that exists in significant numbers in the national economy.
VI. How do we consider FM in the sequential evaluation process?
\18\ As with any adult claim for disability benefits, we use a 5-step
sequential evaluation process to determine whether an adult with an MDI
of FM is disabled.\19\
---------------------------------------------------------------------------

\18\ As we have already noted, we refer in this SSR only to
adult disability claims, but the guidance in the SSR applies to all
disability cases under titles II and XVI involving FM. We use
different sequential evaluation processes for claims of children
under title XVI and in continuing disability reviews of adults and
children under titles II and XVI. See 20 CFR 404.1594, 416.924,
416.994, and 416.994a. We also use a modification of the 5-step
sequential evaluation process for adults in 20 CFR 416.920 when we
do age-18 redeterminations under title XVI. See 20 CFR 416.987.
\19\ See 20 CFR 404.1520 and 416.920.
---------------------------------------------------------------------------

A. At step 1, we consider the person's work activity. If a person
with FM is doing substantial gainful activity, we find that he or she
is not disabled.
B. At step 2, we consider whether the person has a ``severe''
MDI(s). If we find that the person has an MDI that could reasonably be
expected to produce the pain or other symptoms the person alleges, we
will consider those symptom(s) in deciding whether the person's
impairment(s) is severe. If the person's pain or other symptoms cause a
limitation or restriction that has more than a minimal effect on the
ability to perform basic work activities, we will

[[Page 43644]]

find that the person has a severe impairment(s).\20\
---------------------------------------------------------------------------

\20\ See SSR 96-3p: Titles II and XVI: Considering Allegations
of Pain and Other Symptoms in Determining Whether a Medically
Determinable Impairment is Severe, 61 FR 34468 (July 2, 1996) (also
available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR96-03-di-01.html).
---------------------------------------------------------------------------

C. At step 3, we consider whether the person's impairment(s) meets
or medically equals the criteria of any of the listings in the Listing
of Impairments in appendix 1, subpart P of 20 CFR part 404 (appendix
1). FM cannot meet a listing in appendix 1 because FM is not a listed
impairment. At step 3, therefore, we determine whether FM medically
equals a listing (for example, listing 14.09D in the listing for
inflammatory arthritis), or whether it medically equals a listing in
combination with at least one other medically determinable impairment.
D. Residual Functional Capacity (RFC) assessment: In our
regulations and SSR 96-8p,\21\ we explain that we assess a person's RFC
when the person's impairment(s) does not meet or equal a listed
impairment. We base our RFC assessment on all relevant evidence in the
case record. We consider the effects of all of the person's medically
determinable impairments, including impairments that are ``not
severe.'' For a person with FM, we will consider a longitudinal record
whenever possible because the symptoms of FM can wax and wane so that a
person may have ``bad days and good days.''
---------------------------------------------------------------------------

\21\ See 20 CFR 404.1520(e), 416.920(e); SSR 96-8p: Titles II
and XVI: Assessing Residual Functional Capacity in Initial Claims,
61 FR 34474 (July 2, 1996) (also available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-08-di-01.html).
---------------------------------------------------------------------------

E. At steps 4 and 5, we use our RFC assessment to determine whether
the person is capable of doing any past relevant work (step 4) or any
other work that exists in significant numbers in the national economy
(step 5). If the person is able to do any past relevant work, we find
that he or she is not disabled. If the person is not able to do any
past relevant work or does not have such work experience, we determine
whether he or she can do any other work. The usual vocational
considerations apply.\22\
---------------------------------------------------------------------------

\22\ See 20 CFR 404.1560-404.1569a and 416.960-416.969a.
---------------------------------------------------------------------------

1. Widespread pain and other symptoms associated with FM, such as
fatigue, may result in exertional limitations that prevent a person
from doing the full range of unskilled work in one or more of the
exertional categories in appendix 2 of subpart P of part 404 (appendix
2).\23\ People with FM may also have nonexertional physical or mental
limitations because of their pain or other symptoms.\24\ Some may have
environmental restrictions, which are also nonexertional.
---------------------------------------------------------------------------

\23\ See SSR 83-12: Title II and XVI: Capability To Do Other
Work--The Medical-Vocational Rules as a Framework for Evaluating
Exertional Limitations Within a Range of Work or Between Ranges of
Work (available at https://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR83-12-di-02.html).
\24\ See SSR 85-15: Titles II and XVI: Capability To Do Other
Work--The Medical-Vocational Rules as a Framework for Evaluating
Solely Nonexertional Impairments (available at: https://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR85-15-di-02.html);
and SSR 96-4p.
---------------------------------------------------------------------------

2. Adjudicators must be alert to the possibility that there may be
exertional or nonexertional (for example, postural or environmental)
limitations that erode a person's occupational base sufficiently to
preclude the use of a rule in appendix 2 to direct a decision. In such
cases, adjudicators must use the rules in appendix 2 as a framework for
decision-making and may need to consult a vocational resource.\25\
---------------------------------------------------------------------------

\25\ See SSR 83-12; SSR 83-14: Titles II and XVI: Capability To
Do Other Work--The Medical-Vocational Rules as a Framework for
Evaluating a Combination of Exertional and Nonexertional Impairments
(available at https://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR83-14-di-02.html); SSR 85-15; and 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, 61
FR 34478 (July 2, 1996) (also available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-09-di-01.html).

DATES: Effective Date: This SSR is effective on July 25, 2012.
Cross-References: SSR 82-63: Titles II and XVI: Medical-Vocational
Profiles Showing an Inability To Make an Adjustment to Other Work; SSR
83-12: Title II and XVI: Capability To Do Other Work--The Medical-
Vocational Rules as a Framework for Evaluating Exertional Limitations
Within a Range of Work or Between Ranges of Work; SSR 83-14: Titles II
and XVI: Capability To Do Other Work--The Medical-Vocational Rules as a
Framework for Evaluating a Combination of Exertional and Nonexertional
Impairments; SSR 85-15: Titles II and XVI: Capability To Do Other
Work--The Medical-Vocational Rules as a Framework for Evaluating Solely
Nonexertional Impairments; SSR 96-3p: Titles II and XVI: Considering
Allegations of Pain and Other Symptoms in Determining Whether a
Medically Determinable Impairment is Severe; SSR 96-4p: Policy
Interpretation Ruling Titles II and XVI: Symptoms, Medically
Determinable Physical and Mental Impairments, and Exertional and
Nonexertional Limitations; SSR 96-7p: Titles II and XVI: Evaluation of
Symptoms in Disability Claims: Assessing the Credibility of an
Individual's Statements; SSR 96-8p: Titles II and XVI: Assessing
Residual Functional Capacity in Initial Claims; 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; SSR 99-2p: Titles II and XVI: Evaluating Cases Involving Chronic
Fatigue Syndrome (CFS); SSR 02-2p: Titles II and XVI: Evaluation of
Interstitial Cystitis; and SSR 06-3p: Titles II and XVI: Considering
Opinions and Other Evidence from Sources Who Are Not ``Acceptable
Medical Sources'' in Disability Claims; Considering Decisions on
Disability by Other Governmental and Nongovernmental Agencies; and
Program Operations Manual System (POMS) DI 22505.001, DI 22505.003, DI
24510.057, DI 24515.012, DI 24515.061-DI 24515.063, DI 24515.075, DI
24555.001, DI 25010.001, and DI 25025.001.

[FR Doc. 2012-17936 Filed 7-24-12; 8:45 am]
BILLING CODE 4191-02-P

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.