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[Federal Register: April 30, 1999 (Volume 64, Number 83)]
[Notices]
[Page 23380-23384]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr30ap99-143]
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SOCIAL SECURITY ADMINISTRATION
Social Security Ruling, SSR 99-2p.; Titles II and XVI: Evaluating
Cases Involving Chronic Fatigue Syndrome (CFS)
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling.
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SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of
Social Security gives notice of Social Security Ruling, SSR 99-2p. This
Ruling clarifies disability policy for the evaluation and adjudication
of disability claims invo1ving Chronic Fatigue Syndrome (CFS). This
Ruling explains that, when it is accompanied by appropriate medical
signs or laboratory findings, CFS is a medically determinable
impairment that can be the basis for a finding of ``disability.'' This
Ruling ensures that all adjudicators will use the same policies and
procedures in evaluating disability claims involving CFS, and provides
a consolidated statement of these policies and procedures.
EFFECTIVE DATE: April 30, 1999.
FOR FURTHER INFORMATION CONTACT: Carolyn Kiefer, Office of Disability,
Division of Medical and Vocational Policy, Social Security
Administration, 6401 Security Boulevard, Baltimore, MD 21235-6401,
(410) 965-9104.
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 to be 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If this Social Security Ruling is later superseded, modified, or
rescinded, we will publish a notice in the Federal Register to that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, Programs 96.001 Social
Security--Disability Insurance; 96.006 Supplemental Security Income)
Dated: April 23, 1999.
Kenneth S. Apfel,
Commissioner of Social Security.
Policy Interpretation Ruling Titles II and XVI: Evaluating Cases
Involving Chronic Fatigue Syndrome (CFS)
Purpose
To restate and clarify the policies of the Social Security
Administration for developing and evaluating title II and title XVI
claims for disability on the basis of Chronic Fatigue Syndrome (CFS),
also frequently known as Chronic Fatigue and Immune Dysfunction
Syndrome.
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
404.1505, 40404.1508-404.1513, 404.1520, 404.1520a, 404.1521, 404.1523,
404.1526-404.1529, 404.1560-404.1569a and 404.1593-404.1594;
[[Page 23381]]
and Regulations No. 16, subpart I, sections 416.905, 416.906, 416.908-
416.913, 416.920, 416.920a, 416.921, 416.923, 416.924, 416.924b,
416.924c, 416.926, 416.926a, 416.927-416.929, 416.960-416.969a,
416.987, 416.993, 416.994, and 416.994a.
Introduction
CFS is a systemic disorder consisting of a complex of symptoms that
may vary in incidence, duration, and severity. The current case
criteria for CFS, developed by an international group convened by the
Centers for Disease Control and Prevention (CDC) as an identification
tool and research definition, include a requirement for four or more of
a specified list of symptoms. These constitute a patient's complaints
as reported to a provider of treatment.
However, the Social Security Act (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 medical signs, symptoms
and laboratory findings. Disability may not be established on the basis
of an individual's statement of symptoms alone.
This Ruling explains that CFS, when accompanied by appropriate
medical signs or 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 CFS.
Policy Interpretation
CFS constitutes a medically determinable impairment when it is
accompanied by medical signs or laboratory findings, as discussed
below. CFS may be a disabling impairment.
Definition of CFS
CFS is a systemic disorder consisting of a complex of symptoms that
may vary in incidence, duration, and severity. It is characterized in
part by prolonged fatigue that lasts 6 months or more and that results
in substantial reduction in previous levels of occupational,
educational, social, or personal activities. In accordance with
criteria established by the CDC, a physician should make a diagnosis of
CFS ``only after alternative medical and psychiatric causes of chronic
fatiguing illness have been excluded'' (Annals of Internal Medicine,
121:953-9, 1994). CFS has been diagnosed in children, particularly
adolescents, as well as in adults.
Under the CDC definition, the hallmark of CFS is the presence of
clinically evaluated, persistent or relapsing chronic fatigue that is
of new or definite onset (i.e., has not been lifelong), cannot be
explained by another physical or mental disorder, is not the result of
ongoing exertion, is not substantially alleviated by rest, and results
in substantial reduction in previous levels of occupational,
educational, social, or personal activities. Additionally, the current
CDC definition of CFS requires the concurrence of 4 or more of the
following symptoms, all of which must have persisted or recurred during
6 or more consecutive months of illness and must not have pre-dated the
fatigue:
<bullet> Self-reported impairment in short-term memory or
concentration severe enough to cause substantial reduction in
previous levels of occupational, educational, social, or personal
activities;
<bullet> Sore throat;
<bullet> Tender cervical or axillary lymph nodes;
<bullet> Muscle pain;
<bullet> Multi-joint pain without joint swelling or redness;
<bullet> Headaches of a new type, pattern, or severity;
<bullet> Unrefreshing sleep; and
<bullet> Postexertional malaise lasting more than 24 hours.
Within these parameters, an individual with CFS can also exhibit a
wide range of other manifestations, such as muscle weakness, swollen
underarm (axillary) glands, sleep disturbances, visual difficulties
(trouble focusing or severe photosensitivity), orthostatic intolerance
(e.g., lightheadedness or increased fatigue with prolonged standing),
other neurocognitive problems (e.g., difficulty comprehending and
processing information), fainting, dizziness, and mental problems
(e.g., depression, irritability, anxiety).
Requirement for a Medically Determinable Impairment
Sections 216(i) and 1614(a)(3) of the Act define ``disability''
<SUP>1</SUP> 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 for a
continuous period of not less than 12 months.<SUP>2</SUP> 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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