80 FR 19522 - Revised Listings for Growth Disorders and Weight Loss in Children

SOCIAL SECURITY ADMINISTRATION

Federal Register Volume 80, Issue 70 (April 13, 2015)

Page Range		19522-19530
FR Document		2015-08185

This rule adopts, with one change, the rule for evaluating growth disorders in children we proposed in a notice of proposed rulemaking (NPRM) published in the Federal Register on May 22, 2013. Several body systems in the Listing of Impairments (listings) contain listings for children based on impairment of linear growth or weight loss. We are replacing those listings with new listings for low birth weight (LBW) and failure to thrive; a new listing for genitourinary impairments; and revised listings for growth failure in combination with a respiratory, cardiovascular, digestive, or immune system disorder. These revisions reflect our program experience, advances in medical knowledge, and comments we received from medical experts and the public.

Federal Register, Volume 80 Issue 70 (Monday, April 13, 2015)

[Federal Register Volume 80, Number 70 (Monday, April 13, 2015)]
[Rules and Regulations]
[Pages 19522-19530]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2015-08185]

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SOCIAL SECURITY ADMINISTRATION

20 CFR Parts 404 and 416

[Docket No. SSA-2011-0081]
RIN 0960-AG28

Revised Listings for Growth Disorders and Weight Loss in Children

AGENCY: Social Security Administration.

ACTION: Final rule.

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SUMMARY: This rule adopts, with one change, the rule for evaluating
growth disorders in children we proposed in a notice of proposed
rulemaking (NPRM) published in the Federal Register on May 22, 2013.
Several body systems in the Listing of Impairments (listings) contain
listings for children based on impairment of linear growth or weight
loss. We are replacing those listings with new listings for low birth
weight (LBW) and failure to thrive; a new listing for genitourinary
impairments; and revised listings for growth failure in combination
with a respiratory, cardiovascular, digestive, or immune system
disorder. These revisions reflect our program experience, advances in
medical knowledge, and comments we received from medical experts and
the public.

DATES: This rule is effective June 12, 2015.

[[Page 19523]]

FOR FURTHER INFORMATION CONTACT: Cheryl A. Williams, Office of Medical
Policy, Social Security Administration, 6401 Security Boulevard,
Baltimore, Maryland 21235-6401, (410) 965-1020. For information on
eligibility or filing for benefits, call our national toll-free number,
1-800-772-1213, or TTY 1-800-325-0778, or visit our Internet site,
Social Security Online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION:

Background

We are adopting, as final, the rule for evaluating growth disorders
in children we proposed in an NPRM published in the Federal Register on
May 22, 2013 at 78 FR 30249. We made one addition to this rule as the
result of a public comment suggesting we provide guidance for
evaluating LBW in children born at less than 32 weeks gestation or
weighing less than 1325 grams. We revised the table in listing 100.04B
to include 32 weeks in the Gestational Age column because we believe
that this guidance is appropriate.
The preamble to the NPRM discussed the remaining changes from our
current rule and our reasons for proposing those changes. To the extent
that we are adopting the proposed rule as published, we are not
repeating that information here. Interested readers may refer to the
preamble to the NPRM, available at http://www.regulations.gov under
docket number SSA-2011-0081.

Why are we revising the listings for evaluating growth disorders in
children?

We are revising the listings for evaluating growth disorders in
children to update the medical criteria, provide more information on
how we evaluate growth disorders, reflect our program experience, and
address adjudicator questions.

Public Comments on the NPRM

In the NPRM, we provided the public with a 60-day comment period,
which ended on July 22, 2013. We received six comments. The commenters
included state agencies that make disability determinations for us, the
National Association of Disability Examiners, medical organizations,
such as the American Academy of Pediatrics, and advocacy groups, such
as the Endocrine Society. We carefully considered all of the comments,
summarized the commenters' views, and responded to all of the
significant issues that were within the scope of this rule. Some
commenters noted provisions with which they agreed and did not make
suggestions for changes in those provisions. We did not summarize or
respond to those comments.

Listing 100.04 Low Birth Weight in Infants From Birth to Attainment of
Age 1

Low Birth Weight

Comment: One commenter suggested that we provide guidance in the
listings at 100.04A or 100.04B, or in the introductory text at 100.00,
on diaries used to schedule continuing disability reviews (CDR) for LBW
infants. The commenter believes that, while this guidance is already in
our internal operating instructions, providing it in the regulations
would reduce the number of incorrect diaries being set for LBW cases.
Response: We did not adopt this comment. In 100.00B, we include a
reference to our rule for CDRs for LBW cases at Sec. 416.990(b)(11).
Additionally, the Act requires, with one exception, that we perform a
CDR not later than 12 months after the birth of an infant whose LBW is
a contributing factor material to the determination that the infant is
disabled. We will continue to provide guidance on diaries for LBW cases
and cases involving other disabling impairments in our internal
operating instructions. We do not believe it is necessary to repeat
this guidance in the regulation.
Comment: One commenter expressed concern that listing 100.04
suggests that LBW is a disability. The commenter felt that it should be
clear that weight is ``a proxy measure for prematurity, dysphagia, and
other functional impairments that are associated with disabilities,
rather than weight as a disability itself.'' The commenter did not
provide suggested language to include in our rule.
Response: We did not adopt this comment. We agree that, for the
purposes of listing 100.04, weight is a proxy measure for disability in
infants from birth to the attainment of age 1. However, we do not
believe that providing additional guidance is necessary for the clarity
of our rule. As we noted in the preamble to the proposed rule, we based
listing 100.04 on sections 416.926a(m)(6) and (m)(7) of our functional
equivalence rule.\1\ Our adjudicators have over 20 years of experience
evaluating claims filed on behalf of children based on LBW under our
functional equivalence rule. In our experience applying this rule, we
have not found that the type of guidance the commenter suggested is
necessary in order to apply the rule properly.
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\1\ 78 FR at 30350.
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Evaluating Infants Born at 33 Weeks Weighing Less Than 1325 Grams

Comment: One commenter suggested that we add guidance for
evaluating infants who weigh between 1200 grams and 1325 grams, and who
are born at gestational ages of 32 weeks or less.
Response: We partially adopted this comment. We agree that it is
appropriate to provide guidance for evaluating LBW in infants who are
born at 32 weeks gestational age. We revised the table in 100.04B to
provide a birth weight value of 1250 grams or less for the gestational
age of 32 weeks. However, we did not provide birth weight values for
gestational ages less than 32 weeks. The birth weight values that we
would provide for infants born at less than 32 weeks would be less than
1200 grams and, thus, the birth weight would meet the criterion in
100.04A.

Listing 100.05 Failure To Thrive in Children From Birth to Attainment
of Age 3

Growth Measurements

Comment: One commenter recommended including growth curves in
100.05A to make administrative processing for pediatricians easier.
Another commenter suggested that we make determinations based on growth
measurements alone without requiring a diagnosis of developmental
delay.
Response: We did not adopt these comments. In 100.05A, we require
three weight-for-length measurements or body mass index (BMI)-for-age
measurements that are within a 12-month period, at least 60-days apart,
and less than the third percentile on the appropriate table in listing
105.08B.2. The adjudicator making the disability determination uses the
information from growth curves provided by the child's pediatrician to
find the corresponding values on the tables provided. We do not believe
it is necessary to include the growth curves in the listing because our
adjudicators use the listing, rather than the pediatrician who
evaluates a child.
As we stated in the NPRM, our program experience has shown that
growth failure alone is not disabling (78 FR at 30251). To meet the
severity requirements for listing 100.05B, the child must have growth
failure with a developmental delay of the appropriate severity required
by the listing. Children with growth failure without developmental
delay may be evaluated in the appropriate body system of the underlying
condition causing the growth failure.

[[Page 19524]]

Developmental Testing

Comment: One commenter questioned the requirement for two narrative
developmental reports in 100.05C and the requirement that these two
reports be at least 120 days apart. This commenter suggested that, if
we keep the requirement for two reports, we should require a shorter
period of either 30 or 60 days between them. Another commenter also
expressed concern about the requirements for the evidence of
developmental delay. This commenter was concerned about the
availability of these records from providers.
Response: We did not adopt these comments. In 100.05C, we require
two narrative developmental reports when a report of a standardized
developmental assessment required by 100.05B is not available. As we
explained in the NPRM, abnormal findings noted on repeated
examinations, and information in narrative developmental reports, that
may include the results of developmental screening tests, can identify
a child who is not developing or achieving skills within expected
timeframes.\2\
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\2\ 78 FR at 30251.
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We do not believe that 30 or 60 days is enough time for these kinds
of changes to appear on testing. We believe that 120 days is an
appropriate period for developmental testing to be performed and to
allow for any changes in development to show on testing.
While we understand the commenter's concern about the availability
of evidence, we believe that, for the children whose impairments we
evaluate under listing 100.05, evidence generally will be available
from providers because these children are likely to be identified, and
subsequently treated because of their identification, by early
intervention programs.
Comment: One commenter noted that most early intervention programs
use ``a 25 percent delay criteria as opposed to the two-thirds
criteria'' required in 100.05C. However, the commenter did not provide
any suggestions for changing the criterion.
Response: We did not adopt this comment. We recognize that early
intervention programs often use a 25 percent delay criterion to
determine eligibility for intervention services and to identify the
needed services. In contrast, we evaluate a child's delay to determine
whether the underlying impairment is disabling because it results in
``marked and severe functional limitations.'' An impairment results in
``marked and severe functional limitations'' only if it meets,
medically equals, or functionally equals the listings. An impairment is
of listing-level severity if it results in ``marked'' limitations in
two domains of functioning or an ``extreme'' limitation in one
domain.\3\ The level of delay that we require in 100.05C is consistent
with our definition of ``marked limitation'' in Sec.
416.926a(e)(2)(ii).
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\3\ See 20 CFR 416.926a(a).
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Comment: One commenter expressed concern about acceptable
timeframes for performing developmental testing in relation to
disability determinations stated in 100.05B and 100.05C. The commenter
suggested that the testing to establish the child's current level of
development be performed within 6 months of adjudication.
Response: We partially adopted this comment. We agree that evidence
about a child's development must be recent and current in relation to a
disability determination, and we have revised listings 100.05B and
100.05C2 to clarify this requirement. However, the facts in a specific
case determine whether the evidence is current. Determining factors
include, but are not limited to, the age of the child, the amount of
delay, and the developmental trajectory documented over time. We are
not setting specific timeframes for when developmental testing must be
performed, but we are specifying that the evidence must reflect the
child's current development.

Linear Growth

Comment: One commenter agreed with our use of weight-for-length and
BMI-for-age charts to evaluate growth failure, rather than of linear
(height or length) growth charts. The commenter expressed concern,
however, that an underlying condition could cause a child to have such
profound growth failure that BMI for the child's age would become
normal, despite his or her significant growth failure.
Response: We did not adopt this comment. We understand the
commenter's concerns that some children may have underlying conditions
that cause linear growth impairments while their BMI-for-age
measurements are normal. After attainment of age 2, most children
without an underlying medical disorder follow a growth trajectory that
remains fairly constant during childhood.
Our adjudicative experience has shown that a declining linear
growth rate is not always indicative of a disabling condition. Short
stature, length, or height below the third percentile, in and of
itself, is not a medically determinable impairment, although it can be
the result of a medically determinable impairment. We will evaluate
children with growth failure that does not meet the requirements of
listings 100.04 and 100.05 and is associated with a known medically
determinable impairment under the affected body system.
Comment: One commenter was concerned that, while the majority of
children over the age of 3 with growth failure have signs and symptoms
of an underlying disorder in the respiratory, cardiovascular,
digestive, genitourinary, or immune body system, some children over the
age of 3 will not. This commenter suggested that we include exceptions
for conditions, such as Turner syndrome (female hypogonadism) and
acquired growth hormone deficiency, where growth failure may be a
significant component of the disease process.
Response: We did not adopt this comment. After a child attains age
3, we will evaluate his or her impairment under the affected body
system. The two examples provided by the commenter are endocrine
disorders. Although these two disorders are not listed impairments for
children, they may rise to listing-level severity because of their
effects in other body systems. As the commenter explained, children
with Turner syndrome may experience complications, such as heart
disease, to a degree that is disabling. We would evaluate the
complications under the affected body system.

Listing 103.06 Growth Failure Due to Any Chronic Respiratory Disorder

Comment: Two commenters were concerned with the requirement for
oxygen supplementation in 103.06A. The commenters noted that some
respiratory disorders, such as asthma, bronchiectasis, and cystic
fibrosis, could result in listing-level growth failure without
requiring oxygen supplementation.
Response: We did not adopt these comments. We agree with the
commenters that some respiratory disorders could result in listing-
level growth failure without requiring oxygen supplementation; however,
we did not revise 103.06 as a result. We use other listings, such as
103.02, 103.03, and 103.04, in the respiratory body system to evaluate
these disorders.\4\ We believe that these respiratory listings, and our
functional equivalence rule for evaluating disability in children,

[[Page 19525]]

adequately address the disorders referred to by the commenters.\5\
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\4\ See 20 CFR part 404, subpart P, Appendix 1.
\5\ See 20 CFR 416.924a and 416.926a.
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What is our authority to make rules and set procedures for determining
whether a person is disabled under the statutory definition?

The Act authorizes us to make rules and regulations and to
establish necessary and appropriate procedures to implement them.\6\
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\6\ 42 U.S.C. 405(a), 902(a)(5), and 1383(d)(1).
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When will we use this final rule?

We will begin to use this final rule on its effective date. We will
continue to use the current listings until the date this final rule
becomes effective. We will apply the final rule to new applications
filed on or after the effective date of the final rule and to claims
that are pending on or after the effective date.\7\
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\7\ This means that we will use this final rule on and after its
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 rule that was in effect at the time we issued
the decisions. If a court reverses our final decision and remands a
case for further administrative proceedings after the effective date
of this final rule, we will apply this final rule to the entire
period at issue in the decision we make after the court's remand.
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How long will this final rule be effective?

This final rule will remain in effect for 5 years after the date it
becomes effective, unless we extend it or revise and issue it again.

Regulatory Procedures

Executive Order 12866, as Supplemented by Executive Order 13563

We consulted with the Office of Management and Budget (OMB) and
determined that this final rule meets the criteria for a significant
regulatory action under Executive Order 12866, as supplemented by
Executive Order 13563. Therefore, OMB reviewed this final rule.

Regulatory Flexibility Act

We certify that this final rule would not have a significant
economic impact on a substantial number of small entities because they
affect individuals only. Therefore, a regulatory flexibility analysis
is not required under the Regulatory Flexibility Act, as amended.

Paperwork Reduction Act

This final rule does not create any new or affect any existing
collections and, therefore, does not require OMB approval under the
Paperwork Reduction Act.

(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social
Security--Disability Insurance; 96.002, Social Security--Retirement
Insurance; 96.004, Social Security--Survivors Insurance; and 96.006,
Supplemental Security Income).

List of Subjects

20 CFR Part 404

Administrative practice and procedure; Blind, Disability benefits;
Old-Age, Survivors, and Disability Insurance; Reporting and
recordkeeping requirements; Social Security.

20 CFR Part 416

Administrative practice and procedure; Aged, Blind, Disability
benefits; Public assistance programs; Reporting and recordkeeping
requirements; Supplemental Security Income (SSI).

Carolyn W. Colvin,
Acting Commissioner of Social Security.

For the reasons set out in the preamble, we are amending 20 CFR
part 404 subpart P and part 416 subpart I as set forth below:

PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE
(1950-)

0
1. The authority citation for subpart P of part 404 continues to read
as follows:

Authority: Secs. 202, 205(a)-(b) and (d)-(h), 216(i), 221(a),
(i), and (j), 222(c), 223, 225, and 702(a)(5) of the Social Security
Act (42 U.S.C. 402, 405(a)-(b) and (d)-(h), 416(i), 421(a), (i), and
(j), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193,
110 Stat. 2105, 2189; sec. 202, Pub. L. 108-203, 118 Stat. 509 (42
U.S.C. 902 note).

0
2. Amend appendix 1 to subpart P of part 404 as follows:
0
a. Revise item 1 of the introductory text before part A of appendix 1.
0
b. Amend part B by revising the body system name for section 100.00 in
the table of contents.
0
c. Revise sections 100.00 and 100.01 of part B.
0
d. Remove sections 100.02 and 100.03 of part B.
0
e. Add sections 100.04 and 100.05 of part B
0
f. Add section 103.00F of part B.
0
g. Add listing 103.06 of part B.
0
h. Revise section 104.00C2b introductory text of part B.
0
i. Revise section 104.00C2b(ii) of part B.
0
j. Add section 104.00C3 of part B.
0
k. Revise listing 104.02C of part B.
0
l. Revise section 105.00G of part B.
0
m. Revise listing 105.08 of part B.
0
n. Redesignate section 106.00C5 of part B as 106.00C6 and add new
section 106.00C5.
0
o. Add listing 106.08 of part B.
0
p. Add section 114.00F4d of part B.
0
q. Revise listing 114.08H of part B.
The revisions and additions read as follows:

APPENDIX 1 TO SUBPART P OF PART 404--LISTING OF IMPAIRMENTS

* * * * *
1. Low Birth Weight and Failure to Thrive (100.00): June 12,
2020.
* * * * *
Part B
* * * * *
100.00 Low Birth Weight and Failure to Thrive.
* * * * *

100.00 LOW BIRTH WEIGHT AND FAILURE TO THRIVE

A. What conditions do we evaluate under these listings? We
evaluate low birth weight (LBW) in infants from birth to attainment
of age 1 and failure to thrive (FTT) in infants and toddlers from
birth to attainment of age 3.
B. How do we evaluate disability based on LBW under 100.04? In
100.04A and 100.04B, we use an infant's birth weight as documented
by an original or certified copy of the infant's birth certificate
or by a medical record signed by a physician. Birth weight means the
first weight recorded after birth. In 100.04B, gestational age is
the infant's age based on the date of conception as recorded in the
medical record. If the infant's impairment meets the requirements
for listing 100.04A or 100.04B, we will follow the rule in Sec.
416.990(b)(11) of this chapter.
C. How do we evaluate disability based on FTT under 100.05?
1. General. We establish FTT with or without a known cause when
we have documentation of an infant's or a toddler's growth failure
and developmental delay from an acceptable medical source(s) as
defined in Sec. 416.913(a) of this chapter. We require
documentation of growth measurements in 100.05A and developmental
delay described in 100.05B or 100.05C within the same consecutive
12-month period. The dates of developmental testing and reports may
be different from the dates of growth measurements. After the
attainment of age 3, we evaluate growth failure under the affected
body system(s).
2. Growth failure. Under 100.05A, we use the appropriate
table(s) under 105.08B in the digestive system to determine whether
a child's growth is less than the third percentile. The child does
not need to have a digestive disorder for purposes of 100.05.
a. For children from birth to attainment of age 2, we use the
weight-for-length table corresponding to the child's gender (Table I
or Table II).
b. For children age 2 to attainment of age 3, we use the body
mass index (BMI)-for-age table corresponding to the child's gender
(Table III or Table IV).

[[Page 19526]]

c. BMI is the ratio of a child's weight to the square of his or
her height. We calculate BMI using the formulas in 105.00G2c.
d. Growth measurements. The weight-for-length measurements for
children from birth to the attainment of age 2 and BMI-for-age
measurements for children age 2 to attainment of age 3 that are
required for this listing must be obtained within a 12-month period
and at least 60 days apart. If a child attains age 2 during the
evaluation period, additional measurements are not needed. Any
measurements taken before the child attains age 2 can be used to
evaluate the impairment under the appropriate listing for the
child's age. If the child attains age 3 during the evaluation
period, the measurements can be used to evaluate the impairment in
the affected body system.
3. Developmental delay.
a. Under 100.05B and C, we use reports from acceptable medical
sources to establish delay in a child's development.
b. Under 100.05B, we document the severity of developmental
delay with results from a standardized developmental assessment,
which compares a child's level of development to the level typically
expected for his or her chronological age. If the child was born
prematurely, we may use the corrected chronological age (CCA) for
comparison. (See Sec. 416.924b(b) of this chapter.) CCA is the
chronological age adjusted by a period of gestational prematurity.
CCA = (chronological age)--(number of weeks premature). Acceptable
medical sources or early intervention specialists, physical or
occupational therapists, and other sources may conduct standardized
developmental assessments and developmental screenings. The results
of these tests and screenings must be accompanied by a statement or
records from an acceptable medical source who established the child
has a developmental delay.
c. Under 100.05C, when there are no results from a standardized
developmental assessment in the case record, we need narrative
developmental reports from the child's medical sources in sufficient
detail to assess the severity of his or her developmental delay. A
narrative developmental report is based on clinical observations,
progress notes, and well-baby check-ups. To meet the requirements
for 100.05C, the report must include: The child's developmental
history; examination findings (with abnormal findings noted on
repeated examinations); and an overall assessment of the child's
development (that is, more than one or two isolated skills) by the
medical source. Some narrative developmental reports may include
results from developmental screening tests, which can identify a
child who is not developing or achieving skills within expected
timeframes. Although medical sources may refer to screening test
results as supporting evidence in the narrative developmental
report, screening test results alone cannot establish a diagnosis or
the severity of developmental delay.
D. How do we evaluate disorders that do not meet one of these
listings?
1. We may find infants disabled due to other disorders when
their birth weights are greater than 1200 grams but less than 2000
grams and their weight and gestational age do not meet listing
100.04. The most common disorders of prematurity and LBW include
retinopathy of prematurity (ROP), chronic lung disease of infancy
(CLD, previously known as bronchopulmonary dysplasia, or BPD),
intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC),
and periventricular leukomalacia (PVL). Other disorders include poor
nutrition and growth failure, hearing disorders, seizure disorders,
cerebral palsy, and developmental disorders. We evaluate these
disorders under the affected body systems.
2. We may evaluate infants and toddlers with growth failure that
is associated with a known medical disorder under the body system of
that medical disorder, for example, the respiratory or digestive
body systems.
3. If an infant or toddler has a severe medically determinable
impairment(s) that does not meet the criteria of any listing, we
must also consider whether the child has an impairment(s) that
medically equals a listing (see Sec. 416.926 of this chapter). If
the child's impairment(s) does not meet or medically equal a
listing, we will determine whether the child's impairment(s)
functionally equals the listings (see Sec. 416.926a of this
chapter) considering the factors in Sec. 416.924a of this chapter.
We use the rule in Sec. 416.994a of this chapter when we decide
whether a child continues to be disabled.

100.01 Category of Impairments, Low Birth Weight and Failure to Thrive

100.04 Low birth weight in infants from birth to attainment of
age 1.
A. Birth weight (see 100.00B) of less than 1200 grams.

B. The following gestational age and birth weight:

------------------------------------------------------------------------
Gestational age (in weeks) Birth weight
------------------------------------------------------------------------
37-40............................... 2000 grams or less.
36.................................. 1875 grams or less.
35.................................. 1700 grams or less.
34.................................. 1500 grams or less.
33.................................. 1325 grams or less.
32.................................. 1250 grams or less.
------------------------------------------------------------------------

100.05 Failure to thrive in children from birth to attainment of
age 3 (see 100.00C), documented by A and B, or A and C.
A. Growth failure as required in 1 or 2:
1. For children from birth to attainment of age 2, three weight-
for-length measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate weight-for-
length table in listing 105.08B1; or
2. For children age 2 to attainment of age 3, three BMI-for-age
measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate BMI-for-age
table in listing 105.08B2.

AND

B. Developmental delay (see 100.00C1 and C3), established by an
acceptable medical source and documented by findings from one
current report of a standardized developmental assessment (see
100.00C3b) that:
1. Shows development not more than two-thirds of the level
typically expected for the child's age; or
2. Results in a valid score that is at least two standard
deviations below the mean.

C. Developmental delay (see 100.00C3), established by an
acceptable medical source and documented by findings from two
narrative developmental reports (see 100.00C3c) that:
1. Are dated at least 120 days apart (see 100.00C1); and
2. Indicate current development not more than two-thirds of the
level typically expected for the child's age.
* * * * *

103.00 RESPIRATORY SYSTEM

* * * * *
F. How do we evaluate growth failure due to any chronic
respiratory disorder?
1. To evaluate growth failure due to any chronic respiratory
disorder, we require documentation of the oxygen supplementation
described in 103.06A and the growth measurements in 103.06B within
the same consecutive 12-month period. The dates of oxygen
supplementation may be different from the dates of growth
measurements.
2. Under 103.06B, we use the appropriate table(s) under 105.08B
in the digestive system to determine whether a child's growth is
less than the third percentile.
a. For children from birth to attainment of age 2, we use the
weight-for-length table corresponding to the child's gender (Table I
or Table II).
b. For children age 2 to attainment of age 18, we use the body
mass index (BMI)-for-age table corresponding to the child's gender
(Table III or Table IV).
c. BMI is the ratio of a child's weight to the square of his or
her height. We calculate BMI using the formulas in 105.00G2c.
* * * * *
103.06 Growth failure due to any chronic respiratory disorder
(see 103.00F), documented by:
A. Hypoxemia with the need for at least 1.0 L/min of oxygen
supplementation for at least 4 hours per day and for at least 90
consecutive days.

AND

[[Page 19527]]

a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate BMI-for-age
table under 105.08B2.
* * * * *

104.00 CARDIOVASCULAR SYSTEM

* * * * *
C. Evaluating Chronic Heart Failure
* * * * *
2. What evidence of CHF do we need?
* * * * *
b. To establish that you have chronic heart failure, we require
that your medical history and physical examination describe
characteristic symptoms and signs of pulmonary or systemic
congestion or of limited cardiac output associated with abnormal
findings on appropriate medically acceptable imaging. When a
remediable factor, such as arrhythmia, triggers an acute episode of
heart failure, you may experience restored cardiac function, and a
chronic impairment may not be present.
* * * * *
(ii) During infancy, other manifestations of chronic heart
failure may include repeated lower respiratory tract infections.
* * * * *
3. How do we evaluate growth failure due to CHF?
a. To evaluate growth failure due to CHF, we require
documentation of the clinical findings of CHF described in 104.00C2
and the growth measurements in 104.02C within the same consecutive
12-month period. The dates of clinical findings may be different
from the dates of growth measurements.
b. Under 104.02C, we use the appropriate table(s) under 105.08B
in the digestive system to determine whether a child's growth is
less than the third percentile.
(i) For children from birth to attainment of age 2, we use the
weight-for-length table corresponding to the child's gender (Table I
or Table II).
(ii) For children age 2 to attainment of age 18, we use the body
mass index (BMI)-for-age table corresponding to the child's gender
(Table III or Table IV).
(iii) BMI is the ratio of a child's weight to the square of his
or her height. We calculate BMI using the formulas in 105.00G2c.
* * * * *

104.02 * * *

* * * * *
C. Growth failure as required in 1 or 2:
1. For children from birth to attainment of age 2, three weight-
for-length measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate weight-for-
length table under 105.08B1; or
2. For children age 2 to attainment of age 18, three BMI-for-age
measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate BMI-for-age
table under 105.08B2.
* * * * *

105.00 DIGESTIVE SYSTEM

* * * * *
G. How do we evaluate growth failure due to any digestive
disorder?
1. To evaluate growth failure due to any digestive disorder, we
require documentation of the laboratory findings of chronic
nutritional deficiency described in 105.08A and the growth
measurements in 105.08B within the same consecutive 12-month period.
The dates of laboratory findings may be different from the dates of
growth measurements.
2. Under 105.08B, we evaluate a child's growth failure by using
the appropriate table for age and gender.
a. For children from birth to attainment of age 2, we use the
weight-for-length table (see Table I or Table II).
b. For children age 2 to attainment of age 18, we use the body
mass index (BMI)-for-age table (see Tables III or IV).
c. BMI is the ratio of a child's weight to the square of the
child's height. We calculate BMI using one of the following
formulas:

English Formula
BMI = [Weight in Pounds/(Height in Inches x Height in Inches)] x
703
Metric Formulas
BMI = Weight in Kilograms/(Height in Meters x Height in Meters)
BMI = [Weight in Kilograms/(Height in Centimeters x Height in
Centimeters)] x 10,000
* * * * *
105.08 Growth failure due to any digestive disorder (see
105.00G), documented by A and B:
A. Chronic nutritional deficiency present on at least two
evaluations at least 60 days apart within a consecutive 12-month
period documented by one of the following:
1. Anemia with hemoglobin less than 10.0 g/dL; or
2. Serum albumin of 3.0 g/dL or less;

AND

B. Growth failure as required in 1 or 2:
1. For children from birth to attainment of age 2, three weight-
for-length measurements that are:
a. Within a 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on Table I or Table II; or

Table I--Males Birth to Attainment of Age 2
[Third Percentile Values for Weight-for-Length]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Weight Length Weight Length Weight
Length (centimeters) (kilograms) (centimeters) (kilograms) (centimeters) (kilograms)
--------------------------------------------------------------------------------------------------------------------------------------------------------
45.0.......................................................... 1.597 64.5 6.132 84.5 10.301
45.5.......................................................... 1.703 65.5 6.359 85.5 10.499
46.5.......................................................... 1.919 66.5 6.584 86.5 10.696
47.5.......................................................... 2.139 67.5 6.807 87.5 10.895
48.5.......................................................... 2.364 68.5 7.027 88.5 11.095
49.5.......................................................... 2.592 69.5 7.245 89.5 11.296
50.5.......................................................... 2.824 70.5 7.461 90.5 11.498
51.5.......................................................... 3.058 71.5 7.674 91.5 11.703
52.5.......................................................... 3.294 72.5 7.885 92.5 11.910
53.5.......................................................... 3.532 73.5 8.094 93.5 12.119
54.5.......................................................... 3.771 74.5 8.301 94.5 12.331
55.5.......................................................... 4.010 75.5 8.507 95.5 12.546
56.5.......................................................... 4.250 76.5 8.710 96.5 12.764
57.5.......................................................... 4.489 77.5 8.913 97.5 12.987
58.5.......................................................... 4.728 78.5 9.113 98.5 13.213
59.5.......................................................... 4.966 79.5 9.313 99.5 13.443
60.5.......................................................... 5.203 80.5 9.512 100.5 13.678
61.5.......................................................... 5.438 81.5 9.710 101.5 13.918
62.5.......................................................... 5.671 82.5 9.907 102.5 14.163
63.5.......................................................... 5.903 83.5 10.104 103.5 14.413
--------------------------------------------------------------------------------------------------------------------------------------------------------

[[Page 19528]]

Table II--Females Birth to Attainment of Age 2
[Third Percentile Values for Weight-for-Length]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Weight Length Weight Length Weight
Length (centimeters) (kilograms) (centimeters) (kilograms) (centimeters) (kilograms)
--------------------------------------------------------------------------------------------------------------------------------------------------------
45.0.......................................................... 1.613 64.5 5.985 84.5 10.071
45.5.......................................................... 1.724 65.5 6.200 85.5 10.270
46.5.......................................................... 1.946 66.5 6.413 86.5 10.469
47.5.......................................................... 2.171 67.5 6.625 87.5 10.670
48.5.......................................................... 2.397 68.5 6.836 88.5 10.871
49.5.......................................................... 2.624 69.5 7.046 89.5 11.074
50.5.......................................................... 2.852 70.5 7.254 90.5 11.278
51.5.......................................................... 3.081 71.5 7.461 91.5 11.484
52.5.......................................................... 3.310 72.5 7.667 92.5 11.691
53.5.......................................................... 3.538 73.5 7.871 93.5 11.901
54.5.......................................................... 3.767 74.5 8.075 94.5 12.112
55.5.......................................................... 3.994 75.5 8.277 95.5 12.326
56.5.......................................................... 4.220 76.5 8.479 96.5 12.541
57.5.......................................................... 4.445 77.5 8.679 97.5 12.760
58.5.......................................................... 4.892 78.5 8.879 98.5 12.981
59.5.......................................................... 5.113 79.5 9.078 99.5 13.205
60.5.......................................................... 5.333 80.5 9.277 100.5 13.431
61.5.......................................................... 5.552 81.5 9.476 101.5 13.661
62.5.......................................................... 5.769 82.5 9.674 102.5 13.895
63.5.......................................................... 5.769 83.5 9.872 103.5 14.132
--------------------------------------------------------------------------------------------------------------------------------------------------------

2. For children age 2 to attainment of age 18, three BMI-for-age
measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on Table III or Table IV.

Table III--Males Age 2 to Attainment of Age 18
[Third Percentile Values for BMI-for-Age]
----------------------------------------------------------------------------------------------------------------
Age (yrs. and Age (yrs. and
Age (yrs. and mos.) BMI mos.) BMI mos.) BMI
----------------------------------------------------------------------------------------------------------------
2.0 to 2.1............ 14.5 10.11 to 11.2 14.3 14.9 to 14.10 16.1
2.2 to 2.4............ 14.4 11.3 to 11.5 14.4 14.11 to 15.0 16.2
2.5 to 2.7............ 14.3 11.6 to 11.8 14.5 15.1 to 15.3 16.3
2.8 to 2.11........... 14.2 11.9 to 11.11 14.6 15.4 to 15.5 16.4
3.0 to 3.2............ 14.1 12.0 to 12.1 14.7 15.6 to 15.7 16.5
3.3 to 3.6............ 14.0 12.2 to 12.4 14.8 15.8 to 15.9 16.6
3.7 to 3.11........... 13.9 12.5 to 12.7 14.9 15.10 to 15.11 16.7
4.0 to 4.5............ 13.8 12.8 to 12.9 15.0 16.0 to 16.1 16.8
4.6 to 5.0............ 13.7 12.10 to 13.0 15.1 16.2 to 16.3 16.9
5.1 to 6.0............ 13.6 13.1 to 13.2 15.2 16.4 to 16.5 17.0
6.1 to 7.6............ 13.5 13.3 to 13.4 15.3 16.6 to 16.8 17.1
7.7 to 8.6............ 13.6 13.5 to 13.7 15.4 16.9 to 16.10 17.2
8.7 to 9.1............ 13.7 13.8 to 13.9 15.5 16.11 to 17.0 17.3
9.2 to 9.6............ 13.8 13.10 to 13.11 15.6 17.1 to 17.2 17.4
9.7 to 9.11........... 13.9 14.0 to 14.1 15.7 17.3 to 17.5 17.5
10.0 to 10.3.......... 14.0 14.2 to 14.4 15.8 17.6 to 17.7 17.6
10.4 to 10.7.......... 14.1 14.5 to 14.6 15.9 17.8 to 17.9 17.7
10.8 to 10.10......... 14.2 14.7 to 14.8 16.0 17.10 to 17.11 17.8
----------------------------------------------------------------------------------------------------------------

Table IV--Females Age 2 to Attainment of Age 18
[Third Percentile Values for BMI-for-Age]
----------------------------------------------------------------------------------------------------------------
Age (yrs. and Age (yrs. and
Age (yrs. and mos.) BMI mos.) BMI mos.) BMI
----------------------------------------------------------------------------------------------------------------
2.0 to 2.2....................................... 14.1 10.8 to 10.10 14.0 14.3 to 14.5 15.6
2.3 to 2.6....................................... 14.0 10.11 to 11.2 14.1 14.6 to 14.7 15.7
2.7 to 2.10...................................... 13.9 11.3 to 11.5 14.2 14.8 to 14.9 15.8
2.11 to 3.2...................................... 13.8 11.6 to 11.7 14.3 14.10 to 15.0 15.9
3.3 to 3.6....................................... 13.7 11.8 to 11.10 14.4 15.1 to 15.2 16.0
3.7 to 3.11...................................... 13.6 11.11 to 12.1 14.5 15.3 to 15.5 16.1
4.0 to 4.4....................................... 13.5 12.2 to 12.4 14.6 15.6 to 15.7 16.2
4.5 to 4.11...................................... 13.4 12.5 to 12.6 14.7 15.8 to 15.10 16.3
5.0 to 5.9....................................... 13.3 12.7 to 12.9 14.8 15.11 to 16.0 16.4
5.10 to 7.6...................................... 13.2 12.10 to 12.11 14.9 16.1 to 16.3 16.5

[[Page 19529]]

7.7 to 8.4....................................... 13.3 13.0 to 13.2 15.0 16.4 to 16.6 16.6
8.5 to 8.10...................................... 13.4 13.3 to 13.4 15.1 16.7 to 16.9 16.7
8.11 to 9.3...................................... 13.5 13.5 to 13.7 15.2 16.10 to 17.0 16.8
9.4 to 9.8....................................... 13.6 13.8 to 13.9 15.3 17.1 to 17.3 16.9
9.9 to 10.0...................................... 13.7 13.10 to 14.0 15.4 17.4 to 17.7 17.0
10.1 to 10.4..................................... 13.8 14.1 to 14.2 15.5 17.8 to 17.11 17.1
10.5 to 10.7..................................... 13.9
----------------------------------------------------------------------------------------------------------------

* * * * *

106.00 GENITOURINARY IMPAIRMENTS

* * * * *
C. What other factors do we consider when we evaluate your
genitourinary disorder?
* * * * *
5. Growth failure due to any chronic renal disease.
a. To evaluate growth failure due to any chronic renal disease,
we require documentation of the laboratory findings described in
106.08A and the growth measurements in 106.08B within the same
consecutive 12-month period. The dates of laboratory findings may be
different from the dates of growth measurements.
b. Under 106.08B, we use the appropriate table(s) under 105.08B
in the digestive system to determine whether a child's growth is
less than the third percentile.
(i) For children from birth to attainment of age 2, we use the
weight-for-length table corresponding to the child's gender (Table I
or Table II).
(ii) For children age 2 to attainment of age 18, we use the body
mass index (BMI)-for-age table corresponding to the child's gender
(Table III or Table IV).
(iii) BMI is the ratio of a child's weight to the square of his
or her height. We calculate BMI using the formulas in 105.00G2c.
* * * * *
106.08 Growth failure due to any chronic renal disease (see
106.00C5), with:
A. Serum creatinine of 2 mg/dL or greater, documented at least
two times within a consecutive 12-month period with at least 60 days
between measurements.

AND

B. Growth failure as required in 1 or 2:
1. For children from birth to attainment of age 2, three weight-
for-length measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate weight-for-
length table under 105.08B1; or
2. For children age 2 to attainment of age 18, three BMI-for-age
measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate BMI-for-age
table under 105.08B2.
* * * * *
114.00 IMMUNE SYSTEM DISORDERS
* * * * *
F. * * *
* * * * *
4. HIV infection manifestations specific to children.
* * * * *
d. Growth failure due to HIV immune suppression.
(i) To evaluate growth failure due to HIV immune suppression, we
require documentation of the laboratory values described in 114.08H1
and the growth measurements in 114.08H2 or 114.08H3 within the same
consecutive 12-month period. The dates of laboratory findings may be
different from the dates of growth measurements.
(ii) Under 114.08H2 and 114.08H3, we use the appropriate table
under 105.08B in the digestive system to determine whether a child's
growth is less than the third percentile.
(A) For children from birth to attainment of age 2, we use the
weight-for-length table corresponding to the child's gender (Table I
or Table II).
(B) For children age 2 to attainment of age 18, we use the body
mass index (BMI)-for-age table corresponding to the child's gender
(Table III or Table IV).
(C) BMI is the ratio of a child's weight to the square of his or
her height. We calculate BMI using the formulas in 105.00G2c.
* * * * *

114.08 * * *

* * * * *
H. Immune suppression and growth failure (see 114.00F4d)
documented by 1 and 2, or by 1 and 3.
1. CD4 measurement:
a. For children from birth to attainment of age 5, CD4
percentage of less than 20 percent; or
b. For children age 5 to attainment of age 18, absolute CD4
count of less than 200 cells/mm\3\, or CD4 percentage of less than
14 percent; and
2. For children from birth to attainment of age 2, three weight-
for-length measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate weight-for-
length table under 105.08B1; or
3. For children age 2 to attainment of age 18, three BMI-for-age
measurements that are:
a. Within a consecutive 12-month period; and
b. At least 60 days apart; and
c. Less than the third percentile on the appropriate BMI-for-age
table under 105.08B2.
* * * * *

PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND
DISABLED

Subpart I--[Amended]

0
3. The authority citation for subpart I of part 416 continues to read
as follows:

Authority: Secs. 221(m), 702(a)(5), 1611, 1614, 1619, 1631(a),
(c), (d)(1), and (p), and 1633 of the Social Security Act (42 U.S.C.
421(m), 902(a)(5), 1382, 1382c, 1382h, 1383(a), (c), (d)(1), and
(p), and 1383b); secs. 4(c) and 5, 6(c)-(e), 14(a), and 15, Pub. L.
98-460, 98 Stat. 1794, 1801, 1802, and 1808 (42 U.S.C. 421 note, 423
note, and 1382h note).

0
4. Amend Sec. 416.924b by revising paragraph (b) to read as follows:

Sec. 416.924b Age as a factor of evaluation in the sequential
evaluation process for children.

* * * * *
(b) Correcting chronological age of premature infants. We generally
use chronological age (a child's age based on birth date) when we
decide whether, or the extent to which, a physical or mental impairment
or combination of impairments causes functional limitations. However,
if you were born prematurely, we may consider you younger than your
chronological age when we evaluate your development. We may use a
``corrected'' chronological age (CCA); that is, your chronological age
adjusted by a period of gestational prematurity. We consider an infant
born at less than 37 weeks' gestation to be born prematurely.
(1) We compute your CCA by subtracting the number of weeks of
prematurity (the difference between 40 weeks of full-term gestation and
the number of actual weeks of gestation) from your chronological age.
For example, if your chronological age is 20

[[Page 19530]]

weeks but you were born at 32 weeks gestation (8 weeks premature), then
your CCA is 12 weeks.
(2) We evaluate developmental delay in a premature child until the
child's prematurity is no longer a relevant factor, generally no later
than about chronological age 2.
(i) If you have not attained age 1 and were born prematurely, we
will assess your development using your CCA.
(ii) If you are over age 1 and have a developmental delay, and
prematurity is still a relevant factor, we will decide whether to
correct your chronological age. We will base our decision on our
judgment and all the facts in your case. If we decide to correct your
chronological age, we may correct it by subtracting the full number of
weeks of prematurity or a lesser number of weeks. If your developmental
delay is the result of your medically determinable impairment(s) and is
not attributable to your prematurity, we will decide not to correct
your chronological age.
(3) Notwithstanding the provisions in paragraph (b)(1) of this
section, we will not compute a CCA if the medical evidence shows that
your treating source or other medical source has already taken your
prematurity into consideration in his or her assessment of your
development. We will not compute a CCA when we find you disabled under
listing 100.04 of the Listing of Impairments.

Sec. 416.926a [Amended]

0
5. Amend Sec. 416.926a by removing paragraphs (m)(6) and (m)(7) and
redesignating paragraph (m)(8) as (m)(6).

0
6. Amend Sec. 416.934 by adding paragraphs (j) and (k) to read as
follows:

Sec. 416.934 Impairments which may warrant a finding of presumptive
disability or presumptive blindness.

* * * * *
(j) Infants weighing less than 1200 grams at birth, until
attainment of 1 year of age.
(k) Infants weighing at least 1200 but less than 2000 grams at
birth, and who are small for gestational age, until attainment of 1
year of age. (Small for gestational age means a birth weight that is at
or more than 2 standard deviations below the mean or that is less than
the third growth percentile for the gestational age of the infant.)

[FR Doc. 2015-08185 Filed 4-10-15; 8:45 am]
BILLING CODE 4191-02-P

19524 Federal Register / Vol. 80, No. 70 / Monday, April 13, 2015 / Rules and Regulations

Developmental Testing functional limitations’’ only if it meets, medically determinable impairment,
Comment: One commenter questioned medically equals, or functionally equals although it can be the result of a
the requirement for two narrative the listings. An impairment is of listing- medically determinable impairment. We
developmental reports in 100.05C and level severity if it results in ‘‘marked’’ will evaluate children with growth
the requirement that these two reports limitations in two domains of failure that does not meet the
be at least 120 days apart. This functioning or an ‘‘extreme’’ limitation requirements of listings 100.04 and
commenter suggested that, if we keep in one domain.3 The level of delay that 100.05 and is associated with a known
the requirement for two reports, we we require in 100.05C is consistent with medically determinable impairment
should require a shorter period of either our definition of ‘‘marked limitation’’ in under the affected body system.
§ 416.926a(e)(2)(ii). Comment: One commenter was
30 or 60 days between them. Another
Comment: One commenter expressed
commenter also expressed concern concerned that, while the majority of
concern about acceptable timeframes for
about the requirements for the evidence children over the age of 3 with growth
performing developmental testing in
of developmental delay. This failure have signs and symptoms of an
relation to disability determinations
commenter was concerned about the underlying disorder in the respiratory,
stated in 100.05B and 100.05C. The
availability of these records from cardiovascular, digestive, genitourinary,
commenter suggested that the testing to
providers. or immune body system, some children
establish the child’s current level of
Response: We did not adopt these over the age of 3 will not. This
development be performed within 6
comments. In 100.05C, we require two commenter suggested that we include
months of adjudication.
narrative developmental reports when a Response: We partially adopted this exceptions for conditions, such as
report of a standardized developmental comment. We agree that evidence about Turner syndrome (female
assessment required by 100.05B is not a child’s development must be recent hypogonadism) and acquired growth
available. As we explained in the and current in relation to a disability hormone deficiency, where growth
NPRM, abnormal findings noted on determination, and we have revised failure may be a significant component
repeated examinations, and information listings 100.05B and 100.05C2 to clarify of the disease process.
in narrative developmental reports, that this requirement. However, the facts in Response: We did not adopt this
may include the results of a specific case determine whether the comment. After a child attains age 3, we
developmental screening tests, can evidence is current. Determining factors will evaluate his or her impairment
identify a child who is not developing include, but are not limited to, the age under the affected body system. The two
or achieving skills within expected of the child, the amount of delay, and examples provided by the commenter
timeframes.2 the developmental trajectory are endocrine disorders. Although these
We do not believe that 30 or 60 days documented over time. We are not two disorders are not listed impairments
is enough time for these kinds of setting specific timeframes for when for children, they may rise to listing-
changes to appear on testing. We believe developmental testing must be level severity because of their effects in
that 120 days is an appropriate period performed, but we are specifying that other body systems. As the commenter
for developmental testing to be the evidence must reflect the child’s explained, children with Turner
performed and to allow for any changes current development. syndrome may experience
in development to show on testing. complications, such as heart disease, to
While we understand the Linear Growth
a degree that is disabling. We would
commenter’s concern about the Comment: One commenter agreed evaluate the complications under the
availability of evidence, we believe that, with our use of weight-for-length and affected body system.
for the children whose impairments we BMI-for-age charts to evaluate growth
evaluate under listing 100.05, evidence failure, rather than of linear (height or Listing 103.06 Growth Failure Due to
generally will be available from length) growth charts. The commenter Any Chronic Respiratory Disorder
providers because these children are expressed concern, however, that an Comment: Two commenters were
likely to be identified, and subsequently underlying condition could cause a concerned with the requirement for
treated because of their identification, child to have such profound growth oxygen supplementation in 103.06A.
by early intervention programs. failure that BMI for the child’s age The commenters noted that some
Comment: One commenter noted that would become normal, despite his or respiratory disorders, such as asthma,
most early intervention programs use ‘‘a her significant growth failure. bronchiectasis, and cystic fibrosis, could
25 percent delay criteria as opposed to Response: We did not adopt this
result in listing-level growth failure
the two-thirds criteria’’ required in comment. We understand the
without requiring oxygen
100.05C. However, the commenter did commenter’s concerns that some
supplementation.
not provide any suggestions for children may have underlying
changing the criterion. conditions that cause linear growth Response: We did not adopt these
Response: We did not adopt this impairments while their BMI-for-age comments. We agree with the
comment. We recognize that early measurements are normal. After commenters that some respiratory
intervention programs often use a 25 attainment of age 2, most children disorders could result in listing-level
percent delay criterion to determine without an underlying medical disorder growth failure without requiring oxygen
eligibility for intervention services and follow a growth trajectory that remains supplementation; however, we did not
to identify the needed services. In fairly constant during childhood. revise 103.06 as a result. We use other
listings, such as 103.02, 103.03, and
wreier-aviles on DSK5TPTVN1PROD with RULES

contrast, we evaluate a child’s delay to Our adjudicative experience has
determine whether the underlying shown that a declining linear growth 103.04, in the respiratory body system
impairment is disabling because it rate is not always indicative of a to evaluate these disorders.4 We believe
results in ‘‘marked and severe disabling condition. Short stature, that these respiratory listings, and our
functional limitations.’’ An impairment length, or height below the third functional equivalence rule for
results in ‘‘marked and severe percentile, in and of itself, is not a evaluating disability in children,

2 78 FR at 30251. 3 See 20 CFR 416.926a(a). 4 See 20 CFR part 404, subpart P, Appendix 1.

VerDate Sep<11>2014 15:35 Apr 10, 2015 Jkt 235001 PO 00000 Frm 00014 Fmt 4700 Sfmt 4700 E:\FR\FM\13APR1.SGM 13APR1

19526 Federal Register / Vol. 80, No. 70 / Monday, April 13, 2015 / Rules and Regulations

c. BMI is the ratio of a child’s weight to the greater than 1200 grams but less than 2000 AND
square of his or her height. We calculate BMI grams and their weight and gestational age do B. Developmental delay (see 100.00C1 and
using the formulas in 105.00G2c. not meet listing 100.04. The most common C3), established by an acceptable medical
d. Growth measurements. The weight-for- disorders of prematurity and LBW include source and documented by findings from one
length measurements for children from birth retinopathy of prematurity (ROP), chronic current report of a standardized
to the attainment of age 2 and BMI-for-age lung disease of infancy (CLD, previously developmental assessment (see 100.00C3b)
measurements for children age 2 to known as bronchopulmonary dysplasia, or that:
attainment of age 3 that are required for this BPD), intraventricular hemorrhage (IVH),
1. Shows development not more than two-
listing must be obtained within a 12-month necrotizing enterocolitis (NEC), and
thirds of the level typically expected for the
period and at least 60 days apart. If a child periventricular leukomalacia (PVL). Other
child’s age; or
attains age 2 during the evaluation period, disorders include poor nutrition and growth
additional measurements are not needed. failure, hearing disorders, seizure disorders, 2. Results in a valid score that is at least
Any measurements taken before the child cerebral palsy, and developmental disorders. two standard deviations below the mean.
attains age 2 can be used to evaluate the We evaluate these disorders under the OR
impairment under the appropriate listing for affected body systems. C. Developmental delay (see 100.00C3),
the child’s age. If the child attains age 3 2. We may evaluate infants and toddlers established by an acceptable medical source
during the evaluation period, the with growth failure that is associated with a and documented by findings from two
measurements can be used to evaluate the known medical disorder under the body narrative developmental reports (see
impairment in the affected body system. system of that medical disorder, for example, 100.00C3c) that:
3. Developmental delay. the respiratory or digestive body systems. 1. Are dated at least 120 days apart (see
a. Under 100.05B and C, we use reports 3. If an infant or toddler has a severe 100.00C1); and
from acceptable medical sources to establish medically determinable impairment(s) that 2. Indicate current development not more
delay in a child’s development. does not meet the criteria of any listing, we than two-thirds of the level typically
b. Under 100.05B, we document the must also consider whether the child has an expected for the child’s age.
severity of developmental delay with results impairment(s) that medically equals a listing
from a standardized developmental (see § 416.926 of this chapter). If the child’s * * * * *
assessment, which compares a child’s level impairment(s) does not meet or medically 103.00 RESPIRATORY SYSTEM
of development to the level typically equal a listing, we will determine whether
expected for his or her chronological age. If the child’s impairment(s) functionally equals * * * * *
the child was born prematurely, we may use the listings (see § 416.926a of this chapter) F. How do we evaluate growth failure due
the corrected chronological age (CCA) for considering the factors in § 416.924a of this to any chronic respiratory disorder?
comparison. (See § 416.924b(b) of this chapter. We use the rule in § 416.994a of this 1. To evaluate growth failure due to any
chapter.) CCA is the chronological age chapter when we decide whether a child chronic respiratory disorder, we require
adjusted by a period of gestational continues to be disabled. documentation of the oxygen
prematurity. CCA = (chronological age)— supplementation described in 103.06A and
100.01 Category of Impairments, Low Birth the growth measurements in 103.06B within
(number of weeks premature). Acceptable Weight and Failure to Thrive
medical sources or early intervention the same consecutive 12-month period. The
specialists, physical or occupational 100.04 Low birth weight in infants from dates of oxygen supplementation may be
therapists, and other sources may conduct birth to attainment of age 1. different from the dates of growth
standardized developmental assessments and A. Birth weight (see 100.00B) of less than measurements.
developmental screenings. The results of 1200 grams. 2. Under 103.06B, we use the appropriate
these tests and screenings must be OR table(s) under 105.08B in the digestive
accompanied by a statement or records from B. The following gestational age and birth system to determine whether a child’s growth
an acceptable medical source who weight: is less than the third percentile.
established the child has a developmental a. For children from birth to attainment of
delay. Gestational age 2, we use the weight-for-length table
c. Under 100.05C, when there are no age Birth weight corresponding to the child’s gender (Table I
results from a standardized developmental (in weeks) or Table II).
assessment in the case record, we need b. For children age 2 to attainment of age
narrative developmental reports from the 37–40 .......... 2000 grams or less. 18, we use the body mass index (BMI)-for-age
child’s medical sources in sufficient detail to 36 ................ 1875 grams or less. table corresponding to the child’s gender
assess the severity of his or her 35 ................ 1700 grams or less. (Table III or Table IV).
developmental delay. A narrative 34 ................ 1500 grams or less. c. BMI is the ratio of a child’s weight to the
developmental report is based on clinical 33 ................ 1325 grams or less. square of his or her height. We calculate BMI
observations, progress notes, and well-baby 32 ................ 1250 grams or less. using the formulas in 105.00G2c.
check-ups. To meet the requirements for * * * * *
100.05C, the report must include: The child’s 100.05 Failure to thrive in children from 103.06 Growth failure due to any chronic
developmental history; examination findings birth to attainment of age 3 (see 100.00C), respiratory disorder (see 103.00F),
(with abnormal findings noted on repeated documented by A and B, or A and C. documented by:
examinations); and an overall assessment of A. Growth failure as required in 1 or 2: A. Hypoxemia with the need for at least 1.0
the child’s development (that is, more than 1. For children from birth to attainment of L/min of oxygen supplementation for at least
one or two isolated skills) by the medical age 2, three weight-for-length measurements 4 hours per day and for at least 90
source. Some narrative developmental that are:
consecutive days.
reports may include results from a. Within a consecutive 12-month period;
developmental screening tests, which can and AND
identify a child who is not developing or b. At least 60 days apart; and B. Growth failure as required in 1 or 2:
achieving skills within expected timeframes. c. Less than the third percentile on the 1. For children from birth to attainment of
Although medical sources may refer to appropriate weight-for-length table in listing age 2, three weight-for-length measurements
screening test results as supporting evidence 105.08B1; or that are:
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in the narrative developmental report, 2. For children age 2 to attainment of age a. Within a consecutive 12-month period;
screening test results alone cannot establish 3, three BMI-for-age measurements that are: and
a diagnosis or the severity of developmental a. Within a consecutive 12-month period; b. At least 60 days apart; and
delay. and c. Less than the third percentile on the
D. How do we evaluate disorders that do b. At least 60 days apart; and appropriate weight-for-length table under
not meet one of these listings? c. Less than the third percentile on the 105.08B1; or
1. We may find infants disabled due to appropriate BMI-for-age table in listing 2. For children age 2 to attainment of age
other disorders when their birth weights are 105.08B2. 18, three BMI-for-age measurements that are:

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Federal Register / Vol. 80, No. 70 / Monday, April 13, 2015 / Rules and Regulations 19527

a. Within a consecutive 12-month period; (i) For children from birth to attainment of be different from the dates of growth
and age 2, we use the weight-for-length table measurements.
b. At least 60 days apart; and corresponding to the child’s gender (Table I 2. Under 105.08B, we evaluate a child’s
c. Less than the third percentile on the or Table II). growth failure by using the appropriate table
appropriate BMI-for-age table under (ii) For children age 2 to attainment of age for age and gender.
105.08B2. 18, we use the body mass index (BMI)-for-age a. For children from birth to attainment of
* * * * * table corresponding to the child’s gender age 2, we use the weight-for-length table (see
(Table III or Table IV). Table I or Table II).
104.00 CARDIOVASCULAR SYSTEM (iii) BMI is the ratio of a child’s weight to
b. For children age 2 to attainment of age
* * * * * the square of his or her height. We calculate
18, we use the body mass index (BMI)-for-age
C. Evaluating Chronic Heart Failure BMI using the formulas in 105.00G2c.
table (see Tables III or IV).
* * * * * * * * * * c. BMI is the ratio of a child’s weight to the
2. What evidence of CHF do we need? 104.02 * * * square of the child’s height. We calculate
* * * * * * * * * * BMI using one of the following formulas:
b. To establish that you have chronic heart C. Growth failure as required in 1 or 2: English Formula
failure, we require that your medical history 1. For children from birth to attainment of BMI = [Weight in Pounds/(Height in Inches
and physical examination describe age 2, three weight-for-length measurements × Height in Inches)] × 703
characteristic symptoms and signs of that are: Metric Formulas
pulmonary or systemic congestion or of a. Within a consecutive 12-month period; BMI = Weight in Kilograms/(Height in
limited cardiac output associated with and Meters × Height in Meters)
abnormal findings on appropriate medically b. At least 60 days apart; and BMI = [Weight in Kilograms/(Height in
acceptable imaging. When a remediable c. Less than the third percentile on the Centimeters × Height in Centimeters)] ×
factor, such as arrhythmia, triggers an acute appropriate weight-for-length table under 10,000
episode of heart failure, you may experience 105.08B1; or
restored cardiac function, and a chronic 2. For children age 2 to attainment of age * * * * *
impairment may not be present. 18, three BMI-for-age measurements that are: 105.08 Growth failure due to any
a. Within a consecutive 12-month period; digestive disorder (see 105.00G), documented
* * * * *
and by A and B:
(ii) During infancy, other manifestations of
chronic heart failure may include repeated b. At least 60 days apart; and A. Chronic nutritional deficiency present
c. Less than the third percentile on the on at least two evaluations at least 60 days
lower respiratory tract infections.
appropriate BMI-for-age table under apart within a consecutive 12-month period
* * * * * 105.08B2. documented by one of the following:
3. How do we evaluate growth failure due 1. Anemia with hemoglobin less than 10.0
* * * * *
to CHF? g/dL; or
a. To evaluate growth failure due to CHF, 105.00 DIGESTIVE SYSTEM
2. Serum albumin of 3.0 g/dL or less;
we require documentation of the clinical * * * * *
findings of CHF described in 104.00C2 and AND
G. How do we evaluate growth failure due
the growth measurements in 104.02C within to any digestive disorder? B. Growth failure as required in 1 or 2:
the same consecutive 12-month period. The 1. To evaluate growth failure due to any 1. For children from birth to attainment of
dates of clinical findings may be different digestive disorder, we require documentation age 2, three weight-for-length measurements
from the dates of growth measurements. of the laboratory findings of chronic that are:
b. Under 104.02C, we use the appropriate nutritional deficiency described in 105.08A a. Within a 12-month period; and
table(s) under 105.08B in the digestive and the growth measurements in 105.08B b. At least 60 days apart; and
system to determine whether a child’s growth within the same consecutive 12-month c. Less than the third percentile on Table
is less than the third percentile. period. The dates of laboratory findings may I or Table II; or

TABLE I—MALES BIRTH TO ATTAINMENT OF AGE 2
[Third Percentile Values for Weight-for-Length]

Length Weight Length Weight Length Weight
(centimeters) (kilograms) (centimeters) (kilograms) (centimeters) (kilograms)

45.0 .................................................................. 1.597 64.5 6.132 84.5 10.301
45.5 .................................................................. 1.703 65.5 6.359 85.5 10.499
46.5 .................................................................. 1.919 66.5 6.584 86.5 10.696
47.5 .................................................................. 2.139 67.5 6.807 87.5 10.895
48.5 .................................................................. 2.364 68.5 7.027 88.5 11.095
49.5 .................................................................. 2.592 69.5 7.245 89.5 11.296
50.5 .................................................................. 2.824 70.5 7.461 90.5 11.498
51.5 .................................................................. 3.058 71.5 7.674 91.5 11.703
52.5 .................................................................. 3.294 72.5 7.885 92.5 11.910
53.5 .................................................................. 3.532 73.5 8.094 93.5 12.119
54.5 .................................................................. 3.771 74.5 8.301 94.5 12.331
55.5 .................................................................. 4.010 75.5 8.507 95.5 12.546
56.5 .................................................................. 4.250 76.5 8.710 96.5 12.764
57.5 .................................................................. 4.489 77.5 8.913 97.5 12.987
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58.5 .................................................................. 4.728 78.5 9.113 98.5 13.213
59.5 .................................................................. 4.966 79.5 9.313 99.5 13.443
60.5 .................................................................. 5.203 80.5 9.512 100.5 13.678
61.5 .................................................................. 5.438 81.5 9.710 101.5 13.918
62.5 .................................................................. 5.671 82.5 9.907 102.5 14.163
63.5 .................................................................. 5.903 83.5 10.104 103.5 14.413

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19528 Federal Register / Vol. 80, No. 70 / Monday, April 13, 2015 / Rules and Regulations

TABLE II—FEMALES BIRTH TO ATTAINMENT OF AGE 2
[Third Percentile Values for Weight-for-Length]

Length Weight Length Weight Length Weight
(centimeters) (kilograms) (centimeters) (kilograms) (centimeters) (kilograms)

45.0 .................................................................. 1.613 64.5 5.985 84.5 10.071
45.5 .................................................................. 1.724 65.5 6.200 85.5 10.270
46.5 .................................................................. 1.946 66.5 6.413 86.5 10.469
47.5 .................................................................. 2.171 67.5 6.625 87.5 10.670
48.5 .................................................................. 2.397 68.5 6.836 88.5 10.871
49.5 .................................................................. 2.624 69.5 7.046 89.5 11.074
50.5 .................................................................. 2.852 70.5 7.254 90.5 11.278
51.5 .................................................................. 3.081 71.5 7.461 91.5 11.484
52.5 .................................................................. 3.310 72.5 7.667 92.5 11.691
53.5 .................................................................. 3.538 73.5 7.871 93.5 11.901
54.5 .................................................................. 3.767 74.5 8.075 94.5 12.112
55.5 .................................................................. 3.994 75.5 8.277 95.5 12.326
56.5 .................................................................. 4.220 76.5 8.479 96.5 12.541
57.5 .................................................................. 4.445 77.5 8.679 97.5 12.760
58.5 .................................................................. 4.892 78.5 8.879 98.5 12.981
59.5 .................................................................. 5.113 79.5 9.078 99.5 13.205
60.5 .................................................................. 5.333 80.5 9.277 100.5 13.431
61.5 .................................................................. 5.552 81.5 9.476 101.5 13.661
62.5 .................................................................. 5.769 82.5 9.674 102.5 13.895
63.5 .................................................................. 5.769 83.5 9.872 103.5 14.132

2. For children age 2 to attainment of age a. Within a consecutive 12-month period; c. Less than the third percentile on Table
18, three BMI-for-age measurements that are: and III or Table IV.
b. At least 60 days apart; and

TABLE III—MALES AGE 2 TO ATTAINMENT OF AGE 18
[Third Percentile Values for BMI-for-Age]

Age Age Age
(yrs. and BMI (yrs. and mos.) BMI (yrs. and mos.) BMI
mos.)

2.0 to 2.1 ...... 14.5 10.11 to 11.2 14.3 14.9 to 14.10 16.1
2.2 to 2.4 ...... 14.4 11.3 to 11.5 14.4 14.11 to 15.0 16.2
2.5 to 2.7 ...... 14.3 11.6 to 11.8 14.5 15.1 to 15.3 16.3
2.8 to 2.11 .... 14.2 11.9 to 11.11 14.6 15.4 to 15.5 16.4
3.0 to 3.2 ...... 14.1 12.0 to 12.1 14.7 15.6 to 15.7 16.5
3.3 to 3.6 ...... 14.0 12.2 to 12.4 14.8 15.8 to 15.9 16.6
3.7 to 3.11 .... 13.9 12.5 to 12.7 14.9 15.10 to 15.11 16.7
4.0 to 4.5 ...... 13.8 12.8 to 12.9 15.0 16.0 to 16.1 16.8
4.6 to 5.0 ...... 13.7 12.10 to 13.0 15.1 16.2 to 16.3 16.9
5.1 to 6.0 ...... 13.6 13.1 to 13.2 15.2 16.4 to 16.5 17.0
6.1 to 7.6 ...... 13.5 13.3 to 13.4 15.3 16.6 to 16.8 17.1
7.7 to 8.6 ...... 13.6 13.5 to 13.7 15.4 16.9 to 16.10 17.2
8.7 to 9.1 ...... 13.7 13.8 to 13.9 15.5 16.11 to 17.0 17.3
9.2 to 9.6 ...... 13.8 13.10 to 13.11 15.6 17.1 to 17.2 17.4
9.7 to 9.11 .... 13.9 14.0 to 14.1 15.7 17.3 to 17.5 17.5
10.0 to 10.3 .. 14.0 14.2 to 14.4 15.8 17.6 to 17.7 17.6
10.4 to 10.7 .. 14.1 14.5 to 14.6 15.9 17.8 to 17.9 17.7
10.8 to 10.10 14.2 14.7 to 14.8 16.0 17.10 to 17.11 17.8

TABLE IV—FEMALES AGE 2 TO ATTAINMENT OF AGE 18
[Third Percentile Values for BMI-for-Age]

Age Age Age
BMI BMI BMI
(yrs. and mos.) (yrs. and mos.) (yrs. and mos.)

2.0 to 2.2 .......................................................................................................... 14.1 10.8 to 10.10 14.0 14.3 to 14.5 15.6
2.3 to 2.6 .......................................................................................................... 14.0 10.11 to 11.2 14.1 14.6 to 14.7 15.7
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2.7 to 2.10 ........................................................................................................ 13.9 11.3 to 11.5 14.2 14.8 to 14.9 15.8
2.11 to 3.2 ........................................................................................................ 13.8 11.6 to 11.7 14.3 14.10 to 15.0 15.9
3.3 to 3.6 .......................................................................................................... 13.7 11.8 to 11.10 14.4 15.1 to 15.2 16.0
3.7 to 3.11 ........................................................................................................ 13.6 11.11 to 12.1 14.5 15.3 to 15.5 16.1
4.0 to 4.4 .......................................................................................................... 13.5 12.2 to 12.4 14.6 15.6 to 15.7 16.2
4.5 to 4.11 ........................................................................................................ 13.4 12.5 to 12.6 14.7 15.8 to 15.10 16.3
5.0 to 5.9 .......................................................................................................... 13.3 12.7 to 12.9 14.8 15.11 to 16.0 16.4
5.10 to 7.6 ........................................................................................................ 13.2 12.10 to 12.11 14.9 16.1 to 16.3 16.5

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Document Created: 2015-12-18 11:21:59
Document Modified: 2015-12-18 11:21:59

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		Rules and Regulations
Action		Final rule.
Dates		This rule is effective June 12, 2015.
Contact		Cheryl A. Williams, Office of Medical Policy, Social Security Administration, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, (410) 965-1020. For information on eligibility or filing for benefits, call our national toll-free number, 1-800-772-1213, or TTY 1-800-325-0778, or visit our Internet site, Social Security Online, at http://www.socialsecurity.gov.
FR Citation		80 FR 19522
RIN Number		0960-AG28
CFR Citation		20 CFR 404 20 CFR 416