It is essential that you present the following Social Regulations that governs those with PPS to your case worker or attorney working to get you Social Security Disability Income (SSDI).
Also be aware that after you are approved for SSDI, it takes 24 months to be eligible for Medicare.
The Ruling defines post polio sequelae as "the documented residuals of acute polioencephalomyelitis, caused by one of three types of polioviruses affecting the brain and spinal cord. No matter which neurons are attacked by the virus, the severity of any residual deficit depends upon how many cells within a specific area are destroyed. Latest 2003 US Social Security regulation governing Post Polio Sequelae also known as Post Polio Syndrome is as follows:
[Federal Register:
July 2, 2003 (Volume 68, Number 127)]
[Notices]
[Page 39611-39614]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr02jy03-144]
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SOCIAL SECURITY ADMINISTRATION
Social Security Ruling, SSR 03-1p.; Titles II and XVI:
Development and Evaluation of Disability Claims Involving Postpolio
Sequelae
AGENCY: Social Security Administration.
ACTION: Notice of Social Security ruling.
________________________________________________________________
SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of Social Security gives notice of Social Security Ruling, SSR 03-1p. This Ruling clarifies the policies of the Social Security Administration for developing and evaluating title II and title XVI claims for disability on the basis of postpolio sequelae. Postpolio sequelae refer to the documented residuals of acute polio infection, as well as other disorders that have an etiological link to either the acute polio infection or to the chronic deficits that resulted from the infection. These disorders typically manifest late in the lives of polio survivors, and include such things as postpolio syndrome (also known as the late effects of poliomyelitis), the early presence of advanced degenerative arthritis, sleep disorders, respiratory insufficiency, and various mental disorders.
EFFECTIVE DATE: July 2, 2003.
FOR FURTHER INFORMATION CONTACT: Carolyn Kiefer, Office of Medical Policy, Social Security Administration, 6401 Security Boulevard, Baltimore, MD 21235-6401, (410) 965-9104 or TTY (410) 966-5609. 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 Web site, Social Security Online, at http://www.socialsecurity.gov.
SUPPLEMENTARY INFORMATION: Although we are not required to do so pursuant to 5 U.S.C. 552(a)(1) and (a)(2),we are publishing this Social Security Ruling in accordance with 20 CFR 402.35(b)(1). Social Security Rulings make available to the public precedential decisions relating to the Federal old-age, survivors, disability, supplemental security income, and black lung benefits programs. Social Security Rulings may be based on case decisions made at all administrative levels of adjudication, Federal court decisions, Commissioner's decisions, opinions of the Office of the General Counsel, and policy interpretations of the law and regulations. Although Social Security Rulings do not have the same force and effect as the statute or regulations, they are binding on all components of the Social Security Administration, in accordance with 20 CFR 402.35(b)(1), and are relied upon as precedents in adjudicating cases. If this Social Security Ruling is later superseded, modified, or rescinded, we will publish a notice in the Federal Register to that effect.
(Catalog of Federal Domestic Assistance, Program Nos. 96.001 Social Security--Disability Insurance; 96.006 Supplemental Security Income)
Dated: June 26, 2003.
Jo Anne B. Barnhart,
Commissioner of Social Security.
Policy Interpretation Ruling
Purpose: To provide guidance on SSA policy concerning the development and evaluation of postpolio sequelae in disability claims filed under titles II and XVI of the Social Security Act (the Act).
Citations (Authority): Sections 216(i), 223(d), 223(f), 1614(a)(3) and 1614(a)(4) of the Social Security Act, as amended; Regulations No. 4, subpart P, sections 404.1502, 404.1505, 404.1508, 404.1509, 404.1511-404.1513, 404.1520, 404.1520a, 404.1521, 404.1523, 404.1525,404.1526, 404.1528, 404.1529, 404.1530, 404.1545, 404.1546, 404.1560-404.1569a; and 404.1593-404.1594 and Regulations No. 16, subpart I, sections 416.902, 416.905, 416.906, 416.908, 416.909, 416.911, 416.913, 416.920, 416.920a, 416.921, 416.923, 416.924, 416.924a- 416.924c, 416.925, 416.926, 416.926a, 416.928, 416.929, 416.930, 416.945, 416.946, 416.960-416.969a, 416.987, and 416.993-416.994a.
Introduction: "Postpolio sequelae" refers to the
documented residuals of acute polioencephalomyelitis (polio)\1\
infection as well as other disorders that have an etiological link
to either the acute polio infection or to chronic
deficits resulting from the acute infection. Disorders that may
manifest late in the lives of polio survivors include postpolio
syndrome (also known as the late effects of poliomyelitis), early
advanced degenerative arthritis, sleep
disorders, respiratory insufficiency, and a variety of mental
disorders. Any one or a combination of these disorders,
appropriately documented, will constitute the presence of "postpolio
sequelae" for purposes of developing and
evaluating claims for disability on the basis of postpolio sequelae
under Social Security disability. Even though some polio survivors
may have had previously undetected motor residuals following the
acute polio infection, they may still report progressive muscle
weakness later in life and manifest any of the disorders listed
above.
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\1\ Polio is caused by one of three types of polioviruses affecting
the brain and spinal cord. No matter which neurons are attacked by
the virus, the severity of any residual deficit depends upon how
many cells within a specific area are destroyed. Fortunately, the
polio infection was eradicated in the United States during the late
1950s following the development of oral polio vaccine and successful
mass immunization. Most polio survivors in this country are now in
their forties or older, but polio continues to be a common infection
in underdeveloped countries. The World Health Organization is
sponsoring immunization programs in hopes of completely eradicating
the disease. Most individuals who contract polio only have mild
symptoms at the time of the initial infection and then fully
recover. Only 2 percent of infected persons experience paralysis
from polio. Deaths from acute polio infection usually occur within
the first few days following the onset of paralysis. About one-third
of those individuals who do develop paralysis are left with some
degree of permanent weakness, commonly involving a single extremity.
Postpolio muscle paralysis is of the lower motor neuron variety and
is characterized by weakness, muscle atrophy, and reflex loss.
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The Act and our implementing regulations require that an individual
establish disability based on the existence of a medically
determinable impairment; i.e., one that can be shown by medical
evidence, consisting of symptoms,
signs, and laboratory findings. Disability may not be established on
the basis of an individual's statement of symptoms alone.This Ruling
explains that postpolio sequelae, when accompanied by appropriate
symptoms, signs, and laboratory findings, is a medically
determinable impairment that can be the basis for a finding of
"disability." It also provides guidance for the evaluation
of claims involving postpolio sequelae.Policy Interpretation:
Postpolio sequelae constitute a medically determinable impairment
when documented by appropriate medical signs, symptoms, and
laboratory findings. Postpolio sequelae may be the basis for a
finding of "disability," as discussed below. When making a
determination of disability in cases of postpolio sequelae, the
adjudicator or decision maker must be sure that all of the
individual's functional limitations have been considered. To do
this, the adjudicator must make a comprehensive assessment of the
cumulative and interactive effects of all of the individual's
impairments and related symptoms, including the effects of postpolio
sequelae.
Sections 216(i) and 1614(a)(3) of the Social Security
Act (the Act) define "disability" \2\ as the inability to
engage in any substantial gainful activity (SGA) by reason of any
medically determinable physical or mental impairment (or combination
of impairments) which can be expected to result in death or which
has lasted or can be expected to last a continuous period of not
less than 12 months. Sections 223(d)(3) and 1614(a)(3)(D) of the
Act, and 20 CFR 404.1508 and 416.908, require that an impairment
result from anatomical, physiological, or psychological
abnormalities that can be shown by medically acceptable clinical and
laboratory diagnostic techniques. The Act and regulations further
require that an impairment be established by medical evidence that
consists of signs, symptoms, and laboratory findings, and not only
by an individual's statement of symptoms.
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\2\ Except for statutory blindness.
For purposes of disability claims adjudication, postpolio sequelae refer to multiple physical and mental disorders that may be manifested by polio survivors many years following acute polio infection. Any one or a combination of these disorders appropriately documented by signs, symptoms, and laboratory findings will constitute the presence of postpolio sequelae. The term "postpolio sequelae" includes the documented residuals of acute infection as well as all other documented clinical conditions that have an etiological link to either the acute infection or to its residual deficits.
Motor weakness is the most common residual of acute polio infection and is usually manifested by observable weakness, muscle atrophy, and reduced peripheral reflexes. These obvious clinical findings are used to document the history of poliomyelitis. Electromyographic studies may be used by clinicians in clarifying the cause and extent of neuromuscular impairment, but should not be needed for purposes of disability decisionmaking. Nonetheless, when electromyography (EMG) results are available for review, these data should be considered in decisionmaking. Typically, we will not order or purchase EMG studies.
In the absence of evidence to the contrary, and as long as the medical findings support a reasonable medical link between the prior polio infection and the present manifestation of any one or combination of the disorders discussed in the ruling, we will find that the individual has postpolio sequelae. For example, an individual with a history of polio affecting the left lower extremity who, on examination, has weakness and atrophy of the left thigh musculature with an observable limp now complains of chronic left lower extremity pain and is found to have lumbar stenosis documented by medically acceptable imaging. As discussed below, due to the chronic postural imbalance related to the effects of polio, a reasonable medical link exists between this individual's current medical condition (degenerative lumbar spine disease) and his/her prior polio residuals. Accordingly, we would make a finding of postpolio sequelae. On the other hand, an individual with a history of polio (for example, stating "I was in an iron lung") who, on examination, has normal motor findings, including normal posture and gait, now complains of pain clinically consistent with chronic radiculopathy, and has medically acceptable imaging demonstrating degenerative arthritis in the lumbar spine.
This individual's current medical condition does not demonstrate a reasonable medical connection with the prior polio; instead, the degenerative arthritis should be adjudicated as a musculoskeletal disorder unrelated to the prior polio infection.Postpolio sequelae include such disorders as postpolio syndrome (also know as the late effects of poliomyelitis), early advanced degenerative arthritis, sleep disorders, respiratory insufficiency, and various mental disorders. These disorders and documentation issues concerning them are discussed in detail below.
According to the National Institute of Neurological Disorders and Stroke (NINDS), postpolio syndrome is a condition that affects polio survivors anywhere from 10 to 40 years after recovery from an initial paralytic attack of the poliomyelitis virus. The NINDS states that postpolio syndrome is characterized by a further weakening of muscles that were previously affected by the polio infection. The signs and symptoms include fatigue, slowly progressive muscle weakness, and, at times, muscular atrophy. The NINDS states that joint pain and increasing skeletal deformities such as scoliosis are common. Not all polio survivors experience these clinical problems, and the extent to which polio survivors are affected by postpolio syndrome varies. The onset of new or worsening signs and symptoms is associated with a further reduction of the individual's capacity to independently carry out activities of daily living.
Up to indexPolio survivors often manifest motor residuals in a single extremity and thus function day-to-day with chronic postural imbalance. Clinicians have described degenerative musculoskeletal disorders etiologically linked to long-standing postural imbalance. Abnormal weight-bearing in polio survivors produces exaggerated wear and tear on the bones and joints of the spine or limbs that are overused to compensate for limbs weakened by polio. Early onset of advanced degenerative arthritis can be found in a compensatory extremity or spine.
Where such an etiological relationship is clear, clinically
documented early advanced degenerative arthritis in a compensating
limb or spine is considered one of the postpolio
sequelae. Documentation of early advanced degenerative arthritis may
include medically appropriate imaging or abnormal physical findings
of advanced arthritis on clinical examination.
Chronic pain disorders related to early degenerative osteoarthritis
should be evaluated based on the impact of the pain and its
treatment on the individual's physical and mental functioning.
Some polio survivors report the occurrence of sleep disorders that are determined by clinical evaluation to be related to respiratory insufficiency during sleep. The poliovirus has demonstrated a propensity to attack the motor neurons responsible for respiratory function, and, during the acute infection, some individuals require ventilatory assistance. For example, years ago patients with acute polio infection were placed in an "iron lung" for ventilatory assistance. Some patients who required such assistance recovered and may have returned to normal lives without obvious signs of respiratory insufficiency. Some polio survivors, however, have reported the onset of sleep disorders years following the acute polio infection, and physicians have linked these sleep disorders to weakening of the respiratory musculature. During sleep, even slight weakness of the respiratory musculature may become clinically significant and interfere with breathing capacity. Chronic sleep deprivation resulting from repeated episodes of sleep apnea may result in the development of excessive daytime drowsiness or cognitive and behavioral changes.
Respiratory insufficiency should be documented by abnormal pulmonary
function studies. The presence of a sleep disorder related to
respiratory insufficiency requires documentation by longitudinal
treatment records, including such things as abnormal polysomnography
or other appropriate evidence. Note, however, that we \3\ generally
will not purchase a polysomnogram (also called a PSG, sleep study,
or sleep test). See also 3.00H of the Respiratory System medical
listings for additional information concerning sleep-related
breathing disorders (see 20 CFR appendix 1 to subpart P of part
404--Listing of Impairments).
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\3\ The terms we and us in this Social Security Ruling have the same
meaning as in 20 CFR 404.1502 and 416.902. We or us refers to either
the Social Security Administration or the State agency making the
disability or blindness determination; that is, our adjudicators at all levels of the
administrative review process and our quality reviewers.
Some polio survivors report the onset of problems with attention, concentration, cognition, or behavior. Some researchers have suggested that certain cognitive and behavioral deficits are the result of the prior polio infection that involved the brain, although others do not agree with that concept. Other researchers have suggested that the traumatic psychological experiences associated with acute polio infection are revived when polio survivors recognize the onset of further weakness and functional loss.
Many polio survivors endured a life-threatening infection as young children. They may have spent extended periods away from their homes and families while hospitalized with paralysis or respiratory dysfunction, or while undergoing multiple orthopedic surgeries. Often they endured many months, or sometimes years, of hospitalization and rehabilitation. The psychological effect of perceiving the onset of further weakness, fatigue, respiratory dysfunction or joint pain, many years following the acute infection, can be significant. Signs and symptoms of anxiety and depression may produce further deterioration in function.
Any mental impairment that could have an etiological link to the acute polio infection or its chronic residuals may be considered a manifestation of postpolio sequelae. Deficits in attention, cognition, or behavior may be demonstrated by reduced concentration capacity, inability to persist in tasks, or memory problems. Also, behavioral abnormalities may be demonstrated by mood changes, social withdrawal, or other behaviors inappropriate for the individual. Mood disorders characterized by anxiety and depression may also be seen and clinically documented in these individuals.
Up to Index
Individuals experiencing postpolio sequelae may complain of the new
onset of reduced physical and mental functional ability. Complaints
of fatigue, weakness, intolerance to cold, joint and muscle pain,
shortness of breath and sleep problems, mood changes, or decreased
attention and concentration capacity may hallmark the onset of
postpolio sequelae. Weakness, fatigue, or muscle and joint pain may
cause increasing problems in activities such as lifting, bending,
prolonged standing, walking, climbing stairs, using a wheelchair,
transferring from a wheelchair (e.g., from wheelchair to toilet),
sleeping, dressing, and any activity that requires repetition or
endurance. Changes in attention, cognition, or behavior may be
manifested by reduced capacity to concentrate on tasks, memory
deficits, mood changes, social withdrawal, or inappropriate
behavior.
Many polio survivors who had been in a stable condition may begin to
require new or additional assistive devices, such as braces, canes,
crutches, walkers, wheelchairs, or pulmonary support. The reduced
ability to sustain
customary activities, including work, may result. A previously
stable functional capacity may be further diminished.
Many individuals with medically severe polio residuals have worked
despite their limitations. The new onset of further physical or
mental impairments (even though they may appear to be relatively
minor) in polio survivors may
result in further functional problems that can limit or prevent
their ability to continue work activity. Postpolio sequelae may
effectively alter the ability of these individuals to continue
functioning at the same level they maintained for years following
their initial polio infection.
We generally will rely on documentation provided by the individual's treating physicians and psychologists (including a report of the medical history, physical examination, and available laboratory findings) to establish the presence of postpolio sequelae as a medically determinable impairment. In the absence of evidence to the contrary, we will make a finding that a medically determinable impairment is established if any of the disorders discussed above have been documented by acceptable clinical signs, symptoms, and laboratory findings.
However, if evidence indicates that the diagnosis is questionable, we will contact the treating source for clarification, in accordance with 20 CFR 404.1512(e) and 416.912(e). Of course, if a favorable disability determination or decision can be made based on the available evidence of record, whether or not a link to the prior polio infection is evident, no further development need be undertaken.
The careful development of postpolio sequelae should include descriptions of the past acute illness (old records are not required), as well as a report of the current findings on physical examination. The examination report should also include the severity of any residual weakness, as well as the onset, pattern, and severity of any new physical or mental deficits. A description of current functional limitations and restrictions on physical and mental activity should be obtained from the examiner.
When possible, detailed longitudinal treatment records from the treating source should be obtained. In cases where severity of the impairment is unclear, an examination by a physician or psychologist who is knowledgeable about polio and postpolio sequelae is appropriate, if such a specialist is available.
Up to indexEvidence from employers and other third party sources may be valuable in documenting a loss of a previous level of functioning and should be sought when there is a discrepancy or a question of credibility in the evidence of record and a fully favorable determination or decision cannot be made based on the available evidence. For detailed discussions regarding these factors, please refer to SSR 96-7p, "Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual's Statements," and SSR 96-8p, "Titles II and XVI: Assessing the Residual Functional Capacity (RFC) in Initial Claims."
Up to IndexOnce postpolio sequelae has been documented as a medically determinable impairment, the impact of any of the symptoms of postpolio sequelae, including fatigue, weakness, pain, intolerance to cold, etc., must be considered both in determining the severity of the impairment and in assessing the individual's RFC. The adjudicator must make a comprehensive assessment of the cumulative and interactive effects of all of the individual's impairments and related symptoms, including the effects of postpolio sequelae. Evaluate all symptoms and their effects in accordance with 20 CFR 404.1529 and 416.929, and SSR 96-7p, "Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual's Statements."
Up to IndexMost postpolio sequelae are stable or very slowly progressive disorders. The medical evidence should readily support an expected duration of at least 12 or more months.
Up to IndexThe listing criteria under our current listing 11.11, Anterior poliomyelitis, may be applied both to cases of static polio (where there has been no reported worsening after initial recovery) and to cases presenting with postpolio sequelae. All documented postpolio sequelae must be considered either alone or in combination to determine whether the medical criteria of listing 11.11, or any other listing, have been met or equaled. If the impairment is not found to meet or equal a listed impairment, we consider the impact of the impairment and any related symptoms in determining an individual's RFC and we proceed to evaluate the individual's impairment under our sequential evaluation procedures in accordance with 20 CFR 404.1545 and 416.945. It is essential that the cumulative and interactive effects of all of the individual's impairments, including symptoms, be carefully assessed in determining the individual's RFC in these cases.
Up to IndexA disability onset date in cases involving postpolio sequelae is set based on the individual's allegations, his or her work history, and the medical and other evidence concerning impairment severity. Generally, the new problems associated with postpolio sequelae are gradual and non-traumatic, but acute injuries or events, such as herniated discs, or broken bones from falls, may be markers for establishing a disability onset date. For additional discussion concerning the determination of onset date, refer to SSR 83-20, "Titles II and XVI: Onset of Disability."
Effective Date: This ruling is effective upon publication in the Federal Register.
Cross References: SSR 83-20, "Titles II and XVI: Onset of Disability," 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 96-7p, "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," 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."
[FR Doc. 03-16719 Filed 7-1-03; 8:45 am]
BILLING CODE 4191-02-P