Social Security Ruling, SSR 14-3p; Titles II and XVI: Evaluating Endocrine Disorders Other Than Diabetes Mellitus, 31380-31385 [2014-12612]
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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
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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: https://www.ssa.gov/OP_
Home/rulings. POMS are available at: https://
secure.ssa.gov/apps10/poms.nsf/partlist.
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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.
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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.
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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
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(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
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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).
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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
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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).
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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).
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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.
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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.
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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).
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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.
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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:
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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: https://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
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]]>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]
-----------------------------------------------------------------------
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:
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\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).
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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).
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\10\ See 20 CFR 404.1545 and 416.945; and SSR 96-8p and SSR 96-
9p.
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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.
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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.
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\14\ See 20 CFR 416.910.
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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.
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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:
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\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).
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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).
[[Page 31384]]
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: https://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
