Social Security Ruling, SSR 14-1p; Titles II and XVI: Evaluating Claims Involving Chronic Fatigue Syndrome (CFS), 18750-18754 [2014-07465]

Agencies

• Social Security Administration

[Federal Register Volume 79, Number 64 (Thursday, April 3, 2014)]
[Notices]
[Pages 18750-18754]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-07465]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2013-0060]


Social Security Ruling, SSR 14-1p; Titles II and XVI: Evaluating 
Claims Involving Chronic Fatigue Syndrome (CFS)

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are providing notice of SSR 14-1p. This SSR provides 
guidance on how we develop evidence to establish that a person has a 
medically determinable impairment of chronic fatigue syndrome and how 
we evaluate chronic fatigue syndrome in disability claims and 
continuing disability reviews under titles II and XVI of the Social 
Security Act.

DATES: Effective Date: April 3, 2014.

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

SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do 
not require us to publish this SSR, we are doing so in accordance with 
20 CFR 402.35(b)(1).
    Through SSRs, we convey to the public, precedential decisions 
relating to the Federal old-age, survivors, disability, supplemental 
security income, and special veterans 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 18751]]

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

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

    Dated: March 27, 2014.
Carolyn W. Colvin,
Acting Commissioner of Social Security.

POLICY INTERPRETATION RULING

TITLES II AND XVI: EVALUATING CASES INVOLVING CHRONIC FATIGUE SYNDROME 
(CFS)

    This Social Security Ruling (SSR) rescinds and replaces SSR 99-
2p: ``Titles II and XVI: Evaluating Cases Involving Chronic Fatigue 
Syndrome (CFS).''
    PURPOSE: This SSR clarifies our policy on how we develop 
evidence to establish that a person has a medically determinable 
impairment (MDI) of CFS and how we evaluate this impairment in 
disability claims and continuing disability reviews under titles II 
and XVI the Social Security Act (Act).\1\
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    \1\ For simplicity, we refer in this SSR only to initial adult 
claims for disability benefits under titles II and XVI of the Act 
and to the steps of the sequential evaluation process we use to 
determine disability in those claims. 20 CFR 404.1520 and 416.920. 
The policy interpretations in this SSR apply to all cases in which 
we must make determinations about disability, including claims of 
children (that is, people who have not attained age 18) who apply 
for benefits based on disability under title XVI of the Act, 
disability redeterminations for children who became eligible for 
Supplemental Security Income under title XVI as a child and who were 
eligible for such benefits for the month before the month in which 
they attained age 18, and to continuing disability reviews of adults 
and children under titles II and XVI of the Act. 20 CFR 404.1594, 
416.924, 416.987, 416.994, and 416.994a.
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    CITATIONS: 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 404.1502, 404.1505, 404.1508-404.1513, 
404.1519a, 404.1520, 404.1520a, 404.1521, 404.1523, 404.1526-
404.1529, 404.1545, 404.1560-404.1569a, 404.1593, 404.1594, 
appendices 1 and 2; and Regulations No. 16, subpart I, sections 
416.902, 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:

    CFS is a systemic disorder consisting of a complex of symptoms 
that may vary in frequency, duration, and severity. In 1994, an 
international panel convened by the Centers for Disease Control and 
Prevention (CDC) developed a case definition for CFS that serves as 
an identification tool and research definition.\2\ In 2003, an 
expert subcommittee of Health Canada, the Canadian health agency, 
convened a consensus workshop that developed a clinical case 
definition for CFS, known as the Canadian Consensus Criteria 
(CCC).\3\ In 2011, a private international group developed 
guidelines, known as the International Consensus Criteria (ICC),\4\ 
for diagnosing myalgic encephalomyelitis (ME).\5\ Members of this 
international group and other medical experts consider ME to be a 
subtype of CFS.\6\ We adapted the CDC criteria, and to some extent 
the CCC and ICC, when we formulated the criteria in this SSR.\7\
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    \2\ See Center for Disease Control and Prevention, ``Chronic 
Fatigue Syndrome (CFS),'' available at: https://www.cdc.gov/cfs.
    \3\ See Carruthers, B.M., et al. Myalgic Encephalomyelitis/
Chronic Fatigue Syndrome: Clinical Working Case Definition, 
Diagnostic and Treatment Protocols, Journal of Chronic Fatigue 
Syndrome, Jan; 11(1), 7-36 (2003); see also, Myalgic 
Encephalomyelitis/Chronic Fatigue Syndrome: A Clinical Case 
Definition and Guidelines for Medical Practitioners, Canada: 
Carruthers & van de Sande, 2005 (available at: https://sacfs.asn.au/download/consensus_overview_me_cfs.pdf).
    \4\ See Carruthers, B.M., et al. Myalgic Encephalomyelitis: 
International Consensus Criteria, Journal of Internal Medicine, Apr; 
270(4), 327-338 (2011); also, Carruthers, B.M. & van de Sande, 
M.I.,eds., Myalgic Encephalomyelitis--Adult & Pediatric: 
International Consensus Primer for Medical Practitioners, Canada: 
Carruthers & van de Sande, 2012 (available at: https://sacfs.asn.au/download/me_international_consensus_primer_for_medical_practitioners.pdf).
    \5\ Although the panel that developed the ICC considers its 
criteria appropriate for diagnosing only ME, we consider the ICC 
helpful in establishing an MDI of CFS because of the similarities 
between CFS and ME. For example, ME also is a systemic disorder that 
manifests many of the same symptoms as CFS, including prolonged 
fatigue.
    \6\ Medical experts who consider ME to be a subtype of CFS may 
use hybrid terms to describe the syndrome, such as CFS/ME and ME/
CFS.
    \7\ We adapted the CDC criteria, CCC, and ICC because the Act 
and our regulations require a claimant to establish by objective 
medical evidence that he or she has a medically determinable 
impairment. See 223(d)(5)(A) and 1614(a)(3)(D) of the Act, 20 CFR 
404.1058 and 416.908, and SSR 96-4p: Titles II and XVI: Symptoms, 
Medically Determinable Physical and Mental Impairments, and 
Exertional and Nonexertional Limitations, 61 FR 34488 (1996) (also 
available at https://www.ba.ssa.gov/OP_Home/rulings/di/01/SSR96-04-di-01.html.
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    We consider a person to be ``disabled'' \8\ if he or she is 
unable to engage in any substantial gainful activity by reason of 
any medically determinable physical or mental impairment(s) \9\ 
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. We require that an MDI result from anatomical, 
physiological, or psychological abnormalities, as shown by medically 
acceptable clinical and laboratory diagnostic techniques.\10\ The 
Act and our regulations further require that the impairment be 
established by medical evidence that consists of signs, symptoms, 
and laboratory findings; therefore, a claimant may not be found 
disabled on the basis of a person's statement of symptoms alone.\11\ 
In this SSR, we explain that CFS, when accompanied by appropriate 
medical signs or laboratory findings, is an MDI that can be the 
basis for a finding of ``disability.'' We also explain how we 
evaluate CFS claims.

    \8\ Except for statutory blindness.
    \9\ We use the term ``impairment(s)'' in this SSR to refer to an 
``impairment or a combination of impairments.''
    \10\ See sections 223(d)(3) and 1614(a)(3)(D) of the Act, and 20 
CFR 404.1508 and 416.908.
    \11\ See sections 223(d)(5)(A) and 1614(a)(3)(D) of the Act; 20 
CFR 404.1508 and 416.908; and SSR 96-4p.
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POLICY INTERPRETATION

    CFS constitutes an MDI when accompanied by medical signs or 
laboratory findings, as discussed below. CFS may be a disabling 
impairment. This policy interpretation clarifies how our 
adjudicators should apply our regulations in determining whether a 
person claiming benefits based on CFS is disabled under titles II 
and XVI the Act. Adults and children may claim these benefits. As 
mentioned, we include ME as a subtype of CFS. When we refer to CFS 
in this SSR, we include ME.

I. What is CFS?

    CFS is a systemic disorder that may vary in frequency, duration, 
and severity. CFS can occur in children,\12\ particularly 
adolescents, as well as in adults.
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    \12\ In children, symptoms may progress more gradually than in 
adolescents or adults.
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    The CDC and other medical experts characterize CFS, in part, as 
a syndrome that causes prolonged fatigue lasting 6 months or more, 
resulting in a substantial reduction in previous levels of 
occupational, educational, social, or personal activities. In 
accordance with the CDC case definition of CFS, a physician should 
make a diagnosis of CFS ``only after alternative medical and 
psychiatric causes of chronic fatiguing illness have been 
excluded.'' \13\
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    \13\ See Fukuda, K. et al. The Chronic Fatigue Syndrome: A 
Comprehensive Approach to a Definition and Study, Annals of Internal 
Medicine, Dec. 121(12), 953-9596 (1994).
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    A. General. Under the CDC case definition, the hallmark of CFS 
is the presence of clinically evaluated, persistent or relapsing 
chronic fatigue that:
    1. Is of new or definite onset (that is, has not been lifelong);
    2. Cannot be explained by another physical or mental disorder;
    3. Is not the result of ongoing exertion;
    4. Is not substantially alleviated by rest; and
    5. Results in substantial reduction in previous levels of 
occupational, educational, social, or personal activities.
    B. Additional indications of CFS. CFS results in additional 
symptoms, some more common than others.
    1. Diagnostic Symptoms. The CDC case definition requires the 
concurrence of 4 or more specific symptoms that persisted or 
recurred during 6 or more consecutive months of illness and did not 
pre-date the fatigue:
     Postexertional malaise lasting more than 24 hours 
(which may be the most common secondary symptom);
     Self-reported impairment(s) in short-term memory or 
concentration severe enough to cause substantial reduction in 
previous

[[Page 18752]]

levels of occupational, educational, social, or personal activities; 
\14\
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    \14\ We may consider self-reported impairments in short-term 
memory or concentration to be symptoms of CFS. As we explain in 
section IIE, when these impairments are documented by mental status 
examination or psychological testing, we may also consider them to 
be medical signs or laboratory findings.
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     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; and
     Waking unrefreshed.\15\
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    \15\ ``Waking unrefreshed'' may be shown in the case record by a 
person's reports that describe 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.
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    2. Other Symptoms. Within these parameters, the CDC case 
definition, CCC, and ICC describe a wide range of other symptoms a 
person with CFS may exhibit: \16\
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    \16\ In addition, generalized pain and neurological symptoms 
(for example, headaches, cognitive impairments, sleep disturbance, 
and dyslexia evident when fatigued) may be common in children and 
adolescents. Episodes of intense postexertional weakness may occur, 
eventually causing a previously active child to reduce or avoid 
physical activity.
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     Muscle weakness;
     Disturbed sleep patterns (for example, insomnia, 
prolonged sleeping, frequent awakenings, or vivid dreams or 
nightmares);
     Visual difficulties (for example, trouble focusing, 
impaired depth perception, severe photosensitivity, or eye pain);
     Orthostatic intolerance (for example, lightheadedness, 
fainting, dizziness, or increased fatigue with prolonged standing);
     Respiratory difficulties (for example, labored 
breathing or sudden breathlessness);
     Cardiovascular abnormalities (for example, palpitations 
with or without cardiac arrhythmias);
     Gastrointestinal discomfort (for example, nausea, 
bloating, or abdominal pain); and
     Urinary or bladder problems (for example, urinary 
frequency, nocturia, dysuria, or pain in the bladder region).
    3. Co-occurring Conditions. People with CFS may have co-
occurring conditions, such as fibromyalgia (FM),\17\ myofascial pain 
syndrome, temporomandibular joint syndrome, irritable bowel 
syndrome, interstitial cystitis,\18\ Raynaud's phenomenon, 
migraines, chronic lymphocytic thyroiditis, or Sjogren's syndrome. 
Co-occurring conditions may also include new allergies or 
sensitivities to foods, odors, chemicals, medications, noise, 
vibrations, or touch, or the loss of thermostatic stability (for 
example, chills, night sweats, or intolerance of extreme 
temperatures).
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    \17\ See SSR 12-2p: Titles II and XVI: Evaluation of 
Fibromyalgia, 77 FR 43640(2012)(also available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR2012-02-di-01.html).
    \18\ See SSR 02-2p: Titles II and XVI: Evaluation of 
Interstitial Cystitis, 67 FR 67436 (2002) (also available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR2002-02-di-01.html).
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II. How does a person establish an MDI of CFS?

A. General.

    1. A person can establish that he or she has an MDI of CFS by 
providing appropriate evidence from an acceptable medical 
source.\19\ 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 CFS; determine whether the person's symptoms have 
improved, worsened, or remained stable; and establish the 
physician's assessment of the person's physical strength and 
functional abilities.
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    \19\ See 20 CFR 404.1513(a) and 416.913(a).
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    2. We will find that a person has an MDI of CFS if a licensed 
physician diagnosed CFS, and this diagnosis is not inconsistent with 
the other evidence in the person's case record. Under the CDC case 
definition, a physician can make the diagnosis of CFS based on a 
person's reported symptoms alone after ruling out other possible 
causes for the person's symptoms.\20\ However, as mentioned, 
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 we may find that a person has an MDI 
of CFS. If we cannot find that the person has an MDI of CFS but 
there is evidence of another MDI, we will not evaluate the 
impairment under this SSR. Instead, we will evaluate it under the 
rules that apply for that impairment.
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    \20\ Some examples of other disorders that may have symptoms 
that are the same or similar to those resulting from CFS include 
Addison's disease, Cushing's syndrome, hypothyroidism, iron 
deficiency, B12 deficiency, iron overload syndrome, diabetes 
mellitus, cancer, upper airway resistance syndrome, sleep apnea, 
rheumatologic disorders, multiple sclerosis, Parkinsonism, 
myasthenia gravis, Lyme disease, and chronic hepatitis.
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    B. Medical signs. For the 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 help 
establish the existence of an MDI of 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; \21\ 
or
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    \21\ There is considerable overlap of symptoms between CFS and 
FM, but people with CFS who also have tender points have an MDI. 
People with impairments that fulfill the American College of 
Rheumatology criteria for FM (which includes a minimum number of 
tender points) may also fulfill the criteria for CFS. See SSR 12-2p. 
However, we may still find that a person with CFS has an MDI if he 
or she does not have the specified number of tender points to 
establish FM.
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     Any other medical signs that are consistent with 
medically accepted clinical practice and are consistent with the 
other evidence in the case record. For example, the CCC and ICC 
explain that an acute infectious inflammatory event may precede the 
onset of CFS, and that other medical signs may be present, including 
the following:
    [cir] Frequent viral infections with prolonged recovery;
    [cir] Sinusitis;
    [cir] Ataxia;
    [cir] Extreme pallor; and
    [cir] Pronounced weight change.
    C. Laboratory findings. At this time, we cannot identify 
specific laboratory findings that are widely accepted as being 
associated with CFS. However, the absence of a definitive test does 
not preclude our reliance upon certain laboratory findings to 
establish the existence of an MDI in people with CFS. While standard 
laboratory test results in the normal range are characteristic for 
many people with CFS, and they should not be relied upon to the 
exclusion of all other clinical evidence in decisions regarding the 
presence and severity of an MDI, the following laboratory findings 
establish the existence of an MDI in people 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; or
     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).
    D. Additional signs and laboratory findings. Because of the 
ongoing research into the etiology and manifestations of CFS, the 
medical criteria discussed above are only examples of physical and 
mental signs and laboratory findings that can help us establish the 
existence of an MDI; they are not all-inclusive. As medical research 
advances regarding CFS, we may discover additional signs and 
laboratory findings to establish that people have an MDI of CFS. For 
example, scientific studies now suggest there may be subsets of CFS 
with different causes, including viruses such as Human Herpesvirus 
6. Thus, we may document the existence of CFS with medical signs and 
laboratory findings other than those listed above provided such 
evidence is consistent with medically accepted clinical practice, 
and is consistent with the other evidence in the case record.
    E. Mental limitations. Some people with CFS report ongoing 
problems with short-term memory, information processing, visual-
spatial difficulties, comprehension, concentration, speech, word-
finding, calculation, and other symptoms suggesting persistent 
neurocognitive impairment. When ongoing deficits in these areas have 
been documented by mental status examination or

[[Page 18753]]

psychological testing, such findings may constitute medical signs or 
(in the case of psychological testing) laboratory findings that 
establish the presence of an MDI.\22\ When medical signs or 
laboratory findings suggest a persistent neurological impairment or 
other mental problems, and these signs or findings are appropriately 
documented in the medical record, we may find that the person has an 
MDI.
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    \22\ See 20 CFR 404.1528 and 416.928.
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III. How do we document CFS?

    A. General. In cases in which CFS is alleged, we generally need 
longitudinal evidence because medical signs, symptoms, and 
laboratory findings of CFS fluctuate in frequency and severity and 
often continue over a period of many months or years.
    1. Longitudinal clinical records reflecting ongoing medical 
evaluation and treatment from the person's medical sources, 
especially treating sources, are extremely helpful in documenting 
the presence of any medical signs or laboratory findings, as well as 
the person's functional status over time. The longitudinal record 
should contain detailed medical observations, information about 
treatment, the person's response to treatment, and a detailed 
description of how the impairment limits the person's ability to 
function.
    2. 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 CFS or 
any of the person's other impairments. Under our regulations and SSR 
06-03p, we also may consider evidence from medical sources we do not 
consider ``acceptable medical sources'' to help us evaluate the 
severity and functional effects of the impairment(s).\23\
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    \23\ See 20 CFR 404.1513(d)(4), 416.913(d)(4); and SSR 06-03p: 
Titles II and XVI: Considering Opinions and Other Evidence from 
Sources Who Are Not ``Acceptable Medical Sources'' in Disability 
Claims, 71 FR 45593 (2006) (also available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03-di-01.html).
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    3. We may also consider information from nonmedical sources.\24\ 
This information may also help us assess the person's ability to 
function day-to-day and over time. It may also assist us in 
assessing the person's allegations about symptoms and their effects 
(see section IV below). Examples of nonmedical sources include:
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    \24\ See SSR 06-03p.
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     Spouses, parents, siblings, other relatives, neighbors, 
friends, and clergy;
     Past employers, rehabilitation counselors, and 
teachers; and
     Statements from SSA personnel who interviewed the 
person.
    4. Before we make a determination that you are not disabled, we 
will make every reasonable effort to develop your complete medical 
history and help you get medical reports from your own medical 
sources. Generally, we will request evidence from your medical 
sources for the 12-month period preceding the month of application 
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 application.\25\
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    \25\ See 20 CFR 404.1512(d)(2) and 416.912(d) concerning 
situations in which we would develop an earlier period.
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    5. When the alleged onset of disability secondary to CFS 
occurred less than 12 months before adjudication, we must evaluate 
the medical evidence and project the degree of impairment severity 
that is likely to exist at the end of 12 months.\26\ Information 
about the person's treatment and response to treatment, as well as 
any medical source opinions about the person's prognosis at the end 
of 12 months, helps us decide whether to expect the MDI to be of 
disabling severity for at least 12 consecutive months.
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    \26\ To meet the statutory requirement for ``disability,'' a 
person must have been unable to engage in any substantial gainful 
activity by reason of any medically determinable physical or mental 
impairment which is 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. See 42 U.S.C. 423(d)(1) and 1382c(a)(3)(A). Thus, the 
existence of an impairment(s) for 12 continuous months is not 
controlling; rather, it is the existence of a disabling impairment 
which has lasted or can be expected to last for at least 12 months 
that meets the duration requirement of the Act.
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    B. How do we consider medical opinions about a person's 
impairment? We consider the nature of the treatment relationship 
between the medical source \27\ and the claimant when we evaluate 
the source's medical opinions about a person's impairment(s). If we 
find that a treating source's medical opinion regarding the nature 
and severity of a person's impairment(s) is well-supported by 
medically acceptable clinical and laboratory diagnostic techniques, 
and the opinion is not inconsistent with the other substantial 
evidence in the case record, we will give it controlling weight.\28\ 
If a medical source states that a person is ``disabled'' or ``unable 
to work,'' or provides an opinion on issues such as whether an 
impairment(s) meets or is equivalent in severity to the requirements 
of a listing, a person's residual functional capacity (RFC), or the 
application of vocational factors, we consider these statements to 
be opinions on issues reserved to the Commissioner. We must still 
consider such opinions in adjudicating a disability claim; however, 
we will not give any special significance to such an opinion because 
of its source.\29\
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    \27\ See 20 CFR 404.1502 and 416.902 for the definitions of 
``medical source'' and ``treating source.''
    \28\ See 20 CFR 404.1527(c)(2) and 416.927(c)(2); SSR 96-2p, 
Titles II and XVI: Giving Controlling Weight to Treating Source/
Medical Opinions, 61 FR 34492 (2006) (also available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-02-di-01.html)
    \29\ See SSR 96-5p, Titles II and XVI: Medical Source Opinions 
on Issues Reserved to the Commissioner, 61 FR 34471 (1996) (also 
available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-05-di-01.html).
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    C. Resolving conflicts. Conflicting evidence in the medical 
record is not unusual in cases of CFS due to the complicated 
diagnostic process involved. We may seek clarification of any such 
conflicts in the medical evidence first from the person's treating 
or other medical sources, in accordance with our rules.
    D. What do we do if there is insufficient evidence to determine 
whether the person has an MDI of CFS or is disabled?
    1. When there is insufficient evidence for us to determine 
whether the person has an MDI of CFS or is disabled, we may take one 
or more actions to try to resolve the insufficiency: \30\
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    \30\ See 20 CFR 404.1520b(c) and 416.920b(c).
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     We may recontact the person's treating or other 
source(s) to see if the information we need is available;
     We may request additional existing records;
     We may ask the person or others for more information; 
or
     We may purchase a consultative examination (CE) at our 
expense.\31\
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    \31\ See 20 CFR 404.1520b(c)(3) and 416.920b(c)(3). The type of 
CE we purchase will depend on the nature of the person's symptoms 
and the extent of the evidence already in the case record. We may 
purchase a CE without recontacting a person's treating or other 
source 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).
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    2. When we are unable to resolve an insufficiency in the 
evidence, and we need to determine whether the person has an MDI of 
CFS or is disabled, we may make a determination or decision based on 
the evidence we have.\32\
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    \32\ See 20 CFR 404.1520b(d) and 416.920b(d).
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    IV. How do we evaluate a person's statements about his or her 
symptoms and functional limitations?
    Generally, we follow a two-step process:
    A. First step of the symptom-evaluation process. There must be 
medical signs and findings that show the person has an MDI(s) which 
we could reasonably expect to produce the fatigue or other symptoms 
alleged.\33\ If we find that a person has an MDI that we could 
reasonably expect to produce the alleged symptoms, the first step of 
our two-step process for evaluating symptoms is satisfied.
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    \33\ See 20 CFR 404.1529(b) and 416.929(b).
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    B. Second step of the symptom-evaluation process. After finding 
that the MDI could reasonably be expected to produce the alleged 
symptoms, we evaluate the intensity and persistence of the person's 
symptoms and determine the extent to which they 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. We will make a finding about the credibility of the 
person's statements regarding the effects of his or her symptoms on 
functioning.\34\ When we need additional

[[Page 18754]]

information to assess the credibility of the individual's statements 
about symptoms and their effects, we will make every reasonable 
effort to obtain available information that could shed light on the 
credibility of the person's statements.
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    \34\ See SSR 96-7p: Titles II and XVI: Evaluation of Symptoms in 
Disability Claims: Assessing the Credibility of an Individual's 
Statements, 61 FR 34483 (1996) (also available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-07-di-01.html).
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V. How do we find a person disabled based on an MDI of CFS?

    Once we establish that a person has an MDI of CFS, we will 
consider this MDI in the sequential evaluation process to determine 
whether the person is disabled.\35\ 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.
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    \35\ See 20 CFR 404.1520, 416.920 and 416.924.
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VI. How do we consider CFS in the sequential evaluation process?

    We adjudicate claims involving CFS using the sequential 
evaluation process, just as we do for any impairment. Once we find 
that an MDI(s) exists (see section II), we must establish the 
severity of the impairment(s). We determine the severity of a 
person's impairment(s) based on the totality of medical signs, 
symptoms, and laboratory findings, and the effects of the 
impairment(s), including any related symptoms, on the person's 
ability to function. Additionally, several other disorders 
(including, but not limited to FM, 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 person's symptoms, it may be necessary to pursue 
additional medical or other development. As mentioned, if we cannot 
find that the person has an MDI of CFS but there is evidence of 
another MDI, we will not evaluate the impairment under this SSR. 
Instead, we will evaluate it under the rules that apply for that 
impairment.
    A. Step 1. We consider the person's work activity. If a person 
with CFS is doing substantial gainful activity, we find that he or 
she is not disabled.
    B. Step 2. If we establish that a person has an MDI that meets 
the duration requirement,\36\ and the person alleges fatigue, pain, 
symptoms of neurocognitive problems, or other symptoms consistent 
with CFS, we must consider these symptoms in deciding whether the 
person's impairment is ``severe'' in step 2 of the sequential 
evaluation process, and at any later steps reached in the sequential 
evaluation process. If we find fatigue, pain, neurocognitive 
symptoms, or other symptoms cause a limitation or restriction, and 
they have more than a minimal effect on a person's ability to 
perform basic work activities, we must find that the person has a 
``severe'' impairment.\37\
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    \36\ See 20 CFR 404.1509 and 416.909.
    \37\ 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 (1996) (also 
available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR96-03-di-01.html).
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    C. Step 3. When we find that a person has a severe MDI, we must 
proceed with the sequential evaluation process and next consider 
whether the person's impairment is of the severity contemplated by 
the Listing of Impairments.\38\ CFS is not a listed impairment; 
therefore, we cannot find that a person with CFS alone has an 
impairment that meets the requirements of a listed impairment. 
However, we will compare the specific findings in each case to any 
pertinent listing (for example, listing 14.06B in the listing for 
repeated manifestations of undifferentiated or mixed connective 
tissue disease) to determine whether medical equivalence may 
exist.\39\ Further, in cases in which a person with CFS has 
psychological manifestations related to CFS, we must consider 
whether the person's impairment meets or equals the severity of any 
impairment in the mental disorders listings.\40\
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    \38\ See 20 CFR 404, subpart P, appendix 1.
    \39\ In evaluating title XVI claims for disability benefits for 
people under age 18, we will consider whether the impairment(s) 
functionally equals the listings. See 20 CFR 416.926a.
    \40\ See sections 12.00 and 112.00 of 20 CFR part 404, subpart 
P, appendix 1.
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    D. Steps 4 and 5. For those impairments that do not meet or 
equal the severity of a listing, we must make an assessment of the 
person's RFC. After we make our RFC assessment, our evaluation must 
proceed to the fourth step of the sequential evaluation process, if 
we do not use an expedited process.\41\ If necessary, we then 
proceed to the fifth step of the sequential evaluation process.\42\ 
In assessing RFC, we must consider all of the person's impairment-
related symptoms in deciding how such symptoms may affect functional 
capacities.\43\ The RFC assessment must be based on all the relevant 
evidence in the record.\44\ If we do not use an expedited process, 
we must determine that the person's impairment(s) precludes the 
performance of past relevant work (or if there was no past relevant 
work). If we determine that the person's impairment precludes 
performance of past relevant work, we must make a finding about the 
person's ability to perform other work.\45\ We must apply the usual 
vocational considerations in determining the person's ability to 
perform other work.\46\
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    \41\ See 404.1520(h) and 416.920(h).
    \42\ The fourth and fifth steps of the sequential evaluation 
process are not applicable to claims for benefits under title XVI 
for people under age 18. See 20 CFR 416.924.
    \43\ See 404.1529(d) and 416.929(d), and SSR 96-7p.
    \44\ See 20 CFR 404.1545(a) and 416.945(a).
    \45\ See SSR 96-8p: Titles II and XVI: Assessing Residual 
Functional Capacity in Initial claims, 61 FR 34474 (1996) (also 
available at https://www.ba.ssa.gov/OP_Home/rulings/di/01/SSR96-08-di-01.html.
    \46\ See 20 CFR 404.1560-404.1569a and 416.960-416.969a, and SSR 
11-2p: Titles II and XVI: Documenting and Evaluating Disability in 
Young Adults, 76 FR 56263 (2011) (also available at https://www.ba.ssa.gov/OP_Home/rulings/di/01/SSR2011-02-di-01.html).
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    E. Continuing disability reviews. In those cases in which we 
find that a person is disabled based on CFS, we will schedule an 
appropriate continuing disability review.\47\ For this review, we 
take into account relevant individual case facts, such as the 
combined severity of other chronic or static impairments and the 
person's vocational factors.
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    \47\ See 20 CFR 404.1593, 404.1594, 404.1579, 416.993, 416.994 
and 416.994a.
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    EFFECTIVE DATE: This SSR is effective on April 3, 2014.
    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 
96-2p, Titles II and XVI: Giving Controlling Weight to Treating 
Source Medical Opinions; 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, Titles II 
and XVI: Symptoms, Medically Determinable Physical and Mental 
Impairments, and Exertional and Nonexertional Limitations; SSR 96-
5p, Titles II and XVI: Medical Source Opinions on Issues Reserved to 
the Commissioner; 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 02-2p, Titles II and XVI: Evaluation of Interstitial 
Cystitis; SSR 06-03p, 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; SSR 11-2p, 
Titles II and XVI: Documenting and Evaluating Disability in Young 
Adults; SSR 12-2p, Titles II and XVI: Evaluation of Fibromyalgia; 
and Program Operations Manual System (POMS) DI 22505.001, DI 
22505.003, DI 24505.003, DI 24510.057, DI 24515.012, DI 24515.061-DI 
24515.063, DI 24515.066-DI 24515.067, DI 24515.075, DI 24555.001, DI 
25010.001, and DI 25025.001.

[FR Doc. 2014-07465 Filed 4-2-14; 8:45 am]
BILLING CODE 4191-02-P