Equaling: the three-fold way Jeff Vasiloff, MD, MPH: [email protected] Note: these are my...

Equaling: the three-fold way

Jeff Vasiloff, MD, MPH: [email protected]: these are my personal opinions and interpretations of SSA policy; that is, they are not policy statements of SSA, and they and should not be used as such. Each case needs to be looked at on a case-by-case basis following all

SSA policies and guidelines.

“Equal rights for all, special privileges for none.”

Thomas Jefferson

Useful POMS references for equaling

• DI 28090.040 Discussion of Meets or Equals– General overview (big picture) of equaling

• DI 24505.015 Finding Disability Based on the Listing of Impairments– Detailed explanations on how to equal, including

examples

• DI 24515.061 How We Evaluate Symptoms, Including Pain– Very important about how to “factor in” pain and other

symptoms like shortness of breath

Highlights of DI 24505.015 B. Medical equivalence

• 1. What is medical equivalence?

• An impairment(s) is medically equivalent to a listed impairment…if it is at least equal in severity and duration to the criteria of any listed impairment.

Highlights of DI 24505.015 B. Medical equivalence (continued)

• 2. How do we determine medical equivalence?

• We can determine medical equivalence in the

following three ways:

Medical Equivalence: first of three ways (“Type 1”)

• 1. If the claimant has an impairment that is described in the listing, BUT – The claimant’s impairment does not exhibit 1 or more of

the specified findings, OR

• the claimant’s impairment does exhibit all of the findings, BUT

– 1 or more of the findings is not as severe as specified,

»THEN the claimant’s impairment is medically

equivalent IF other findings related to the impairment is of at least equal medical significance to the (missing) criteria

Medical Equivalence: second of three ways (“Type 2”)

• 2. If the claimant has an impairment that is not described in the listings, THEN – The claimant’s impairment and findings will be

compared with those of a closely analogous listing. THEN IF• the findings are of at least equal medical

equivalence to those of a listed impairment, THEN

– the claimant’s impairment is medically equivalent to the analogous listed impairment.

Medical Equivalence: third of three ways (“Type 3”)

• 3. If the claimant has a combination of impairments, but none of them meets a listing, THEN– the claimant’s findings from the combination of

impairments will be compared to the findings of related listings. THEN IF• the claimant’s findings are of at least equal

medical significance to the findings of a related listing, THEN

– the claimant’s combination of impairments is medically equivalent to the selected related listing.

“Writing up” an equals per POMS

1. (Always) discuss the claimant’s symptoms, findings, and test results (in, for example, the FOFAE)

– This is always the first step of all equals (as well as other claims)

“Writing up” an equals per POMS: TYPE 1 Equals (missing finding in a listing)

1. Mention the findings of the pertinent listing

2. Mention the missing finding(s)

3. Identify a “substitute” finding or several “substitute” findings that “make up for” or “equal” the missing finding(s) in terms of severity or “seriousness”

4. Explain why the substitute finding(s) “make up for” or “equal” the “intention” of the missing finding(s)

“Writing up” an equals per POMS: TYPE 2 Equals (only an analogous listing exists)

1. Mention the listing that most closely resembles the claimant’s condition/impairment; that is, the analogous listing

2. Mention the findings or criteria of the analogous listing

3. Identify the specific findings of the claimant’s condition/impairment that are analogous to (or closely correspond) to the findings of the listing

4. Explain how the claimant’s findings rise to the level of producing a level of impairment that is equivalent to that of the analogous listing

“Writing up” an equals per POMS: TYPE 3 Equals (combinations of impairments)

1. Mention the listing that pertains to the claimant’s worst (or most severe) condition/impairment

2. Mention the findings of that listing

3. Explain how the claimant does have a severe impairment in a (listing) area, but not so severe as to completely meet the listing

“Writing up” an equals per POMS: TYPE 3 Equals (combinations of impairments)

[continued]4. Mention all the claimant’s other

conditions/impairments and findings

5. Explain the severity of each of the other conditions/impairments and the “seriousness” of the findings

6. Explain how the effects--added together—of the combination of impairments and findings are equivalent in severity to the “intent” of the selected listing

A fact about impairments and function

• It is often true that having to function with 2 impairments is more difficult than having to function with 1 impairment

• It is often true that having to function with 3 impairments is more difficult than having to function with 2 impairments

• Having 4 or more impairments likely poses a severe challenge to function

• Some impairment “combinations” are, in general, especially limiting or “disabling”

Frequent SSA adult claimant impairment/conditions

Respiratory

• COPD• Obesity- hypoventilation• Asthma•Pulm . hypertension

Cardiac

• Heart failure• Angina• Claudication• Venous insufficiency

Metabolic

• Morbid obesity• Diabetes• Diabetic foot ulcers• Charcot foot

Orthopedic

• Osteoarthritis:• Spine• Knee• Hip

• Antalgic gait• Rotator cuff disease

Neurologic

• Neuropathy• Hemiparesis• Multiple sclerosis• Unstable gait• Carpal tunnel

Idiopathic

• Myofascial pain• Fibromyalgia• Inflammatory arthritis

•Rheumatoid arthritis•Lupus, etc.

Gastrointestinal

• Cirrhosis• Hepatitis C• Malnutrition

Kidney

• Chronic kidney disease• Nephrosis

Hematologic

• Anemia

Some serious combinations of impairments

• Obesity + weight-bearing arthritis

• Obesity + lung disease

• Weight-bearing arthritis + claudication

• Weight-bearing arthritis + neuropathy

• Visual impairment + neuropathy

• Visual impairment + hearing impairment

• Heart + lung disease• Heart failure + angina• Claudication + angina• Hemiparesis + weigh-

bearing arhritis• Hemiparesis + lung

disease• Amputation on one side +

neuropathy on the other• Amputation + an arm/hand

problem

Highlights of DI 24515.061 How We Evaluate Symptoms, Including Pain

• A. […], we consider all your symptoms, including pain, and the extent to which your symptoms can reasonably be accepted as consistent with the objective medical evidence, and other evidence…

• However, statements about your pain or other symptoms will not alone establish that you are disabled; there must be medical signs and laboratory findings which show that you have a medical impairment(s) which could reasonably be expected to produce the pain or other symptoms alleged…

Highlights of DI 24515.061 How We Evaluate Symptoms, Including Pain

(continued)B. Your symptoms, such as pain, fatigue, shortness

of breath, weakness, or nervousness, will not be found to affect your ability to do basic work activities unless medical signs or laboratory findings show that a medically determinable impairment(s) is present…

Now for some…

…FUN!

Mini-cases…

…That are GIGANTIC in importance!

And remember, when you hear hoof beats, do not think of zebras, think of what is common:

Respiratory


Cardiac


Metabolic


Orthopedic



Neurologic


Idiopathic



Gastrointestinal


Kidney


Hematologic

• Anemia

Mini-case 1

• Long history of progressively worsening shortness of breath with exertion

• Hyperinflation by CXR; emphysema by CT

• Taking 2 prescribed bronchodilators, and has wheezes on several examinations

• FEV1 a year and a half ago was 47% predicted (40% is usually listing level)

• Stable state oxygen saturation at rest in the outpatient clinic was 85%; he was then prescribed oxygen

What listing might we consider?


• 4.02?

• 3.02?

• 15.02?

Which part of 3.02 is the most relevant?

• 3.02 Chronic pulmonary insufficiency• A. Based on FEV1?• B. Based on FVC?• C. 1. Based on DLCO?• C 2. Based on resting stable state hypoxemia

(PO2)?• C 3. Based on stable state hypoxemia (PO2)

with exercise?

What listing requirement of 3.02C2 is MISSING?

What listing requirement of 3.02C2 is MISSING?

• No stable-state blood gases (for which to find a listing level degree of hypoxemia, that is, a listing level of PO2)

What are you going to REPLACE the missing requirement WITH?

• Hemoglobin of 15• Creatinine of 1.1• Oxygen saturation of 85%• Ejection fraction of 0.6

So what type of equals is this?

– Type 1 (missing finding in a listing)?

– Type 2 (only an analogous listing exists)?

– Type 3 (combination of impairments)?


√Type 1 (missing finding in a listing)?



How would you “write up” the equals?

Writing up the equals of Mini-case 1

• The claimant has classic COPD by history, symptoms, physical signs, imaging (chest-xray and CT), and PFS that are just above listing level. He is significantly impaired by exertional dyspnea. While no stable-state blood gases have been drawn to assess PO2 level, he did undergo oxygen saturation testing to reveal a resting saturation of only 85%, which correlates to a PO2 of less than 55 mmHg (the listing level for 3.02C2). He was placed on 24/7 oxygen due to this. He has also been receiving prescribed treatment. Taking everything together, his impairment equals 3.02C2.

Mini-case 2• Consider the SAME claimant as in Mini-case 1 but

instead of having a stable-state resting oxygen saturation of 85%, he had a resting saturation of 92% (Normal? Above listings? Below listings?)

• But in addition, the T/S conducted a “6 minute walk test” which showed that the oxygen saturation was 85% at the end of the walk.

• Would this claimant ‘s impairment equal one of the 3.02 listings?




with exercise?

Mini-case 2

• In THIS case, therefore, we would equal 3.02C3

Mini-case 3 (an example from POMS)

• Difficulty walking, chronic pain and stiffness of the left leg, especially the knee

• X-ray of the left knee: moderate tricompartmental osteoarthritis

• X-ray of left ankle: moderate osteoarthritis• Antalgic gait with an obligatory cane• Decreased range of motion of both left knee and

left ankle--otherwise no abnormal joint findings


• 1.04

• 1.02

• 11.04

• 17.09

Does this claimant meet all of the (many) criteria in 1.02?

• 1.02 Major dysfunction of a joint or joints WITH: – i) gross anatomical deformity (e.g., subluxation,

contracture, bony ankylosis, fibrous ankylosis, instability, etc.), AND

– ii) chronic pain and stiffness, WITH– iii) signs of limitation of motion, OR other abnormal

motion of the affected joint, AND – iv) findings on medical imaging of joint space narrowing,

bony destruction, or ankylosis, WITH– A. Involvement of one major peripheral weight-bearing

joint (hip, knee, ankle), RESULTING IN• inability to ambulate effectively

Answer: almost but not quite• 1.02 Major dysfunction of a joint or joints WITH:

– i) gross anatomical deformity (e.g., subluxation, contracture, bony ankylosis, fibrous ankylosis, instability, etc.), AND

ii) √chronic pain and stiffness, WITH

iii) √signs of limitation of motion, OR other abnormal motion of the affected joint AND

iv) √findings on medical imaging of joint space narrowing, bony destruction, or ankylosis, WITH

– A. √ Involvement of one major peripheral weight-bearing joint (hip, knee, ankle), RESULTING IN

– √inability to ambulate effectively

So what is missing is a …

• i) gross anatomical deformity (e.g., subluxation, contracture, bony ankylosis, fibrous ankylosis, instability…)

This is missing because the claimant has:

• No subluxation (abnormal movement of a bone out of its normal joint position)

• No contracture (fixed limited mobility of a joint)• No fibrous ankylosis (usually a total immobility of the

bones within a joint due to the growth of abnormal fibrous tissue)

• No bony ankylosis (usually a total immobility of the bones within a joint due to the growth of abnormal bone)

• No instability (excessive movement or laxity or floppiness of the bones within a joint)

•


• The listing calls for impairment of one joint. BUT

• The claimant, in fact, has two joints in which function is impaired. THEREFORE,

• Let us substitute the second joint with impaired function for the lack of having a gross anatomic deformity of the first joint

Writing up the equals of Mini-case 3

• The claimant has ineffective ambulation due to significant, well-documented tricompartmental osteoarthritis of the left knee (by x-ray). There is chronic pain, stiffness, and decreased range of motion. While she does not have a gross anatomical deformity as defined in the listing, she has a second weight-bearing joint that is impaired by x-ray-documented osteoarthritis. Further, the left ankle impairment is severe, interferes with ambulation, and contributes to his cane-dependence. The additional ankle impairment indicates as much severity as if she did have a gross anatomical deformity such as a knee flexion contracture. Thus, her impairment equals the intent of 1.02A.

Mini-case 4 (another example from POMS)

• Recurrent migraine headaches for years despite regular physician contact and prescribed treatment

• Has aura, gets “spaced out,” and then has an intense headache with severe throbbing pain

• Associated with nausea and photophobia• Must lie down in a dark and quiet room for 4 to 72

hours—at these times has difficulty with ADLs• Has 2 or more of such headaches per week• No compliance concerns

Is there a listing for migraine headaches?

Is there a listing for migraine headaches?

• No—that would be too EASY!

What listing is most closely related to this claimant’s impairment?

• 11.02

• 11.03

• 11.04

• 11.99

11.03 is most closely related to this claimant’s impairment

• 11.03: Epilepsy—nonconvulsive WITH detailed description of a typical seizure including all associated phenomena, OCCURRING more than 1 time per week IN SPITE OF 3 or more months of prescribed treatment, WITH– Alteration of awareness, OR– Loss of consciousness [but without convulsions], AND– Transient postictal (“after-seizure”) manifestations OF– Unconventional behavior OR significant interference

with activities during the day

Why is 11.03 appropriate to use with migraine headaches?

Why is 11.03 appropriate to use with migraine headaches?

• Because both nonconvulsive seizures and migraines: – “Come and go”; that is, they are intermittent or

“paroxysmal”– Have a sudden, unexpected onset– Can recur rarely or frequently– Commonly affect impair or “cloud” consciousness– Can cause significant inability to function during the

occurrence or “spell” and as well as for several hours afterward

– Require medications that can cause side effects

Thus, migraines can impair function in a similar or “analogous” way as do some

seizures • Therefore, because no migraine listing exists, it is

appropriate to use a listing that deals with an analogous disease or condition



–√ Type 2 (only an analogous listing exists)?


Writing up the equals of Mini-case 4• While not having epilepsy, the claimant has recurrent

episodes of well-documented and well-described, classic migraine headaches characterized by an aura (as is often true with seizures), a feeling of being “spaced out” (which is an alteration of consciousness), followed by an incapacitating headache requiring several hours or days to recover. These headaches have occurred despite prescribed treatment, and occur 2 or more times per week. Thus, her episodic clinical manifestations, while not due to epilepsy, produce a very similar incapacity as to that produced by uncontrolled seizures. Thus, her impairment equals the intent of 11.03.

Mini-case 5

• This claimant has a rare disease called cystinuria, so a little bit needs to be said about this:

• It is an inherited defect of kidney and small bowel transport of certain amino acids (like cysteine)

• It is the most common cause of kidney stones in children (but only causes 2% of stones in adults)

• The problem is: frequent stones form, causing recurrent flank pain, hematuria, recurrent urinary tract infections, urinary tract obstruction, and ultimately, in some cases, end stage kidney disease

Mini-case 5 (continued)

• The claimant complains of recurrent severe flank pain due to kidney stones (before they are passed or removed), recurrent pyelonephritis (kidney and sometimes bloodstream infections), chronic flank pain (from kidney stones that remain in the kidney), and vomiting and drowsiness due to narcotics for the pain

• She has had more than 40 lithotripsies (a procedure to breakup kidney stones so they will pass) by age 33 in 2007

Mini-case 5 (continued)

• More than 20 imaging studies confirm multiple and recurrent stones

• She has had many hospitalizations (more than 3 per year since AOD) for surgical stone extractions because they were obstructing the ureters

• She has scarring and moderate atrophy (loss of kidney tissue) of right kidney

Is there a listing for kidney stones or cystinuria?

Is there a listing for kidney stones or cystinuria?

• No

What listing(s) is/are most closely related to this claimant’s impairment?

• 12.04

• 12.05

• 3.03

• 5.06

• Both 3.03 and 5.06

• 11.99

3.03B is closely related to this claimant’s impairment

• 3.03 Asthma WITH• A. Based on FEV1• B. Asthmatic attacks, IN SPITE OF

– prescribed treatment, AND– requiring physician intervention, OCCURRING– 1 or more times every 2 months, OR (really) 6 or more

times in a year• But 24+ hour hospitalizations count as 2 attacks

Why is 3.03B closely related to this claimant’s impairment?

Why is 3.03B closely related to this claimant’s impairment?

• Because 3.03B deals with frequent flare-ups or exacerbations of a disease, exacerbations that are so severe that timely physician intervention in the emergency department or hospital is needed

Thus, recurrent kidney stones--causing obstruction (blockage) of the urinary tract and resultant pain and

kidney infection--can impair function in a similar or “analogous” way as do exacerbations of asthma

• Therefore, because no kidney stone or cystinuria listings existing, it is appropriate to use a listing that deals with an analogous disease or condition

How would you “write up” the equals?• The claimant does not have asthma with frequent and

significant exacerbations, but has a genetically-based disease, cystinuria, which, due to uncontrollable stone formation, causes frequent and significant obstruction of the ureters, sometimes leading to infection, but each time, requiring aggressive outpatient or inpatient surgery to relieve the obstructions. Since AOD, the claimant has never had a year where she has had less than 3 hospitalizations, each > 24 hours. Thus, while she does not have asthma with frequent attacks, she has frequent “attacks” of kidney stones that require even more intense physician-directed interventions than in the usual case of asthma. She is compliant and there is no effective treatment to prevent continuing new stone formation. Thus, her impairment equals the intent of 3.03B.

But what about using 5.06?• 5.06 Inflammatory bowel disease WITH

documentation by imaging, endoscopy, or direct visualization at open surgery, WITH– A. Obstruction of stenotic (“narrowed”) areas in the small

intestine or colon, WITH • dilation of the bowel before the obstruction,

CONFIRMED BY• imaging or direct visualization at open surgery,

REQUIRING • hospitalization to relieve the obstruction, AND• occurring 2 or more times within a 6 month period,

each episode at least 60 days from each other

Why is 5.06A closely related to this claimant’s impairment?

• Because the claimant’s recurrent kidney stones result in recurrent obstruction (and dilation) of the hollow urinary tract--just like inflammatory bowel disease results in stenoses (partial obstruction or complete obstruction) of the hollow gastrointestinal tract

• Also, in both the claimant and those with severe inflammatory bowel disease, the recurrent obstruction requires hospitalization and invasive procedures to relieve the obstruction

Thus, recurrent kidney stones--causing obstruction (blockage) of the urinary tract and resultant pain and

requiring hospitalization to relieve the obstruction can impair function in a similar or “analogous” way as do obstructions of the gastrointestinal tract in inflammatory bowel disease

• Therefore, because no kidney stone or cystinuria listings existing, it is appropriate to use a listing that deals with an analogous disease or condition

How would you “write up” the equals?• The claimant does not have inflammatory bowel disease but

does have a chronic, genetically-based condition (cystinuria) that affects the small bowel as well as the kidneys. While she does not have recurrent bowel obstructions, she has formed multiple kidney stones that do obstruct the ureters. Not only are these obstructions documented by imaging, but require either outpatient or inpatient surgeries to relieve them. Because the formation of new stones cannot be prevented, obstructions have continued and will continue. Further, the obstructions have been so frequent and severe that she has had recurrent kidney infections, which along with the high urinary tract pressures from obstruction, have damaged her kidneys, as evidenced by scarring and atrophy of the right kidney. Thus, her impairment equals the intent of 5.06A.

Mini-case 6

• The claimant’s major problem is exertional fatigue and shortness of breath with minimal activity

• PFS (in the stable state and valid, per CE) reveal an FEV1 of 46% predicted (but this is above the listing level for his height)

• She had a myocardial infarction in the distant past which has caused persistent systolic dysfunction with an ejection fraction (in the stable state) of 0.32 (or 32%) [recall the listing level is 0.3 or less, or 30% or less]

What listings might we consider?

• 3.02

• 4.02

• 5.02

• 7.02

• 3.02 and 4.02




with exercise?

What is the problem with 3.02A in this case?


• The claimant’s FEV1 is above listings, BUT he appears quite limited despite this, probably because he has not only “lung failure” but “heart failure” which are synergistic in limiting exertion due to fatigue and dyspnea

So perhaps he meets 4.02--let us look at the many criteria for this complicated listing

Remember 4.02 has an A part and a B part

• 4.02 Chronic heart failure IN SPITE OF prescribed treatment WITH symptoms AND signs of heart failure (dyspnea, fatigue, jugular venous distension, pulmonary rales or crackles, hepatojugular reflux, or edema) PLUS one severity indicator from list A, and one severity indicator from list B

List A criteria (two options)

1. Ejection fraction of 0.3 or less (30% or less) WITH left ventricular diameter of 6 or more centimeters OR

2. Echocardiography results that confirm significant diastolic dysfunction (intraventricular septal thickness + left ventricular posterior wall thickness = 2.5 cm or more, WITH left atrial diameter of 4.5 cm or more)

List B criteria (this is the first of three options)

• 1. Persistent symptoms of heart failure which seriously limit ADLs, PLUS cardiac stress testing is contraindicated

List B criteria (this is the second of three options)

• 2. Three (3) or more separate episodes of acute heart failure THAT ARE > 2 weeks apart, DURING WHICH stability was attained, WITH– Fluid overload BY SIGNS (edema, jugular venous

distension, hepatojugular reflux, pulmonary edema), OR– IMAGING (cardiac chamber enlargement, pleural

effusions, pulmonary edema by x-ray, ascites), AND REQUIRING

• Intensive physician intervention in a hospital/emergency department LASTING 12 or more hours

List B criteria (this is the third of three options)

• 3. Inability to sustain an aerobic exercise intensity of 5 metabolic equivalents of oxygen consumption (METs) DUE TO:– Cardiopulmonary symptoms (dyspnea, fatigue), OR– Abnormal EKG or rhythm changes, OR– Low blood pressure, OR– Lightheadedness, confusion, or ataxic (unstable and

uncoordinated gait)

What is the problem with the 4.02 listings in this case?

What is the problem with the 4.02 listings in this case?

• Neither the A nor B criteria are met, but, despite this, he has severe systolic dysfunction (EF 0.32; normal is 0.55 or above). However, he appears quite limited despite this, probably because he has not only “heart failure” but “lung failure” which are synergistic in limiting exertion due to fatigue and dyspnea

So what does common sense (and SSA policy!) tell us to do in cases such as

these?


these?

• “ADD” or “SUMMATE” the effects of both impairments to see if the overall effect of the combination of impairments rises to the level of being equivalent to or “equaling” a listing




–√ Type 3 (combination of impairments)?

Writing up the equals of Mini-case 6• The claimant has significant heart failure with stable

state systolic dysfunction of just above listing level (EF = 0.32). She also has significant COPD with an FEV1 that is just above listing level (46% predicted). She has credible symptoms of fatigue and shortness of breath with minimal exertion. Both her heart failure and COPD are synergistic (“combine together in an enhancing or especially additive way”) in limiting exertion. While both her heart disease alone and her lung disease alone do not meet a listing, when the effects of each are added to one another, the effect on her total functioning equals the intent of either 4.02 or 3.02A.

Mini-case 7• Type 2 diabetes, tingling and numbness of the feet,

fatigue, shortness of breath with exertion, knee pain and a limp

• BMI of 52 • Moderate right knee osteoarthritis on x-ray;

probable osteoarthritis of the left knee by physical examination

• Mild to moderate antalgic gait with limp on right• No ambulatory used• Decreased sensation in both legs below the knees• FEV1 of 51% predicted

What listings might we consider?

• 3.02

• 11.14

• 1.02

• Both 3.02 and 1.02

• 3.02 and 11.14 and 1.02




with exercise?


• The recent, stable-state measurement of FEV1 is above listing level

So let us look at 11.14

• 11.14 Peripheral neuropathies WITH disorganization of motor function as described in 11.04B despite prescribed treatment, WHERE 11.04 is: – Significant and persistent disorganization of motor

function in two extremities, resulting in EITHER sustained disturbance of gross and dexterous movements OR gait and station

What is the problem with 11.14 in this case?

What is the problem with 11.14 in this case?

• He does have evidence of a neuropathy, but looking at his ADLs, he can walk about three blocks; the first two at just a little slower than normal for him

• He doesn’t appear to meet the criteria for ineffective ambulation (but he is close)

So let us look at 1.02 again

• 1.02 Major dysfunction of a joint or joints WITH: – i) gross anatomical deformity (e.g., subluxation,

contracture, bony ankylosis, fibrous ankylosis, instability, etc.), AND

– ii) chronic pain and stiffness, WITH

– iii) signs of limitation of motion, OR

– iv) other abnormal motion of the affected joint (?), AND

– v) findings on medical imaging of joint space narrowing, bony destruction, or ankylosis, WITH

– A. Involvement of one major peripheral weight-bearing joint (hip, knee, ankle), RESULTING IN

• inability to ambulate effectively


• Two things: he doesn’t meet ineffective ambulation (but he is close), and also, he has no gross anatomical deformity


these?


these?

• “ADD” or “SUMMATE” the effects of all impairments (including, in this case, his obesity with a BMI of 52) to see if the overall effect of the combination of impairments rises to the level of being equivalent to or “equaling” a listing




–√ Type 3 (combination of impairments)?

Writing up the equals of Mini-case 7• The claimant has four severe impairments: extreme morbid

obesity, lung disease, osteoarthritis in one (if not both knees), and diabetic neuropathy. The morbid obesity is synergistic with his lung disease to limit exertion dramatically. Similarly, his knee arthritis is synergistic with his diabetic neuropathy (with its loss of tactile sensation and proprioception) in limiting the ability to ambulate for even short distances safely. Finally, his obesity is synergistic also with his neuropathy and osteoarthritis in affecting ambulation. While there is no listing for morbid obesity, and while he does not meet a pulmonary listings like 3.02A or a musculoskeletal listing like 1.02A or a peripheral neuropathy listing like 11.14, when the effects of each are added to one another, the effect on total functioning equals the intent of 1.02A or 11.14.

Take home message:• When approaching claims in which there are one or

more severe impairments that do not meet a listing, remember that you can support an equals by: – Substituting an equivalent clinical finding or test

result for one that is missing from a listing– Picking an analogous listing, and explaining how

your claimant’s impairment or condition is closely-correlated to, and therefore, equivalent to the listing

– Taking note of all of the claimant’s nonlisting-level impairments, and explaining how--often through synergy—the combined effects of the impairments are equal to the incapacity produced by a listed impairment that is fully met

And remember, when you hear hoof beats, do not think of zebras, think of what is common:

Respiratory


Cardiac


Metabolic


Orthopedic



Neurologic


Idiopathic



Gastrointestinal


Kidney


Hematologic

• Anemia

Questions and comments?

• Thank you for having me NADE and OADE!

Equaling: the three-fold way Jeff Vasiloff, MD, MPH: [email protected] Note: these are my...

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Transcript of Equaling: the three-fold way Jeff Vasiloff, MD, MPH: [email protected] Note: these are my...