Social Security Ruling, SSR 14-3p; Titles II and XVI: Evaluating Endocrine Disorders Other Than Diabetes Mellitus, 31380-31385 [2014-12612]

Download as PDF sroberts on DSK5SPTVN1PROD with NOTICES 31380 Federal Register / Vol. 79, No. 105 / Monday, June 2, 2014 / Notices manner. For example, a child with DM who requires insulin may have difficulty maintaining attention to details and may make mistakes in his or her schoolwork due to an inability to concentrate. Children with DM may have limitations in the domain of Interacting and relating with others because they are self-conscious about checking their blood glucose levels throughout the day, administering insulin, and following a special diet in the presence of their peers. They may find it difficult to maintain social contacts or participate in sport activities because they believe their peers may not understand their DM care requirements and will bully or tease them because of their requirements. If DM or its treatment causes fatigue or weakness that limits a child’s fine or gross motor functioning, we evaluate those effects in the domain of Moving about and manipulating objects. For example, a young child who experiences weakness and trembling as a consequence of hypoglycemia, or nausea due to hyperglycemia, may have difficulty with coordination, climbing up and down stairs, and running. Other children who have DM may have difficulty meeting their emotional and physical wants and needs in ways that are age-appropriate and in comparison to other same-age children who do not have impairments. For example, a child who refuses to use insulin as needed because of embarrassment about injecting it in the presence of peers may have limitations in the domain of Caring for yourself because this action would endanger his or her health. The ongoing effects of DM and its treatment may affect a child’s health and physical well-being. For example, we evaluate the effects of hypoglycemia or DKA in the domain of Health and physical well-being. Managing DM in young children, particularly, requires intensive care from an adult to maintain the child’s health and physical wellbeing. We evaluate such medical fragility in this domain. It is important to remember that the cumulative physical effects of DM and its treatment can vary in kind and intensity, affecting each child differently. The effects of DM may differ from child to child. We evaluate the effects of a child’s DM, alone or in combination with another impairment(s), including the effects of medication or other treatment, in all relevant domains. When considering the functioning of a child with DM, we use the ‘‘whole child’’ approach to evaluate the particular effects of DM on a child’s VerDate Mar<15>2010 18:59 May 30, 2014 Jkt 232001 activities in any and all of the domains that the child uses to do those activities, based on the evidence in the case record. We find a child disabled if the effects of his or her DM, alone or in combination with another impairment(s), result in ‘‘marked’’ limitations in two domains of functioning or an ‘‘extreme’’ limitation in one domain of functioning. Effective Date: This SSR is effective on June 2, 2014. Cross-References: SSR 96–3p: Titles II and XVI: Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe; SSR 96–8p: 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– 1p: Titles II and XVI: Evaluation of Obesity; SSR 09–1p: Title XVI: Determining Childhood Disability Under the Functional Equivalence Rule—The ‘‘Whole Child’’ Approach; SSR 09–2p: Title XVI: Determining Childhood Disability—Documenting a Child’s Impairment-Related Limitations; SSR 09–3p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Acquiring and Using Information’’; SSR 09–4p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Attending and Completing Tasks’’; SSR 09–5p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Interacting and Relating with Others’’; SSR 09–6p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Moving About and Manipulating Objects’’; SSR 09–7p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Caring for Yourself’’; SSR 09–8p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Health and Physical Well-Being’’; and Program Operations Manual System (POMS) DI 22001.001–DI 22001.035, DI 22505.001, DI 22505.003, DI 24510.005, DI 24510.006, DI 24515.061–DI 24515.063, DI 24570.001, DI 25005.001, DI 25010.001, DI 25015.001, DI 25025.001, DI 25201.005, DI 25220.010, DI PO 00000 25225.001–DI 25225.065, DI 25505.025, and DI 25505.030.24 [FR Doc. 2014–12601 Filed 5–30–14; 8:45 am] BILLING CODE 4191–02–P SOCIAL SECURITY ADMINISTRATION [Docket No. SSA–2013–0048] Social Security Ruling, SSR 14–3p; Titles II and XVI: Evaluating Endocrine Disorders Other Than Diabetes Mellitus Social Security Administration. Notice of Social Security Ruling AGENCY: ACTION: (SSR). SUMMARY: We are giving notice of SSR 14–3p. This SSR provides information about specific endocrine disorders other than diabetes mellitus (DM), and explains the types of impairments and limitations that result from those disorders. It also provides guidance on how we evaluate endocrine disorders in disability claims under titles II and XVI of the Social Security Act. DATES: Effective Date: June 2, 2014. FOR FURTHER INFORMATION CONTACT: Cheryl A. Williams, Office of Medical Policy, 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 under 20 CFR 402.35(b)(1). SSRs make available 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 of our components. 20 CFR 402.35(b)(1). This SSR will be in effect until we publish a notice in the Federal Register that rescinds it, or until we 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.) 24 SSRs are available at: http://www.ssa.gov/OP_ Home/rulings. POMS are available at: https:// secure.ssa.gov/apps10/poms.nsf/partlist. Frm 00098 Fmt 4703 Sfmt 4703 E:\FR\FM\02JNN1.SGM 02JNN1 Federal Register / Vol. 79, No. 105 / Monday, June 2, 2014 / Notices Dated: May 22, 2014. Carolyn W. Colvin, Acting Commissioner of Social Security. We are publishing this SSR to provide the policy guidance we said we would provide in the preamble of the final rules. Policy Interpretation Ruling Titles II and XVI: Evaluating Endocrine Disorders Other Than Diabetes Mellitus Purpose: This SSR provides information about endocrine disorders other than diabetes mellitus (DM), and explains the types of impairments and limitations that result from those disorders. It also provides guidance on how we evaluate endocrine disorders in disability claims under titles II and XVI of the Social Security Act (Act).1 We provide information about the types of impairments and limitations that result from DM, and provide guidance on how we evaluate DM in disability claims under titles II and XVI of the Act in SSR 14–2p. Citations (Authority): Sections 216(i), 223(d), 223(f), 1614(a)(3), and 1614(a)(4) of the Social Security Act, as amended; Regulations No. 4, subpart P, sections 404.1505, 404.1508, 404.1509, 404.1512–404.1513, 404.1520– 404.1520a, 404.1521, 404.1522, 404.1523, 404.1525–404.1530, 404.1545, 404.1546, 404.1560–404.1569a, appendix 1, and appendix 2; and Regulations No. 16, subpart I, sections 416.905, 416.906, 416.908, 416.909, 416.912–416.913, 416.920, 416.920a, 416.921, 416.922, 416.923, 416.924, 416.924a, 416.924b, 416.925, 416.926, 416.926a, 416.927, 416.928, 416.930, 416.945, 416.946, 416.960–416.969a, 416.987, and 416.994–416.994a. sroberts on DSK5SPTVN1PROD with NOTICES Introduction On April 8, 2011, we published final rules in the Federal Register in which we removed the listings for evaluating endocrine disorders in adults and in children from the Listing of Impairments (listings) because they no longer accurately identified people who are disabled.2 3 When we published the final rules, we stated in the preamble that we would provide more detailed information about specific endocrine disorders, the types of impairments and limitations that result from these disorders, and how we evaluate endocrine disorders in disability claims. 1 For simplicity, we refer in this SSR only to initial claims for benefits. However, 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 76 FR 19692 (2011). The final rules were effective on June 7, 2011. 3 The listings are in 20 CFR Part 404, Subpart P, Appendix 1. VerDate Mar<15>2010 18:59 May 30, 2014 Jkt 232001 Policy Interpretation I. Endocrine Disorders Other Than DM A. General Endocrine glands produce hormones responsible for controlling various physiological functions such as metabolism, blood glucose levels, digestion, electrolyte balance, water balance, and sexual function. The major glands in the endocrine system are pituitary, thyroid, parathyroid, adrenal, pancreas, and gonads (testes and ovaries). The glands release hormones into the bloodstream where they travel to targeted organs. When an endocrine gland produces either too much of a hormone (hyperfunction) or too little of a hormone (hypofunction), the hormonal imbalance can cause an endocrine disorder, resulting in complications affecting various parts of the body. Although many endocrine disorders usually require lifelong treatment, medical advances in the diagnosis and treatment of endocrine disorders have resulted in better management of these disorders in adults and children. B. Types of Endocrine Disorders Other Than DM and Their Treatments 1. Pituitary gland disorders. The pituitary gland, sometimes called the ‘‘master gland’’ of the endocrine system, controls the functions of all other endocrine glands (except for the pancreas). a. Hyperpituitarism primarily refers to excess production of growth hormone (GH). Excess GH, which is less common in children, causes an overgrowth of the tissues in the body that are still capable of growing. During childhood, increased production of GH can result in skeletal gigantism. Symptoms and signs of gigantism include bones of excessive length, abnormal bone and body proportions, and delayed epiphyseal fusion. Adults may develop acromegaly, due to increased production of GH. Symptoms and signs of acromegaly include: Enlarged bones of the face, jaw, hands and feet; joint pain or swelling; and vision abnormalities. Treatment includes medications that suppress GH production, radiation therapy, and surgery. b. Hypopituitarism. Decreased blood levels of GH cause delays in bone and physical growth in children. However, low GH levels are not clinically significant in adults. Deficient production of antidiuretic hormone PO 00000 Frm 00099 Fmt 4703 Sfmt 4703 31381 (ADH) may result in diabetes insipidus with excessive urination producing dehydration and electrolyte imbalance. Generally, GH deficiency is treated with growth hormone replacement (hGH) in children and adolescents. Treatment with ADH replacement medications and hydration generally will successfully control the symptoms and signs of diabetes insipidus within 12 months. 2. Thyroid gland disorders. The thyroid gland regulates growth and development, body temperature, metabolic processes, heart rate, blood pressure, and mental function. a. Hyperthyroidism. Excess production of thyroid hormone may abnormally increase the body’s metabolic rate. Symptoms and signs of hyperthyroidism include altered mood, tremors, heart palpitations, hypertension, weight loss, exophthalmos (bulging of the eyes), and goiter (abnormal enlargement of thyroid gland). The most common type of hyperthyroidism is Graves disease, which involves increased secretion of thyroid hormone. Treatment includes lifelong thyroid-suppression medication, radioactive iodine therapy, or surgical removal of the thyroid. Generally, treatment controls the symptoms and signs of hyperthyroidism within 12 months. b. Hypothyroidism. Low production of thyroid hormone may result in an abnormally slow metabolic rate. Some symptoms and signs of hypothyroidism include weakness or fatigue, dry or coarse skin, slow or depressed speech, and adverse mental changes. Adequate amounts of thyroid hormone are critical for the developing brain and nervous system in newborns and infants. The most common cause of hypothyroidism is Hashimoto thyroiditis, in which the body’s immune system mistakenly attacks the thyroid gland. Treatment with thyroid replacement therapy will generally control the symptoms and signs of hypothyroidism within a few months. 3. Parathyroid gland disorders. The four parathyroid glands produce parathyroid hormone or parathormone (PTH), which regulates calcium and phosphorus levels in bone, blood, nerves, muscle, and other body tissues. a. Hyperparathyroidism. Excess PTH production may cause mildly elevated blood calcium levels (hypercalcemia), which do not always require treatment. Symptoms and signs of hyperparathyroidism include constipation, nausea, vomiting, fatigue, and kidney stones. Hyperparathyroidism may also cause significant depletion of bone calcium, resulting in osteoporosis. Treatment E:\FR\FM\02JNN1.SGM 02JNN1 sroberts on DSK5SPTVN1PROD with NOTICES 31382 Federal Register / Vol. 79, No. 105 / Monday, June 2, 2014 / Notices includes surgical removal of the gland(s), which usually resolves the problem. b. Hypoparathyroidism. Low production of PTH may cause abnormally low levels of blood calcium and increased levels of blood phosphorus. Symptoms and signs include muscle cramps, tetany (muscle spasms), excessive nervousness, and headaches. Treatment includes lifelong calcium, vitamin D oral supplements, and a diet high in calcium and low in phosphorus. Treatment generally controls this condition. 4. Adrenal gland disorders. The adrenal glands produce several types of hormones that regulate carbohydrate, protein, and fat metabolism; proper functioning of the immune system; and the body’s ability to respond to stress. a. Hyperadrenalism. Excess cortisol (for example, Cushing syndrome) or other adrenal hormone adversely affects metabolism and cellular functions, together with cardiovascular and musculoskeletal functions. Excess cortisol is characterized by dysmorphic body changes (for example, centripetal obesity), increased facial and body hair in women, and the reduced ability to fight infections. Treatment of adrenal hormone overproduction may include oral medication, surgery, radiation, or a combination of treatments. Treatment generally controls this condition. b. Hypoadrenalism (Addison disease or adrenal insufficiency) is characterized by generalized weakness and fatigue, darkening of skin (hyperpigmentation), muscle wasting, loss of appetite, low blood pressure, electrolyte imbalance, and depression. Treatment requires lifelong supplementation of cortisol and other replacement hormones and medications. Treatment generally controls this condition within 12 months. 5. Pancreatic disorders. The pancreas produces digestive enzymes and insulin. Digestive enzymes help break down food for the absorption of nutrients by the body.4 Insulin is essential to the absorption of glucose from the bloodstream into body cells for conversion into cellular energy. Diabetes mellitus (DM) results from the metabolic changes that occur when blood glucose cannot be transferred into the cells. We describe DM and explain how we evaluate it in SSR 14–2p. 6. Gonadal disorders. The term ‘‘gonads’’ refers to the testes in males and the ovaries in females. Congenital 4 When the pancreas fails to produce enough digestive enzymes (exocrine function), we evaluate any resulting malabsorption of nutrients under the digestive system listings (5.00 and 105.00). VerDate Mar<15>2010 18:59 May 30, 2014 Jkt 232001 gonadal dysfunction (also referred to as primary hypogonadism) is frequently associated with chromosomal disorders or other genetic syndromes. Treatment involves lifelong hormone replacement therapy, which usually controls this condition. II. The Sequential Evaluation Process for Adults We follow a five-step sequential evaluation process when we make a determination or decision whether an adult is disabled due to an endocrine disorder.5 A. Work Activity We determine at step 1 whether an adult with an endocrine disorder is working and, if so, whether the work activity is substantial gainful activity (SGA).6 If an adult is engaging in SGA, we will find that he or she is not disabled. If an adult is not engaging in SGA, we go on to step 2 of the sequential evaluation process. B. Severe Medically Determinable Impairment(s) We determine at step 2 whether an adult has a medically determinable impairment (MDI) that is severe. An MDI must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by a statement of symptoms. When we evaluate the severity of an endocrine disorder, we consider any symptoms, such as fatigue or pain, that could limit functioning.7 If the effects of an endocrine disorder, alone or in combination with another impairment(s), significantly limit an adult’s physical or mental ability to do basic work activities, we find that the impairment(s) is severe. We find, however, that the impairment(s) is ‘‘not severe’’ if it has no more than a minimal effect on the adult’s ability to do basic work activities. If an adult does not have an MDI that is severe, we will find that he or she is not disabled. If an adult does have a severe impairment(s), we go on to step 3 of the sequential evaluation process. C. Evaluating the Effects of Endocrine Disorders under Other Body Systems We next determine at step 3 whether the impairment(s) meets or medically equals a listing, which also considers the medical severity of your impairment(s). Endocrine disorders are not listed impairments for adults. However, the effects of an endocrine 5 See 20 CFR 404.1520(a) and 416.920(a). 20 CFR 404.1510 and 416.910. 7 See 20 CFR 404.1529 and 416.929; and SSR 96– 3p. 6 See PO 00000 Frm 00100 Fmt 4703 Sfmt 4703 disorder, either alone or in combination with another impairment(s), may meet or medically equal the criteria of a listing in an affected body system(s).8 9 Below are some examples of the effects of specific endocrine disorders and the body systems under which we evaluate them: • Effects of hyperpituitarism: Compromised use of the upper or lower extremities due to complications of boney structures, under the musculoskeletal system listings (1.00). • Effects of hypopituitarism: ADH deficiency that is untreated or unresponsive to treatment resulting in heart failure or arrhythmia, under the cardiovascular system listings (4.00). • Effects of hyperthyroidism: Irregular heartbeat (arrhythmia) or other cardiac dysfunction, under the cardiovascular system listings (4.00); weight loss, under the digestive system listings (5.00); strokes, under the neurological listings (11.00); and mood or anxiety disorders, under the mental disorders listings (12.00). • Effects of hyperparathyroidism: Fractures related to osteoporosis, under the musculoskeletal system listings (1.00); PTH-induced hypercalcemia that leads to cataracts, under the special senses and speech listings (2.00); kidney stones, kidney dysfunction, and bone demineralization (osteodystrophy), under the genitourinary impairments listings (6.00); and mood disorders (such as depression) and anxiety disorders, under the mental disorders listings (12.00). • Effects of hypoparathyroidism: Cardiac anomalies associated with congenital absence of the parathyroid glands, under the cardiovascular system listings (4.00); muscle spasms (tetany) or convulsions, under the neurological listings (11.00); immune deficiency disorders associated with congenital absence of the parathyroid glands, under the immune system disorders listings (14.00). • Effects of hyperadrenalism: Fractures, under the musculoskeletal system listings (1.00); and elevated blood pressure and cardiovascular disease, under the cardiovascular system listings (4.00). • Effects of hypoadrenalism: Compromised use of the upper or lower extremities, due to generalized muscle weakness and joint pain, under the musculoskeletal system listings (1.00); weight loss, under the digestive system listings (5.00); and mood disorders 8 See 20 CFR 404.1509, 404.1525, 404.1526, 416.909, 416.925, and 416.926. 9 We evaluate endocrine cancers under the malignant neoplastic diseases listings (13.00). E:\FR\FM\02JNN1.SGM 02JNN1 Federal Register / Vol. 79, No. 105 / Monday, June 2, 2014 / Notices including depression, under the mental disorders listings (12.00). • Effects of gonadal disorders: Congenital heart disease associated with female hypogonadism, under the cardiovascular system listings (4.00); and learning problems and emotional changes associated with male hypogonadism (for example, Klinefelter syndrome) and female hypogonadism (for example, Turner syndrome), under the mental disorders listings (12.00). sroberts on DSK5SPTVN1PROD with NOTICES D. Assessing Residual Functional Capacity 1. When the effects of an endocrine disorder(s), alone or in combination with another impairment(s), are severe but do not meet or medically equal the criteria of a listing, we assess an adult’s residual functional capacity (RFC).10 RFC is the most an adult can do despite his or her limitation(s). 2. The combined effects of an endocrine disorder and another impairment(s) can be greater than the effects of each of the impairments considered separately. We consider all work-related physical and mental limitations, whether due to an adult’s endocrine disorder, other impairment(s), or combination of impairments. For example, some endocrine disorders, such as skeletal gigantism, may cause pain and difficulty walking effectively, due to complications with bone growth. Other endocrine disorders, such as hypothyroidism, may cause severe fatigue because of a hormonal imbalance, limiting an adult’s ability to perform work activities on a sustained basis. Limitations in an adult’s functioning associated with an endocrine disorder or a combination of impairments may also result from the effects of treatment, such as hormone replacement medications, or complications that persist despite treatment. 3. We then proceed to step 4 and, if necessary, step 5 of the sequential evaluation process. We use the RFC assessment at step 4 to evaluate whether an adult is capable of performing any past relevant work (PRW) as he or she actually performed it or as the job is generally performed in the national economy. If an adult’s RFC precludes the performance of PRW (or if there was no PRW), we use the RFC assessment to make a finding at step 5 about his or her ability to perform other work that exists in significant numbers in the national 10 See 20 CFR 404.1545 and 416.945; and SSR 96– 8p and SSR 96–9p. VerDate Mar<15>2010 18:59 May 30, 2014 Jkt 232001 economy. The usual vocational considerations apply.11 III. The Sequential Evaluation Process for Children We follow a three-step sequential evaluation process when we make a determination or decision whether a child is disabled due to an endocrine disorder.12 13 A. Work Activity We determine at step 1 whether a child is working and, if so, whether the work activity is SGA.14 If a child is engaging in SGA, we find that he or she is not disabled. If a child is not engaging in SGA, we go on to step 2 of the sequential evaluation process. B. Severe Medically Determinable Impairment(s) We determine at step 2 whether a child has an MDI that is severe. An MDI must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by a statement of symptoms.15 When we evaluate severity, we consider the effects of the endocrine disorder on the child’s functioning, including: Limitations as a result of treatment; and the kinds and extent of help, support, and supervision the child needs compared to that of children the same age who do not have impairments.16 If the child’s endocrine disorder, alone or in combination with another impairment(s), causes more than minimal functional limitations, we find that the impairment(s) is severe. We find that the impairment(s) is ‘‘not severe’’ if it causes no more than minimal functional limitations. If a child does not have an MDI that is severe, we find that he or she is not disabled. If a child does have a severe impairment(s), we go on to step 3 of the sequential evaluation process. C. Meets or Medically Equals a Listing, or Functionally Equals the Listings 1. Evaluating the effects of endocrine disorders under other body systems. Endocrine disorders (except DM for children who have not attained age 6 and who require daily insulin) are not 11 See 20 CFR 404.1560–404.1569a and 416.960– 416.969a. 12 The process described in this section applies to determinations and decisions made for children under title XVI. See 20 CFR 416.924. 13 Under title II, we use the adult definition of disability to make disability determinations or decisions for people under age 18. 14 See 20 CFR 416.910. 15 See 20 CFR 416.908 and 416.924(c). 16 In 20 CFR 416.924a(b), we provide guidance on factors that are relevant whenever we evaluate a child’s functioning. PO 00000 Frm 00101 Fmt 4703 Sfmt 4703 31383 listed impairments for children of any age. However, endocrine disorders may be of listing-level severity because of their effects in other body systems. We determine whether the effects of an endocrine disorder, alone or in combination with another impairment(s), meet or medically equal the criteria of a listing in an affected body system(s).17 18 Below are some examples of the effects of specific endocrine disorders and the body systems under which we evaluate them: • Effects of hyperpituitarism: Compromised use of the upper or lower extremities due to complications of boney structures, under the musculoskeletal system listings (101.00); and mental status changes due to a child’s physical appearance, under the mental disorders listings (112.00). • Effects of hypopituitarism: Delayed long bone growth that does not respond to GH replacement treatment, under the musculoskeletal system listings (101.00); and ADH deficiency that is untreated or unresponsive to treatment resulting in heart failure or arrhythmia, under the cardiovascular system listings (104.00). • Effects of hyperthyroidism: Irregular heartbeat (arrhythmia) or other cardiac dysfunction, under the cardiovascular system listings (104.00); weight loss, under the digestive system listings (105.00); strokes, under the neurological listings (111.00); and mood or anxiety disorders, under the mental disorders listings (112.00). • Effects of hypothyroidism: Growth failure with delayed physical development (children may gain weight yet still have a slowed growth rate) resulting from undiagnosed or inadequately treated hypothyroidism, under the growth impairment listings (100.00); and intellectual disability or other cognitive disorders resulting from inadequately treated hypothyroidism, under the mental disorders listings (112.00). • Effects of hyperparathyroidism: Fractures related to osteoporosis, under the musculoskeletal system listings (101.00); PTH-induced hypercalcemia that leads to cataracts, under the special senses and speech listings (102.00); kidney stones, kidney dysfunction, and bone demineralization (osteodystrophy), under the genitourinary impairments listings (106.00); and mood disorders, such as depression and anxiety disorders, under the mental disorders listings (112.00). 17 See 20 CFR 416.909, 416.924(a), 416.925, and 416.926. 18 We evaluate endocrine cancers under the malignant neoplastic diseases listings (113.00). E:\FR\FM\02JNN1.SGM 02JNN1 sroberts on DSK5SPTVN1PROD with NOTICES 31384 Federal Register / Vol. 79, No. 105 / Monday, June 2, 2014 / Notices • Effects of hypoparathyroidism: Cardiac anomalies associated with congenital absence of the parathyroid glands, under the cardiovascular system listings (104.00); muscle spasms (tetany) or convulsions, under the neurological listings (111.00); and immune deficiency disorders associated with congenital absence of the parathyroid glands, under the immune system disorders listings (114.00). • Effects of hyperadrenalism: Fractures, under the musculoskeletal system listings (101.00); and elevated blood pressure and cardiovascular disease, under the cardiovascular system listings (104.00). • Effects of hypoadrenalism: Compromised use of the upper or lower extremities, due to generalized muscle weakness and joint pain, under the musculoskeletal system listings (101.00); weight loss, under the digestive system listings (105.00); and mood disorders including depression, under the mental disorders listings (112.00). • Effects of gonadal disorders: Congenital heart disease associated with female hypogonadism, under the cardiovascular system listings (104.00); and learning problems and emotional changes associated with male hypogonadism (for example, Klinefelter syndrome) and female hypogonadism (for example, Turner syndrome), under the mental disorders listings (112.00). 2. Evaluating the effects of endocrine disorders under functional equivalence. When the effects of a child’s endocrine disorder, alone or in combination with another impairment(s), are severe but do not meet or medically equal a listing in any affected body system, we determine whether they result in limitations that functionally equal the listings.19 By ‘‘functionally equal the listings,’’ we mean that the child’s impairment(s) must be of listing-level severity. In evaluating the effects of a child’s endocrine disorder, alone or in combination with another impairment(s), on his or her functioning, we consider what the child cannot do, has difficulty doing, needs help doing, or is restricted from doing because of his or her impairment(s). We must explain any limitation in a child’s ability to function age-appropriately on the basis of an MDI(s).20 To functionally equal the listings, an impairment(s) must be of listing-level severity; that is, it must result in ‘‘marked’’ limitations in two domains of functioning or an ‘‘extreme’’ limitation in one domain of functioning. Domains 19 See 20 See 20 CFR 416.926a; SSRs 09–1p and 09–2p. 20 CFR 416.924a(b) and 416.926a. VerDate Mar<15>2010 18:59 May 30, 2014 Jkt 232001 are broad areas of functioning intended to capture all of what a child can or cannot do. When we determine whether a child’s impairment(s) functionally equals the listings, we use the following six domains: • Acquiring and using information; • Attending and completing tasks; • Interacting and relating with others; • Moving about and manipulating objects; • Caring for yourself; and • Health and physical well-being. When we evaluate a child’s functioning in these six domains, we consider how the child functions compared to children the same age who do not have impairments. The first five domains describe the abilities a child uses to develop the skills that he or she uses to function in day-to-day activities. In domain six, we consider the cumulative physical effects of physical and mental impairments and their associated treatments on a child’s health and functioning. This domain does not address typical development and functioning. Rather, it addresses how such things as recurrent illness, the side effects of medication, and the need for ongoing treatment affect a child’s body; that is, the child’s health and physical well-being. An endocrine disorder, alone or in combination with another impairment(s), may affect a child’s functioning in any domain. We evaluate each child’s limitations by considering all relevant information from acceptable medical sources (for example, a pediatrician or psychologist), other medical sources (for example, a physical or occupational therapist), and nonmedical sources such as parents, teachers, and other people who know the child.21 22 We also consider factors such as the: • Kinds and extent of help, support, and supervision a child with an endocrine disorder needs that exceed what a child the same age would typically need; and • Effects of medications and other treatments, including adverse and beneficial effects. Some children with inadequately treated hypothyroidism (or hyperthyroidism), for example, may have limitations in Attending and completing tasks due to their difficulty listening to the teacher, maintaining focus, staying on task in the classroom, or excessive fatigue. Other children with panhypopituitarism after surgery for craniopharyngioma (a benign tumor that 21 See 22 See PO 00000 20 CFR 416.913(a). 20 CFR 416.924a(a). Frm 00102 Fmt 4703 Sfmt 4703 develops near the pituitary gland), for example, may experience partial loss of visual fields in both eyes (hemianopsia) and, therefore, have difficulty Moving about and manipulating objects. Some adolescents with inadequately treated growth hormone deficiency may appear many years younger than their chronological age. These children may have difficulty Interacting and relating with others due to their physical appearance, or may experience difficulty shopping or getting an afterschool job because of being mistakenly perceived as a much younger child. The effects of an endocrine disorder may differ from child to child. We evaluate the effects of a child’s endocrine disorder, alone or in combination with another impairment(s), including the effects of medication or other treatment, in all relevant domains. When considering the functioning of a child with an endocrine disorder, we use the ‘‘whole child’’ approach to evaluate the particular effects of the endocrine disorder on a child’s activities in any and all of the domains that the child uses to do those activities, based on the evidence in the case record. We find a child disabled if the effects of his or her endocrine disorder, alone or in combination with another impairment(s), result in ‘‘marked’’ limitations in two domains of functioning or an ‘‘extreme’’ limitation in one domain of functioning. Effective Date: This SSR is effective on June 2, 2014. Cross-References: SSR 96–3p: Titles II and XVI: Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe; SSR 96–8p: 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– 1p: Titles II and XVI: Evaluation of Obesity; SSR 09–1p: Title XVI: Determining Childhood Disability Under the Functional Equivalence Rule—The ‘‘Whole Child’’ Approach; SSR 09–2p: Title XVI: Determining Childhood Disability—Documenting a Child’s Impairment-Related Limitations; SSR 09–3p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Acquiring and Using Information’’; SSR 09–4p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Attending and Completing Tasks’’; SSR 09–5p: Title XVI: E:\FR\FM\02JNN1.SGM 02JNN1 Federal Register / Vol. 79, No. 105 / Monday, June 2, 2014 / Notices Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Interacting and Relating With Others’’; SSR 09–6p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Moving About and Manipulating Objects’’; SSR 09–7p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Caring for Yourself’’; SSR 09–8p: Title XVI: Determining Childhood Disability—The Functional Equivalence Domain of ‘‘Health and Physical Well-Being’’; and Program Operations Manual System (POMS) DI 22001.001–DI 22001.035, DI 22505.001, DI 22505.003, DI 24510.005, DI 24510.006, DI 24515.061–DI 24515.063, DI 24570.001, DI 25005.001, DI 25010.001, DI 25015.001, DI 25025.001, DI 25201.005, DI 25220.010, DI 25225.001–DI 25225.065, DI 25505.025, and DI 25505.030.23 [FR Doc. 2014–12612 Filed 5–30–14; 8:45 am] BILLING CODE 4191–02–P DEPARTMENT OF STATE [Public Notice 8750] 30-Day Notice of Proposed Information Collection: Nonimmigrant Visa Application Notice of request for public comment and submission to OMB of proposed collection of information. sroberts on DSK5SPTVN1PROD with NOTICES ACTION: SUMMARY: The Department of State has submitted the information collection described below to the Office of Management and Budget (OMB) for approval. In accordance with the Paperwork Reduction Act of 1995 we are requesting comments on this collection from all interested individuals and organizations. The purpose of this Notice is to allow 30 days for public comment. DATES: Submit comments directly to the Office of Management and Budget (OMB) up to July 2, 2014. ADDRESSES: Direct comments to the Department of State Desk Officer in the Office of Information and Regulatory Affairs at the Office of Management and Budget (OMB). You may submit comments by the following methods: • Email: oira_ submission@omb.eop.gov. You must include the DS form number, information collection title, and the OMB control number in the subject line of your message. 23 SSRs are available at: http://www.ssa.gov/OP_ Home/rulings. POMS are available at: https:// secure.ssa.gov/apps10/poms.nsf/partlist. VerDate Mar<15>2010 18:59 May 30, 2014 Jkt 232001 • Fax: 202–395–5806. Attention: Desk Officer for Department of State. FOR FURTHER INFORMATION CONTACT: Direct requests for additional information regarding the collection listed in this notice, including requests for copies of the proposed collection instrument and supporting documents, to Sydney Taylor, who may be reached at PRA_BurdenComments@state.gov. SUPPLEMENTARY INFORMATION: • Title of Information Collection: Nonimmigrant Visa Application. • OMB Control Number: 1405–0018. • Type of Request: Revision of Currently Approved Collection. • Originating Office: CA/VO/L/R. • Form Number: DS–156. • Respondents: All Nonimmigrant Visa Applicants. • Estimated Number of Respondents: 1,000. • Estimated Number of Responses: 1,000. • Average Time per Response: 75. minutes • Total Estimated Burden Time: 1,250 hours. • Frequency: Once per respondent. • Obligation to Respond: Required to Obtain or Retain a Benefit. We are soliciting public comments to permit the Department to: • Evaluate whether the proposed information collection is necessary for the proper functions of the Department. • Evaluate the accuracy of our estimate of the time and cost burden for this proposed collection, including the validity of the methodology and assumptions used. • Enhance the quality, utility, and clarity of the information to be collected. • Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of information technology. Please note that comments submitted in response to this Notice are public record. Before including any detailed personal information, you should be aware that your comments as submitted, including your personal information, will be available for public review. Abstract of proposed collection: Form DS–156 is required by regulation of all nonimmigrant visa applicants who do not use the Online Application for Nonimmigrant Visa (Form DS–160). Posts will use the DS–156 to elicit information necessary to determine an applicant’s visa eligibility. Methodology: The DS–156, Nonimmigrant Visa Application is available online at https:// evisaforms.state.gov/ds156.asp. The PO 00000 Frm 00103 Fmt 4703 Sfmt 4703 31385 applicant must fill out the form online and print out the 2–D Barcode. This form will only be used if applicants cannot access the DS–160, Electronic Application for Nonimmigrant Visa. Dated: May 21, 2014. Don Heflin, Acting Deputy Assistant Secretary, Bureau of Consular Affairs, Department of State. [FR Doc. 2014–12699 Filed 5–30–14; 8:45 am] BILLING CODE 4710–06–P DEPARTMENT OF TRANSPORTATION Federal Aviation Administration Notice of Passenger Facility Charge (PFC) Approvals and Disapprovals Federal Aviation Administration (FAA), DOT. ACTION: Monthly Notice of PFC Approvals and Disapprovals. In March 2014, there were five applications approved. This notice also includes information on two applications, one approved in December 2012 and the other approved in August 2013, inadvertently left off the December 2012 and August 2013 notices, respectively. Additionally, 10 approved amendments to previously approved applications are listed. AGENCY: SUMMARY: The FAA publishes a monthly notice, as appropriate, of PFC approvals and disapprovals under the provisions of the Aviation Safety and Capacity Expansion Act of 1990 (Title IX of the Omnibus Budget Reconciliation Act of 1990) (Pub. L. 101–508) and Part 158 of the Federal Aviation Regulations (14 CFR Part 158). This notice is published pursuant to paragraph d of § 158.29. PFC Applications Approved Public Agency: City of Rochester, Minnesota. Kevin Application Number: 13–06–C– 00–RST. Application Type: Impose and use a PFC. PFC Level: $4.50. Total PFC Revenue Approved In This Decision: $1,698,590. Earliest Charge Effective Date: October 1, 2014. Estimated Charge Expiration Date: January 1, 2017. Classes of Air Carriers Not Required To Collect PFC’s: (1) Nonscheduled/on demand air carriers filing FAA Form 1800–31; (2) commuter/small certificated air carriers filing DOT Form T–100; and (3) foreign air carriers filing DOT Form T–100 that do not meet the threshold requirements for passenger boardings. E:\FR\FM\02JNN1.SGM 02JNN1

Agencies

[Federal Register Volume 79, Number 105 (Monday, June 2, 2014)]
[Notices]
[Pages 31380-31385]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-12612]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2013-0048]


Social Security Ruling, SSR 14-3p; Titles II and XVI: Evaluating 
Endocrine Disorders Other Than Diabetes Mellitus

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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

SUMMARY: We are giving notice of SSR 14-3p. This SSR provides 
information about specific endocrine disorders other than diabetes 
mellitus (DM), and explains the types of impairments and limitations 
that result from those disorders. It also provides guidance on how we 
evaluate endocrine disorders in disability claims under titles II and 
XVI of the Social Security Act.

DATES: Effective Date: June 2, 2014.

FOR FURTHER INFORMATION CONTACT: Cheryl A. Williams, Office of Medical 
Policy, 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 under 20 CFR 
402.35(b)(1).
    SSRs make available 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 of our components. 20 CFR 
402.35(b)(1).
    This SSR will be in effect until we publish a notice in the Federal 
Register that rescinds it, or until we 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.)


[[Page 31381]]


    Dated: May 22, 2014.
Carolyn W. Colvin,
Acting Commissioner of Social Security.

Policy Interpretation Ruling

Titles II and XVI: Evaluating Endocrine Disorders Other Than Diabetes 
Mellitus

    Purpose: This SSR provides information about endocrine disorders 
other than diabetes mellitus (DM), and explains the types of 
impairments and limitations that result from those disorders. It also 
provides guidance on how we evaluate endocrine disorders in disability 
claims under titles II and XVI of the Social Security Act (Act).\1\ We 
provide information about the types of impairments and limitations that 
result from DM, and provide guidance on how we evaluate DM in 
disability claims under titles II and XVI of the Act in SSR 14-2p.
---------------------------------------------------------------------------

    \1\ For simplicity, we refer in this SSR only to initial claims 
for benefits. However, 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 (Authority): Sections 216(i), 223(d), 223(f), 1614(a)(3), 
and 1614(a)(4) of the Social Security Act, as amended; Regulations No. 
4, subpart P, sections 404.1505, 404.1508, 404.1509, 404.1512-404.1513, 
404.1520-404.1520a, 404.1521, 404.1522, 404.1523, 404.1525-404.1530, 
404.1545, 404.1546, 404.1560-404.1569a, appendix 1, and appendix 2; and 
Regulations No. 16, subpart I, sections 416.905, 416.906, 416.908, 
416.909, 416.912-416.913, 416.920, 416.920a, 416.921, 416.922, 416.923, 
416.924, 416.924a, 416.924b, 416.925, 416.926, 416.926a, 416.927, 
416.928, 416.930, 416.945, 416.946, 416.960-416.969a, 416.987, and 
416.994-416.994a.

Introduction

    On April 8, 2011, we published final rules in the Federal Register 
in which we removed the listings for evaluating endocrine disorders in 
adults and in children from the Listing of Impairments (listings) 
because they no longer accurately identified people who are 
disabled.2 3 When we published the final rules, we stated in 
the preamble that we would provide more detailed information about 
specific endocrine disorders, the types of impairments and limitations 
that result from these disorders, and how we evaluate endocrine 
disorders in disability claims. We are publishing this SSR to provide 
the policy guidance we said we would provide in the preamble of the 
final rules.
---------------------------------------------------------------------------

    \2\ 76 FR 19692 (2011). The final rules were effective on June 
7, 2011.
    \3\ The listings are in 20 CFR Part 404, Subpart P, Appendix 1.
---------------------------------------------------------------------------

Policy Interpretation

I. Endocrine Disorders Other Than DM

A. General

    Endocrine glands produce hormones responsible for controlling 
various physiological functions such as metabolism, blood glucose 
levels, digestion, electrolyte balance, water balance, and sexual 
function. The major glands in the endocrine system are pituitary, 
thyroid, parathyroid, adrenal, pancreas, and gonads (testes and 
ovaries). The glands release hormones into the bloodstream where they 
travel to targeted organs. When an endocrine gland produces either too 
much of a hormone (hyperfunction) or too little of a hormone 
(hypofunction), the hormonal imbalance can cause an endocrine disorder, 
resulting in complications affecting various parts of the body. 
Although many endocrine disorders usually require lifelong treatment, 
medical advances in the diagnosis and treatment of endocrine disorders 
have resulted in better management of these disorders in adults and 
children.

B. Types of Endocrine Disorders Other Than DM and Their Treatments

    1. Pituitary gland disorders. The pituitary gland, sometimes called 
the ``master gland'' of the endocrine system, controls the functions of 
all other endocrine glands (except for the pancreas).
    a. Hyperpituitarism primarily refers to excess production of growth 
hormone (GH). Excess GH, which is less common in children, causes an 
overgrowth of the tissues in the body that are still capable of 
growing. During childhood, increased production of GH can result in 
skeletal gigantism. Symptoms and signs of gigantism include bones of 
excessive length, abnormal bone and body proportions, and delayed 
epiphyseal fusion. Adults may develop acromegaly, due to increased 
production of GH. Symptoms and signs of acromegaly include: Enlarged 
bones of the face, jaw, hands and feet; joint pain or swelling; and 
vision abnormalities. Treatment includes medications that suppress GH 
production, radiation therapy, and surgery.
    b. Hypopituitarism. Decreased blood levels of GH cause delays in 
bone and physical growth in children. However, low GH levels are not 
clinically significant in adults. Deficient production of antidiuretic 
hormone (ADH) may result in diabetes insipidus with excessive urination 
producing dehydration and electrolyte imbalance. Generally, GH 
deficiency is treated with growth hormone replacement (hGH) in children 
and adolescents. Treatment with ADH replacement medications and 
hydration generally will successfully control the symptoms and signs of 
diabetes insipidus within 12 months.
    2. Thyroid gland disorders. The thyroid gland regulates growth and 
development, body temperature, metabolic processes, heart rate, blood 
pressure, and mental function.
    a. Hyperthyroidism. Excess production of thyroid hormone may 
abnormally increase the body's metabolic rate. Symptoms and signs of 
hyperthyroidism include altered mood, tremors, heart palpitations, 
hypertension, weight loss, exophthalmos (bulging of the eyes), and 
goiter (abnormal enlargement of thyroid gland). The most common type of 
hyperthyroidism is Graves disease, which involves increased secretion 
of thyroid hormone. Treatment includes lifelong thyroid-suppression 
medication, radioactive iodine therapy, or surgical removal of the 
thyroid. Generally, treatment controls the symptoms and signs of 
hyperthyroidism within 12 months.
    b. Hypothyroidism. Low production of thyroid hormone may result in 
an abnormally slow metabolic rate. Some symptoms and signs of 
hypothyroidism include weakness or fatigue, dry or coarse skin, slow or 
depressed speech, and adverse mental changes. Adequate amounts of 
thyroid hormone are critical for the developing brain and nervous 
system in newborns and infants. The most common cause of hypothyroidism 
is Hashimoto thyroiditis, in which the body's immune system mistakenly 
attacks the thyroid gland. Treatment with thyroid replacement therapy 
will generally control the symptoms and signs of hypothyroidism within 
a few months.
    3. Parathyroid gland disorders. The four parathyroid glands produce 
parathyroid hormone or parathormone (PTH), which regulates calcium and 
phosphorus levels in bone, blood, nerves, muscle, and other body 
tissues.
    a. Hyperparathyroidism. Excess PTH production may cause mildly 
elevated blood calcium levels (hypercalcemia), which do not always 
require treatment. Symptoms and signs of hyperparathyroidism include 
constipation, nausea, vomiting, fatigue, and kidney stones. 
Hyperparathyroidism may also cause significant depletion of bone 
calcium, resulting in osteoporosis. Treatment

[[Page 31382]]

includes surgical removal of the gland(s), which usually resolves the 
problem.
    b. Hypoparathyroidism. Low production of PTH may cause abnormally 
low levels of blood calcium and increased levels of blood phosphorus. 
Symptoms and signs include muscle cramps, tetany (muscle spasms), 
excessive nervousness, and headaches. Treatment includes lifelong 
calcium, vitamin D oral supplements, and a diet high in calcium and low 
in phosphorus. Treatment generally controls this condition.
    4. Adrenal gland disorders. The adrenal glands produce several 
types of hormones that regulate carbohydrate, protein, and fat 
metabolism; proper functioning of the immune system; and the body's 
ability to respond to stress.
    a. Hyperadrenalism. Excess cortisol (for example, Cushing syndrome) 
or other adrenal hormone adversely affects metabolism and cellular 
functions, together with cardiovascular and musculoskeletal functions. 
Excess cortisol is characterized by dysmorphic body changes (for 
example, centripetal obesity), increased facial and body hair in women, 
and the reduced ability to fight infections. Treatment of adrenal 
hormone overproduction may include oral medication, surgery, radiation, 
or a combination of treatments. Treatment generally controls this 
condition.
    b. Hypoadrenalism (Addison disease or adrenal insufficiency) is 
characterized by generalized weakness and fatigue, darkening of skin 
(hyperpigmentation), muscle wasting, loss of appetite, low blood 
pressure, electrolyte imbalance, and depression. Treatment requires 
lifelong supplementation of cortisol and other replacement hormones and 
medications. Treatment generally controls this condition within 12 
months.
    5. Pancreatic disorders. The pancreas produces digestive enzymes 
and insulin. Digestive enzymes help break down food for the absorption 
of nutrients by the body.\4\ Insulin is essential to the absorption of 
glucose from the bloodstream into body cells for conversion into 
cellular energy. Diabetes mellitus (DM) results from the metabolic 
changes that occur when blood glucose cannot be transferred into the 
cells. We describe DM and explain how we evaluate it in SSR 14-2p.
---------------------------------------------------------------------------

    \4\ When the pancreas fails to produce enough digestive enzymes 
(exocrine function), we evaluate any resulting malabsorption of 
nutrients under the digestive system listings (5.00 and 105.00).
---------------------------------------------------------------------------

    6. Gonadal disorders. The term ``gonads'' refers to the testes in 
males and the ovaries in females. Congenital gonadal dysfunction (also 
referred to as primary hypogonadism) is frequently associated with 
chromosomal disorders or other genetic syndromes. Treatment involves 
lifelong hormone replacement therapy, which usually controls this 
condition.

II. The Sequential Evaluation Process for Adults

    We follow a five-step sequential evaluation process when we make a 
determination or decision whether an adult is disabled due to an 
endocrine disorder.\5\
---------------------------------------------------------------------------

    \5\ See 20 CFR 404.1520(a) and 416.920(a).
---------------------------------------------------------------------------

A. Work Activity

    We determine at step 1 whether an adult with an endocrine disorder 
is working and, if so, whether the work activity is substantial gainful 
activity (SGA).\6\ If an adult is engaging in SGA, we will find that he 
or she is not disabled. If an adult is not engaging in SGA, we go on to 
step 2 of the sequential evaluation process.
---------------------------------------------------------------------------

    \6\ See 20 CFR 404.1510 and 416.910.
---------------------------------------------------------------------------

B. Severe Medically Determinable Impairment(s)

    We determine at step 2 whether an adult has a medically 
determinable impairment (MDI) that is severe. An MDI must be 
established by medical evidence consisting of signs, symptoms, and 
laboratory findings, not only by a statement of symptoms. When we 
evaluate the severity of an endocrine disorder, we consider any 
symptoms, such as fatigue or pain, that could limit functioning.\7\ If 
the effects of an endocrine disorder, alone or in combination with 
another impairment(s), significantly limit an adult's physical or 
mental ability to do basic work activities, we find that the 
impairment(s) is severe. We find, however, that the impairment(s) is 
``not severe'' if it has no more than a minimal effect on the adult's 
ability to do basic work activities. If an adult does not have an MDI 
that is severe, we will find that he or she is not disabled. If an 
adult does have a severe impairment(s), we go on to step 3 of the 
sequential evaluation process.
---------------------------------------------------------------------------

    \7\ See 20 CFR 404.1529 and 416.929; and SSR 96-3p.
---------------------------------------------------------------------------

C. Evaluating the Effects of Endocrine Disorders under Other Body 
Systems

    We next determine at step 3 whether the impairment(s) meets or 
medically equals a listing, which also considers the medical severity 
of your impairment(s). Endocrine disorders are not listed impairments 
for adults. However, the effects of an endocrine disorder, either alone 
or in combination with another impairment(s), may meet or medically 
equal the criteria of a listing in an affected body 
system(s).8 9 Below are some examples of the effects of 
specific endocrine disorders and the body systems under which we 
evaluate them:
---------------------------------------------------------------------------

    \8\ See 20 CFR 404.1509, 404.1525, 404.1526, 416.909, 416.925, 
and 416.926.
    \9\ We evaluate endocrine cancers under the malignant neoplastic 
diseases listings (13.00).
---------------------------------------------------------------------------

     Effects of hyperpituitarism: Compromised use of the upper 
or lower extremities due to complications of boney structures, under 
the musculoskeletal system listings (1.00).
     Effects of hypopituitarism: ADH deficiency that is 
untreated or unresponsive to treatment resulting in heart failure or 
arrhythmia, under the cardiovascular system listings (4.00).
     Effects of hyperthyroidism: Irregular heartbeat 
(arrhythmia) or other cardiac dysfunction, under the cardiovascular 
system listings (4.00); weight loss, under the digestive system 
listings (5.00); strokes, under the neurological listings (11.00); and 
mood or anxiety disorders, under the mental disorders listings (12.00).
     Effects of hyperparathyroidism: Fractures related to 
osteoporosis, under the musculoskeletal system listings (1.00); PTH-
induced hypercalcemia that leads to cataracts, under the special senses 
and speech listings (2.00); kidney stones, kidney dysfunction, and bone 
demineralization (osteodystrophy), under the genitourinary impairments 
listings (6.00); and mood disorders (such as depression) and anxiety 
disorders, under the mental disorders listings (12.00).
     Effects of hypoparathyroidism: Cardiac anomalies 
associated with congenital absence of the parathyroid glands, under the 
cardiovascular system listings (4.00); muscle spasms (tetany) or 
convulsions, under the neurological listings (11.00); immune deficiency 
disorders associated with congenital absence of the parathyroid glands, 
under the immune system disorders listings (14.00).
     Effects of hyperadrenalism: Fractures, under the 
musculoskeletal system listings (1.00); and elevated blood pressure and 
cardiovascular disease, under the cardiovascular system listings 
(4.00).
     Effects of hypoadrenalism: Compromised use of the upper or 
lower extremities, due to generalized muscle weakness and joint pain, 
under the musculoskeletal system listings (1.00); weight loss, under 
the digestive system listings (5.00); and mood disorders

[[Page 31383]]

including depression, under the mental disorders listings (12.00).
     Effects of gonadal disorders: Congenital heart disease 
associated with female hypogonadism, under the cardiovascular system 
listings (4.00); and learning problems and emotional changes associated 
with male hypogonadism (for example, Klinefelter syndrome) and female 
hypogonadism (for example, Turner syndrome), under the mental disorders 
listings (12.00).

D. Assessing Residual Functional Capacity

    1. When the effects of an endocrine disorder(s), alone or in 
combination with another impairment(s), are severe but do not meet or 
medically equal the criteria of a listing, we assess an adult's 
residual functional capacity (RFC).\10\ RFC is the most an adult can do 
despite his or her limitation(s).
---------------------------------------------------------------------------

    \10\ See 20 CFR 404.1545 and 416.945; and SSR 96-8p and SSR 96-
9p.
---------------------------------------------------------------------------

    2. The combined effects of an endocrine disorder and another 
impairment(s) can be greater than the effects of each of the 
impairments considered separately. We consider all work-related 
physical and mental limitations, whether due to an adult's endocrine 
disorder, other impairment(s), or combination of impairments. For 
example, some endocrine disorders, such as skeletal gigantism, may 
cause pain and difficulty walking effectively, due to complications 
with bone growth. Other endocrine disorders, such as hypothyroidism, 
may cause severe fatigue because of a hormonal imbalance, limiting an 
adult's ability to perform work activities on a sustained basis. 
Limitations in an adult's functioning associated with an endocrine 
disorder or a combination of impairments may also result from the 
effects of treatment, such as hormone replacement medications, or 
complications that persist despite treatment.
    3. We then proceed to step 4 and, if necessary, step 5 of the 
sequential evaluation process. We use the RFC assessment at step 4 to 
evaluate whether an adult is capable of performing any past relevant 
work (PRW) as he or she actually performed it or as the job is 
generally performed in the national economy. If an adult's RFC 
precludes the performance of PRW (or if there was no PRW), we use the 
RFC assessment to make a finding at step 5 about his or her ability to 
perform other work that exists in significant numbers in the national 
economy. The usual vocational considerations apply.\11\
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    \11\ See 20 CFR 404.1560-404.1569a and 416.960-416.969a.
---------------------------------------------------------------------------

III. The Sequential Evaluation Process for Children

    We follow a three-step sequential evaluation process when we make a 
determination or decision whether a child is disabled due to an 
endocrine disorder.12 13
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    \12\ The process described in this section applies to 
determinations and decisions made for children under title XVI. See 
20 CFR 416.924.
    \13\ Under title II, we use the adult definition of disability 
to make disability determinations or decisions for people under age 
18.
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A. Work Activity

    We determine at step 1 whether a child is working and, if so, 
whether the work activity is SGA.\14\ If a child is engaging in SGA, we 
find that he or she is not disabled. If a child is not engaging in SGA, 
we go on to step 2 of the sequential evaluation process.
---------------------------------------------------------------------------

    \14\ See 20 CFR 416.910.
---------------------------------------------------------------------------

B. Severe Medically Determinable Impairment(s)

    We determine at step 2 whether a child has an MDI that is severe. 
An MDI must be established by medical evidence consisting of signs, 
symptoms, and laboratory findings, not only by a statement of 
symptoms.\15\ When we evaluate severity, we consider the effects of the 
endocrine disorder on the child's functioning, including: Limitations 
as a result of treatment; and the kinds and extent of help, support, 
and supervision the child needs compared to that of children the same 
age who do not have impairments.\16\ If the child's endocrine disorder, 
alone or in combination with another impairment(s), causes more than 
minimal functional limitations, we find that the impairment(s) is 
severe. We find that the impairment(s) is ``not severe'' if it causes 
no more than minimal functional limitations. If a child does not have 
an MDI that is severe, we find that he or she is not disabled. If a 
child does have a severe impairment(s), we go on to step 3 of the 
sequential evaluation process.
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    \15\ See 20 CFR 416.908 and 416.924(c).
    \16\ In 20 CFR 416.924a(b), we provide guidance on factors that 
are relevant whenever we evaluate a child's functioning.
---------------------------------------------------------------------------

C. Meets or Medically Equals a Listing, or Functionally Equals the 
Listings

    1. Evaluating the effects of endocrine disorders under other body 
systems. Endocrine disorders (except DM for children who have not 
attained age 6 and who require daily insulin) are not listed 
impairments for children of any age. However, endocrine disorders may 
be of listing-level severity because of their effects in other body 
systems. We determine whether the effects of an endocrine disorder, 
alone or in combination with another impairment(s), meet or medically 
equal the criteria of a listing in an affected body 
system(s).17 18 Below are some examples of the effects of 
specific endocrine disorders and the body systems under which we 
evaluate them:
---------------------------------------------------------------------------

    \17\ See 20 CFR 416.909, 416.924(a), 416.925, and 416.926.
    \18\ We evaluate endocrine cancers under the malignant 
neoplastic diseases listings (113.00).
---------------------------------------------------------------------------

     Effects of hyperpituitarism: Compromised use of the upper 
or lower extremities due to complications of boney structures, under 
the musculoskeletal system listings (101.00); and mental status changes 
due to a child's physical appearance, under the mental disorders 
listings (112.00).
     Effects of hypopituitarism: Delayed long bone growth that 
does not respond to GH replacement treatment, under the musculoskeletal 
system listings (101.00); and ADH deficiency that is untreated or 
unresponsive to treatment resulting in heart failure or arrhythmia, 
under the cardiovascular system listings (104.00).
     Effects of hyperthyroidism: Irregular heartbeat 
(arrhythmia) or other cardiac dysfunction, under the cardiovascular 
system listings (104.00); weight loss, under the digestive system 
listings (105.00); strokes, under the neurological listings (111.00); 
and mood or anxiety disorders, under the mental disorders listings 
(112.00).
     Effects of hypothyroidism: Growth failure with delayed 
physical development (children may gain weight yet still have a slowed 
growth rate) resulting from undiagnosed or inadequately treated 
hypothyroidism, under the growth impairment listings (100.00); and 
intellectual disability or other cognitive disorders resulting from 
inadequately treated hypothyroidism, under the mental disorders 
listings (112.00).
     Effects of hyperparathyroidism: Fractures related to 
osteoporosis, under the musculoskeletal system listings (101.00); PTH-
induced hypercalcemia that leads to cataracts, under the special senses 
and speech listings (102.00); kidney stones, kidney dysfunction, and 
bone demineralization (osteodystrophy), under the genitourinary 
impairments listings (106.00); and mood disorders, such as depression 
and anxiety disorders, under the mental disorders listings (112.00).

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     Effects of hypoparathyroidism: Cardiac anomalies 
associated with congenital absence of the parathyroid glands, under the 
cardiovascular system listings (104.00); muscle spasms (tetany) or 
convulsions, under the neurological listings (111.00); and immune 
deficiency disorders associated with congenital absence of the 
parathyroid glands, under the immune system disorders listings 
(114.00).
     Effects of hyperadrenalism: Fractures, under the 
musculoskeletal system listings (101.00); and elevated blood pressure 
and cardiovascular disease, under the cardiovascular system listings 
(104.00).
     Effects of hypoadrenalism: Compromised use of the upper or 
lower extremities, due to generalized muscle weakness and joint pain, 
under the musculoskeletal system listings (101.00); weight loss, under 
the digestive system listings (105.00); and mood disorders including 
depression, under the mental disorders listings (112.00).
     Effects of gonadal disorders: Congenital heart disease 
associated with female hypogonadism, under the cardiovascular system 
listings (104.00); and learning problems and emotional changes 
associated with male hypogonadism (for example, Klinefelter syndrome) 
and female hypogonadism (for example, Turner syndrome), under the 
mental disorders listings (112.00).
    2. Evaluating the effects of endocrine disorders under functional 
equivalence. When the effects of a child's endocrine disorder, alone or 
in combination with another impairment(s), are severe but do not meet 
or medically equal a listing in any affected body system, we determine 
whether they result in limitations that functionally equal the 
listings.\19\ By ``functionally equal the listings,'' we mean that the 
child's impairment(s) must be of listing-level severity. In evaluating 
the effects of a child's endocrine disorder, alone or in combination 
with another impairment(s), on his or her functioning, we consider what 
the child cannot do, has difficulty doing, needs help doing, or is 
restricted from doing because of his or her impairment(s). We must 
explain any limitation in a child's ability to function age-
appropriately on the basis of an MDI(s).\20\
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    \19\ See 20 CFR 416.926a; SSRs 09-1p and 09-2p.
    \20\ See 20 CFR 416.924a(b) and 416.926a.
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    To functionally equal the listings, an impairment(s) must be of 
listing-level severity; that is, it must result in ``marked'' 
limitations in two domains of functioning or an ``extreme'' limitation 
in one domain of functioning. Domains are broad areas of functioning 
intended to capture all of what a child can or cannot do.
    When we determine whether a child's impairment(s) functionally 
equals the listings, we use the following six domains:
     Acquiring and using information;
     Attending and completing tasks;
     Interacting and relating with others;
     Moving about and manipulating objects;
     Caring for yourself; and
     Health and physical well-being.
    When we evaluate a child's functioning in these six domains, we 
consider how the child functions compared to children the same age who 
do not have impairments. The first five domains describe the abilities 
a child uses to develop the skills that he or she uses to function in 
day-to-day activities. In domain six, we consider the cumulative 
physical effects of physical and mental impairments and their 
associated treatments on a child's health and functioning. This domain 
does not address typical development and functioning. Rather, it 
addresses how such things as recurrent illness, the side effects of 
medication, and the need for ongoing treatment affect a child's body; 
that is, the child's health and physical well-being.
    An endocrine disorder, alone or in combination with another 
impairment(s), may affect a child's functioning in any domain. We 
evaluate each child's limitations by considering all relevant 
information from acceptable medical sources (for example, a 
pediatrician or psychologist), other medical sources (for example, a 
physical or occupational therapist), and non-medical sources such as 
parents, teachers, and other people who know the child.21 22 
We also consider factors such as the:
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    \21\ See 20 CFR 416.913(a).
    \22\ See 20 CFR 416.924a(a).
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     Kinds and extent of help, support, and supervision a child 
with an endocrine disorder needs that exceed what a child the same age 
would typically need; and
     Effects of medications and other treatments, including 
adverse and beneficial effects.
    Some children with inadequately treated hypothyroidism (or 
hyperthyroidism), for example, may have limitations in Attending and 
completing tasks due to their difficulty listening to the teacher, 
maintaining focus, staying on task in the classroom, or excessive 
fatigue. Other children with panhypopituitarism after surgery for 
craniopharyngioma (a benign tumor that develops near the pituitary 
gland), for example, may experience partial loss of visual fields in 
both eyes (hemianopsia) and, therefore, have difficulty Moving about 
and manipulating objects.
    Some adolescents with inadequately treated growth hormone 
deficiency may appear many years younger than their chronological age. 
These children may have difficulty Interacting and relating with others 
due to their physical appearance, or may experience difficulty shopping 
or getting an afterschool job because of being mistakenly perceived as 
a much younger child.
    The effects of an endocrine disorder may differ from child to 
child. We evaluate the effects of a child's endocrine disorder, alone 
or in combination with another impairment(s), including the effects of 
medication or other treatment, in all relevant domains. When 
considering the functioning of a child with an endocrine disorder, we 
use the ``whole child'' approach to evaluate the particular effects of 
the endocrine disorder on a child's activities in any and all of the 
domains that the child uses to do those activities, based on the 
evidence in the case record.
    We find a child disabled if the effects of his or her endocrine 
disorder, alone or in combination with another impairment(s), result in 
``marked'' limitations in two domains of functioning or an ``extreme'' 
limitation in one domain of functioning.
    Effective Date: This SSR is effective on June 2, 2014.
    Cross-References: SSR 96-3p: Titles II and XVI: Considering 
Allegations of Pain and Other Symptoms in Determining Whether a 
Medically Determinable Impairment is Severe; SSR 96-8p: 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 02-1p: Titles II and XVI: Evaluation of 
Obesity; SSR 09-1p: Title XVI: Determining Childhood Disability Under 
the Functional Equivalence Rule--The ``Whole Child'' Approach; SSR 09-
2p: Title XVI: Determining Childhood Disability--Documenting a Child's 
Impairment-Related Limitations; SSR 09-3p: Title XVI: Determining 
Childhood Disability--The Functional Equivalence Domain of ``Acquiring 
and Using Information''; SSR 09-4p: Title XVI: Determining Childhood 
Disability--The Functional Equivalence Domain of ``Attending and 
Completing Tasks''; SSR 09-5p: Title XVI:

[[Page 31385]]

Determining Childhood Disability--The Functional Equivalence Domain of 
``Interacting and Relating With Others''; SSR 09-6p: Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Moving About and Manipulating Objects''; SSR 09-7p: Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Caring for Yourself''; SSR 09-8p: Title XVI: Determining Childhood 
Disability--The Functional Equivalence Domain of ``Health and Physical 
Well-Being''; and Program Operations Manual System (POMS) DI 22001.001-
DI 22001.035, DI 22505.001, DI 22505.003, DI 24510.005, DI 24510.006, 
DI 24515.061-DI 24515.063, DI 24570.001, DI 25005.001, DI 25010.001, DI 
25015.001, DI 25025.001, DI 25201.005, DI 25220.010, DI 25225.001-DI 
25225.065, DI 25505.025, and DI 25505.030.\23\
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    \23\ SSRs are available at: http://www.ssa.gov/OP_Home/rulings. 
POMS are available at: https://secure.ssa.gov/apps10/poms.nsf/partlist.

[FR Doc. 2014-12612 Filed 5-30-14; 8:45 am]
BILLING CODE 4191-02-P