Revised Medical Criteria for Evaluating Genitourinary Disorders, 61221-61226 [2014-24114]
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Federal Register / Vol. 79, No. 197 / Friday, October 10, 2014 / Rules and Regulations
We do not have information at this
point on the quantity of bananas that the
Philippines expects to ship to the State
of Hawaii or to the U.S. territories, or
the quantity and origin of bananas
already imported into these
destinations. However, Hawaii as well
as the U.S. territories, already import
bananas from other places since the
volume of banana consumption is
greater than their production. In general,
the quantity of U.S. imports from the
Philippines is expected to be relatively
insignificant, equivalent to about 0.05
percent of U.S. imports from other
countries. What percent would go to
Hawaii depends on the demand from
the consumers in the State of Hawaii
and in the other U.S. territories.
Consumers in Hawaii and the U.S.
territories would benefit from the
additional source of fresh bananas,
which are of similar quality as the
domestic ones.
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Executive Order 12988
This final rule allows bananas to be
imported into Guam, Hawaii, and the
Northern Mariana Islands from the
Philippines. State and local laws and
regulations regarding bananas imported
under this rule will be preempted while
the fruit is in foreign commerce. Fresh
fruits are generally imported for
immediate distribution and sale to the
consuming public, and remain in
foreign commerce until sold to the
ultimate consumer. The question of
when foreign commerce ceases in other
cases must be addressed on a case-bycase basis. No retroactive effect will be
given to this rule, and this rule will not
require administrative proceedings
before parties may file suit in court
challenging this rule.
National Environmental Policy Act
An environmental assessment (EA)
and finding of no significant impact
were prepared in 2012 for a final rule
for importation of bananas from the
Philippines into the continental United
States. The EA provided a basis for the
conclusion that the importation of
bananas from the Philippines into the
continental United States, under the
conditions specified in that rule, would
not have a significant impact on the
quality of the human environment.
APHIS reviewed the proposal to import
bananas from the Philippines into
Guam, Hawaii, and the Northern
Mariana Islands under the conditions
specified in this rule, and determined
that this will not have a significant
impact on the quality of the human
environment. APHIS prepared an
amended finding of no significant
impact, and the Administrator of the
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Animal and Plant Health Inspection
Service has determined that an
environmental impact statement need
not be prepared.
The 2012 EA and amended finding of
no significant impact were prepared in
accordance with: (1) The National
Environmental Policy Act of 1969
(NEPA), as amended (42 U.S.C. 4321 et
seq.); (2) regulations of the Council on
Environmental Quality for
implementing the procedural provisions
of NEPA (40 CFR parts 1500–1508); (3)
USDA regulations implementing NEPA
(7 CFR part 1b); and (4) APHIS’ NEPA
Implementing Procedures (7 CFR part
372).
The EA and amended finding of no
significant impact may be viewed on the
Regulations.gov Web site (see footnote
1). Copies of the EA and amended
finding of no significant impact are also
available for public inspection at USDA,
room 1141, South Building, 14th Street
and Independence Avenue SW.,
Washington, DC, between 8 a.m. and
4:30 p.m., Monday through Friday,
except holidays. Persons wishing to
inspect copies are requested to call
ahead on (202) 799–7039 to facilitate
entry into the reading room. In addition,
copies may be obtained by writing to the
individual listed under FOR FURTHER
INFORMATION CONTACT.
61221
recordkeeping requirements, Rice,
Vegetables.
Accordingly, we are amending 7 CFR
part 319 as follows:
PART 319—FOREIGN QUARANTINE
NOTICES
1. The authority citation for part 319
continues to read as follows:
■
Authority: 7 U.S.C. 450, 7701–7772, and
7781–7786; 21 U.S.C. 136 and 136a; 7 CFR
2.22, 2.80, and 371.3.
2. Section 319.56–58 is amended as
follows:
■ a. The introductory text is revised;
■ b. In paragraph (c), the date ‘‘February
9, 2015’’ is removed and the date
‘‘November 10, 2016’’ is added in its
place;
■ c. In paragraph (h)(2), in the second
sentence, the words ‘‘introductory text
of this section’’ are removed and the
words ‘‘operational workplan required
by paragraph (a)(1) of this section’’ are
added in their place; and
■ d. In the OMB citation at the end of
the section, the words ‘‘number 0579–
0394’’ are removed and the words
‘‘numbers 0579–0394 and 0579–0415’’
are added in their place.
The revision reads as follows:
■
§ 319.56–58
Bananas from the Philippines.
Paperwork Reduction Act
In accordance with section 3507(d) of
the Paperwork Reduction Act of 1995
(44 U.S.C. 3501 et seq.), the information
collection or recordkeeping
requirements included in this final rule,
which were filed under 0579–0415,
have been submitted for approval to the
Office of Management and Budget
(OMB). When OMB notifies us of its
decision, if approval is denied, we will
publish a document in the Federal
Register providing notice of what action
we plan to take.
Bananas (Musa spp., which include
M. acuminate cultivars and M.
acuminate x M. balbisiana hybrids) may
be imported into the continental United
States, Guam, Hawaii, and the Northern
Mariana Islands from the Philippines
only under the conditions described in
this section.
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E-Government Act Compliance
The Animal and Plant Health
Inspection Service is committed to
compliance with the E-Government Act
to promote the use of the Internet and
other information technologies, to
provide increased opportunities for
citizen access to Government
information and services, and for other
purposes. For information pertinent to
E-Government Act compliance related
to this rule, please contact Ms. Kimberly
Hardy, APHIS’ Information Collection
Coordinator, at (301) 851–2727.
[FR Doc. 2014–24246 Filed 10–9–14; 8:45 am]
List of Subjects in 7 CFR Part 319
Coffee, Cotton, Fruits, Imports, Logs,
Nursery stock, Plant diseases and pests,
Quarantine, Reporting and
ACTION:
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Fmt 4700
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Done in Washington, DC, this 6th day of
October 2014.
Kevin Shea,
Administrator, Animal and Plant Health
Inspection Service.
BILLING CODE 3410–34–P
SOCIAL SECURITY ADMINISTRATION
20 CFR Part 404
[Docket No. SSA–2009–0038]
RIN 0960–AH03
Revised Medical Criteria for Evaluating
Genitourinary Disorders
Social Security Administration.
Final rules.
AGENCY:
These final rules revise the
criteria in the Listing of Impairments
(listings) that we use to evaluate cases
SUMMARY:
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Federal Register / Vol. 79, No. 197 / Friday, October 10, 2014 / Rules and Regulations
involving genitourinary disorders in
adults and children under titles II and
XVI of the Social Security Act (Act). The
revisions reflect our program experience
and address adjudicator questions we
have received since we last
comprehensively revised this body
system in 2005.
DATES: These rules are effective
December 9, 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.
For information on eligibility or filing
for benefits, call our national toll-free
number, 1–800–772–1213, or TTY
1–800–325–0778, or visit our Internet
site, Social Security Online, at https://
www.socialsecurity.gov.
SUPPLEMENTARY INFORMATION:
Background
We are making final the rules for
evaluating genitourinary disorders that
we proposed in a notice of proposed
rulemaking (NPRM) we published in the
Federal Register on February 4, 2013 at
78 FR 7695. The preamble to the NPRM
provides the background for these
revisions. You can view the preamble to
the NPRM by visiting https://
www.regulations.gov and searching for
document ‘‘SSA–2009–0038–0005.’’ We
are making a number of changes in
response to public comments to the
NPRM, which we explain below.
Why are we revising the listings for
evaluating genitourinary disorders?
We are revising the listings for
evaluating genitourinary disorders to
update the medical criteria, clarify how
we evaluate genitourinary disorders,
and address adjudicator questions.
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Public Comments
In the NPRM, we provided the public
with a 60-day comment period, which
ended on April 5, 2013. We received six
comments. The comments came from
members of the public, disability
adjudicators, and a national association
representing disability examiners in the
State agencies that make disability
determinations for us.
We carefully considered all of the
comments. We have tried to summarize
the commenters’ views accurately and
respond to all of the significant issues
raised by the commenters that were
within the scope of these rules. Some
commenters noted provisions with
which they agreed and did not make
suggestions for changes in those
provisions. We did not summarize or
respond to those comments.
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Comment: One commenter asked if
we would require the estimated
glomerular filtration rate (eGFR) to be
adjusted for race and sex. The
commenter also suggested that we
establish an eGFR calculator to calculate
the eGFR for the criterion in proposed
6.05A.
Response: We did not adopt this
comment. The eGFR is a calculated
value based on the measured serum
creatinine. The formulas used by
laboratories to calculate eGFR all
include adjustments for age, race, and
sex. We will use the eGFR value as
calculated by the laboratory and will not
independently calculate eGFR. Thus, we
will not develop a calculator for eGFR.
Comment: Another commenter noted
that the weight loss criterion in
proposed listing 6.05B4 (body mass
index (BMI) of 18.0 or less) is not
consistent with the weight loss criterion
in listing 5.08 (BMI of less than 17.5)
and suggested that we change the
criterion for consistency.
Response: We did not adopt this
comment. We believe it is appropriate to
use a different BMI criterion for listing
6.05B4 than we use in listing 5.08. The
criterion in listing 6.05B4 considers the
severity of a person’s underlying
chronic kidney disease (CKD) and its
effect on his or her nutrition and
metabolic status. People with CKD are
unable to maintain adequate weight due
to decreased dietary protein intake and
decreased dietary energy intake, which
are hallmarks of kidney failure. People
with CKD may have an increased
prevalence of protein energy
malnutrition. Furthermore, listing 5.08
requires a lower BMI because the listing
considers only weight loss due to any
digestive disorder. Listing 5.08 does not
consider the severity of the individual’s
underlying digestive disorder.
In listing 5.08, we require BMI of less
than 17.5 calculated on at least two
evaluations, at least 60 days apart,
within a consecutive 6-month period. In
final listing 6.05B4, we require the same
number of BMI evaluations within a
consecutive 12-month period. We are
using the consecutive 12-month period
to be consistent with the 12-month
duration requirement.1 The 12-month
period is also consistent with the period
we use when we evaluate
hospitalizations due complications of a
genitourinary disorder in 6.09 and
106.09.
Comment: One commenter expressed
concern about proposed listing 6.09,
regarding how to explain ‘‘CKD
complications requiring hospitalizations
versus hospitalizations due to a group of
1 20
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CFR 404.1509 and 416.909.
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co-morbid conditions, including CKD.’’
The same commenter also suggested
that we add guidance in the
introductory text to address acute
worsening of CKD during
hospitalizations for co-occurring
conditions.
Response: We agree with the
comment and provided clarification
regarding CKD complications in final
listings 6.00C8 and 106.00C5.
Comment: A commenter suggested
revisions to proposed listing 106.07
requesting a 24-month period with 3
surgeries for childhood genitourinary
disorders instead of 3 surgeries within
12-month period.
Response: We are not adopting this
comment because using a 12-month
period for evaluating an impairment is
an intrinsic part of our basic definition
of disability.2 We consider the
combinations of impairments and
limitations in functioning at step 3 of
the sequential evaluation process, using
our medical equivalence and functional
equivalence rules.3 We recognize that
some children who have multiple
surgeries for genitourinary impairments
may have limitations in functioning that
last longer. In such cases, we evaluate
those limitations under our medical
equivalence and functional equivalence
rules.
Comment: One commenter stated that
there are undefined and poorly defined
terms in the genitourinary listings. The
commenter said these terms included
‘‘frequent,’’ ‘‘intractable,’’ ‘‘interferes,’’
‘‘anasarca,’’ ‘‘anorexia,’’ and ‘‘severe
bone pain.’’
Response: We partially adopted this
comment. We provide brief definitions
for several medical terms when we first
use the terms in the introductory text of
these final listings. We define anasarca
in 6.00C6 and 106.00C3; anorexia in
6.00C7; and ‘‘severe bone pain’’ and
‘‘intractable’’ in 6.00C3. We have not
provided definitions for the terms
‘‘frequent’’ and ‘‘interferes.’’ We use
these two terms in our definition of
‘‘severe bone pain’’ and use them in
their common English usage.
Comment: A commenter stated that
there are no listings for combinations of
impairments. The commenter stated that
the NPRM includes only single
genitourinary disorders and leaves out
many important combinations of
disorders. Examples that the commenter
provided included severe CKD not
requiring dialysis and coronary artery
disease; peripheral neuropathy and
2 See 42 U.S.C. 423(d)(1)(a) and (d)(2)(a), and
1382c(a)(3)(A) and 20 CFR 404.1505, 404.1509,
416.905, 416.906, and 416.909.
3 See 20 CFR 416.926 and 416.926a(a).
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generalized edema; and fluid overload
and coronary artery disease. The
commenter also noted ‘‘a complete lack
of listings that consider obesity.’’
Response: We did not adopt this
comment. We recognize that
genitourinary disorders may co-occur
with impairments in other body
systems. In some cases, the impairment
in another body system results from a
genitourinary disorder; for example,
peripheral neuropathy resulting from
CKD. In other cases, the impairment in
another body system is not related to the
genitourinary disorder; for example,
peripheral neuropathy resulting from
diabetes mellitus.
We intend the listings to address
genitourinary disorders and the
complications of those disorders. When
the co-occurring condition or
complication is due to a genitourinary
disorder, we evaluate it under final
listing 6.09. However, when the cooccurring impairments are unrelated,
we believe it is more appropriate to
evaluate the combination under our
medical equivalence rule at step 3 of the
sequential evaluation process, or at
steps 4 and 5 of the sequential
evaluation process.4 At these steps,
adjudicators can account for specific
combinations of impairments,
complications of those impairments,
and limitations of functioning on an
individual case basis. We address this in
the introductory text of final listing
6.00C8.
Comment: A commenter noted that
we provide no quantitative data to show
the validity of any of our genitourinary
proposed listings and noted that many
people engage in substantial gainful
activity (SGA) even though they meet
the requirements of a listing. The
commenter believes that this challenges
the validity of using the listings to
determine whether a person is disabled.
Response: We disagree with this
comment. Our NPRM included an
extensive list of medical and other
references that we relied on in
proposing these rules. We also invited
the public to comment on these
references and the data contained
within them.
The listings help to ensure that
determinations or decisions of disability
have a sound medical basis, that
claimants receive equal treatment
throughout the country, and that we can
readily identify the majority of persons
who are disabled. The level of severity
described in the listings is such that an
individual, whom is not engaging in
SGA and has an impairment that meets
or medically equals all of the criteria of
4 See
20 CFR 404.1526 and 416.926.
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the listing, is generally considered
unable to work because of the medical
impairment alone at step three of the
sequential evaluation process. Thus,
when such a person’s impairment or
combination of impairments meets or
medically equals the level of severity
described in the listing for the required
duration, disability will be found on the
basis of the medical facts alone in the
absence of evidence to the contrary, for
example, the actual performance of
SGA.
Comment: A commenter stated that
the proposed criteria discriminate
against the poor because they include
medical tests that people cannot afford
and that we will not purchase, such as
kidney or bone biopsies, imaging
studies, and 24-hour urine protein tests.
The same commenter also stated that
requirements, such as 90 consecutive
days of prescribed therapy, urologic
surgical procedures, and
hospitalization, discriminate against
people who cannot afford treatment,
and suggested that we delete the
requirements ‘‘[u]nless the
Administration is willing to make a
commitment to purchase these.’’
Response: We did not adopt the
commenter’s suggestion. People with
the very serious genitourinary
impairments described in these listings
generally receive the kinds of diagnostic
tests and treatments described in these
final rules because of urgent medical
need. However, we do not penalize
people who do not have the kinds of
medical evidence that we describe in
these listings. Under our rules, we may
purchase medical examinations or tests
to obtain the evidence that we need, but
we will not purchase diagnostic tests
that involve significant risk to the
person, such as kidney or bone
biopsies.5 Furthermore, we provide
several alternatives for people with
genitourinary impairments to establish
that their impairment is of listing-level
severity at step three of the sequential
evaluation process. If the impairment is
not of listing-level severity, we may find
the person disabled at subsequent steps
of the sequential evaluation process
when considering the person’s residual
functional capacity, age, education, and
work experience.
Comment: Two commenters pointed
out stylistic and technical editorial
issues in the preamble and the proposed
rules.
Response: We have made appropriate
corrections in these final rules.
5 See
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61223
Other Changes
In addition to the changes we made in
response to public comments, we
revised 6.00C1 and 106.00C1 to clarify
the documentation requirement for
hemodialysis or peritoneal dialysis.
What is our authority to make rules
and set procedures for determining
whether a person is disabled under the
statutory definition?
The Act authorizes us to make rules
and regulations and to establish
necessary and appropriate procedures to
implement them.6
How long will these final rules be
effective?
These final rules will remain in effect
for 5 years after the date they become
effective, unless we extend them, or
revise and issue them again.
Regulatory Procedures
Executive Order 12866, as
Supplemented by Executive Order
13563
We consulted with the Office of
Management and Budget (OMB) and
determined that these final rules meet
the criteria for a significant regulatory
action under Executive Order 12866, as
supplemented by Executive Order
13563 and was reviewed by OMB.
Regulatory Flexibility Act
We certify that these final rules will
not have a significant economic impact
on a substantial number of small entities
because they affect individuals only.
Therefore, the Regulatory Flexibility
Act, as amended, does not require us to
prepare a regulatory flexibility analysis.
Paperwork Reduction Act
These final rules do not create any
new or affect any existing collections
and, therefore, do not require OMB
approval under the Paperwork
Reduction Act.
(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; and
96.006, Supplemental Security Income)
List of Subjects in 20 CFR Part 404
Administrative practice and
procedure, Blind, Disability benefits,
Old-Age, survivors, and disability
6 42
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U.S.C. 405(a), 902(a)(5), and 1383(d)(1).
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insurance, Reporting and recordkeeping
requirements, Social Security.
Carolyn W. Colvin,
Acting Commissioner of Social Security.
For the reasons set out in the
preamble, we are amending 20 CFR part
404, subpart P as set forth below:
PART 404—FEDERAL OLD–AGE,
SURVIVORS AND DISABILITY
INSURANCE (1950–)
Subpart P—Determining Disability and
Blindness
1. The authority citation for subpart P
of part 404 continues to read as follows:
■
Authority: Secs. 202, 205(a)–(b) and (d)–
(h), 216(i), 221(a), (i), and (j), 222(c), 223,
225, and 702(a)(5) of the Social Security Act
(42 U.S.C. 402, 405(a)–(b) and (d)–(h), 416(i),
421(a), (i), and (j), 422(c), 423, 425, and
902(a)(5)); sec. 211(b), Pub. L. 104–193, 110
Stat. 2105, 2189; sec. 202, Pub. L. 108–203,
118 Stat. 509 (42 U.S.C. 902 note).
2. Amend appendix 1 to subpart P of
part 404 by:
■ a. Revising item 7 of the introductory
text before part A;
■ b. In part A:
■ i. Revising the body system name for
section 6.00 in the table of contents; and
■ ii. Revising section 6.00;
■ c. In part B:
■ i. Revising the body system name for
section 106.00 in the table of contents;
and
■ ii. Revising section 106.00.
The revisions read as follows:
■
Appendix 1 to Subpart P of Part 404—
Listing of Impairments
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7. Genitourinary Disorders (6.00 and
106.00): December 9, 2019.
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Part A
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6.00
Genitourinary Disorders.
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6.00
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GENITOURINARY DISORDERS
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A. Which disorders do we evaluate under
these listings?
We evaluate genitourinary disorders
resulting in chronic kidney disease (CKD).
Examples of such disorders include chronic
glomerulonephritis, hypertensive
nephropathy, diabetic nephropathy, chronic
obstructive uropathy, and hereditary
nephropathies. We also evaluate nephrotic
syndrome due to glomerular dysfunction
under these listings.
B. What evidence do we need?
1. We need evidence that documents the
signs, symptoms, and laboratory findings of
your CKD. This evidence should include
reports of clinical examinations, treatment
records, and documentation of your response
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to treatment. Laboratory findings, such as
serum creatinine or serum albumin levels,
may document your kidney function. We
generally need evidence covering a period of
at least 90 days unless we can make a fully
favorable determination or decision without
it.
2. Estimated glomerular filtration rate
(eGFR). The eGFR is an estimate of the
filtering capacity of the kidneys that takes
into account serum creatinine concentration
and other variables, such as your age, gender,
and body size. If your medical evidence
includes eGFR findings, we will consider
them when we evaluate your CKD under
6.05.
3. Kidney or bone biopsy. If you have had
a kidney or bone biopsy, we need a copy of
the pathology report. When we cannot get a
copy of the pathology report, we will accept
a statement from an acceptable medical
source verifying that a biopsy was performed
and describing the results.
C. What other factors do we consider when
we evaluate your genitourinary disorder?
1. Chronic hemodialysis or peritoneal
dialysis.
a. Dialysis is a treatment for CKD that uses
artificial means to remove toxic metabolic
byproducts from the blood. Hemodialysis
uses an artificial kidney machine to clean
waste products from the blood; peritoneal
dialysis uses a dialyzing solution that is
introduced into and removed from the
abdomen (peritoneal cavity) either
continuously or intermittently. Under 6.03,
your ongoing dialysis must have lasted or be
expected to last for a continuous period of at
least 12 months. To satisfy the requirements
in 6.03, we will accept a report from an
acceptable medical source that describes
your CKD and your current dialysis, and
indicates that your dialysis will be ongoing.
b. If you are undergoing chronic
hemodialysis or peritoneal dialysis, your
CKD may meet our definition of disability
before you started dialysis. We will
determine the onset of your disability based
on the facts in your case record.
2. Kidney transplant.
a. If you receive a kidney transplant, we
will consider you to be disabled under 6.04
for 1 year from the date of transplant. After
that, we will evaluate your residual
impairment(s) by considering your posttransplant function, any rejection episodes
you have had, complications in other body
systems, and any adverse effects related to
ongoing treatment.
b. If you received a kidney transplant, your
CKD may meet our definition of disability
before you received the transplant. We will
determine the onset of your disability based
on the facts in your case record.
3. Renal osteodystrophy. This condition is
the bone degeneration resulting from chronic
kidney disease-mineral and bone disorder
(CKD–MBD). CKD–MBD occurs when the
kidneys are unable to maintain the necessary
levels of minerals, hormones, and vitamins
required for bone structure and function.
Under 6.05B1, ‘‘severe bone pain’’ means
frequent or intractable (resistant to treatment)
bone pain that interferes with physical
activity or mental functioning.
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4. Peripheral neuropathy. This disorder
results when the kidneys do not adequately
filter toxic substances from the blood. These
toxins can adversely affect nerve tissue. The
resulting neuropathy may affect peripheral
motor or sensory nerves, or both, causing
pain, numbness, tingling, and muscle
weakness in various parts of the body. Under
6.05B2, the peripheral neuropathy must be a
severe impairment. (See §§ 404.1520(c),
404.1521, 416.920(c), and 416.921 of this
chapter.) It must also have lasted or be
expected to last for a continuous period of at
least 12 months.
5. Fluid overload syndrome. This condition
occurs when excess sodium and water
retention in the body due to CKD results in
vascular congestion. Under 6.05B3, we need
a description of a physical examination that
documents signs and symptoms of vascular
congestion, such as congestive heart failure,
pleural effusion (excess fluid in the chest),
ascites (excess fluid in the abdomen),
hypertension, fatigue, shortness of breath, or
peripheral edema.
6. Anasarca (generalized massive edema or
swelling). Under 6.05B3 and 6.06B, we need
a description of the extent of edema,
including pretibial (in front of the tibia),
periorbital (around the eyes), or presacral (in
front of the sacrum) edema. We also need a
description of any ascites, pleural effusion, or
pericardial effusion.
7. Anorexia (diminished appetite) with
weight loss. Anorexia is a frequent sign of
CKD and can result in weight loss. We will
use body mass index (BMI) to determine the
severity of your weight loss under 6.05B4.
(BMI is the ratio of your measured weight to
the square of your measured height.) The
formula for calculating BMI is in section
5.00G.
8. Complications of CKD. The
hospitalizations in 6.09 may be for different
complications of CKD. Examples of
complications from CKD that may result in
hospitalization include stroke, congestive
heart failure, hypertensive crisis, or acute
kidney failure requiring a short course of
hemodialysis. If the CKD complication
occurs during a hospitalization that was
initially for a co-occurring condition, we will
evaluate it under our rules for determining
medical equivalence. (See §§ 404.1526 and
416.926 of this chapter.) We will evaluate cooccurring conditions, including those that
result in hospitalizations, under the listings
for the affected body system or under our
rules for medical equivalence.
D. How do we evaluate disorders that do not
meet one of the genitourinary listings?
1. The listed disorders are only examples
of common genitourinary disorders that we
consider severe enough to prevent you from
doing any gainful activity. If your
impairment(s) does not meet the criteria of
any of these listings, we must also consider
whether you have an impairment(s) that
satisfies the criteria of a listing in another
body system.
2. If you have a severe medically
determinable impairment(s) that does not
meet a listing, we will determine whether
your impairment(s) medically equals a
listing. (See §§ 404.1526 and 416.926 of this
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chapter.) Genitourinary disorders may be
associated with disorders in other body
systems, and we consider the combined
effects of multiple impairments when we
determine whether they medically equal a
listing. If your impairment(s) does not meet
or medically equal the criteria of a listing,
you may or may not have the residual
functional capacity to engage in substantial
gainful activity. We proceed to the fourth
and, if necessary, the fifth steps of the
sequential evaluation process in §§ 404.1520
and 416.920 of this chapter. We use the rules
in §§ 404.1594 and 416.994 of this chapter,
as appropriate, when we decide whether you
continue to be disabled.
6.01 Category of Impairments,
Genitourinary Disorders
6.03 Chronic kidney disease, with
chronic hemodialysis or peritoneal dialysis
(see 6.00C1).
6.04 Chronic kidney disease, with kidney
transplant. Consider under a disability for 1
year following the transplant; thereafter,
evaluate the residual impairment (see
6.00C2).
6.05 Chronic kidney disease, with
impairment of kidney function, with A and
B:
A. Reduced glomerular filtration evidenced
by one of the following laboratory findings
documented on at least two occasions at least
90 days apart during a consecutive 12-month
period:
1. Serum creatinine of 4 mg/dL or greater;
or
2. Creatinine clearance of 20 ml/min. or
less; or
3. Estimated glomerular filtration rate
(eGFR) of 20 ml/min/1.73m2 or less.
AND
B. One of the following:
1. Renal osteodystrophy (see 6.00C3) with
severe bone pain and imaging studies
documenting bone abnormalities, such as
osteitis fibrosa, osteomalacia, or pathologic
fractures; or
2. Peripheral neuropathy (see 6.00C4); or
3. Fluid overload syndrome (see 6.00C5)
documented by one of the following:
a. Diastolic hypertension greater than or
equal to diastolic blood pressure of 110 mm
Hg despite at least 90 consecutive days of
prescribed therapy, documented by at least
two measurements of diastolic blood
pressure at least 90 days apart during a
consecutive 12-month period; or
b. Signs of vascular congestion or anasarca
(see 6.00C6) despite at least 90 consecutive
days of prescribed therapy, documented on at
least two occasions at least 90 days apart
during a consecutive 12-month period; or
4. Anorexia with weight loss (see 6.00C7)
determined by body mass index (BMI) of 18.0
or less, calculated on at least two occasions
at least 90 days apart during a consecutive
12-month period.
6.06 Nephrotic syndrome, with A and B:
A. Laboratory findings as described in 1 or
2, documented on at least two occasions at
least 90 days apart during a consecutive 12month period:
1. Proteinuria of 10.0 g or greater per 24
hours; or
2. Serum albumin of 3.0 g/dL or less, and
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a. Proteinuria of 3.5 g or greater per 24
hours; or
b. Urine total-protein-to-creatinine ratio of
3.5 or greater.
AND
B. Anasarca (see 6.00C6) persisting for at
least 90 days despite prescribed treatment.
6.09 Complications of chronic kidney
disease (see 6.00C8) requiring at least three
hospitalizations within a consecutive 12month period and occurring at least 30 days
apart. Each hospitalization must last at least
48 hours, including hours in a hospital
emergency department immediately before
the hospitalization.
*
*
*
*
*
*
*
*
Part B
*
*
106.00
*
*
106.00
Genitourinary Disorders.
*
*
*
GENITOURINARY DISORDERS
A. Which disorders do we evaluate under
these listings?
We evaluate genitourinary disorders
resulting in chronic kidney disease (CKD).
Examples of such disorders include chronic
glomerulonephritis, hypertensive
nephropathy, diabetic nephropathy, chronic
obstructive uropathy, and hereditary
nephropathies. We also evaluate nephrotic
syndrome due to glomerular dysfunction,
and congenital genitourinary disorders, such
as ectopic ureter, exotrophic urinary bladder,
urethral valves, and Eagle-Barrett syndrome
(prune belly syndrome), under these listings.
B. What evidence do we need?
1. We need evidence that documents the
signs, symptoms, and laboratory findings of
your CKD. This evidence should include
reports of clinical examinations, treatment
records, and documentation of your response
to treatment. Laboratory findings, such as
serum creatinine or serum albumin levels,
may document your kidney function. We
generally need evidence covering a period of
at least 90 days unless we can make a fully
favorable determination or decision without
it.
2. Estimated glomerular filtration rate
(eGFR). The eGFR is an estimate of the
filtering capacity of the kidneys that takes
into account serum creatinine concentration
and other variables, such as your age, gender,
and body size. If your medical evidence
includes eGFR findings, we will consider
them when we evaluate your CKD under
106.05.
3. Kidney or bone biopsy. If you have had
a kidney or bone biopsy, we need a copy of
the pathology report. When we cannot get a
copy of the pathology report, we will accept
a statement from an acceptable medical
source verifying that a biopsy was performed
and describing the results.
C. What other factors do we consider when
we evaluate your genitourinary disorder?
1. Chronic hemodialysis or peritoneal
dialysis.
a. Dialysis is a treatment for CKD that uses
artificial means to remove toxic metabolic
byproducts from the blood. Hemodialysis
PO 00000
Frm 00011
Fmt 4700
Sfmt 4700
61225
uses an artificial kidney machine to clean
waste products from the blood; peritoneal
dialysis uses a dialyzing solution that is
introduced into and removed from the
abdomen (peritoneal cavity) either
continuously or intermittently. Under 106.03,
your ongoing dialysis must have lasted or be
expected to last for a continuous period of at
least 12 months. To satisfy the requirement
in 106.03, we will accept a report from an
acceptable medical source that describes
your CKD and your current dialysis, and
indicates that your dialysis will be ongoing.
b. If you are undergoing chronic
hemodialysis or peritoneal dialysis, your
CKD may meet our definition of disability
before you started dialysis. We will
determine the onset of your disability based
on the facts in your case record.
2. Kidney transplant.
a. If you receive a kidney transplant, we
will consider you to be disabled under
106.04 for 1 year from the date of transplant.
After that, we will evaluate your residual
impairment(s) by considering your posttransplant function, any rejection episodes
you have had, complications in other body
systems, and any adverse effects related to
ongoing treatment.
b. If you received a kidney transplant, your
CKD may meet our definition of disability
before you received the transplant. We will
determine the onset of your disability based
on the facts in your case record.
3. Anasarca (generalized massive edema or
swelling). Under 106.06B, we need a
description of the extent of edema, including
pretibial (in front of the tibia), periorbital
(around the eyes), or presacral (in front of the
sacrum) edema. We also need a description
of any ascites, pleural effusion, or pericardial
effusion.
4. Congenital genitourinary disorder.
Procedures such as diagnostic cystoscopy or
circumcision do not satisfy the requirement
for urologic surgical procedures in 106.07.
5. Complications of CKD. The
hospitalizations in 106.09 may be for
different complications of CKD. Examples of
complications from CKD that may result in
hospitalization include stroke, congestive
heart failure, hypertensive crisis, or acute
kidney failure requiring a short course of
hemodialysis. If the CKD complication
occurs during a hospitalization that was
initially for a co-occurring condition, we will
evaluate it under our rules for determining
medical equivalence. (See § 416.926 of this
chapter.) We will evaluate co-occurring
conditions, including those that result in
hospitalizations, under the listings for the
affected body system or under our rules for
medical equivalence.
D. How do we evaluate disorders that do not
meet one of the genitourinary listings?
1. The listed disorders are only examples
of common genitourinary disorders that we
consider severe enough to result in marked
and severe functional limitations. If your
impairment(s) does not meet the criteria of
any of these listings, we must also consider
whether you have an impairment(s) that
satisfies the criteria of a listing in another
body system.
2. If you have a severe medically
determinable impairment(s) that does not
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Federal Register / Vol. 79, No. 197 / Friday, October 10, 2014 / Rules and Regulations
meet a listing, we will determine whether
your impairment(s) medically equals a
listing. (See § 416.926 of this chapter.)
Genitourinary disorders may be associated
with disorders in other body systems, and we
consider the combined effects of multiple
impairments when we determine whether
they medically equal a listing. If your
impairment(s) does not medically equal a
listing, we will also consider whether it
functionally equals the listings. (See
§ 416.926a of this chapter.) We use the rules
in § 416.994a of this chapter when we decide
whether you continue to be disabled.
mstockstill on DSK4VPTVN1PROD with RULES
106.01 Category of Impairments,
Genitourinary Disorders
*
*
*
*
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22 CFR Parts 120, 121, 123, 126, and
130
[Public Notice 8898]
RIN 1400–AD64
Amendment to the International Traffic
in Arms Regulations: Corrections,
Clarifications, and Movement of
Definitions
Department of State.
Final rule.
AGENCY:
ACTION:
In an effort to streamline,
simplify and clarify the recent revisions
to the International Traffic in Arms
Regulations (ITAR) made pursuant to
the President’s Export Control Reform
(ECR) initiative, the Department of State
is amending the ITAR as part of the
Department of State’s retrospective plan
under Executive Order 13563 completed
on August 17, 2011.
DATES: This rule is effective October 10,
2014.
FOR FURTHER INFORMATION CONTACT: Mr.
C. Edward Peartree, Director, Office of
Defense Trade Controls Policy,
Department of State, telephone (202)
663–2792; email DDTCResponseTeam@
state.gov. ATTN: Regulatory Change,
Omnibus Clarifications. The Department
of State’s full retrospective plan can be
accessed at https://www.state.gov/
documents/organization/181028.pdf.
SUPPLEMENTARY INFORMATION:
SUMMARY:
106.03 Chronic kidney disease, with
chronic hemodialysis or peritoneal dialysis
(see 106.00C1).
106.04 Chronic kidney disease, with
kidney transplant. Consider under a
disability for 1 year following the transplant;
thereafter, evaluate the residual impairment
(see 106.00C2).
106.05 Chronic kidney disease, with
impairment of kidney function, with one of
the following documented on at least two
occasions at least 90 days apart during a
consecutive 12-month period:
A. Serum creatinine of 3 mg/dL or greater;
OR
B. Creatinine clearance of 30 ml/min/
1.73m2 or less;
OR
C. Estimated glomerular filtration rate
(eGFR) of 30 ml/min/1.73m2 or less.
106.06 Nephrotic syndrome, with A
and B:
A. Laboratory findings as described in 1 or
2, documented on at least two occasions at
least 90 days apart during a consecutive 12month period:
1. Serum albumin of 3.0 g/dL or less, or
2. Proteinuria of 40 mg/m2/hr or greater;
AND
B. Anasarca (see 106.00C3) persisting for at
least 90 days despite prescribed treatment.
106.07 Congenital genitourinary disorder
(see 106.00C4) requiring urologic surgical
procedures at least three times in a
consecutive 12-month period, with at least 30
days between procedures. Consider under a
disability for 1 year following the date of the
last surgery; thereafter, evaluate the residual
impairment.
106.09 Complications of chronic kidney
disease (see 106.00C5) requiring at least three
hospitalizations within a consecutive 12month period and occurring at least 30 days
apart. Each hospitalization must last at least
48 hours, including hours in a hospital
emergency department immediately before
the hospitalization.
*
DEPARTMENT OF STATE
Changes in this Rule
The following changes are made to
the ITAR with this final rule: (1)
Definitions previously provided in
§§ 121.3, 121.4, 121.14, and 121.15 are
removed from these sections and
incorporated into U.S. Munitions List
Categories VIII, VII, XX, and VI,
respectively; (2) USML Category II is
amended to clarify that grenade
launchers are controlled in paragraph
(a) as a result of the revisions previously
made to USML Category IV pursuant to
Export Control Reform; (3) USML
Category IX is amended to enumerate
military training not directly related to
a defense article, which is a controlled
activity pursuant to ITAR § 120.9(a)(3).
This change is required in order to
provide exporters a USML category to
cite for military training when not
related to a defense article; (4) The note
to paragraph (b) in the specially
designed definition is revised to clarify
that catch-all controls are only those
that generically control parts,
components, accessories, and
attachments for a specified article and
do not identify a specific specially
PO 00000
Frm 00012
Fmt 4700
Sfmt 4700
designed part, component, accessory, or
attachment. This revision is intended to
help ensure that exporters properly
apply ITAR § 120.41 when classifying
their article and clarify that when a
specific article is described on the
USML, it is enumerated and is not part
of a catch-all; (5) The definitions
previously provided in ITAR § 121.8 are
removed to new ITAR § 120.45; (6) The
policy with regard to when forgings,
castings, and machined bodies are
controlled as defense articles is removed
from ITAR § 121.10 and placed in ITAR
§ 120.6; (7) The threshold for lithiumion batteries controlled in Category
VIII(h)(13) is increased from greater than
28 volts of direct current (VDC) nominal
to greater than 38 VDC nominal, so as
not to control on the USML such
batteries in normal commercial aviation
use; (8) A control for specially designed
parts, components, accessories, and
attachments is added to the helmets
controlled in Category VIII(h)(15); (9)
The phrase ‘‘electric-generating’’ is
added to the control describing fuel
cells in Category VIII(h)(23) to clarify
that fuel bladders and fuel tanks are not
within this control; (10) The word
‘‘enumerated’’ is replaced with the word
‘‘described’’ in the paragraphs of the
USML for technical data and defense
services directly related to the defense
articles in that Category to clarify that
the controls on technical data and
defense services apply even if the
defense article is described in a catchall; (11) Conforming changes are made
to citations throughout these sections;
and (12) Minor reference corrections are
made to Supplement No. 1 to Part 126,
including moving the footnote to the
entire Supplement from the end to the
opening to better clarify if an item is
excluded from eligibility in any row, it
is excluded from that exemption, even
if also described in another row that
contains a description that may also
include that item.
Regulatory Analysis and Notices
Administrative Procedure Act
The Department of State is of the
opinion that controlling the import and
export of defense articles and services is
a foreign affairs function of the United
States Government and that rules
implementing this function are exempt
from 5 U.S.C. 553 and 554.
Regulatory Flexibility Act
Since the Department is of the
opinion that this rule is exempt from the
provisions of 5 U.S.C. 553, there is no
requirement for an analysis under the
Regulatory Flexibility Act.
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Agencies
[Federal Register Volume 79, Number 197 (Friday, October 10, 2014)]
[Rules and Regulations]
[Pages 61221-61226]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-24114]
=======================================================================
-----------------------------------------------------------------------
SOCIAL SECURITY ADMINISTRATION
20 CFR Part 404
[Docket No. SSA-2009-0038]
RIN 0960-AH03
Revised Medical Criteria for Evaluating Genitourinary Disorders
AGENCY: Social Security Administration.
ACTION: Final rules.
-----------------------------------------------------------------------
SUMMARY: These final rules revise the criteria in the Listing of
Impairments (listings) that we use to evaluate cases
[[Page 61222]]
involving genitourinary disorders in adults and children under titles
II and XVI of the Social Security Act (Act). The revisions reflect our
program experience and address adjudicator questions we have received
since we last comprehensively revised this body system in 2005.
DATES: These rules are effective December 9, 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. For information on
eligibility or filing for benefits, call our national toll-free number,
1-800-772-1213, or TTY 1-800-325-0778, or visit our Internet site,
Social Security Online, at https://www.socialsecurity.gov.
SUPPLEMENTARY INFORMATION:
Background
We are making final the rules for evaluating genitourinary
disorders that we proposed in a notice of proposed rulemaking (NPRM) we
published in the Federal Register on February 4, 2013 at 78 FR 7695.
The preamble to the NPRM provides the background for these revisions.
You can view the preamble to the NPRM by visiting https://www.regulations.gov and searching for document ``SSA-2009-0038-0005.''
We are making a number of changes in response to public comments to the
NPRM, which we explain below.
Why are we revising the listings for evaluating genitourinary
disorders?
We are revising the listings for evaluating genitourinary disorders
to update the medical criteria, clarify how we evaluate genitourinary
disorders, and address adjudicator questions.
Public Comments
In the NPRM, we provided the public with a 60-day comment period,
which ended on April 5, 2013. We received six comments. The comments
came from members of the public, disability adjudicators, and a
national association representing disability examiners in the State
agencies that make disability determinations for us.
We carefully considered all of the comments. We have tried to
summarize the commenters' views accurately and respond to all of the
significant issues raised by the commenters that were within the scope
of these rules. Some commenters noted provisions with which they agreed
and did not make suggestions for changes in those provisions. We did
not summarize or respond to those comments.
Comment: One commenter asked if we would require the estimated
glomerular filtration rate (eGFR) to be adjusted for race and sex. The
commenter also suggested that we establish an eGFR calculator to
calculate the eGFR for the criterion in proposed 6.05A.
Response: We did not adopt this comment. The eGFR is a calculated
value based on the measured serum creatinine. The formulas used by
laboratories to calculate eGFR all include adjustments for age, race,
and sex. We will use the eGFR value as calculated by the laboratory and
will not independently calculate eGFR. Thus, we will not develop a
calculator for eGFR.
Comment: Another commenter noted that the weight loss criterion in
proposed listing 6.05B4 (body mass index (BMI) of 18.0 or less) is not
consistent with the weight loss criterion in listing 5.08 (BMI of less
than 17.5) and suggested that we change the criterion for consistency.
Response: We did not adopt this comment. We believe it is
appropriate to use a different BMI criterion for listing 6.05B4 than we
use in listing 5.08. The criterion in listing 6.05B4 considers the
severity of a person's underlying chronic kidney disease (CKD) and its
effect on his or her nutrition and metabolic status. People with CKD
are unable to maintain adequate weight due to decreased dietary protein
intake and decreased dietary energy intake, which are hallmarks of
kidney failure. People with CKD may have an increased prevalence of
protein energy malnutrition. Furthermore, listing 5.08 requires a lower
BMI because the listing considers only weight loss due to any digestive
disorder. Listing 5.08 does not consider the severity of the
individual's underlying digestive disorder.
In listing 5.08, we require BMI of less than 17.5 calculated on at
least two evaluations, at least 60 days apart, within a consecutive 6-
month period. In final listing 6.05B4, we require the same number of
BMI evaluations within a consecutive 12-month period. We are using the
consecutive 12-month period to be consistent with the 12-month duration
requirement.\1\ The 12-month period is also consistent with the period
we use when we evaluate hospitalizations due complications of a
genitourinary disorder in 6.09 and 106.09.
---------------------------------------------------------------------------
\1\ 20 CFR 404.1509 and 416.909.
---------------------------------------------------------------------------
Comment: One commenter expressed concern about proposed listing
6.09, regarding how to explain ``CKD complications requiring
hospitalizations versus hospitalizations due to a group of co-morbid
conditions, including CKD.'' The same commenter also suggested that we
add guidance in the introductory text to address acute worsening of CKD
during hospitalizations for co-occurring conditions.
Response: We agree with the comment and provided clarification
regarding CKD complications in final listings 6.00C8 and 106.00C5.
Comment: A commenter suggested revisions to proposed listing 106.07
requesting a 24-month period with 3 surgeries for childhood
genitourinary disorders instead of 3 surgeries within 12-month period.
Response: We are not adopting this comment because using a 12-month
period for evaluating an impairment is an intrinsic part of our basic
definition of disability.\2\ We consider the combinations of
impairments and limitations in functioning at step 3 of the sequential
evaluation process, using our medical equivalence and functional
equivalence rules.\3\ We recognize that some children who have multiple
surgeries for genitourinary impairments may have limitations in
functioning that last longer. In such cases, we evaluate those
limitations under our medical equivalence and functional equivalence
rules.
---------------------------------------------------------------------------
\2\ See 42 U.S.C. 423(d)(1)(a) and (d)(2)(a), and 1382c(a)(3)(A)
and 20 CFR 404.1505, 404.1509, 416.905, 416.906, and 416.909.
\3\ See 20 CFR 416.926 and 416.926a(a).
---------------------------------------------------------------------------
Comment: One commenter stated that there are undefined and poorly
defined terms in the genitourinary listings. The commenter said these
terms included ``frequent,'' ``intractable,'' ``interferes,''
``anasarca,'' ``anorexia,'' and ``severe bone pain.''
Response: We partially adopted this comment. We provide brief
definitions for several medical terms when we first use the terms in
the introductory text of these final listings. We define anasarca in
6.00C6 and 106.00C3; anorexia in 6.00C7; and ``severe bone pain'' and
``intractable'' in 6.00C3. We have not provided definitions for the
terms ``frequent'' and ``interferes.'' We use these two terms in our
definition of ``severe bone pain'' and use them in their common English
usage.
Comment: A commenter stated that there are no listings for
combinations of impairments. The commenter stated that the NPRM
includes only single genitourinary disorders and leaves out many
important combinations of disorders. Examples that the commenter
provided included severe CKD not requiring dialysis and coronary artery
disease; peripheral neuropathy and
[[Page 61223]]
generalized edema; and fluid overload and coronary artery disease. The
commenter also noted ``a complete lack of listings that consider
obesity.''
Response: We did not adopt this comment. We recognize that
genitourinary disorders may co-occur with impairments in other body
systems. In some cases, the impairment in another body system results
from a genitourinary disorder; for example, peripheral neuropathy
resulting from CKD. In other cases, the impairment in another body
system is not related to the genitourinary disorder; for example,
peripheral neuropathy resulting from diabetes mellitus.
We intend the listings to address genitourinary disorders and the
complications of those disorders. When the co-occurring condition or
complication is due to a genitourinary disorder, we evaluate it under
final listing 6.09. However, when the co-occurring impairments are
unrelated, we believe it is more appropriate to evaluate the
combination under our medical equivalence rule at step 3 of the
sequential evaluation process, or at steps 4 and 5 of the sequential
evaluation process.\4\ At these steps, adjudicators can account for
specific combinations of impairments, complications of those
impairments, and limitations of functioning on an individual case
basis. We address this in the introductory text of final listing
6.00C8.
---------------------------------------------------------------------------
\4\ See 20 CFR 404.1526 and 416.926.
---------------------------------------------------------------------------
Comment: A commenter noted that we provide no quantitative data to
show the validity of any of our genitourinary proposed listings and
noted that many people engage in substantial gainful activity (SGA)
even though they meet the requirements of a listing. The commenter
believes that this challenges the validity of using the listings to
determine whether a person is disabled.
Response: We disagree with this comment. Our NPRM included an
extensive list of medical and other references that we relied on in
proposing these rules. We also invited the public to comment on these
references and the data contained within them.
The listings help to ensure that determinations or decisions of
disability have a sound medical basis, that claimants receive equal
treatment throughout the country, and that we can readily identify the
majority of persons who are disabled. The level of severity described
in the listings is such that an individual, whom is not engaging in SGA
and has an impairment that meets or medically equals all of the
criteria of the listing, is generally considered unable to work because
of the medical impairment alone at step three of the sequential
evaluation process. Thus, when such a person's impairment or
combination of impairments meets or medically equals the level of
severity described in the listing for the required duration, disability
will be found on the basis of the medical facts alone in the absence of
evidence to the contrary, for example, the actual performance of SGA.
Comment: A commenter stated that the proposed criteria discriminate
against the poor because they include medical tests that people cannot
afford and that we will not purchase, such as kidney or bone biopsies,
imaging studies, and 24-hour urine protein tests. The same commenter
also stated that requirements, such as 90 consecutive days of
prescribed therapy, urologic surgical procedures, and hospitalization,
discriminate against people who cannot afford treatment, and suggested
that we delete the requirements ``[u]nless the Administration is
willing to make a commitment to purchase these.''
Response: We did not adopt the commenter's suggestion. People with
the very serious genitourinary impairments described in these listings
generally receive the kinds of diagnostic tests and treatments
described in these final rules because of urgent medical need. However,
we do not penalize people who do not have the kinds of medical evidence
that we describe in these listings. Under our rules, we may purchase
medical examinations or tests to obtain the evidence that we need, but
we will not purchase diagnostic tests that involve significant risk to
the person, such as kidney or bone biopsies.\5\ Furthermore, we provide
several alternatives for people with genitourinary impairments to
establish that their impairment is of listing-level severity at step
three of the sequential evaluation process. If the impairment is not of
listing-level severity, we may find the person disabled at subsequent
steps of the sequential evaluation process when considering the
person's residual functional capacity, age, education, and work
experience.
---------------------------------------------------------------------------
\5\ See 20 CFR 404.1519m and 416.919m.
---------------------------------------------------------------------------
Comment: Two commenters pointed out stylistic and technical
editorial issues in the preamble and the proposed rules.
Response: We have made appropriate corrections in these final
rules.
Other Changes
In addition to the changes we made in response to public comments,
we revised 6.00C1 and 106.00C1 to clarify the documentation requirement
for hemodialysis or peritoneal dialysis.
What is our authority to make rules and set procedures for determining
whether a person is disabled under the statutory definition?
The Act authorizes us to make rules and regulations and to
establish necessary and appropriate procedures to implement them.\6\
---------------------------------------------------------------------------
\6\ 42 U.S.C. 405(a), 902(a)(5), and 1383(d)(1).
---------------------------------------------------------------------------
How long will these final rules be effective?
These final rules will remain in effect for 5 years after the date
they become effective, unless we extend them, or revise and issue them
again.
Regulatory Procedures
Executive Order 12866, as Supplemented by Executive Order 13563
We consulted with the Office of Management and Budget (OMB) and
determined that these final rules meet the criteria for a significant
regulatory action under Executive Order 12866, as supplemented by
Executive Order 13563 and was reviewed by OMB.
Regulatory Flexibility Act
We certify that these final rules will not have a significant
economic impact on a substantial number of small entities because they
affect individuals only. Therefore, the Regulatory Flexibility Act, as
amended, does not require us to prepare a regulatory flexibility
analysis.
Paperwork Reduction Act
These final rules do not create any new or affect any existing
collections and, therefore, do not require OMB approval under the
Paperwork Reduction Act.
(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; and 96.006,
Supplemental Security Income).
List of Subjects in 20 CFR Part 404
Administrative practice and procedure, Blind, Disability benefits,
Old-Age, survivors, and disability
[[Page 61224]]
insurance, Reporting and recordkeeping requirements, Social Security.
Carolyn W. Colvin,
Acting Commissioner of Social Security.
For the reasons set out in the preamble, we are amending 20 CFR
part 404, subpart P as set forth below:
PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE
(1950-)
Subpart P--Determining Disability and Blindness
0
1. The authority citation for subpart P of part 404 continues to read
as follows:
Authority: Secs. 202, 205(a)-(b) and (d)-(h), 216(i), 221(a),
(i), and (j), 222(c), 223, 225, and 702(a)(5) of the Social Security
Act (42 U.S.C. 402, 405(a)-(b) and (d)-(h), 416(i), 421(a), (i), and
(j), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193,
110 Stat. 2105, 2189; sec. 202, Pub. L. 108-203, 118 Stat. 509 (42
U.S.C. 902 note).
0
2. Amend appendix 1 to subpart P of part 404 by:
0
a. Revising item 7 of the introductory text before part A;
0
b. In part A:
0
i. Revising the body system name for section 6.00 in the table of
contents; and
0
ii. Revising section 6.00;
0
c. In part B:
0
i. Revising the body system name for section 106.00 in the table of
contents; and
0
ii. Revising section 106.00.
The revisions read as follows:
Appendix 1 to Subpart P of Part 404--Listing of Impairments
* * * * *
7. Genitourinary Disorders (6.00 and 106.00): December 9, 2019.
* * * * *
Part A
* * * * *
6.00 Genitourinary Disorders.
* * * * *
6.00 GENITOURINARY DISORDERS
A. Which disorders do we evaluate under these listings?
We evaluate genitourinary disorders resulting in chronic kidney
disease (CKD). Examples of such disorders include chronic
glomerulonephritis, hypertensive nephropathy, diabetic nephropathy,
chronic obstructive uropathy, and hereditary nephropathies. We also
evaluate nephrotic syndrome due to glomerular dysfunction under
these listings.
B. What evidence do we need?
1. We need evidence that documents the signs, symptoms, and
laboratory findings of your CKD. This evidence should include
reports of clinical examinations, treatment records, and
documentation of your response to treatment. Laboratory findings,
such as serum creatinine or serum albumin levels, may document your
kidney function. We generally need evidence covering a period of at
least 90 days unless we can make a fully favorable determination or
decision without it.
2. Estimated glomerular filtration rate (eGFR). The eGFR is an
estimate of the filtering capacity of the kidneys that takes into
account serum creatinine concentration and other variables, such as
your age, gender, and body size. If your medical evidence includes
eGFR findings, we will consider them when we evaluate your CKD under
6.05.
3. Kidney or bone biopsy. If you have had a kidney or bone
biopsy, we need a copy of the pathology report. When we cannot get a
copy of the pathology report, we will accept a statement from an
acceptable medical source verifying that a biopsy was performed and
describing the results.
C. What other factors do we consider when we evaluate your
genitourinary disorder?
1. Chronic hemodialysis or peritoneal dialysis.
a. Dialysis is a treatment for CKD that uses artificial means to
remove toxic metabolic byproducts from the blood. Hemodialysis uses
an artificial kidney machine to clean waste products from the blood;
peritoneal dialysis uses a dialyzing solution that is introduced
into and removed from the abdomen (peritoneal cavity) either
continuously or intermittently. Under 6.03, your ongoing dialysis
must have lasted or be expected to last for a continuous period of
at least 12 months. To satisfy the requirements in 6.03, we will
accept a report from an acceptable medical source that describes
your CKD and your current dialysis, and indicates that your dialysis
will be ongoing.
b. If you are undergoing chronic hemodialysis or peritoneal
dialysis, your CKD may meet our definition of disability before you
started dialysis. We will determine the onset of your disability
based on the facts in your case record.
2. Kidney transplant.
a. If you receive a kidney transplant, we will consider you to
be disabled under 6.04 for 1 year from the date of transplant. After
that, we will evaluate your residual impairment(s) by considering
your post-transplant function, any rejection episodes you have had,
complications in other body systems, and any adverse effects related
to ongoing treatment.
b. If you received a kidney transplant, your CKD may meet our
definition of disability before you received the transplant. We will
determine the onset of your disability based on the facts in your
case record.
3. Renal osteodystrophy. This condition is the bone degeneration
resulting from chronic kidney disease-mineral and bone disorder
(CKD-MBD). CKD-MBD occurs when the kidneys are unable to maintain
the necessary levels of minerals, hormones, and vitamins required
for bone structure and function. Under 6.05B1, ``severe bone pain''
means frequent or intractable (resistant to treatment) bone pain
that interferes with physical activity or mental functioning.
4. Peripheral neuropathy. This disorder results when the kidneys
do not adequately filter toxic substances from the blood. These
toxins can adversely affect nerve tissue. The resulting neuropathy
may affect peripheral motor or sensory nerves, or both, causing
pain, numbness, tingling, and muscle weakness in various parts of
the body. Under 6.05B2, the peripheral neuropathy must be a severe
impairment. (See Sec. Sec. 404.1520(c), 404.1521, 416.920(c), and
416.921 of this chapter.) It must also have lasted or be expected to
last for a continuous period of at least 12 months.
5. Fluid overload syndrome. This condition occurs when excess
sodium and water retention in the body due to CKD results in
vascular congestion. Under 6.05B3, we need a description of a
physical examination that documents signs and symptoms of vascular
congestion, such as congestive heart failure, pleural effusion
(excess fluid in the chest), ascites (excess fluid in the abdomen),
hypertension, fatigue, shortness of breath, or peripheral edema.
6. Anasarca (generalized massive edema or swelling). Under
6.05B3 and 6.06B, we need a description of the extent of edema,
including pretibial (in front of the tibia), periorbital (around the
eyes), or presacral (in front of the sacrum) edema. We also need a
description of any ascites, pleural effusion, or pericardial
effusion.
7. Anorexia (diminished appetite) with weight loss. Anorexia is
a frequent sign of CKD and can result in weight loss. We will use
body mass index (BMI) to determine the severity of your weight loss
under 6.05B4. (BMI is the ratio of your measured weight to the
square of your measured height.) The formula for calculating BMI is
in section 5.00G.
8. Complications of CKD. The hospitalizations in 6.09 may be for
different complications of CKD. Examples of complications from CKD
that may result in hospitalization include stroke, congestive heart
failure, hypertensive crisis, or acute kidney failure requiring a
short course of hemodialysis. If the CKD complication occurs during
a hospitalization that was initially for a co-occurring condition,
we will evaluate it under our rules for determining medical
equivalence. (See Sec. Sec. 404.1526 and 416.926 of this chapter.)
We will evaluate co-occurring conditions, including those that
result in hospitalizations, under the listings for the affected body
system or under our rules for medical equivalence.
D. How do we evaluate disorders that do not meet one of the
genitourinary listings?
1. The listed disorders are only examples of common
genitourinary disorders that we consider severe enough to prevent
you from doing any gainful activity. If your impairment(s) does not
meet the criteria of any of these listings, we must also consider
whether you have an impairment(s) that satisfies the criteria of a
listing in another body system.
2. If you have a severe medically determinable impairment(s)
that does not meet a listing, we will determine whether your
impairment(s) medically equals a listing. (See Sec. Sec. 404.1526
and 416.926 of this
[[Page 61225]]
chapter.) Genitourinary disorders may be associated with disorders
in other body systems, and we consider the combined effects of
multiple impairments when we determine whether they medically equal
a listing. If your impairment(s) does not meet or medically equal
the criteria of a listing, you may or may not have the residual
functional capacity to engage in substantial gainful activity. We
proceed to the fourth and, if necessary, the fifth steps of the
sequential evaluation process in Sec. Sec. 404.1520 and 416.920 of
this chapter. We use the rules in Sec. Sec. 404.1594 and 416.994 of
this chapter, as appropriate, when we decide whether you continue to
be disabled.
6.01 Category of Impairments, Genitourinary Disorders
6.03 Chronic kidney disease, with chronic hemodialysis or
peritoneal dialysis (see 6.00C1).
6.04 Chronic kidney disease, with kidney transplant. Consider
under a disability for 1 year following the transplant; thereafter,
evaluate the residual impairment (see 6.00C2).
6.05 Chronic kidney disease, with impairment of kidney function,
with A and B:
A. Reduced glomerular filtration evidenced by one of the
following laboratory findings documented on at least two occasions
at least 90 days apart during a consecutive 12-month period:
1. Serum creatinine of 4 mg/dL or greater; or
2. Creatinine clearance of 20 ml/min. or less; or
3. Estimated glomerular filtration rate (eGFR) of 20 ml/min/
1.73m\2\ or less.
AND
B. One of the following:
1. Renal osteodystrophy (see 6.00C3) with severe bone pain and
imaging studies documenting bone abnormalities, such as osteitis
fibrosa, osteomalacia, or pathologic fractures; or
2. Peripheral neuropathy (see 6.00C4); or
3. Fluid overload syndrome (see 6.00C5) documented by one of the
following:
a. Diastolic hypertension greater than or equal to diastolic
blood pressure of 110 mm Hg despite at least 90 consecutive days of
prescribed therapy, documented by at least two measurements of
diastolic blood pressure at least 90 days apart during a consecutive
12-month period; or
b. Signs of vascular congestion or anasarca (see 6.00C6) despite
at least 90 consecutive days of prescribed therapy, documented on at
least two occasions at least 90 days apart during a consecutive 12-
month period; or
4. Anorexia with weight loss (see 6.00C7) determined by body
mass index (BMI) of 18.0 or less, calculated on at least two
occasions at least 90 days apart during a consecutive 12-month
period.
6.06 Nephrotic syndrome, with A and B:
A. Laboratory findings as described in 1 or 2, documented on at
least two occasions at least 90 days apart during a consecutive 12-
month period:
1. Proteinuria of 10.0 g or greater per 24 hours; or
2. Serum albumin of 3.0 g/dL or less, and
a. Proteinuria of 3.5 g or greater per 24 hours; or
b. Urine total-protein-to-creatinine ratio of 3.5 or greater.
AND
B. Anasarca (see 6.00C6) persisting for at least 90 days despite
prescribed treatment.
6.09 Complications of chronic kidney disease (see 6.00C8)
requiring at least three hospitalizations within a consecutive 12-
month period and occurring at least 30 days apart. Each
hospitalization must last at least 48 hours, including hours in a
hospital emergency department immediately before the
hospitalization.
* * * * *
Part B
* * * * *
106.00 Genitourinary Disorders.
* * * * *
106.00 GENITOURINARY DISORDERS
A. Which disorders do we evaluate under these listings?
We evaluate genitourinary disorders resulting in chronic kidney
disease (CKD). Examples of such disorders include chronic
glomerulonephritis, hypertensive nephropathy, diabetic nephropathy,
chronic obstructive uropathy, and hereditary nephropathies. We also
evaluate nephrotic syndrome due to glomerular dysfunction, and
congenital genitourinary disorders, such as ectopic ureter,
exotrophic urinary bladder, urethral valves, and Eagle-Barrett
syndrome (prune belly syndrome), under these listings.
B. What evidence do we need?
1. We need evidence that documents the signs, symptoms, and
laboratory findings of your CKD. This evidence should include
reports of clinical examinations, treatment records, and
documentation of your response to treatment. Laboratory findings,
such as serum creatinine or serum albumin levels, may document your
kidney function. We generally need evidence covering a period of at
least 90 days unless we can make a fully favorable determination or
decision without it.
2. Estimated glomerular filtration rate (eGFR). The eGFR is an
estimate of the filtering capacity of the kidneys that takes into
account serum creatinine concentration and other variables, such as
your age, gender, and body size. If your medical evidence includes
eGFR findings, we will consider them when we evaluate your CKD under
106.05.
3. Kidney or bone biopsy. If you have had a kidney or bone
biopsy, we need a copy of the pathology report. When we cannot get a
copy of the pathology report, we will accept a statement from an
acceptable medical source verifying that a biopsy was performed and
describing the results.
C. What other factors do we consider when we evaluate your
genitourinary disorder?
1. Chronic hemodialysis or peritoneal dialysis.
a. Dialysis is a treatment for CKD that uses artificial means to
remove toxic metabolic byproducts from the blood. Hemodialysis uses
an artificial kidney machine to clean waste products from the blood;
peritoneal dialysis uses a dialyzing solution that is introduced
into and removed from the abdomen (peritoneal cavity) either
continuously or intermittently. Under 106.03, your ongoing dialysis
must have lasted or be expected to last for a continuous period of
at least 12 months. To satisfy the requirement in 106.03, we will
accept a report from an acceptable medical source that describes
your CKD and your current dialysis, and indicates that your dialysis
will be ongoing.
b. If you are undergoing chronic hemodialysis or peritoneal
dialysis, your CKD may meet our definition of disability before you
started dialysis. We will determine the onset of your disability
based on the facts in your case record.
2. Kidney transplant.
a. If you receive a kidney transplant, we will consider you to
be disabled under 106.04 for 1 year from the date of transplant.
After that, we will evaluate your residual impairment(s) by
considering your post-transplant function, any rejection episodes
you have had, complications in other body systems, and any adverse
effects related to ongoing treatment.
b. If you received a kidney transplant, your CKD may meet our
definition of disability before you received the transplant. We will
determine the onset of your disability based on the facts in your
case record.
3. Anasarca (generalized massive edema or swelling). Under
106.06B, we need a description of the extent of edema, including
pretibial (in front of the tibia), periorbital (around the eyes), or
presacral (in front of the sacrum) edema. We also need a description
of any ascites, pleural effusion, or pericardial effusion.
4. Congenital genitourinary disorder. Procedures such as
diagnostic cystoscopy or circumcision do not satisfy the requirement
for urologic surgical procedures in 106.07.
5. Complications of CKD. The hospitalizations in 106.09 may be
for different complications of CKD. Examples of complications from
CKD that may result in hospitalization include stroke, congestive
heart failure, hypertensive crisis, or acute kidney failure
requiring a short course of hemodialysis. If the CKD complication
occurs during a hospitalization that was initially for a co-
occurring condition, we will evaluate it under our rules for
determining medical equivalence. (See Sec. 416.926 of this
chapter.) We will evaluate co-occurring conditions, including those
that result in hospitalizations, under the listings for the affected
body system or under our rules for medical equivalence.
D. How do we evaluate disorders that do not meet one of the
genitourinary listings?
1. The listed disorders are only examples of common
genitourinary disorders that we consider severe enough to result in
marked and severe functional limitations. If your impairment(s) does
not meet the criteria of any of these listings, we must also
consider whether you have an impairment(s) that satisfies the
criteria of a listing in another body system.
2. If you have a severe medically determinable impairment(s)
that does not
[[Page 61226]]
meet a listing, we will determine whether your impairment(s)
medically equals a listing. (See Sec. 416.926 of this chapter.)
Genitourinary disorders may be associated with disorders in other
body systems, and we consider the combined effects of multiple
impairments when we determine whether they medically equal a
listing. If your impairment(s) does not medically equal a listing,
we will also consider whether it functionally equals the listings.
(See Sec. 416.926a of this chapter.) We use the rules in Sec.
416.994a of this chapter when we decide whether you continue to be
disabled.
106.01 Category of Impairments, Genitourinary Disorders
106.03 Chronic kidney disease, with chronic hemodialysis or
peritoneal dialysis (see 106.00C1).
106.04 Chronic kidney disease, with kidney transplant. Consider
under a disability for 1 year following the transplant; thereafter,
evaluate the residual impairment (see 106.00C2).
106.05 Chronic kidney disease, with impairment of kidney
function, with one of the following documented on at least two
occasions at least 90 days apart during a consecutive 12-month
period:
A. Serum creatinine of 3 mg/dL or greater;
OR
B. Creatinine clearance of 30 ml/min/1.73m\2\ or less;
OR
C. Estimated glomerular filtration rate (eGFR) of 30 ml/min/
1.73m\2\ or less.
106.06 Nephrotic syndrome, with A and B:
A. Laboratory findings as described in 1 or 2, documented on at
least two occasions at least 90 days apart during a consecutive 12-
month period:
1. Serum albumin of 3.0 g/dL or less, or
2. Proteinuria of 40 mg/m\2\/hr or greater;
AND
B. Anasarca (see 106.00C3) persisting for at least 90 days
despite prescribed treatment.
106.07 Congenital genitourinary disorder (see 106.00C4)
requiring urologic surgical procedures at least three times in a
consecutive 12-month period, with at least 30 days between
procedures. Consider under a disability for 1 year following the
date of the last surgery; thereafter, evaluate the residual
impairment.
106.09 Complications of chronic kidney disease (see 106.00C5)
requiring at least three hospitalizations within a consecutive 12-
month period and occurring at least 30 days apart. Each
hospitalization must last at least 48 hours, including hours in a
hospital emergency department immediately before the
hospitalization.
* * * * *
[FR Doc. 2014-24114 Filed 10-9-14; 8:45 am]
BILLING CODE 4191-02-P