On June 2, 2014, the Social Security Administration (SSA) issued two new Social Security Rulings (SSRs): SSR 14-2p – Titles II and XVI: Evaluating Diabetes Mellitus; and SSR 14-3p -Titles II and XVI: Evaluating Endocrine Disorders Other Than Diabetes Mellitus. Both were effective on the date of publication. 79 Fed. Reg. 31375-31380, 31380-31385 (June 2, 2012).
These SSRs have been three years in the making. In June 2011, SSA rescinded the relevant listings for diabetes and endocrine disorders. In eliminating the listings, SSA noted that medical science had made significant advances in detecting endocrine disorders at earlier stages and newer treatments have resulted in better management of the conditions. As a result, according to SSA, most endocrine disorders would not reach listing level severity or meet the 12-month duration requirement. Listings 9.00 and 109.00 were deemed unnecessary.
The current Listing of Impairments still contain Sections 9.00 and 109.00 pertaining to Endocrine Disorders, but consist only of explanatory materials, with the exception of Listing 109.08, which is limited to children under six requiring daily insulin. See the June 2011 edition of this newsletter. At the time, SSA indicated that it would evaluate endocrine disorders under listings for other body systems, providing various examples. It also acknowledged that it would proceed to the final steps of the Sequential Evaluation in cases where endocrine disorders do not meet any other listing, and would evaluate residual functional capacity.
In rescinding the listings, SSA promised that an SSR containing more detailed guidelines for evaluating endocrine disorders would be forthcoming. Finally, we have not one but two SSRs.
SSR 14-2p – Diabetes Mellitus
In the new SSR, SSA reiterates that medical advances have resulted in better management of diabetes mellitus (DM), but acknowledges that it continues to recognize DM as a potential cause of disability. As in the introduction to the new “listing,” the SSR sets forth explanations of the two types of DM (Type I, previously known as juvenile-onset DM, and Type 2, previously known as adult-onset or non-insulin dependent diabetes). It describes in some detail the complications of blood glucose monitoring in both adults and children. And like the listing, the SSR gives information about hyperglycemia, including diabetic ketoacidosis (DKA) and chronic hyperglycemia. The SSR, however, includes more descriptions of symptoms that might be associated with these conditions, including, for example, difficulty concentrating when hyperglycemic.
SSR 14-2p contains a section on chronic DM complications, describing retinopathy, cardiovascular disease, nephropathy, and neuropathy. The SSR cross references relevant listings for evaluating these complications, including the vision listings at 2.00 and 102.00, cardiac at 4.00 and 104.00, genitourinary at 6.00 and 106.00, and neurological at 11.00 and 110.00. It also describes particular symptoms associated with these conditions.
The SSR provides a lengthy description of hypoglycemia, or abnormally low levels of blood glucose, reciting associated symptoms and signs, such as weakness, hunger, sweating, nervousness, palpitations, and difficulty with concentration. It emphasizes the potential seriousness of severe hypoglycemia if not treated promptly. And it acknowledges “hypoglycemia unawareness,” where people cannot recognize or experience the symptoms, and thus do not seek treatment for reasons beyond their control. The SSR also specifically addresses the co-morbidity of obesity with DM, cross-referencing SSR 02-1p, and acknowledging that a person with DM and obesity may have more severe complications than the effects of each considered separately.
In setting forth how the Sequential Evaluation is followed in evaluating DM in adults, the SSR cross-references several listings in addition to those outlined above: amputations considered under 1.00; intestinal necrosis under 5.00; slow healing bacterial and fungal infections under 8.00 for skin disorders; and cognitive impairments, depression, anxiety and eating disorders under 12.00.
The SSR provides some specific examples of potential work-related limitations that might be considered in assessing residual functional capacity, such as difficulty walking, operating foot controls, or manipulating objects due to peripheral neuropathy. Or adults with chronic hyperglycemia might experience fatigue or difficulty with concentration. But as with any RFC determination, the crux is evaluating function. The SSR does not provide any particular guidance in determining degrees of functional loss.
SSR 14-2p may prove more helpful in evaluating children’s claims. It cross-references the growth impairment listings at 100.00 in addition to the childhood counterparts of the adult listings mentioned above. As to functional equivalence, the SSR refers specifically to the assessment of the need for 24-hour-a-day adult supervision for children over the age of six who are not able to recognize and respond to hypoglycemic symptoms. The SSR recognizes that children’s developmental abilities vary greatly. Some children over six with hypoglycemic unawareness who need 24 hour supervision will be considered disabled under the functional equivalence rules.
The SSR also details ways in which DM may result in limitations in the various domains of functioning. For example, a child requiring insulin might have fluctuating glucose levels that could affect ability to concentrate in school, resulting in limitations in the domains of acquiring and using information and/or attending and concentrating. Or a child may have difficulty interacting with others if she is self-conscious about checking her glucose levels throughout the day, or administering insulin or following a special diet in front of her peers. The same child might refuse to use her insulin because of embarrassment, and have a limitation in the domain of caring for self. Or fatigue and weakness could limit a child’s fine or gross motor functioning, resulting in limitations in the domain of moving about and manipulating objects.
Whether these limitations rise to the level or marked or extreme will undoubtedly vary from case to case. But the examples provided in SSR 14-2p, particularly as to children, should help guide advocates seek out evidence and testimony might be most relevant and persuasive.
SSR 14-3p – Endocrine Disorders Other Than Diabetes Mellitus
As with SSR 14-2p, this SSR provides more detailed information on various endocrine disorders than set forth in current Sections 9.00 and 109.00. It includes scientific background on the role of endocrine glands in the body, including the pituitary glands, thyroid glands, adrenal glands, pancreas, and gonads. Like the SSR for DM, it underscores that although endocrine disorders usually require lifelong treatment, medical advances have resulted in better management of these disorders.
The SSR lists various endocrine disorders other than DM, and their treatments. Included are explanations of hyper and hypo pituitary disorders, hyper and hypothyroid disorders, hyper and hypo adrenal disorders, pancreatic disorders (which are covered in SSR 14-2p), and gonadal disorders, including chromosomal disorders and genetic syndrome. The SSR gives examples of symptoms and signs associated with each disorder. But it also reminds adjudicators that they are generally controlled by treatment.
SSR 14-3p cross-references listings for other body systems that may be affected by endocrine disorders. It then lists “some examples of the effects of specific endocrine disorders and the body systems under which we evaluate them” for determining Listings level severity. The SSR expressly states these are only “some examples,” and admonishes adjudicators to consider endocrine disorders in combination with other impairments in the Step 3 analysis. Query whether adjudicators will be able to see beyond these examples? Similarly, the limited guidance on RFC assessment provides a few examples of possible limitations of function resulting from various disorders. While they may help justify the significance of some claimants’ symptoms, will they inhibit adjudicators from recognizing the significance of other permutations?
Like SSR 14-2p, this SSR also contains a section for evaluating childhood SSI claims. There are some helpful examples of symptoms that could cause limitations in various domains of functioning, but they are not as extensive as those in SSR 14-2p.
Both SSRs indicate that they are applicable to continuing disability reviews (CDRs) and age 18 reviews, as well as initial claims.
These new SSRs are part of a collection that SSA has issued concerning particular impairments. The March 2014 edition of this newsletter highlighted SSR 14-1p on Chronic Fatigue. Others include:SSR 02-2p: Interstitial Cystitis
- SSR 03-1p: Postpolio Sequelae
- SSR 03-2p: Reflex Sympathetic Dystrophy Syndrome/Complex Regional Pain Syndrome
- SSR 06-01p: Tremolite Asbestos-Related Impairments
- SSR 12-2p: Fibromyalgia
As with all these SSRs, there are aspects of the two new ones that can be helpful to claimants and advocates. But it will be up to us to insist that ALJs apply them properly. Let us know how you fare on this mission!