80 FR 14215 - Social Security Ruling, SSR 15-1p; Titles II and XVI: Evaluating Cases Involving Interstitial Cystitis (IC)

SOCIAL SECURITY ADMINISTRATION

Federal Register Volume 80, Issue 52 (March 18, 2015)

Page Range		14215-14220
FR Document		2015-05680

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.

Federal Register, Volume 80 Issue 52 (Wednesday, March 18, 2015)

[Federal Register Volume 80, Number 52 (Wednesday, March 18, 2015)]
[Notices]
[Pages 14215-14220]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2015-05680]

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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).

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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\
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\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.
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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\
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\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.

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[[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\
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\3\ Hanno, P.M., et al., Diagnosis and treatment of interstitial
cystitis/bladder pain syndrome, American Urological Association,
(2014) (available at: http://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: http://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: http://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: http://kidney.niddk.nih.gov/KUDiseases/pubs/interstitialcystitis/index.aspx).
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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 http://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\
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\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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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: http://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: http://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.
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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\
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\17\ We will not purchase this procedure to establish an MDI of
IC because it is an invasive procedure.
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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\
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\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
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\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.
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3. Antiproliferative factor (APF) accumulation in the urine.\20\
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\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\
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\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.
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\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:
http://www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03-di-01.html).
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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:
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\23\ See 20 CFR 404.1513(d)(2-4) and 416.913(d)(2-4), and also
SSR 06-03p.
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Spouses, parents, siblings, other relatives, neighbors,
friends, and clergy;
Past employers, rehabilitation counselors, and teachers;
and
Statements from SSA 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\
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\24\ See 20 CFR 404.1512(d) and 416.912(d).
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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\
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\26\ See 20 CFR 404.1520b(c) and 416.920b(c).
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We may recontact the person's treating or other source(s)
to see if the information we need is available;
We may request additional existing records 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\
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\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).
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2. When we are unable to resolve an insufficiency in the evidence,
and we need to determine whether the person has an MDI of IC or is
disabled, we may make a determination or decision based on the evidence
we have.\28\
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\28\ See 20 CFR 404.1520b(d) and 416.920b(d).
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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\
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\29\ See 20 CFR 404.1520b and 416.920b.
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IV. How do we evaluate a person's statements about his or her symptoms
and functional limitations?

Generally, we follow a two-step 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.
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\30\ See 20 CFR 404.1520, 416.920, and 416.924.
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B. Second step of the symptom evaluation process. After finding
that the MDI could reasonably be expected to produce the alleged
symptoms, we evaluate the intensity and persistence of the person's
symptoms and determine the extent to which they limit the person's
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.
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\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: http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-07-di-01.html).
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V. How do we find a person disabled based on an MDI of 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.
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\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: http://www.ssa.gov/OP_Home/rulings/di/01/SSR96-03-di-01.html).
---------------------------------------------------------------------------

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\
---------------------------------------------------------------------------

\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.
---------------------------------------------------------------------------

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\
---------------------------------------------------------------------------

\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 http://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 http://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.
---------------------------------------------------------------------------

\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 http://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: http://www. social
security. gov/OP_Home/rulings/di/02/SSR85-15-di-02.html).
---------------------------------------------------------------------------

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\
---------------------------------------------------------------------------

\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 http://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 http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR96-09-di-01.html).
---------------------------------------------------------------------------

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.
---------------------------------------------------------------------------

\46\ See 20 CFR 404.1594, 416.994, and 416.994a.
---------------------------------------------------------------------------

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

Federal Register / Vol. 80, No. 52 / Wednesday, March 18, 2015 / Notices 14217

examination that includes urinalysis evidence must document that this 3. Other symptoms. In addition to
and urine culture. NIDDK notes that physician reviewed the person’s chronic pain and urinary urgency or
diagnostic tests physicians may also use medical history and conducted a frequency or both, the person may
to rule out other conditions include physical examination, and that his or report additional IC symptoms, such as:
cystoscopy, biopsy of the bladder wall her diagnosis is not inconsistent with • Suprapubic tenderness on physical
and urethra, distention of the bladder the other substantial evidence in the examination;
under anesthesia, and, in men, culture person’s case record.15 However, we • Sexual dysfunction (including
of prostate secretions.12 cannot rely on the physician’s diagnosis dyspareunia);
C. IC may co-occur with fibromyalgia, alone to establish an MDI of IC. The • Sleep dysfunction; and
chronic fatigue syndrome, irritable physician may make a diagnosis of IC • Chronic fatigue or tiredness.
bowel syndrome, inflammatory bowel based only on the person’s reported C. Medical signs. Medical signs can
disease, vulvodynia, chronic headaches, symptoms, after examining the person support a diagnosis of IC and help
Sjögren’s syndrome, endometriosis, or and ruling out other diseases that could establish the MDI. These signs include
systemic lupus erythematosus. cause the symptoms. Thus, as the following, which can be detected
D. Treatments for IC are mostly previously mentioned, there must also during a medical procedure that
directed at symptom control. They be medical signs or laboratory findings stretches the bladder with fluid
include, but are not limited to: Changes to establish an MDI of IC. (cystoscopy under anesthesia with
in diet; physical therapy and pelvic 3. If we cannot establish that a person bladder distention): 17
floor strengthening exercises; stress has an MDI of IC, but there is evidence 1. Fibrosis (bladder-wall stiffening);
management; bladder distention; of another MDI, we will not evaluate the 2. Diffuse glomerulations (pinpoint
bladder instillation; oral drugs, such as impairment under this SSR. Instead, we bleeding caused by recurrent irritation)
prescription drugs indicated for IC (for will evaluate it under the rules that on the bladder wall; and
example, Elmiron and dimethyl apply for that impairment. 3. Hunner’s ulcers (patches of broken
sulfoxide), antidepressants, B. Symptoms. IC symptoms may vary skin) on the bladder wall.18
antihistamines, antacids, anticoagulants, in incidence, duration, and severity D. Laboratory findings. Laboratory test
and narcotic analgesics; transcutaneous from person to person, and even in the findings can also support a diagnosis of
electrical nerve stimulation; and same person. For example, a woman’s IC. We will make every reasonable effort
surgery, such as substitution cystoplasty symptoms may worsen around the time to obtain the results of appropriate
or urinary diversion with or without of menstruation. Symptoms of IC laboratory testing. However, we will not
cystectomy. Treatment is not effective include, but are not limited to: purchase complex, costly, or invasive
for everyone because response varies 1. Pain. People who have IC report tests. Some laboratory tests and findings
among patients. chronic bladder and pelvic pain, are more widely used and accepted than
pressure, and discomfort. This pain may others. The following laboratory
II. How does a person establish an MDI range from mild discomfort to extreme findings can help establish an MDI of
of IC? distress. The intensity of the pain may IC:
A. General increase as the bladder fills and 1. Repeated sterile urine cultures
1. A person can establish that he or decrease as it empties. In addition to while IC symptoms continue;
bladder and pelvic pain, people with IC 2. Positive potassium sensitivity test
she has an MDI of IC by providing
may experience vaginal, testicular, (Parson’s test); 19 and
appropriate evidence from an acceptable
penile, low back, or thigh pain. 3. Antiproliferative factor (APF)
medical source.13 A licensed physician
2. Urinary urgency and frequency. accumulation in the urine.20
(a medical or osteopathic doctor) is the
People who have IC may report an E. Other signs and findings. Because
only acceptable medical source who can
urgent need to urinate (urgency) or a of the ongoing research into the etiology
provide evidence establishing an MDI of
frequent need to urinate (frequency), or and manifestations of IC, the medical
IC. This acceptable medical source often
both. Some people with severe cases of criteria discussed above are only
is the person’s treating source(s) who
IC may need to void as often as 60 times examples of signs and laboratory
makes the diagnosis of IC. A treating
per day, including nighttime urinary findings that help establish an MDI of
source(s) may be the person’s own
frequency (nocturia) with associated IC; they are not all-inclusive. As
physician or other acceptable medical
sleep disruption.16 medical research advances regarding IC,
source who provides, or has provided,
we may rely on other signs and
medical evaluation or treatment and 15 We use the term ‘‘not inconsistent’’ to indicate
laboratory findings to help establish an
who has, or has had, an ongoing that a diagnosis of IC need not be supported directly MDI of IC. For example, gene studies are
treatment relationship with the by all the other evidence (that is, it does not have
to be consistent with all the other evidence) as long exploring whether there are various
person.14
as there is no other substantial evidence in the case
2. We generally will rely on the record that contradicts or conflicts with the http://kidney.niddk.nih.gov/KUDiseases/pubs/
judgment of a licensed physician who diagnosis. Whether a diagnosis of IC is ‘‘not interstitialcystitis/index.aspx.) As used by the
has made a diagnosis of IC. The inconsistent’’ with the other substantial evidence is NIDDK, the word ‘‘severe’’ is not meant in the same
a judgment that adjudicators must make in each sense that we use the word to describe a severe
12 Descriptions of these tests are available at
case. In situations in which the diagnosis of IC is impairment at the second step of our sequential
inconsistent with the other substantial evidence in evaluation process.
http://kidney.niddk.nih.gov/kudiseases/pubs/ the person’s case record, the adjudicator may 17 We will not purchase this procedure to
interstitialcystitis/#diagnosis. Evidence that a determine that the diagnosis is not entitled to
physician used any of these tests or other laboratory establish an MDI of IC because it is an invasive
‘‘controlling weight’’ in establishing whether the
tests to make a diagnosis of IC (that is, to rule out procedure.
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person has an MDI. However, the adjudicator
other diseases that could explain the person’s should not reject the diagnosis, but instead must
18 Hunner’s ulcers are rare and may be present in

symptoms) helps establish the existence of an MDI weigh it using all of the factors provided in 20 CFR only 5–10 percent of individuals with IC.
of IC. 404.1527 and 416.927. See SSR 96–2p, Titles II and 19 Although validated by some studies, the
13 See 20 CFR 404.1513(a) and 416.913(a). potassium sensitivity test is not yet recommended
XVI: Giving Controlling Weight to Treating Source
14 We may consider an acceptable medical source Medical Opinions, 61 FR 34492 2006 (also available for routine clinical use and can be painful for the
who has treated or evaluated the person only a few at: http://www.socialsecurity.gov/OP_Home/ patient. We will not purchase this procedure to
times or only after long intervals (for example, rulings/di/01/SSR96-02-di-01.html). establish an MDI of IC because it is an invasive
twice a year) to be a treating source. See 20 CFR 16 See NIDDK National Kidney and Urologic procedure.
404.1502 and 416.902. Diseases Information Clearinghouse (available at: 20 Physicians do not routinely measure APF.

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14218 Federal Register / Vol. 80, No. 52 / Wednesday, March 18, 2015 / Notices

subtypes of IC. Thus, we may document therapists are examples of these other take one or more actions to try to resolve
the existence of IC as an MDI with medical sources. the insufficiency: 26
medical signs and laboratory findings 3. Information from nonmedical • We may recontact the person’s
other than those listed above, provided sources can also help us evaluate the treating or other source(s) to see if the
such evidence is consistent with severity of a person’s IC.23 This information we need is available;
medically accepted clinical practice and information may help us assess the • We may request additional existing
the other evidence in the case record. person’s ability to function day-to-day records from treating or other sources;
F. Mental conditions. People who and over time. It may also help us when • We may ask the person or others for
have IC may report ongoing mental we make findings about credibility of more information; or
conditions directly associated with their the person’s allegations about symptoms • We may purchase a consultative
IC. For example, a person may report and their effects. Examples of examination (CE) at our expense.27
having anxiety or depression associated nonmedical sources include: 2. When we are unable to resolve an
with IC symptoms of chronic bladder • Spouses, parents, siblings, other insufficiency in the evidence, and we
and pelvic pain, and urinary urgency, relatives, neighbors, friends, and clergy; need to determine whether the person
frequency, or both. When these mental • Past employers, rehabilitation has an MDI of IC or is disabled, we may
conditions are documented by mental counselors, and teachers; and make a determination or decision based
status examination(s) or psychological • Statements from SSA and State on the evidence we have.28
testing, they may constitute medical agency personnel who interviewed the C. How do we resolve conflicts in the
signs or (in the case of psychological person. evidence? Conflicting evidence in the
testing) laboratory findings that help 4. Before we make a determination medical record is not unusual in cases
establish an MDI of IC.21 whether or not the person is disabled, of IC due to the complicated diagnostic
III. How do we document IC? we will make every reasonable effort to process involved. We will consider
develop his or her complete medical conflicting medical evidence in
A. General. In cases of alleged IC, we
history and help the person get medical accordance with our rules.29
generally need to have longitudinal
reports from his or her medical sources.
evidence because symptoms, signs, and IV. How do we evaluate a person’s
Generally, we will request evidence
laboratory findings of IC may fluctuate statements about his or her symptoms
from the person’s medical sources for
in frequency and severity and may and functional limitations?
the 12-month period preceding the
continue over a period of months or Generally, we follow a two-step
month of application unless there is
years. symptom evaluation process:
1. Longitudinal clinical records reason to believe that development of an
earlier period is necessary, or unless the A. First step of the symptom
reflecting ongoing medical evaluation
alleged onset of disability is less than 12 evaluation process. There must be
and treatment from the person’s medical
months before the date of application.24 medical signs or laboratory findings that
sources, especially treating sources, are
5. When the alleged onset of disability show the person has an MDI(s) which
extremely helpful in documenting the
presence of any signs or laboratory secondary to IC occurred less than 12 we could reasonably expect to produce
findings, as well as the person’s months before adjudication, we must the pain or other symptoms alleged.30 If
limitations over time. The longitudinal evaluate the medical evidence and we find that a person has an MDI that
record should contain medical project the degree of impairment we could reasonably expect to produce
observations, information about severity that is likely to exist at the end the alleged symptoms, the first step of
treatment, the person’s response to of 12 months.25 Information about the our two-step process for evaluating
treatment, and a detailed description of person’s treatment and response to symptoms is satisfied.
how the impairment affects the person’s treatment, including any medical source B. Second step of the symptom
ability to function. opinions about the person’s prognosis at evaluation process. After finding that
2. In addition to obtaining evidence the end of 12 months, helps us decide the MDI could reasonably be expected
from a physician, we may request whether to expect an MDI of IC to be of to produce the alleged symptoms, we
evidence from other acceptable medical disabling severity for at least 12 evaluate the intensity and persistence of
sources, such as psychologists, both to consecutive months. the person’s symptoms and determine
determine whether the person has the extent to which they limit the
B. What do we do if there is insufficient person’s functional capacity for work. In
another MDI(s) and to evaluate the evidence to determine whether the
severity and functional effects of IC in evaluating the intensity, persistence,
person has an MDI of IC or is disabled? and functionally limiting effects of
combination with other impairments the
person may have. Under our regulations 1. When there is insufficient evidence symptoms, we consider all of the
and SSR 06–03p, we also may consider for us to determine whether the person evidence in the case record, including
evidence from other medical sources we has an MDI of IC or is disabled, we may the person’s daily activities;
do not consider acceptable medical
26 See 20 CFR 404.1520b(c) and 416.920b(c).
sources to help us evaluate the severity 23 See 20 CFR 404.1513(d)(2–4) and 416.913(d)(2–
27 See
4), and also SSR 06–03p. 20 CFR 404.1520b(c)(3), and
and functional effects of the 416.920b(c)(3). The type of CE we purchase will
24 See 20 CFR 404.1512(d) and 416.912(d).
impairment(s).22 Nurse practitioners, 25 To meet the statutory requirement for depend on the nature of the person’s symptoms and
physician assistants, and physical ‘‘disability,’’ a person must have been unable to the extent of the evidence already in the case
engage in any substantial gainful activity because of record. For example, we may purchase a CE to help
21 See20 CFR 404.1528 and 416.928. any medically determinable physical or mental evaluate depression, anxiety, or other mental
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22 See impairment that is expected to result in death or conditions associated with the person’s IC. We may
20 CFR 404.1513(d)(1), 416.913(d)(1); SSR
that has lasted or can be expected to last for a purchase a CE without recontacting a person’s
06–03p: Titles II and XVI: Considering Opinions
and Other Evidence from Sources Who Are Not continuous period of not less than 12 months. Thus, treating or other source if the source cannot provide
‘‘Acceptable Medical Sources’’ in Disability Claims; the existence of an impairment(s) for 12 continuous the necessary information or the information is not
Considering Decisions on Disability by Other months is not controlling; rather, it is the existence available from the source. See 20 CFR 404.1519a(b)
Governmental and Nongovernmental Agencies, 71 of a disabling impairment that has lasted or can be and 416.919a(b).
28 See 20 CFR 404.1520b(d) and 416.920b(d).
FR 45593 (2006) (also available at: http:// expected to last for at least 12 months that meets
29 See 20 CFR 404.1520b and 416.920b.
www.ssa.gov/OP_Home/rulings/di/01/SSR2006-03- the duration requirement of the Act. See 20 CFR
di-01.html). 404.1509 and 416.909. 30 See 20 CFR 404.1520, 416.920, and 416.924.

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Document Created: 2018-02-21 09:39:44
Document Modified: 2018-02-21 09:39:44

Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Notices
Action		Notice of Social Security Ruling (SSR).
Dates		Effective Date: March 18, 2015.
Contact		Cheryl Williams, Office of Medical Policy, Social Security Administration, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, (410) 965-1020.
FR Citation		80 FR 14215