Social Security Ruling, SSR 15-1p; Titles II and XVI: Evaluating Cases Involving Interstitial Cystitis (IC), 14215-14220 [2015-05680]
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Brent J. Fields,
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[FR Doc. 2015–06094 Filed 3–17–15; 8:45 am]
SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA–2014–0053]
Social Security Ruling, SSR 15–1p;
Titles II and XVI: Evaluating Cases
Involving Interstitial Cystitis (IC)
Social Security Administration.
Notice of Social Security Ruling
AGENCY:
(SSR).
We are providing notice of
SSR 15–1p. This SSR provides guidance
on how we develop evidence to
establish that a person has a medically
determinable impairment of interstitial
cystitis (IC), and how we evaluate IC in
disability claims and continuing
disability reviews under titles II and
XVI of the Social Security Act.
DATES: Effective Date: March 18, 2015.
FOR FURTHER INFORMATION CONTACT:
Cheryl 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
SUMMARY:
150 17
PO 00000
require us to publish this SSR, we are
doing so in accordance with 20 CFR
402.35(b)(1).
Through SSRs, we convey to the
public SSA precedential decisions
relating to the Federal old-age,
survivors, disability, supplemental
security income, and special veterans
benefits programs. We may base SSRs
on determinations or decisions made at
all levels of administrative adjudication,
Federal court decisions, Commissioner’s
decisions, opinions of the Office of the
General Counsel, or other
interpretations of the law and
regulations.
Although SSRs do not have the same
force and effect as statutes or
regulations, they are binding on all
components of the Social Security
Administration. 20 CFR 402.35(b)(1).
This SSR will remain in effect until
we publish a notice in the Federal
Register that rescinds it, or we publish
a new SSR that replaces or modifies it.
(Catalog of Federal Domestic Assistance,
Programs Nos. 96.001, Social Security—
Disability Insurance; 96.002, Social
Security—Retirement Insurance; 96.004,
Social Security—Survivors Insurance;
96.006—Supplemental Security Income.)
Dated: March 3, 2015.
Carolyn W. Colvin,
Acting Commissioner of Social Security.
Policy Interpretation Ruling
BILLING CODE 8011–01–P
ACTION:
Titles II and XVI: Evaluating Cases
Involving Interstitial Cystitis (IC)
This Social Security Ruling (SSR)
rescinds and replaces SSR 02–2p:
‘‘Titles II and XVI: Evaluation of
Interstitial Cystitis.’’ 1
Purpose: This SSR clarifies our policy
on how we develop evidence to
establish that a person has a medically
determinable impairment (MDI) of IC
and how we evaluate this impairment in
disability claims and continuing
disability reviews under titles II and
XVI of the Social Security Act (Act).2
1 We will use this Social Security Ruling (SSR)
beginning on its effective date. We will apply this
SSR to new applications filed on or after the
effective date of the SSR and to claims that are
pending on and after the effective date. This means
that we will use these rules on and after their
effective date in any case in which we make a
determination or decision. We expect that Federal
courts will review our final decisions using the
rules that were in effect at the time we issued the
decisions. If a court reverses our final rules and
remands a case for further administrative
proceedings after the effective date of these final
rules, we will apply these final rules to the entire
period at issue in the decision we make after the
court’s remand.
2 For simplicity, we refer in this SSR only to
initial adult claims for disability benefits under
titles II and XVI of the Act and to the steps of the
CFR 200.30–3(a)(12).
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Federal Register / Vol. 80, No. 52 / Wednesday, March 18, 2015 / Notices
Citations: Sections 216(i), 223(d),
223(f), 1614(a)(3) and 1614(a)(4) of the
Social Security Act, as amended;
Regulations No. 4, subpart P, sections
404.1502, 404.1505, 04.1508–404.1513,
404.1519a, 404.1520, 404.1520a,
404.1520b, 404.1521, 404.1523,
404.1526, 404.1527–404.1529, 404.1545,
404.1560–404.1569a, 404.1593,
404.1594, appendices 1 and 2; and
Regulations No. 16, subpart I, sections
416.902, 416.905, 416.906, 416.908–
416.913, 416.919a, 416.920, 416.920a,
416.920b, 416.921, 416.923, 416.924,
416.924a, 416.926, 416.926a, 416.925,
416.927–416.929, 416.945, 416.960–
416–969a, 416.987, 416.993, 416.994,
and 416.994a.
Introduction
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IC is a complex genitourinary disorder
involving recurring pain or discomfort
in the bladder and pelvic region. The
American Urological Association
(AUA), National Institute of Diabetes
and Digestive and Kidney Diseases
(NIDDK), and other medical experts may
use the terms ‘‘interstitial cystitis/
bladder pain syndrome (IC/BPS)’’ and
‘‘interstitial cystitis/painful bladder
syndrome (IC/PBS)’’ to describe this
disorder because they consider the term
‘‘interstitial cystitis’’ to be synonymous
with the terms ‘‘bladder pain
syndrome’’ and ‘‘painful bladder
syndrome.’’ When we refer to IC in this
SSR, we include IC/BPS and IC/PBS.
The AUA has developed guidelines
providing a clinical framework for
diagnosing and treating IC/BPS.3 These
guidelines use a definition of IC
accepted by the Society for
Urodynamics and Female Urology: ‘‘An
unpleasant sensation (pain, pressure,
discomfort) perceived to be related to
the urinary bladder, associated with
lower urinary tract symptoms of more
than six weeks duration, in the absence
of infection or other identifiable
sequential evaluation process we use to determine
disability in those claims. 20 CFR 404.1520 and
416.920. The policy interpretations in this SSR
apply to all cases in which we must make
determinations about disability, including claims of
children (that is, people who have not attained age
18) who apply for benefits based on disability under
title XVI of the Act, disability redeterminations for
children who became eligible for Supplemental
Security Income under title XVI as a child and who
were eligible for such benefits for the month before
the month in which they attained age 18, and to
continuing disability reviews of adults and children
under titles II and XVI of the Act. 20 CFR 404.1594,
416.924, 416.987, 416.994, and 416.994a.
3 Hanno, P.M., et al., Diagnosis and treatment of
interstitial cystitis/bladder pain syndrome,
American Urological Association, (2014) (available
at: https://www.auanet.org/common/pdf/education/
clinical-guidance/IC-Bladder-Pain-SyndromeRevised.pdf).
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causes.’’ 4 NIDDK’s National Kidney and
Urologic Diseases Information
Clearinghouse explains that the term IC/
PBS (and IC/BPS) includes all cases of
urinary pain not attributed to other
causes, such as infection or urinary
stones.5 NIDDK further explains that the
term ‘‘interstitial cystitis’’ is used alone
(without PBS or BPS) to describe cases
of urinary pain that meet all of the IC
criteria NIDDK established in 1987 for
research purposes.6 We took into
consideration the AUA and NIDDK
descriptions of IC when we formulated
the criteria in this SSR. For example, we
adapted the AUA and NIDDK
descriptions to help develop criteria for
establishing an MDI of IC.7
Except for statutory blindness, we
find a person to be ‘‘disabled’’ if he or
she is unable to do any substantial
gainful activity by reason of a medically
determinable physical or mental
impairment(s) or combination of
impairments that can be expected to
result in death or has lasted or can be
expected to last for a continuous period
of not less than 12 months.8 We require
an MDI to result from anatomical,
physiological, or psychological
abnormalities, as shown by medically
acceptable clinical and laboratory
diagnostic techniques.9 The Act and our
regulations further require that medical
evidence establishing an MDI consist of
signs, symptoms, and laboratory
findings. Thus, we cannot determine
that a person who has IC is disabled on
the basis of his or her statement of
4 Hanno, P. and Dmochowski, R., Status of
international consensus on interstitial cystitis/
bladder pain syndrome/painful bladder syndrome:
2008 snapshot, Neurology and Urodynamics,
Apr;28(4), 274–286 (2009).
5 See NIDDK National Kidney and Urologic
Diseases Information Clearinghouse, ‘‘Interstitial
Cystitis/Painful Bladder Syndrome’’ (2013)
available at: https://kidney.niddk.nih.gov/
KUDiseases/pubs/interstitialcystitis/index.aspx.
6 Gillenwater, J.Y., et al., Summary of the
National Institute of Arthritis, Diabetes, Digestive
and Kidney Diseases Workshop on Interstitial
Cystitis, National Institutes of Health, Bethesda,
Maryland, August 28–29, 1987, The Journal of
Urology, Jul;140(1), 203–206 (1988).
7 We adapted the AUA and NIDDK descriptions
of IC, which are mainly symptom-based, because
the Act and our regulations require a claimant to
establish by objective medical evidence (that is,
medical signs and laboratory findings) that he or
she has a medically determinable impairment. See
223(d)(5)(A) and 1614(a)(3)(D) of the Act, 20 CFR
404.1508 and 416.908, and SSR 96–4p: Titles II and
XVI: Symptoms, Medically Determinable Physical
and Mental Impairments, and Exertional and
Nonexertional Limitations, 61 FR 34388 (1996) (also
available at: https://www.ssa.gov/OP_Home/rulings/
di/01/SSR96-04-di-01.html).
8 See 20 CFR 404.1505 and 416.905.
9 See sections 223(d)(3) and 1614(a)(3)(D) of the
Act, and 20 CFR 404.1508 and 416.908.
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symptoms alone.10 In this SSR, we
explain that IC, when accompanied by
appropriate symptoms and medical
signs or laboratory findings, is an MDI
that can be the basis for a finding of
‘‘disability.’’ We also explain how we
evaluate IC in disability claims.
Policy Interpretation
IC constitutes an MDI when
producing appropriate symptoms and
medical signs or laboratory findings,
and may result in a disabling
impairment. There are some signs and
findings that could indicate IC, but there
are no specific signs or findings that are
universally accepted. However, for our
program purposes, we are choosing to
rely upon certain signs and findings to
establish the existence of an MDI of IC.
Once we establish that a person has an
MDI of IC by taking into consideration
these signs or findings, we use the
sequential evaluation process to
determine whether the person is
disabled. This policy interpretation
clarifies how our adjudicators should
apply our regulations in establishing an
MDI of IC and determining disability
under titles II and XVI of the Act.
I. What is IC?
A. IC is a complex genitourinary
disorder resulting in recurring pain or
discomfort in the bladder and pelvic
region. The AUA and other medical
experts characterize IC, in part, as an
unpleasant sensation (pain, pressure,
discomfort) perceived to be related to
the urinary bladder, associated with
lower urinary tract symptoms of more
than six weeks duration, in the absence
of infection or other identifiable causes.
IC is most common in women and
sometimes occurs before age 18.11 It is
not unusual for people to have
prodromal (early predictive) symptoms
years or decades before they get IC.
Prodromal symptoms may include
periodic episodes of urinary frequency,
bladder pain, or pelvic pain.
B. In accordance with the AUA
guidelines, a physician should make a
diagnosis of IC only after reviewing the
person’s medical history and
conducting a physical examination. The
physician should also conduct
laboratory tests to rule out certain
medical conditions that may result in
the same or similar symptoms. For
example, the AUA guidelines
recommend a basic laboratory
10 See sections 223(d)(5)(A) and 1614(a)(3)(D) of
the Act; 20 CFR 404.1508 and 416.908; and SSR 96–
4p.
11 See NIDDK National Kidney and Urologic
Diseases Information Clearinghouse (available at:
https://kidney.niddk.nih.gov/KUDiseases/pubs/
interstitialcystitis/index.aspx).
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examination that includes urinalysis
and urine culture. NIDDK notes that
diagnostic tests physicians may also use
to rule out other conditions include
cystoscopy, biopsy of the bladder wall
and urethra, distention of the bladder
under anesthesia, and, in men, culture
of prostate secretions.12
C. IC may co-occur with fibromyalgia,
chronic fatigue syndrome, irritable
bowel syndrome, inflammatory bowel
disease, vulvodynia, chronic headaches,
¨
Sjogren’s syndrome, endometriosis, or
systemic lupus erythematosus.
D. Treatments for IC are mostly
directed at symptom control. They
include, but are not limited to: Changes
in diet; physical therapy and pelvic
floor strengthening exercises; stress
management; bladder distention;
bladder instillation; oral drugs, such as
prescription drugs indicated for IC (for
example, Elmiron and dimethyl
sulfoxide), antidepressants,
antihistamines, antacids, anticoagulants,
and narcotic analgesics; transcutaneous
electrical nerve stimulation; and
surgery, such as substitution cystoplasty
or urinary diversion with or without
cystectomy. Treatment is not effective
for everyone because response varies
among patients.
II. How does a person establish an MDI
of IC?
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A. General
1. A person can establish that he or
she has an MDI of IC by providing
appropriate evidence from an acceptable
medical source.13 A licensed physician
(a medical or osteopathic doctor) is the
only acceptable medical source who can
provide evidence establishing an MDI of
IC. This acceptable medical source often
is the person’s treating source(s) who
makes the diagnosis of IC. A treating
source(s) may be the person’s own
physician or other acceptable medical
source who provides, or has provided,
medical evaluation or treatment and
who has, or has had, an ongoing
treatment relationship with the
person.14
2. We generally will rely on the
judgment of a licensed physician who
has made a diagnosis of IC. The
12 Descriptions of these tests are available at
https://kidney.niddk.nih.gov/kudiseases/pubs/
interstitialcystitis/#diagnosis. Evidence that a
physician used any of these tests or other laboratory
tests to make a diagnosis of IC (that is, to rule out
other diseases that could explain the person’s
symptoms) helps establish the existence of an MDI
of IC.
13 See 20 CFR 404.1513(a) and 416.913(a).
14 We may consider an acceptable medical source
who has treated or evaluated the person only a few
times or only after long intervals (for example,
twice a year) to be a treating source. See 20 CFR
404.1502 and 416.902.
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evidence must document that this
physician reviewed the person’s
medical history and conducted a
physical examination, and that his or
her diagnosis is not inconsistent with
the other substantial evidence in the
person’s case record.15 However, we
cannot rely on the physician’s diagnosis
alone to establish an MDI of IC. The
physician may make a diagnosis of IC
based only on the person’s reported
symptoms, after examining the person
and ruling out other diseases that could
cause the symptoms. Thus, as
previously mentioned, there must also
be medical signs or laboratory findings
to establish an MDI of IC.
3. If we cannot establish that a person
has an MDI of IC, but there is evidence
of another MDI, we will not evaluate the
impairment under this SSR. Instead, we
will evaluate it under the rules that
apply for that impairment.
B. Symptoms. IC symptoms may vary
in incidence, duration, and severity
from person to person, and even in the
same person. For example, a woman’s
symptoms may worsen around the time
of menstruation. Symptoms of IC
include, but are not limited to:
1. Pain. People who have IC report
chronic bladder and pelvic pain,
pressure, and discomfort. This pain may
range from mild discomfort to extreme
distress. The intensity of the pain may
increase as the bladder fills and
decrease as it empties. In addition to
bladder and pelvic pain, people with IC
may experience vaginal, testicular,
penile, low back, or thigh pain.
2. Urinary urgency and frequency.
People who have IC may report an
urgent need to urinate (urgency) or a
frequent need to urinate (frequency), or
both. Some people with severe cases of
IC may need to void as often as 60 times
per day, including nighttime urinary
frequency (nocturia) with associated
sleep disruption.16
15 We use the term ‘‘not inconsistent’’ to indicate
that a diagnosis of IC need not be supported directly
by all the other evidence (that is, it does not have
to be consistent with all the other evidence) as long
as there is no other substantial evidence in the case
record that contradicts or conflicts with the
diagnosis. Whether a diagnosis of IC is ‘‘not
inconsistent’’ with the other substantial evidence is
a judgment that adjudicators must make in each
case. In situations in which the diagnosis of IC is
inconsistent with the other substantial evidence in
the person’s case record, the adjudicator may
determine that the diagnosis is not entitled to
‘‘controlling weight’’ in establishing whether the
person has an MDI. However, the adjudicator
should not reject the diagnosis, but instead must
weigh it using all of the factors provided in 20 CFR
404.1527 and 416.927. See SSR 96–2p, Titles II and
XVI: Giving Controlling Weight to Treating Source
Medical Opinions, 61 FR 34492 2006 (also available
at: https://www.socialsecurity.gov/OP_Home/
rulings/di/01/SSR96-02-di-01.html).
16 See NIDDK National Kidney and Urologic
Diseases Information Clearinghouse (available at:
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14217
3. Other symptoms. In addition to
chronic pain and urinary urgency or
frequency or both, the person may
report additional IC symptoms, such as:
• Suprapubic tenderness on physical
examination;
• Sexual dysfunction (including
dyspareunia);
• Sleep dysfunction; and
• Chronic fatigue or tiredness.
C. Medical signs. Medical signs can
support a diagnosis of IC and help
establish the MDI. These signs include
the following, which can be detected
during a medical procedure that
stretches the bladder with fluid
(cystoscopy under anesthesia with
bladder distention): 17
1. Fibrosis (bladder-wall stiffening);
2. Diffuse glomerulations (pinpoint
bleeding caused by recurrent irritation)
on the bladder wall; and
3. Hunner’s ulcers (patches of broken
skin) on the bladder wall.18
D. Laboratory findings. Laboratory test
findings can also support a diagnosis of
IC. We will make every reasonable effort
to obtain the results of appropriate
laboratory testing. However, we will not
purchase complex, costly, or invasive
tests. Some laboratory tests and findings
are more widely used and accepted than
others. The following laboratory
findings can help establish an MDI of
IC:
1. Repeated sterile urine cultures
while IC symptoms continue;
2. Positive potassium sensitivity test
(Parson’s test); 19 and
3. Antiproliferative factor (APF)
accumulation in the urine.20
E. Other signs and findings. Because
of the ongoing research into the etiology
and manifestations of IC, the medical
criteria discussed above are only
examples of signs and laboratory
findings that help establish an MDI of
IC; they are not all-inclusive. As
medical research advances regarding IC,
we may rely on other signs and
laboratory findings to help establish an
MDI of IC. For example, gene studies are
exploring whether there are various
https://kidney.niddk.nih.gov/KUDiseases/pubs/
interstitialcystitis/index.aspx.) As used by the
NIDDK, the word ‘‘severe’’ is not meant in the same
sense that we use the word to describe a severe
impairment at the second step of our sequential
evaluation process.
17 We will not purchase this procedure to
establish an MDI of IC because it is an invasive
procedure.
18 Hunner’s ulcers are rare and may be present in
only 5–10 percent of individuals with IC.
19 Although validated by some studies, the
potassium sensitivity test is not yet recommended
for routine clinical use and can be painful for the
patient. We will not purchase this procedure to
establish an MDI of IC because it is an invasive
procedure.
20 Physicians do not routinely measure APF.
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subtypes of IC. Thus, we may document
the existence of IC as an MDI with
medical signs and laboratory findings
other than those listed above, provided
such evidence is consistent with
medically accepted clinical practice and
the other evidence in the case record.
F. Mental conditions. People who
have IC may report ongoing mental
conditions directly associated with their
IC. For example, a person may report
having anxiety or depression associated
with IC symptoms of chronic bladder
and pelvic pain, and urinary urgency,
frequency, or both. When these mental
conditions are documented by mental
status examination(s) or psychological
testing, they may constitute medical
signs or (in the case of psychological
testing) laboratory findings that help
establish an MDI of IC.21
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III. How do we document IC?
A. General. In cases of alleged IC, we
generally need to have longitudinal
evidence because symptoms, signs, and
laboratory findings of IC may fluctuate
in frequency and severity and may
continue over a period of months or
years.
1. Longitudinal clinical records
reflecting ongoing medical evaluation
and treatment from the person’s medical
sources, especially treating sources, are
extremely helpful in documenting the
presence of any signs or laboratory
findings, as well as the person’s
limitations over time. The longitudinal
record should contain medical
observations, information about
treatment, the person’s response to
treatment, and a detailed description of
how the impairment affects the person’s
ability to function.
2. In addition to obtaining evidence
from a physician, we may request
evidence from other acceptable medical
sources, such as psychologists, both to
determine whether the person has
another MDI(s) and to evaluate the
severity and functional effects of IC in
combination with other impairments the
person may have. Under our regulations
and SSR 06–03p, we also may consider
evidence from other medical sources we
do not consider acceptable medical
sources to help us evaluate the severity
and functional effects of the
impairment(s).22 Nurse practitioners,
physician assistants, and physical
21 See
20 CFR 404.1528 and 416.928.
20 CFR 404.1513(d)(1), 416.913(d)(1); SSR
06–03p: Titles II and XVI: Considering Opinions
and Other Evidence from Sources Who Are Not
‘‘Acceptable Medical Sources’’ in Disability Claims;
Considering Decisions on Disability by Other
Governmental and Nongovernmental Agencies, 71
FR 45593 (2006) (also available at: https://
www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03di-01.html).
22 See
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therapists are examples of these other
medical sources.
3. Information from nonmedical
sources can also help us evaluate the
severity of a person’s IC.23 This
information may help us assess the
person’s ability to function day-to-day
and over time. It may also help us when
we make findings about credibility of
the person’s allegations about symptoms
and their effects. Examples of
nonmedical sources include:
• Spouses, parents, siblings, other
relatives, neighbors, friends, and clergy;
• Past employers, rehabilitation
counselors, and teachers; and
• Statements from SSA and State
agency personnel who interviewed the
person.
4. Before we make a determination
whether or not the person is disabled,
we will make every reasonable effort to
develop his or her complete medical
history and help the person get medical
reports from his or her medical sources.
Generally, we will request evidence
from the person’s medical sources for
the 12-month period preceding the
month of application unless there is
reason to believe that development of an
earlier period is necessary, or unless the
alleged onset of disability is less than 12
months before the date of application.24
5. When the alleged onset of disability
secondary to IC occurred less than 12
months before adjudication, we must
evaluate the medical evidence and
project the degree of impairment
severity that is likely to exist at the end
of 12 months.25 Information about the
person’s treatment and response to
treatment, including any medical source
opinions about the person’s prognosis at
the end of 12 months, helps us decide
whether to expect an MDI of IC to be of
disabling severity for at least 12
consecutive months.
B. What do we do if there is insufficient
evidence to determine whether the
person has an MDI of IC or is disabled?
1. When there is insufficient evidence
for us to determine whether the person
has an MDI of IC or is disabled, we may
23 See 20 CFR 404.1513(d)(2–4) and 416.913(d)(2–
4), and also SSR 06–03p.
24 See 20 CFR 404.1512(d) and 416.912(d).
25 To meet the statutory requirement for
‘‘disability,’’ a person must have been unable to
engage in any substantial gainful activity because of
any medically determinable physical or mental
impairment that is expected to result in death or
that has lasted or can be expected to last for a
continuous period of not less than 12 months. Thus,
the existence of an impairment(s) for 12 continuous
months is not controlling; rather, it is the existence
of a disabling impairment that has lasted or can be
expected to last for at least 12 months that meets
the duration requirement of the Act. See 20 CFR
404.1509 and 416.909.
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take one or more actions to try to resolve
the insufficiency: 26
• We may recontact the person’s
treating or other source(s) to see if the
information we need is available;
• We may request additional existing
records from treating or other sources;
• We may ask the person or others for
more information; or
• We may purchase a consultative
examination (CE) at our expense.27
2. When we are unable to resolve an
insufficiency in the evidence, and we
need to determine whether the person
has an MDI of IC or is disabled, we may
make a determination or decision based
on the evidence we have.28
C. How do we resolve conflicts in the
evidence? Conflicting evidence in the
medical record is not unusual in cases
of IC due to the complicated diagnostic
process involved. We will consider
conflicting medical evidence in
accordance with our rules.29
IV. How do we evaluate a person’s
statements about his or her symptoms
and functional limitations?
Generally, we follow a two-step
symptom evaluation process:
A. First step of the symptom
evaluation process. There must be
medical signs or laboratory findings that
show the person has an MDI(s) which
we could reasonably expect to produce
the pain or other symptoms alleged.30 If
we find that a person has an MDI that
we could reasonably expect to produce
the alleged symptoms, the first step of
our two-step process for evaluating
symptoms is satisfied.
B. Second step of the symptom
evaluation process. After finding that
the MDI could reasonably be expected
to produce the alleged symptoms, we
evaluate the intensity and persistence of
the person’s symptoms and determine
the extent to which they limit the
person’s functional capacity for work. In
evaluating the intensity, persistence,
and functionally limiting effects of
symptoms, we consider all of the
evidence in the case record, including
the person’s daily activities;
26 See
20 CFR 404.1520b(c) and 416.920b(c).
20 CFR 404.1520b(c)(3), and
416.920b(c)(3). The type of CE we purchase will
depend on the nature of the person’s symptoms and
the extent of the evidence already in the case
record. For example, we may purchase a CE to help
evaluate depression, anxiety, or other mental
conditions associated with the person’s IC. We may
purchase a CE without recontacting a person’s
treating or other source if the source cannot provide
the necessary information or the information is not
available from the source. See 20 CFR 404.1519a(b)
and 416.919a(b).
28 See 20 CFR 404.1520b(d) and 416.920b(d).
29 See 20 CFR 404.1520b and 416.920b.
30 See 20 CFR 404.1520, 416.920, and 416.924.
27 See
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medications or other treatments the
person uses, or has used, to alleviate
symptoms; the nature and frequency of
the person’s attempts to obtain medical
treatment for symptoms; and statements
by other people about the person’s
symptoms. We will make a finding
about the extent to which symptoms,
such as pain, affect his or her capacity
to perform basic work activities.31 When
we need additional information to
assess the person’s statements about
symptoms and their effects, we will
make every reasonable effort to obtain
available information that could shed
light on the person’s statements.
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V. How do we find a person disabled
based on an MDI of IC?
Once we establish that a person has
an MDI of IC, we will consider this MDI
in the sequential evaluation process to
determine whether the person is
disabled.32 As we explain in section VI
below, we consider the severity of the
impairment, whether the impairment
meets or medically equals the
requirements of a listed impairment,
and whether the impairment prevents
the person from doing his or her past
relevant work or other work that exists
in significant numbers in the national
economy.
VI. How do we use the sequential
evaluation process to evaluate IC?
We adjudicate claims involving IC
using the sequential evaluation process,
just as we do for any impairment. Once
we find that an MDI(s) exists (see
section II), we must establish the
severity of the impairment(s) based on
the totality of signs, symptoms, and
laboratory findings, and the effects of
the impairment(s), including any related
symptoms, on the person’s ability to
function. Additionally, several other
disorders may share characteristics
similar to those of IC. When there is
evidence of the potential presence of
another disorder that may adequately
explain the person’s symptoms, it may
be necessary to pursue additional
medical or other development. As
mentioned, if we cannot find that the
person has an MDI of IC but there is
evidence of another MDI, we will not
evaluate the impairment under this SSR.
Instead, we will evaluate it under the
rules that apply for that impairment.
A. Step 1. We consider the person’s
work activity. If a person with IC is
31 See 20 CFR 404.1529 and 416.929. See also SSR
96–7p: Titles II and XVI: Evaluation of Symptoms
in Disability Claims: Assessing the Credibility of an
Individual’s Statements, 61 FR 34483 (1996) (also
available at: https://www.socialsecurity.gov/OP_
Home/rulings/di/01/SSR96-07-di-01.html).
32 See 20 CFR 404.1520, 416.920, and 416.924.
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19:00 Mar 17, 2015
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engaged in substantial gainful activity,
we will find that he or she is not
disabled.
B. Step 2. If we find that a person with
IC has an MDI that meets the duration
requirement,33 and the person alleges
pain and other symptoms consistent
with IC, we must consider these
symptoms in deciding whether the
person’s impairment is ‘‘severe’’ at step
2 of the sequential evaluation process,
and at any later steps reached in the
sequential evaluation process. If we find
that the person’s pain, urinary urgency
or urinary frequency, or other symptoms
have more than a minimal effect on a
person’s ability to perform basic work
activities, we must find that the person
has a ‘‘severe’’ impairment.34
C. Step 3. When we find that a person
with IC has a severe MDI, we must
proceed to step three and consider the
medical severity of the impairment(s).
At this step, we consider whether a
person’s impairment(s) meets or equals
in severity one of the impairments in
the Listing of Impairments.35 IC is not
a listed impairment; therefore, we
cannot find that a person with IC alone
has an impairment that meets a listing.
However, we will compare the specific
findings in each case to any pertinent
listing to determine whether medical
equivalence may exist.36 We also may
find medical equivalence if the person
has multiple impairments, including IC,
none of which meets or medically
equals the requirements of a listing, but
the combination of impairments is
medically equivalent in severity to a
listed impairment. In cases in which a
person with IC has psychological
manifestations related to IC, we must
consider whether the person’s
impairment meets or equals the severity
of any impairment in the mental
disorders listings (see section IIF).37
D. Steps 4 and 5. For those
impairments that do not meet or
medically equal the severity of a listing,
33 See
20 CFR 404.1509 and 416.909.
SSR 96–3p: Titles II and XVI: Considering
Allegations of Pain and Other Symptoms in
Determining Whether a Medically Determinable
Impairment Is Severe, 61 FR 34468 (1996) (also
available at: https://www.ssa.gov/OP_Home/rulings/
di/01/SSR96-03-di-01.html).
35 See 20 CFR, part 404, subpart P, appendix 1.
36 In evaluating title XVI claims for disability
benefits for people under age 18, we will consider
whether the impairment(s) functionally equals the
listings. See 20 CFR 416.926a. For example, the
functional limitations of IC, by itself or in
combination with another impairment(s), may
establish an extreme limitation in one broad area of
functioning (for example, attending and completing
tasks) or marked limitation in two broad areas (for
example, attending and completing tasks, and
interacting or relating with others).
37 See sections 12.00 and 112.00 of 20 CFR, part
404, subpart P, appendix 1.
34 See
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14219
we must make an assessment of the
person’s residual functional capacity
(RFC). The RFC assessment must be
based on all the relevant evidence in the
record.38 In assessing RFC related to an
MDI of IC, we must consider all of the
person’s impairment-related symptoms
in deciding how such symptoms may
affect functional capacity.39 For
example, many people with IC have
chronic pelvic pain, which can affect
the ability to focus and sustain attention
on the task at hand. Nocturia may
disrupt sleeping patterns and lead to
drowsiness and lack of mental clarity
during the day. Urinary frequency can
necessitate trips to the bathroom as
often as every 10 to 15 minutes, day and
night. Consequently, some individuals
with IC essentially may confine
themselves to their homes. After we
consider such impairment-related
symptoms and we make our RFC
assessment, our evaluation must
proceed to the fourth step of the
sequential evaluation process, unless an
expedited process applies.40 If
necessary, we then proceed to the fifth
step of the sequential evaluation
process.41 If we do not use an expedited
process, we must determine whether the
person’s impairment(s) precludes the
performance of past relevant work
(unless we determine that there was no
past relevant work). If we determine that
the person’s impairment(s) precludes
performance of past relevant work or
there was no past relevant work, we
must make a finding about the person’s
ability to perform other work. We must
apply the usual vocational
considerations in determining the
person’s ability to perform other work.42
38 See 20 CFR 404.1545(a) and 416.945(a), and
also SSR 96–8p: Titles II and XVI: Assessing
Residual Functional Capacity in Initial Claims, 61
FR 34474 (1996) (also available at https://
www.ssa.gov/OP_Home/rulings/di/01/SSR96-08-di01.html). Our RFC assessments must consider the
person’s maximum ability to do sustained work
activities in an ordinary work setting on a regular
and continuous basis. Generally, a ‘‘regular and
continuous basis’’ means eight hours a day, for five
days a week, or an equivalent work schedule of 40
hours per week. In cases involving IC, chronic
fatigue may affect the person’s physical and mental
ability to sustain work activity, and this may be
especially true in cases involving urinary
frequency.
39 See 20 CFR 404.1529(d) and 416.929(d), and
SSR 96–7p.
40 See 20 CFR 404.1520(h) and 416.920(h).
41 The fourth and fifth steps of the sequential
evaluation process are not applicable to claims for
benefits under title XVI for people under age 18.
See 20 CFR 416.924.
42 See 20 CFR 404.1560–404.1569a and 416.960–
416.969a, and SSR 11–2p: Titles II and XVI:
Documenting and Evaluating Disability in Young
Adults, 76 FR 56263 (2011) (also available at
https://www.ssa.gov/OP_Home/rulings/di/01/
SSR2011-02-di-01.html).
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mstockstill on DSK4VPTVN1PROD with NOTICES
1. Pain and other symptoms
associated with IC may result in
exertional limitations that prevent a
person from doing a full range of
unskilled work in one or more of the
exertional categories in appendix 2 of
subpart P of part 404 (appendix 2).43
People with IC may also have
nonexertional physical or mental
limitations because of their pain or
other symptoms.44 Some may have
environmental restrictions, which are
also nonexertional.
2. Exertional and nonexertional
limitations resulting from IC may affect
the person’s ability to perform routine
movement and necessary physical
activity in the work environment, such
as sitting, standing, walking, lifting,
carrying, pushing, and pulling. These
limitations may also affect the person’s
ability to do postural functions, such as
climbing, balancing, stooping, and
crouching, or they may affect the
person’s ability to tolerate extreme heat,
humidity, or hazards.
3. Adjudicators must be alert to the
possibility that there may be exertional
or nonexertional (for example, postural
or environmental) limitations that erode
a person’s occupational base sufficiently
to preclude the use of a rule in appendix
2 to direct a decision. In such cases,
adjudicators must use the rules in
appendix 2 as a framework for decisionmaking and may need to consult a
vocational resource.45
E. Continuing disability reviews. In
those cases in which we find that a
person has a disability based on IC, we
will conduct an appropriate continuing
disability review as required by law.46
For this review, we take into account
relevant individual case facts, such as
the combined severity of other chronic
43 See SSR 83–12: Title II and SVI: Capability To
Do Other Work—The Medical-Vocational Rules as
a Framework for Evaluating Exertional Limitations
Within a Range of Work or Between Ranges of Work
(available at https://www.socialsecurity.gov/OP_
Home/rulings/di/02/SSR83-12-di-02.html).
44 See SSR 85–15: Titles II and XVI: Capability To
Do Other Work—Medical-Vocational Rules as a
Framework for Evaluating Solely Nonexertional
Impairments (available at: https://
www. social security. gov/OP_Home/rulings/di/02/
SSR85-15-di-02.html).
45 See SSR 83–12; SSR 83–14: Titles II and XVI:
Capability To Do Other Work—The MedicalVocational Rules as a Framework for Evaluating a
Combination of Exertional and Nonexertional
Impairments (available at https://www.social
security.gov/OP_Home/rulings/di/02/SSR83-14-di02.html); SSR 85–15; and SSR 96–9p, Titles II and
XVI: Determining Capability to Do Other Work—
Implications of a Residual Functional Capacity for
Less Than a Full Range of Sedentary Work, 61 FR
34478 (July 2, 1996) (also available at https://www.
socialsecurity.gov/OP_Home/rulings/di/01/SSR9609-di-01.html).
46 See 20 CFR 404.1594, 416.994, and 416.994a.
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or static impairments, and the person’s
vocational factors.
Effective Date: This SSR is effective
on March 18, 2015.
Cross-References: SSR 82–63: Titles II
and XVI: Medical-Vocational Profiles
Showing an Inability To Make an
Adjustment to Other Work; SSR 83–12:
Titles II and XVI: Capability To Do
Other Work—The Medical-Vocational
Rules as a Framework for Evaluating
Exertional Limitations Within a Range
of Work or Between Ranges of Work;
SSR 83–14: Titles II and XVI: Capability
To Do Other Work—The MedicalVocational Rules as a Framework for
Evaluating a Combination of Exertional
and Nonexertional Impairments; SSR
85–15: Titles II and XVI: Capability To
Do Other Work—The MedicalVocational Rules as a Framework for
Evaluating Solely Nonexertional
Impairments; SSR 96–2p, Titles II and
XVI: Giving Controlling Weight to
Treating Source Medical Opinions; SSR
96–3p, Titles II and XVI: Considering
Allegations of Pain and Other
Symptoms in Determining Whether a
Medically Determinable Impairment Is
Severe; SSR 96–4p, Titles II and XVI:
Symptoms, Medically Determinable
Physical and Mental Impairments, and
Exertional and Nonexertional
Limitations; SSR 96–5p, Titles II and
XVI: Medical Source Opinions on Issues
Reserved to the Commissioner; SSR 96–
7p, Titles II and XVI: Evaluation of
Symptoms in Disability Claims:
Assessing the Credibility of an
Individual’s Statements; SSR 96–8p,
Titles II and XVI: Assessing Residual
Functional Capacity in Initial Claims;
SSR 96–9p, Titles II and XVI:
Determining Capability to Do Other
Work—Implications of a Residual
Functional Capacity for Less Than a
Full Range of Sedentary Work; SSR 06–
03p, Titles II and XVI: Considering
Opinions and Other Evidence from
Sources Who Are Not ‘‘Acceptable
Medical Sources’’ in Disability Claims;
Considering Decisions on Disability by
Other Governmental and
Nongovernmental Agencies; SSR 12–2p,
Titles II and XVI: Evaluation of
Fibromyalgia; SSR 14–1p, Titles II and
XVI: Evaluating Cases Involving Chronic
Fatigue Syndrome (CFS); and Program
Operations Manual System (POMS) DI
22505.001, DI 22505.003, DI 24505.003,
DI 24510.057, DI 24515.012, DI
24515.061–DI 24515.063, DI 24515.066,
DI 24515.067, DI 24515.075, DI
24555.001, DI 25010.001, and DI
25025.001.
[FR Doc. 2015–05680 Filed 3–17–15; 8:45 am]
BILLING CODE 4191–02–P
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DEPARTMENT OF TRANSPORTATION
Federal Motor Carrier Safety
Administration
[Docket No. FMCSA–2013–0022]
Qualification of Drivers; Exemption
Applications; Vision
Federal Motor Carrier Safety
Administration (FMCSA), DOT.
ACTION: Notice of renewal of
exemptions; request for comments.
AGENCY:
FMCSA announces its
decision to renew the exemptions from
the vision requirement in the Federal
Motor Carrier Safety Regulations for 11
individuals. FMCSA has statutory
authority to exempt individuals from
the vision requirement if the
exemptions granted will not
compromise safety. The Agency has
concluded that granting these
exemption renewals will provide a level
of safety that is equivalent to or greater
than the level of safety maintained
without the exemptions for these
commercial motor vehicle (CMV)
drivers.
SUMMARY:
This decision is effective April
16, 2015. Comments must be received
on or before April 17, 2015.
ADDRESSES: You may submit comments
bearing the Federal Docket Management
System (FDMS) numbers: Docket No.
[Docket No. FMCSA–2013–0022], using
any of the following methods:
• Federal eRulemaking Portal: Go to
https://www.regulations.gov. Follow the
on-line instructions for submitting
comments.
• Mail: Docket Management Facility;
U.S. Department of Transportation, 1200
New Jersey Avenue SE., West Building
Ground Floor, Room W12–140,
Washington, DC 20590–0001.
• Hand Delivery or Courier: West
Building Ground Floor, Room W12–140,
1200 New Jersey Avenue SE.,
Washington, DC, between 9 a.m. and 5
p.m., Monday through Friday, except
Federal Holidays.
• Fax: 1–202–493–2251.
Instructions: Each submission must
include the Agency name and the
docket number for this notice. Note that
DOT posts all comments received
without change to https://
www.regulations.gov, including any
personal information included in a
comment. Please see the Privacy Act
heading below.
Docket: For access to the docket to
read background documents or
comments, go to https://
www.regulations.gov at any time or
Room W12–140 on the ground level of
DATES:
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]]>Agencies
[Federal Register Volume 80, Number 52 (Wednesday, March 18, 2015)]
[Notices]
[Pages 14215-14220]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2015-05680]
=======================================================================
-----------------------------------------------------------------------
SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA-2014-0053]
Social Security Ruling, SSR 15-1p; Titles II and XVI: Evaluating
Cases Involving Interstitial Cystitis (IC)
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling (SSR).
-----------------------------------------------------------------------
SUMMARY: We are providing notice of SSR 15-1p. This SSR provides
guidance on how we develop evidence to establish that a person has a
medically determinable impairment of interstitial cystitis (IC), and
how we evaluate IC in disability claims and continuing disability
reviews under titles II and XVI of the Social Security Act.
DATES: Effective Date: March 18, 2015.
FOR FURTHER INFORMATION CONTACT: Cheryl 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 in accordance with
20 CFR 402.35(b)(1).
Through SSRs, we convey to the public SSA precedential decisions
relating to the Federal old-age, survivors, disability, supplemental
security income, and special veterans benefits programs. We may base
SSRs on determinations or decisions made at all levels of
administrative adjudication, Federal court decisions, Commissioner's
decisions, opinions of the Office of the General Counsel, or other
interpretations of the law and regulations.
Although SSRs do not have the same force and effect as statutes or
regulations, they are binding on all components of the Social Security
Administration. 20 CFR 402.35(b)(1).
This SSR will remain in effect until we publish a notice in the
Federal Register that rescinds it, or we publish a new SSR that
replaces or modifies it.
(Catalog of Federal Domestic Assistance, Programs Nos. 96.001,
Social Security--Disability Insurance; 96.002, Social Security--
Retirement Insurance; 96.004, Social Security--Survivors Insurance;
96.006--Supplemental Security Income.)
Dated: March 3, 2015.
Carolyn W. Colvin,
Acting Commissioner of Social Security.
Policy Interpretation Ruling
Titles II and XVI: Evaluating Cases Involving Interstitial Cystitis
(IC)
This Social Security Ruling (SSR) rescinds and replaces SSR 02-2p:
``Titles II and XVI: Evaluation of Interstitial Cystitis.'' \1\
---------------------------------------------------------------------------
\1\ We will use this Social Security Ruling (SSR) beginning on
its effective date. We will apply this SSR to new applications filed
on or after the effective date of the SSR and to claims that are
pending on and after the effective date. This means that we will use
these rules on and after their effective date in any case in which
we make a determination or decision. We expect that Federal courts
will review our final decisions using the rules that were in effect
at the time we issued the decisions. If a court reverses our final
rules and remands a case for further administrative proceedings
after the effective date of these final rules, we will apply these
final rules to the entire period at issue in the decision we make
after the court's remand.
---------------------------------------------------------------------------
Purpose: This SSR clarifies our policy on how we develop evidence
to establish that a person has a medically determinable impairment
(MDI) of IC and how we evaluate this impairment in disability claims
and continuing disability reviews under titles II and XVI of the Social
Security Act (Act).\2\
---------------------------------------------------------------------------
\2\ For simplicity, we refer in this SSR only to initial adult
claims for disability benefits under titles II and XVI of the Act
and to the steps of the sequential evaluation process we use to
determine disability in those claims. 20 CFR 404.1520 and 416.920.
The policy interpretations in this SSR apply to all cases in which
we must make determinations about disability, including claims of
children (that is, people who have not attained age 18) who apply
for benefits based on disability under title XVI of the Act,
disability redeterminations for children who became eligible for
Supplemental Security Income under title XVI as a child and who were
eligible for such benefits for the month before the month in which
they attained age 18, and to continuing disability reviews of adults
and children under titles II and XVI of the Act. 20 CFR 404.1594,
416.924, 416.987, 416.994, and 416.994a.
---------------------------------------------------------------------------
[[Page 14216]]
Citations: Sections 216(i), 223(d), 223(f), 1614(a)(3) and
1614(a)(4) of the Social Security Act, as amended; Regulations No. 4,
subpart P, sections 404.1502, 404.1505, 04.1508-404.1513, 404.1519a,
404.1520, 404.1520a, 404.1520b, 404.1521, 404.1523, 404.1526, 404.1527-
404.1529, 404.1545, 404.1560-404.1569a, 404.1593, 404.1594, appendices
1 and 2; and Regulations No. 16, subpart I, sections 416.902, 416.905,
416.906, 416.908-416.913, 416.919a, 416.920, 416.920a, 416.920b,
416.921, 416.923, 416.924, 416.924a, 416.926, 416.926a, 416.925,
416.927-416.929, 416.945, 416.960-416-969a, 416.987, 416.993, 416.994,
and 416.994a.
Introduction
IC is a complex genitourinary disorder involving recurring pain or
discomfort in the bladder and pelvic region. The American Urological
Association (AUA), National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK), and other medical experts may use the terms
``interstitial cystitis/bladder pain syndrome (IC/BPS)'' and
``interstitial cystitis/painful bladder syndrome (IC/PBS)'' to describe
this disorder because they consider the term ``interstitial cystitis''
to be synonymous with the terms ``bladder pain syndrome'' and ``painful
bladder syndrome.'' When we refer to IC in this SSR, we include IC/BPS
and IC/PBS.
The AUA has developed guidelines providing a clinical framework for
diagnosing and treating IC/BPS.\3\ These guidelines use a definition of
IC accepted by the Society for Urodynamics and Female Urology: ``An
unpleasant sensation (pain, pressure, discomfort) perceived to be
related to the urinary bladder, associated with lower urinary tract
symptoms of more than six weeks duration, in the absence of infection
or other identifiable causes.'' \4\ NIDDK's National Kidney and
Urologic Diseases Information Clearinghouse explains that the term IC/
PBS (and IC/BPS) includes all cases of urinary pain not attributed to
other causes, such as infection or urinary stones.\5\ NIDDK further
explains that the term ``interstitial cystitis'' is used alone (without
PBS or BPS) to describe cases of urinary pain that meet all of the IC
criteria NIDDK established in 1987 for research purposes.\6\ We took
into consideration the AUA and NIDDK descriptions of IC when we
formulated the criteria in this SSR. For example, we adapted the AUA
and NIDDK descriptions to help develop criteria for establishing an MDI
of IC.\7\
---------------------------------------------------------------------------
\3\ Hanno, P.M., et al., Diagnosis and treatment of interstitial
cystitis/bladder pain syndrome, American Urological Association,
(2014) (available at: https://www.auanet.org/common/pdf/education/clinical-guidance/IC-Bladder-Pain-Syndrome-Revised.pdf).
\4\ Hanno, P. and Dmochowski, R., Status of international
consensus on interstitial cystitis/bladder pain syndrome/painful
bladder syndrome: 2008 snapshot, Neurology and Urodynamics,
Apr;28(4), 274-286 (2009).
\5\ See NIDDK National Kidney and Urologic Diseases Information
Clearinghouse, ``Interstitial Cystitis/Painful Bladder Syndrome''
(2013) available at: https://kidney.niddk.nih.gov/KUDiseases/pubs/interstitialcystitis/index.aspx.
\6\ Gillenwater, J.Y., et al., Summary of the National Institute
of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on
Interstitial Cystitis, National Institutes of Health, Bethesda,
Maryland, August 28-29, 1987, The Journal of Urology, Jul;140(1),
203-206 (1988).
\7\ We adapted the AUA and NIDDK descriptions of IC, which are
mainly symptom-based, because the Act and our regulations require a
claimant to establish by objective medical evidence (that is,
medical signs and laboratory findings) that he or she has a
medically determinable impairment. See 223(d)(5)(A) and
1614(a)(3)(D) of the Act, 20 CFR 404.1508 and 416.908, and SSR 96-
4p: Titles II and XVI: Symptoms, Medically Determinable Physical and
Mental Impairments, and Exertional and Nonexertional Limitations, 61
FR 34388 (1996) (also available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR96-04-di-01.html).
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Except for statutory blindness, we find a person to be ``disabled''
if he or she is unable to do any substantial gainful activity by reason
of a medically determinable physical or mental impairment(s) or
combination of impairments that can be expected to result in death or
has lasted or can be expected to last for a continuous period of not
less than 12 months.\8\ We require an MDI to result from anatomical,
physiological, or psychological abnormalities, as shown by medically
acceptable clinical and laboratory diagnostic techniques.\9\ The Act
and our regulations further require that medical evidence establishing
an MDI consist of signs, symptoms, and laboratory findings. Thus, we
cannot determine that a person who has IC is disabled on the basis of
his or her statement of symptoms alone.\10\ In this SSR, we explain
that IC, when accompanied by appropriate symptoms and medical signs or
laboratory findings, is an MDI that can be the basis for a finding of
``disability.'' We also explain how we evaluate IC in disability
claims.
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\8\ See 20 CFR 404.1505 and 416.905.
\9\ See sections 223(d)(3) and 1614(a)(3)(D) of the Act, and 20
CFR 404.1508 and 416.908.
\10\ See sections 223(d)(5)(A) and 1614(a)(3)(D) of the Act; 20
CFR 404.1508 and 416.908; and SSR 96-4p.
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Policy Interpretation
IC constitutes an MDI when producing appropriate symptoms and
medical signs or laboratory findings, and may result in a disabling
impairment. There are some signs and findings that could indicate IC,
but there are no specific signs or findings that are universally
accepted. However, for our program purposes, we are choosing to rely
upon certain signs and findings to establish the existence of an MDI of
IC. Once we establish that a person has an MDI of IC by taking into
consideration these signs or findings, we use the sequential evaluation
process to determine whether the person is disabled. This policy
interpretation clarifies how our adjudicators should apply our
regulations in establishing an MDI of IC and determining disability
under titles II and XVI of the Act.
I. What is IC?
A. IC is a complex genitourinary disorder resulting in recurring
pain or discomfort in the bladder and pelvic region. The AUA and other
medical experts characterize IC, in part, as an unpleasant sensation
(pain, pressure, discomfort) perceived to be related to the urinary
bladder, associated with lower urinary tract symptoms of more than six
weeks duration, in the absence of infection or other identifiable
causes. IC is most common in women and sometimes occurs before age
18.\11\ It is not unusual for people to have prodromal (early
predictive) symptoms years or decades before they get IC. Prodromal
symptoms may include periodic episodes of urinary frequency, bladder
pain, or pelvic pain.
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\11\ See NIDDK National Kidney and Urologic Diseases Information
Clearinghouse (available at: https://kidney.niddk.nih.gov/KUDiseases/pubs/interstitialcystitis/index.aspx).
---------------------------------------------------------------------------
B. In accordance with the AUA guidelines, a physician should make a
diagnosis of IC only after reviewing the person's medical history and
conducting a physical examination. The physician should also conduct
laboratory tests to rule out certain medical conditions that may result
in the same or similar symptoms. For example, the AUA guidelines
recommend a basic laboratory
[[Page 14217]]
examination that includes urinalysis and urine culture. NIDDK notes
that diagnostic tests physicians may also use to rule out other
conditions include cystoscopy, biopsy of the bladder wall and urethra,
distention of the bladder under anesthesia, and, in men, culture of
prostate secretions.\12\
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\12\ Descriptions of these tests are available at https://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/#diagnosis. Evidence that a physician used any of these tests or
other laboratory tests to make a diagnosis of IC (that is, to rule
out other diseases that could explain the person's symptoms) helps
establish the existence of an MDI of IC.
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C. IC may co-occur with fibromyalgia, chronic fatigue syndrome,
irritable bowel syndrome, inflammatory bowel disease, vulvodynia,
chronic headaches, Sj[ouml]gren's syndrome, endometriosis, or systemic
lupus erythematosus.
D. Treatments for IC are mostly directed at symptom control. They
include, but are not limited to: Changes in diet; physical therapy and
pelvic floor strengthening exercises; stress management; bladder
distention; bladder instillation; oral drugs, such as prescription
drugs indicated for IC (for example, Elmiron and dimethyl sulfoxide),
antidepressants, antihistamines, antacids, anticoagulants, and narcotic
analgesics; transcutaneous electrical nerve stimulation; and surgery,
such as substitution cystoplasty or urinary diversion with or without
cystectomy. Treatment is not effective for everyone because response
varies among patients.
II. How does a person establish an MDI of IC?
A. General
1. A person can establish that he or she has an MDI of IC by
providing appropriate evidence from an acceptable medical source.\13\ A
licensed physician (a medical or osteopathic doctor) is the only
acceptable medical source who can provide evidence establishing an MDI
of IC. This acceptable medical source often is the person's treating
source(s) who makes the diagnosis of IC. A treating source(s) may be
the person's own physician or other acceptable medical source who
provides, or has provided, medical evaluation or treatment and who has,
or has had, an ongoing treatment relationship with the person.\14\
---------------------------------------------------------------------------
\13\ See 20 CFR 404.1513(a) and 416.913(a).
\14\ We may consider an acceptable medical source who has
treated or evaluated the person only a few times or only after long
intervals (for example, twice a year) to be a treating source. See
20 CFR 404.1502 and 416.902.
---------------------------------------------------------------------------
2. We generally will rely on the judgment of a licensed physician
who has made a diagnosis of IC. The evidence must document that this
physician reviewed the person's medical history and conducted a
physical examination, and that his or her diagnosis is not inconsistent
with the other substantial evidence in the person's case record.\15\
However, we cannot rely on the physician's diagnosis alone to establish
an MDI of IC. The physician may make a diagnosis of IC based only on
the person's reported symptoms, after examining the person and ruling
out other diseases that could cause the symptoms. Thus, as previously
mentioned, there must also be medical signs or laboratory findings to
establish an MDI of IC.
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\15\ We use the term ``not inconsistent'' to indicate that a
diagnosis of IC need not be supported directly by all the other
evidence (that is, it does not have to be consistent with all the
other evidence) as long as there is no other substantial evidence in
the case record that contradicts or conflicts with the diagnosis.
Whether a diagnosis of IC is ``not inconsistent'' with the other
substantial evidence is a judgment that adjudicators must make in
each case. In situations in which the diagnosis of IC is
inconsistent with the other substantial evidence in the person's
case record, the adjudicator may determine that the diagnosis is not
entitled to ``controlling weight'' in establishing whether the
person has an MDI. However, the adjudicator should not reject the
diagnosis, but instead must weigh it using all of the factors
provided in 20 CFR 404.1527 and 416.927. See SSR 96-2p, Titles II
and XVI: Giving Controlling Weight to Treating Source Medical
Opinions, 61 FR 34492 2006 (also available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-02-di-01.html).
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3. If we cannot establish that a person has an MDI of IC, but there
is evidence of another MDI, we will not evaluate the impairment under
this SSR. Instead, we will evaluate it under the rules that apply for
that impairment.
B. Symptoms. IC symptoms may vary in incidence, duration, and
severity from person to person, and even in the same person. For
example, a woman's symptoms may worsen around the time of menstruation.
Symptoms of IC include, but are not limited to:
1. Pain. People who have IC report chronic bladder and pelvic pain,
pressure, and discomfort. This pain may range from mild discomfort to
extreme distress. The intensity of the pain may increase as the bladder
fills and decrease as it empties. In addition to bladder and pelvic
pain, people with IC may experience vaginal, testicular, penile, low
back, or thigh pain.
2. Urinary urgency and frequency. People who have IC may report an
urgent need to urinate (urgency) or a frequent need to urinate
(frequency), or both. Some people with severe cases of IC may need to
void as often as 60 times per day, including nighttime urinary
frequency (nocturia) with associated sleep disruption.\16\
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\16\ See NIDDK National Kidney and Urologic Diseases Information
Clearinghouse (available at: https://kidney.niddk.nih.gov/KUDiseases/pubs/interstitialcystitis/index.aspx.) As used by the NIDDK, the
word ``severe'' is not meant in the same sense that we use the word
to describe a severe impairment at the second step of our sequential
evaluation process.
---------------------------------------------------------------------------
3. Other symptoms. In addition to chronic pain and urinary urgency
or frequency or both, the person may report additional IC symptoms,
such as:
Suprapubic tenderness on physical examination;
Sexual dysfunction (including dyspareunia);
Sleep dysfunction; and
Chronic fatigue or tiredness.
C. Medical signs. Medical signs can support a diagnosis of IC and
help establish the MDI. These signs include the following, which can be
detected during a medical procedure that stretches the bladder with
fluid (cystoscopy under anesthesia with bladder distention): \17\
---------------------------------------------------------------------------
\17\ We will not purchase this procedure to establish an MDI of
IC because it is an invasive procedure.
---------------------------------------------------------------------------
1. Fibrosis (bladder-wall stiffening);
2. Diffuse glomerulations (pinpoint bleeding caused by recurrent
irritation) on the bladder wall; and
3. Hunner's ulcers (patches of broken skin) on the bladder
wall.\18\
---------------------------------------------------------------------------
\18\ Hunner's ulcers are rare and may be present in only 5-10
percent of individuals with IC.
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D. Laboratory findings. Laboratory test findings can also support a
diagnosis of IC. We will make every reasonable effort to obtain the
results of appropriate laboratory testing. However, we will not
purchase complex, costly, or invasive tests. Some laboratory tests and
findings are more widely used and accepted than others. The following
laboratory findings can help establish an MDI of IC:
1. Repeated sterile urine cultures while IC symptoms continue;
2. Positive potassium sensitivity test (Parson's test); \19\ and
---------------------------------------------------------------------------
\19\ Although validated by some studies, the potassium
sensitivity test is not yet recommended for routine clinical use and
can be painful for the patient. We will not purchase this procedure
to establish an MDI of IC because it is an invasive procedure.
---------------------------------------------------------------------------
3. Antiproliferative factor (APF) accumulation in the urine.\20\
---------------------------------------------------------------------------
\20\ Physicians do not routinely measure APF.
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E. Other signs and findings. Because of the ongoing research into
the etiology and manifestations of IC, the medical criteria discussed
above are only examples of signs and laboratory findings that help
establish an MDI of IC; they are not all-inclusive. As medical research
advances regarding IC, we may rely on other signs and laboratory
findings to help establish an MDI of IC. For example, gene studies are
exploring whether there are various
[[Page 14218]]
subtypes of IC. Thus, we may document the existence of IC as an MDI
with medical signs and laboratory findings other than those listed
above, provided such evidence is consistent with medically accepted
clinical practice and the other evidence in the case record.
F. Mental conditions. People who have IC may report ongoing mental
conditions directly associated with their IC. For example, a person may
report having anxiety or depression associated with IC symptoms of
chronic bladder and pelvic pain, and urinary urgency, frequency, or
both. When these mental conditions are documented by mental status
examination(s) or psychological testing, they may constitute medical
signs or (in the case of psychological testing) laboratory findings
that help establish an MDI of IC.\21\
---------------------------------------------------------------------------
\21\ See 20 CFR 404.1528 and 416.928.
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III. How do we document IC?
A. General. In cases of alleged IC, we generally need to have
longitudinal evidence because symptoms, signs, and laboratory findings
of IC may fluctuate in frequency and severity and may continue over a
period of months or years.
1. Longitudinal clinical records reflecting ongoing medical
evaluation and treatment from the person's medical sources, especially
treating sources, are extremely helpful in documenting the presence of
any signs or laboratory findings, as well as the person's limitations
over time. The longitudinal record should contain medical observations,
information about treatment, the person's response to treatment, and a
detailed description of how the impairment affects the person's ability
to function.
2. In addition to obtaining evidence from a physician, we may
request evidence from other acceptable medical sources, such as
psychologists, both to determine whether the person has another MDI(s)
and to evaluate the severity and functional effects of IC in
combination with other impairments the person may have. Under our
regulations and SSR 06-03p, we also may consider evidence from other
medical sources we do not consider acceptable medical sources to help
us evaluate the severity and functional effects of the
impairment(s).\22\ Nurse practitioners, physician assistants, and
physical therapists are examples of these other medical sources.
---------------------------------------------------------------------------
\22\ See 20 CFR 404.1513(d)(1), 416.913(d)(1); SSR 06-03p:
Titles II and XVI: Considering Opinions and Other Evidence from
Sources Who Are Not ``Acceptable Medical Sources'' in Disability
Claims; Considering Decisions on Disability by Other Governmental
and Nongovernmental Agencies, 71 FR 45593 (2006) (also available at:
https://www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03-di-01.html).
---------------------------------------------------------------------------
3. Information from nonmedical sources can also help us evaluate
the severity of a person's IC.\23\ This information may help us assess
the person's ability to function day-to-day and over time. It may also
help us when we make findings about credibility of the person's
allegations about symptoms and their effects. Examples of nonmedical
sources include:
---------------------------------------------------------------------------
\23\ See 20 CFR 404.1513(d)(2-4) and 416.913(d)(2-4), and also
SSR 06-03p.
---------------------------------------------------------------------------
Spouses, parents, siblings, other relatives, neighbors,
friends, and clergy;
Past employers, rehabilitation counselors, and teachers;
and
Statements from SSA and State agency personnel who
interviewed the person.
4. Before we make a determination whether or not the person is
disabled, we will make every reasonable effort to develop his or her
complete medical history and help the person get medical reports from
his or her medical sources. Generally, we will request evidence from
the person's medical sources for the 12-month period preceding the
month of application unless there is reason to believe that development
of an earlier period is necessary, or unless the alleged onset of
disability is less than 12 months before the date of application.\24\
---------------------------------------------------------------------------
\24\ See 20 CFR 404.1512(d) and 416.912(d).
---------------------------------------------------------------------------
5. When the alleged onset of disability secondary to IC occurred
less than 12 months before adjudication, we must evaluate the medical
evidence and project the degree of impairment severity that is likely
to exist at the end of 12 months.\25\ Information about the person's
treatment and response to treatment, including any medical source
opinions about the person's prognosis at the end of 12 months, helps us
decide whether to expect an MDI of IC to be of disabling severity for
at least 12 consecutive months.
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\25\ To meet the statutory requirement for ``disability,'' a
person must have been unable to engage in any substantial gainful
activity because of any medically determinable physical or mental
impairment that is expected to result in death or that has lasted or
can be expected to last for a continuous period of not less than 12
months. Thus, the existence of an impairment(s) for 12 continuous
months is not controlling; rather, it is the existence of a
disabling impairment that has lasted or can be expected to last for
at least 12 months that meets the duration requirement of the Act.
See 20 CFR 404.1509 and 416.909.
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B. What do we do if there is insufficient evidence to determine whether
the person has an MDI of IC or is disabled?
1. When there is insufficient evidence for us to determine whether
the person has an MDI of IC or is disabled, we may take one or more
actions to try to resolve the insufficiency: \26\
---------------------------------------------------------------------------
\26\ See 20 CFR 404.1520b(c) and 416.920b(c).
---------------------------------------------------------------------------
We may recontact the person's treating or other source(s)
to see if the information we need is available;
We may request additional existing records from treating
or other sources;
We may ask the person or others for more information; or
We may purchase a consultative examination (CE) at our
expense.\27\
---------------------------------------------------------------------------
\27\ See 20 CFR 404.1520b(c)(3), and 416.920b(c)(3). The type of
CE we purchase will depend on the nature of the person's symptoms
and the extent of the evidence already in the case record. For
example, we may purchase a CE to help evaluate depression, anxiety,
or other mental conditions associated with the person's IC. We may
purchase a CE without recontacting a person's treating or other
source if the source cannot provide the necessary information or the
information is not available from the source. See 20 CFR
404.1519a(b) and 416.919a(b).
---------------------------------------------------------------------------
2. When we are unable to resolve an insufficiency in the evidence,
and we need to determine whether the person has an MDI of IC or is
disabled, we may make a determination or decision based on the evidence
we have.\28\
---------------------------------------------------------------------------
\28\ See 20 CFR 404.1520b(d) and 416.920b(d).
---------------------------------------------------------------------------
C. How do we resolve conflicts in the evidence? Conflicting
evidence in the medical record is not unusual in cases of IC due to the
complicated diagnostic process involved. We will consider conflicting
medical evidence in accordance with our rules.\29\
---------------------------------------------------------------------------
\29\ See 20 CFR 404.1520b and 416.920b.
---------------------------------------------------------------------------
IV. How do we evaluate a person's statements about his or her symptoms
and functional limitations?
Generally, we follow a two-step symptom evaluation process:
A. First step of the symptom evaluation process. There must be
medical signs or laboratory findings that show the person has an MDI(s)
which we could reasonably expect to produce the pain or other symptoms
alleged.\30\ If we find that a person has an MDI that we could
reasonably expect to produce the alleged symptoms, the first step of
our two-step process for evaluating symptoms is satisfied.
---------------------------------------------------------------------------
\30\ See 20 CFR 404.1520, 416.920, and 416.924.
---------------------------------------------------------------------------
B. Second step of the symptom evaluation process. After finding
that the MDI could reasonably be expected to produce the alleged
symptoms, we evaluate the intensity and persistence of the person's
symptoms and determine the extent to which they limit the person's
functional capacity for work. In evaluating the intensity, persistence,
and functionally limiting effects of symptoms, we consider all of the
evidence in the case record, including the person's daily activities;
[[Page 14219]]
medications or other treatments the person uses, or has used, to
alleviate symptoms; the nature and frequency of the person's attempts
to obtain medical treatment for symptoms; and statements by other
people about the person's symptoms. We will make a finding about the
extent to which symptoms, such as pain, affect his or her capacity to
perform basic work activities.\31\ When we need additional information
to assess the person's statements about symptoms and their effects, we
will make every reasonable effort to obtain available information that
could shed light on the person's statements.
---------------------------------------------------------------------------
\31\ See 20 CFR 404.1529 and 416.929. See also SSR 96-7p: Titles
II and XVI: Evaluation of Symptoms in Disability Claims: Assessing
the Credibility of an Individual's Statements, 61 FR 34483 (1996)
(also available at: https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-07-di-01.html).
---------------------------------------------------------------------------
V. How do we find a person disabled based on an MDI of IC?
Once we establish that a person has an MDI of IC, we will consider
this MDI in the sequential evaluation process to determine whether the
person is disabled.\32\ As we explain in section VI below, we consider
the severity of the impairment, whether the impairment meets or
medically equals the requirements of a listed impairment, and whether
the impairment prevents the person from doing his or her past relevant
work or other work that exists in significant numbers in the national
economy.
---------------------------------------------------------------------------
\32\ See 20 CFR 404.1520, 416.920, and 416.924.
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VI. How do we use the sequential evaluation process to evaluate IC?
We adjudicate claims involving IC using the sequential evaluation
process, just as we do for any impairment. Once we find that an MDI(s)
exists (see section II), we must establish the severity of the
impairment(s) based on the totality of signs, symptoms, and laboratory
findings, and the effects of the impairment(s), including any related
symptoms, on the person's ability to function. Additionally, several
other disorders may share characteristics similar to those of IC. When
there is evidence of the potential presence of another disorder that
may adequately explain the person's symptoms, it may be necessary to
pursue additional medical or other development. As mentioned, if we
cannot find that the person has an MDI of IC but there is evidence of
another MDI, we will not evaluate the impairment under this SSR.
Instead, we will evaluate it under the rules that apply for that
impairment.
A. Step 1. We consider the person's work activity. If a person with
IC is engaged in substantial gainful activity, we will find that he or
she is not disabled.
B. Step 2. If we find that a person with IC has an MDI that meets
the duration requirement,\33\ and the person alleges pain and other
symptoms consistent with IC, we must consider these symptoms in
deciding whether the person's impairment is ``severe'' at step 2 of the
sequential evaluation process, and at any later steps reached in the
sequential evaluation process. If we find that the person's pain,
urinary urgency or urinary frequency, or other symptoms have more than
a minimal effect on a person's ability to perform basic work
activities, we must find that the person has a ``severe''
impairment.\34\
---------------------------------------------------------------------------
\33\ See 20 CFR 404.1509 and 416.909.
\34\ See SSR 96-3p: Titles II and XVI: Considering Allegations
of Pain and Other Symptoms in Determining Whether a Medically
Determinable Impairment Is Severe, 61 FR 34468 (1996) (also
available at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR96-03-di-01.html).
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C. Step 3. When we find that a person with IC has a severe MDI, we
must proceed to step three and consider the medical severity of the
impairment(s). At this step, we consider whether a person's
impairment(s) meets or equals in severity one of the impairments in the
Listing of Impairments.\35\ IC is not a listed impairment; therefore,
we cannot find that a person with IC alone has an impairment that meets
a listing. However, we will compare the specific findings in each case
to any pertinent listing to determine whether medical equivalence may
exist.\36\ We also may find medical equivalence if the person has
multiple impairments, including IC, none of which meets or medically
equals the requirements of a listing, but the combination of
impairments is medically equivalent in severity to a listed impairment.
In cases in which a person with IC has psychological manifestations
related to IC, we must consider whether the person's impairment meets
or equals the severity of any impairment in the mental disorders
listings (see section IIF).\37\
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\35\ See 20 CFR, part 404, subpart P, appendix 1.
\36\ In evaluating title XVI claims for disability benefits for
people under age 18, we will consider whether the impairment(s)
functionally equals the listings. See 20 CFR 416.926a. For example,
the functional limitations of IC, by itself or in combination with
another impairment(s), may establish an extreme limitation in one
broad area of functioning (for example, attending and completing
tasks) or marked limitation in two broad areas (for example,
attending and completing tasks, and interacting or relating with
others).
\37\ See sections 12.00 and 112.00 of 20 CFR, part 404, subpart
P, appendix 1.
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D. Steps 4 and 5. For those impairments that do not meet or
medically equal the severity of a listing, we must make an assessment
of the person's residual functional capacity (RFC). The RFC assessment
must be based on all the relevant evidence in the record.\38\ In
assessing RFC related to an MDI of IC, we must consider all of the
person's impairment-related symptoms in deciding how such symptoms may
affect functional capacity.\39\ For example, many people with IC have
chronic pelvic pain, which can affect the ability to focus and sustain
attention on the task at hand. Nocturia may disrupt sleeping patterns
and lead to drowsiness and lack of mental clarity during the day.
Urinary frequency can necessitate trips to the bathroom as often as
every 10 to 15 minutes, day and night. Consequently, some individuals
with IC essentially may confine themselves to their homes. After we
consider such impairment-related symptoms and we make our RFC
assessment, our evaluation must proceed to the fourth step of the
sequential evaluation process, unless an expedited process applies.\40\
If necessary, we then proceed to the fifth step of the sequential
evaluation process.\41\ If we do not use an expedited process, we must
determine whether the person's impairment(s) precludes the performance
of past relevant work (unless we determine that there was no past
relevant work). If we determine that the person's impairment(s)
precludes performance of past relevant work or there was no past
relevant work, we must make a finding about the person's ability to
perform other work. We must apply the usual vocational considerations
in determining the person's ability to perform other work.\42\
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\38\ See 20 CFR 404.1545(a) and 416.945(a), and also SSR 96-8p:
Titles II and XVI: Assessing Residual Functional Capacity in Initial
Claims, 61 FR 34474 (1996) (also available at https://www.ssa.gov/OP_Home/rulings/di/01/SSR96-08-di-01.html). Our RFC assessments must
consider the person's maximum ability to do sustained work
activities in an ordinary work setting on a regular and continuous
basis. Generally, a ``regular and continuous basis'' means eight
hours a day, for five days a week, or an equivalent work schedule of
40 hours per week. In cases involving IC, chronic fatigue may affect
the person's physical and mental ability to sustain work activity,
and this may be especially true in cases involving urinary
frequency.
\39\ See 20 CFR 404.1529(d) and 416.929(d), and SSR 96-7p.
\40\ See 20 CFR 404.1520(h) and 416.920(h).
\41\ The fourth and fifth steps of the sequential evaluation
process are not applicable to claims for benefits under title XVI
for people under age 18. See 20 CFR 416.924.
\42\ See 20 CFR 404.1560-404.1569a and 416.960-416.969a, and SSR
11-2p: Titles II and XVI: Documenting and Evaluating Disability in
Young Adults, 76 FR 56263 (2011) (also available at https://www.ssa.gov/OP_Home/rulings/di/01/SSR2011-02-di-01.html).
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[[Page 14220]]
1. Pain and other symptoms associated with IC may result in
exertional limitations that prevent a person from doing a full range of
unskilled work in one or more of the exertional categories in appendix
2 of subpart P of part 404 (appendix 2).\43\ People with IC may also
have nonexertional physical or mental limitations because of their pain
or other symptoms.\44\ Some may have environmental restrictions, which
are also nonexertional.
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\43\ See SSR 83-12: Title II and SVI: Capability To Do Other
Work--The Medical-Vocational Rules as a Framework for Evaluating
Exertional Limitations Within a Range of Work or Between Ranges of
Work (available at https://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR83-12-di-02.html).
\44\ See SSR 85-15: Titles II and XVI: Capability To Do Other
Work--Medical-Vocational Rules as a Framework for Evaluating Solely
Nonexertional Impairments (available at: https://www. social
security. gov/OP_Home/rulings/di/02/SSR85-15-di-02.html).
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2. Exertional and nonexertional limitations resulting from IC may
affect the person's ability to perform routine movement and necessary
physical activity in the work environment, such as sitting, standing,
walking, lifting, carrying, pushing, and pulling. These limitations may
also affect the person's ability to do postural functions, such as
climbing, balancing, stooping, and crouching, or they may affect the
person's ability to tolerate extreme heat, humidity, or hazards.
3. Adjudicators must be alert to the possibility that there may be
exertional or nonexertional (for example, postural or environmental)
limitations that erode a person's occupational base sufficiently to
preclude the use of a rule in appendix 2 to direct a decision. In such
cases, adjudicators must use the rules in appendix 2 as a framework for
decision-making and may need to consult a vocational resource.\45\
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\45\ See SSR 83-12; SSR 83-14: Titles II and XVI: Capability To
Do Other Work--The Medical-Vocational Rules as a Framework for
Evaluating a Combination of Exertional and Nonexertional Impairments
(available at https://www.socialsecurity.gov/OP_Home/rulings/di/02/SSR83-14-di-02.html); SSR 85-15; and SSR 96-9p, Titles II and XVI:
Determining Capability to Do Other Work--Implications of a Residual
Functional Capacity for Less Than a Full Range of Sedentary Work, 61
FR 34478 (July 2, 1996) (also available at https://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-09-di-01.html).
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E. Continuing disability reviews. In those cases in which we find
that a person has a disability based on IC, we will conduct an
appropriate continuing disability review as required by law.\46\ For
this review, we take into account relevant individual case facts, such
as the combined severity of other chronic or static impairments, and
the person's vocational factors.
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\46\ See 20 CFR 404.1594, 416.994, and 416.994a.
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Effective Date: This SSR is effective on March 18, 2015.
Cross-References: SSR 82-63: Titles II and XVI: Medical-Vocational
Profiles Showing an Inability To Make an Adjustment to Other Work; SSR
83-12: Titles II and XVI: Capability To Do Other Work--The Medical-
Vocational Rules as a Framework for Evaluating Exertional Limitations
Within a Range of Work or Between Ranges of Work; SSR 83-14: Titles II
and XVI: Capability To Do Other Work--The Medical-Vocational Rules as a
Framework for Evaluating a Combination of Exertional and Nonexertional
Impairments; SSR 85-15: Titles II and XVI: Capability To Do Other
Work--The Medical-Vocational Rules as a Framework for Evaluating Solely
Nonexertional Impairments; SSR 96-2p, Titles II and XVI: Giving
Controlling Weight to Treating Source Medical Opinions; SSR 96-3p,
Titles II and XVI: Considering Allegations of Pain and Other Symptoms
in Determining Whether a Medically Determinable Impairment Is Severe;
SSR 96-4p, Titles II and XVI: Symptoms, Medically Determinable Physical
and Mental Impairments, and Exertional and Nonexertional Limitations;
SSR 96-5p, Titles II and XVI: Medical Source Opinions on Issues
Reserved to the Commissioner; SSR 96-7p, Titles II and XVI: Evaluation
of Symptoms in Disability Claims: Assessing the Credibility of an
Individual's Statements; SSR 96-8p, Titles II and XVI: Assessing
Residual Functional Capacity in Initial Claims; SSR 96-9p, Titles II
and XVI: Determining Capability to Do Other Work--Implications of a
Residual Functional Capacity for Less Than a Full Range of Sedentary
Work; SSR 06-03p, Titles II and XVI: Considering Opinions and Other
Evidence from Sources Who Are Not ``Acceptable Medical Sources'' in
Disability Claims; Considering Decisions on Disability by Other
Governmental and Nongovernmental Agencies; SSR 12-2p, Titles II and
XVI: Evaluation of Fibromyalgia; SSR 14-1p, Titles II and XVI:
Evaluating Cases Involving Chronic Fatigue Syndrome (CFS); and Program
Operations Manual System (POMS) DI 22505.001, DI 22505.003, DI
24505.003, DI 24510.057, DI 24515.012, DI 24515.061-DI 24515.063, DI
24515.066, DI 24515.067, DI 24515.075, DI 24555.001, DI 25010.001, and
DI 25025.001.
[FR Doc. 2015-05680 Filed 3-17-15; 8:45 am]
BILLING CODE 4191-02-P
