C
Interim Report, December 2005

At the first committee meeting, held on January 30, 2005, the Social Security Administration (SSA) asked the committee to focus its attention initially on tasks 8-10 of its charge (see Appendix B) and, if possible, to issue its findings and recommendations on those tasks as soon as possible. The committee agreed that it would address these issues in an interim letter report. However, the committee also made clear that, after completing all of its deliberations, it might refine those preliminary recommendations.

The committee issued its interim report, Improving the Social Security Disability Decision Process: Interim Report, on these three tasks on December 21, 2005. That interim report is included in this appendix. In the interim report, the committee made 13 recommendations with respect to SSA’s use of medical expertise in its disability decision-making process. Now that the committee has completed all of its deliberations, the committee adopts these recommendations as its final recommendations on these issues, subject to the following additional comments with respect to Recommendations 1-2 and 1-7 (addressing qualification requirements for physicians and psychologists who serve as medical consultants [MCs] for the state Disability Determination Services agencies and as medical experts [MEs] at administrative law judge hearings).

In recommendations 1-2 and 1-7, the committee recommended that SSA require that physicians and psychologists who serve as MCs and MEs be board certified. As the committee noted in the interim report, “board certification is rapidly becoming the standard credential for the practice of medicine or psychology.” The committee realizes that, although board cer-



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Improving the Social Security Disability Decision Process C Interim Report, December 2005 At the first committee meeting, held on January 30, 2005, the Social Security Administration (SSA) asked the committee to focus its attention initially on tasks 8-10 of its charge (see Appendix B) and, if possible, to issue its findings and recommendations on those tasks as soon as possible. The committee agreed that it would address these issues in an interim letter report. However, the committee also made clear that, after completing all of its deliberations, it might refine those preliminary recommendations. The committee issued its interim report, Improving the Social Security Disability Decision Process: Interim Report, on these three tasks on December 21, 2005. That interim report is included in this appendix. In the interim report, the committee made 13 recommendations with respect to SSA’s use of medical expertise in its disability decision-making process. Now that the committee has completed all of its deliberations, the committee adopts these recommendations as its final recommendations on these issues, subject to the following additional comments with respect to Recommendations 1-2 and 1-7 (addressing qualification requirements for physicians and psychologists who serve as medical consultants [MCs] for the state Disability Determination Services agencies and as medical experts [MEs] at administrative law judge hearings). In recommendations 1-2 and 1-7, the committee recommended that SSA require that physicians and psychologists who serve as MCs and MEs be board certified. As the committee noted in the interim report, “board certification is rapidly becoming the standard credential for the practice of medicine or psychology.” The committee realizes that, although board cer-

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Improving the Social Security Disability Decision Process tification has become the norm for physicians, relatively few psychologists are board certified. The committee therefore modified its recommendation to recommend that SSA continue the current requirements for psychologists participating as MCs or MEs but establish a long-term goal requiring that psychologists be board certified.

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Improving the Social Security Disability Decision Process Improving the Social Security Disability Decision ProcessInterim Report Committee on Improving the Disability Decision Process: SSA’s Listing of Impairments and Agency Access to Medical Expertise Medical Follow-Up Agency INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Improving the Social Security Disability Decision Process THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. SS00-04-60083 between the National Academy of Sciences and Social Security Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Improving the Social Security Disability Decision Process “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Improving the Social Security Disability Decision Process THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Improving the Social Security Disability Decision Process COMMITTEE ON IMPROVING THE DISABILITY DECISION PROCESS: SSA’S LISTING OF IMPAIRMENTS AND AGENCY ACCESS TO MEDICAL EXPERTISE JOHN D. STOBO (Chair), President, University of Texas Medical Branch at Galveston, University of Texas FRANK S. BLOCH (Vice Chair), Professor of Law, Vanderbilt University Law School, Nashville, TN GUNNAR B.J. ANDERSSON, Professor and Chairman, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL RICHARD V. BURKHAUSER, Professor and Chairman, Department of Policy Analysis and Management, Cornell University, Ithaca, NY DIANA D. CARDENAS, Professor and Chief, Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA (Dr. Cardenas became a professor at the University of Florida.) SHEILA T. FITZGERALD, Associate Professor, Division of Occupational Health, School of Hygiene and Public Health, Johns Hopkins University School of Nursing, Baltimore, MD ARTHUR GARSON, Dean, School of Medicine, Vice President, University of Virginia, Charlottesville, VA KRISTOFER J. HAGGLUND, Associate Dean for Health Policy and Professor of Health Psychology, School of Health Professions, University of Missouri, Columbia, MO ALLEN W. HEINEMANN, Professor, Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Director, Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago RONALD LEOPOLD, Vice President, MetLife, Alpharetta, GA LARRY G. MASSANARI, Former Acting Commissioner, Social Security Administration, Exton, PA STEPHEN G. PAUKER, Professor, Tufts University School of Medicine, Vice Chairman for Clinical Affairs, Department of Medicine, Associate Physician-In-Chief, Tufts-New England Medical Center, Boston, MA LINDA A. RANDOLPH, President and CEO, Developing Families Center, Inc., Washington, DC BRIAN M. SCHULMAN, Private Practice in Occupational Psychiatry, Bethesda, MD PETER W. THOMAS, Principal, Powers Pyles Sutter & Verville, PC, Washington, DC

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Improving the Social Security Disability Decision Process CRAIG A. VELOZO, Professor and Associate Chair, Department of Occupational Therapy, College of Public Health and Health Professions, University of Florida; Research Health Scientist, Rehabilitation Outcomes Research Center, North Florida/South Georgia Veterans Health System Project Staff MICHAEL McGEARY, Study Director MORGAN A. FORD, Program Officer SUSAN R. McCUTCHEN, Research Associate REINE Y. HOMAWOO, Senior Program Assistant RICK ERDTMANN, Director, Medical Follow-up Agency PAMELA RAMEY-McCRAY, Administrative Assistant ANDREA COHEN, Financial Associate DAVID K. BARNES, Consultant

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Improving the Social Security Disability Decision Process Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Veronica D. Feeg, George Mason University School of Nursing, Fairfax, VA Claude Earl Fox, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Linda P. Fried, Johns Hopkins University Center on Aging and Health, Baltimore, MD Patricia M. Owens, Consultation in Health & Disability Programs, Brooklyn, NY James M. Perrin, Massachusetts General Hospital, Boston, MA Harold A. Pincus, University of Pittsburgh Medical Center, Pittsburgh, PA Glenn S. Pransky, Liberty Mutual Research Institute for Safety, Hopkinton, MA Stephen T. Wegener, Johns Hopkins University School of Medicine, Baltimore, MD

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Improving the Social Security Disability Decision Process Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Joseph P. New-house, Harvard University, and Lee Goldman, University of California, San Francisco. Appointed by the National Research Council and Institute of Medicine, respectively, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Improving the Social Security Disability Decision Process Preface The Institute of Medicine (IOM) Committee on Improving the Disability Decision Process has been working since it first met in January 2005 to develop recommendations to the Social Security Administration (SSA) on how to improve the medical aspects of its disability determination process. By law, Social Security can only pay benefits to those unable to engage in substantial gainful activity because of a “medically determinable physical or mental impairment 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” (emphasis added). Medical and psychological expertise is critical both in developing the criteria for measuring the severity and functional impact of an impairment or impairments on an applicant’s ability to work and in applying the criteria to individual cases where the medical evidence does not clearly meet the criteria in the eyes of a nonmedical disability examiner. The committee’s final report is due in 2006, but SSA asked the committee to focus first on the expertise issues and provide early recommendations on the qualifications of the medical and psychological experts involved in the disability decision process in a short interim report. SSA is currently in the process of revamping its disability decision process and, according to a Notice of Proposed Rulemaking (NPRM) published in the Federal Register in July 2005, plans to establish a national network of medical and psychological experts who meet qualification standards set by the Commissioner of Social Security. The NPRM did not specify the qualification standards but noted that they would be promulgated within six months of the effec-

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Improving the Social Security Disability Decision Process ANNEX TABLE 3 Case Mix Compared with Mix of Medical Consultant Specialties Clinical Field Percentage of MCs in the Clinical Specialty Percentage of Initial Decisions Involving the Clinical Field Cardiology 1.7% 6.7% Child psychiatry 0.6% 0.5% Child psychology * 3.7% Endocrinology 0.2% 3.8% Family practice 6.8% 0.0% Gastroenterology 0.3% 2.4% Internal medicine 16.3% 6.3% Neurology 1.9% 6.8% Oncology 0.3% 4.7% Orthopedics 2.5% 19.9% Pediatrics 9.8% 0.9% Psychiatry 10.7% 19.6% Psychology 31.2% 7.5% Pulmonology 0.3% 4.7% Rheumatology 0.3% 6.7% *Less than 0.1 percent. NOTE: Part-time medical consultants are assumed to work 20 hours a week. SOURCE: Unpublished table provided by the Office of Disability and Income Support Programs, SSA

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Improving the Social Security Disability Decision Process ANNEX TABLE 4 Number of Medical Experts by Specialty, June 2005 Specialty Number Percentage Clinical psychology 415 22.3 Internal medicine 371 19.9 Psychiatry 235 12.6 Orthopedic surgery 121 6.5 Pediatrics 115 6.2 Neurology 102 5.5 Cardiovascular diseases 71 3.8 Ophthalmology 57 3.1 Family practice 31 1.7 Pulmonary diseases 22 1.2 Child psychiatry 21 1.1 Physical medicine and rehabilitation 20 1.0 Rheumatology 19 1.0 General surgery 18 1.0 Occupational medicine 18 0.8 Gastroenterology 15 0.8 General preventive medicine 15 0.8 Urological surgery 14 0.7 Endocrinology 13 0.6 Child psychology 12 0.6 Neurological surgery 12 0.6 Emergency medicine 11 0.6 Medical oncology 11 0.6 All others 122 6.6 Total 1,861 100.0 NOTE: The number of specialties is more than the number of MEs (1,575), because some practice in more than one specialty. SOURCE: Unpublished table provided by the Office of Hearings and Appeals, SSA.

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Improving the Social Security Disability Decision Process ANNEX TABLE 5 Number of Medical Experts by Specialty and Federal Region, June 2005 Federal Region Clinical Psychology Internal Medicine Psychiatry Orthopedic Surgery Pediatrics Neurology Cardiovascular Diseases Ophthalmology Other Total Region I 18 23 16 10 6 9 4 5 18 109 Region II 13 25 20 7 9 7 5 5 29 120 Region III 31 35 28 3 7 13 5 5 45 172 Region IV 110 85 78 42 39 25 20 12 93 504 Region V 73 56 30 20 23 17 7 8 52 286 Region VI 47 46 22 16 6 14 6 6 48 211 Region VII 12 14 3 1 3 1 3 1 16 54 Region VIII 37 7 0 0 2 4 0 1 10 61 Region IX 43 53 32 16 12 8 19 14 47 244 Region X 31 27 6 6 8 4 2 0 16 100 All regions 415 371 235 121 115 102 71 57 374 1,861 SOURCE: Unpublished table provided by the Office of Hearings and Appeals, SSA.

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Improving the Social Security Disability Decision Process ANNEX TABLE 6 Impairment Codes of DDS Presumptive Disability Decisions with a Reversal Rate of Less Than 5 percent, CY 2004 SSA Impairment Code Number of DDS PD Decisions Number Reversed Reversal Rate (percent) 4160-Chronic pulmonary heart disease 163 8 4.9 2940-Organic mental disorders 4,505 215 4.8 3060-Somatoform disorders 42 2 4.8 3370-Disorders of the autonomic nervous system 64 3 4.7 4920-Emphysema 193 9 4.7 1830-Malignant neoplasm/ovary and other uterine adnexa 314 14 4.5 1640-Malignant neoplasm/thymus, heart, mediastinum 23 1 4.3 3430-Cerebral palsy 1,835 78 4.3 4430-Peripheral vascular disease 516 21 4.1 2950-Schizophrenic/paranoid functional disorders 4,944 198 4.0 1920-Malignant neoplasm/other parts of the nervous system 76 3 3.9 1900-Malignant neoplasm/eye 31 1 3.2 1710-Malignant neoplasm/connective and other soft tissue 99 3 3.0 1910-Malignant neoplasm/brain 830 23 2.8 3360-Other disorders of the spinal cord 517 14 2.7 1410-Malignant neoplasm/tongue 192 5 2.6 7600-Multiple body dysfunction 714 18 2.5 1510-Malignant neoplasm/stomach 249 6 2.4 1990-Malignant neoplasm/unspecified sites 131 3 2.3 2070-Leukemias 1,058 24 2.3 8060-Vertebral fracture/cord lesion 766 18 2.3 2630-Malnutrition/weight loss 139 3 2.2 7840-Loss of voice 983 20 2.0 2990-Childhood origin psychosis (adult) 637 12 1.9 3180-Mental retardation 9,643 185 1.9 1720-Malignant melanoma of skin 179 3 1.7 5850-Chronic renal failure 4,173 62 1.5 2990-Developmental disabilities including autism (children) 2,558 36 1.4 1620-Malignant neoplasm/trachea, bronchus, lung 2,606 35 1.3 1980-Malignant neoplasm/distant sites 78 1 1.3 3320-Parkinson’s disease 154 2 1.3 1500-Malignant neoplasm/esophagus 367 4 1.1 1630-Malignant neoplasm/pleura 98 1 1.0 3350-Anterior horn cell disorder (ALS) 113 1 0.9 7580-Chromosome anomaly/Down syndrome 1,443 8 0.6 7650-Birth weight under 1200 grams 3,291 12 0.4 1550-Malignant neoplasm of liver and intrahepatic bile ducts 710 2 0.3 0940-Neurosyphilis 3 0 0.0 1560-Malignant neoplasm/gallbladder 56 0 0.0

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Improving the Social Security Disability Decision Process SSA Impairment Code Number of DDS PD Decisions Number Reversed Reversal Rate percent) 1570-Malignant neoplasm/pancreas 400 0 0.0 1760-Malignant Kaposi’s sarcoma 8 0 0.0 1780-Malignant neoplasm/skeletal system 4 0 0.0 2730-Disorders of plasma protein metabolism 3 0 0.0 3210-Arachnoiditis 10 0 0.0 5010-Asbestosis 6 0 0.0 7050-Hidradenitis suppurativa 16 0 0.0 9330-Chronic fatigue syndrome 11 0 0.0 SOURCE: Unpublished table provided by the Office of Disability and Income Support Programs, SSA.

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Improving the Social Security Disability Decision Process ANNEX TABLE 7 SSA Impairment Codes by Allowance Rate, from Highest to Lowest, CY 2004 SSA Impairment Code Number of Decisions Number of Allowances Allowance Rate (percent) All codes 2,532,798 947,266 37.4 1550-Malignant neoplasm of liver and intrahepatic bile ducts 4,653 4,616 99.2 1570-Malignant neoplasm/pancreas 3,304 3,258 98.6 3350-Anterior horn cell disorder (ALS) 1,534 1,506 98.2 7650-Birth weight under 1200 grams 17,235 16,890 98.0 7580-Chromosome anomaly/Down syndrome 5,242 5,111 97.5 1980-Malignant neoplasm/distant sites 619 599 96.8 1630-Malignant neoplasm/pleura 806 776 96.3 1560-Malignant neoplasm/gallbladder 450 432 96.0 1620-Malignant neoplasm/trachea, bronchus, lung 19,291 18,307 94.9 1500-Malignant neoplasm/esophagus 2,916 2,744 94.1 2990-Developmental disabilities including autism (children) 10,759 9,920 92.2 1910-Malignant neoplasm/brain 6,302 5,754 91.3 1510-Malignant neoplasm/stomach 1,966 1,779 90.5 5850-Chronic renal failure 22,195 19,998 90.1 1780-Malignant neoplasm/skeletal system 20 18 90.0 1720-Malignant melanoma of skin 1,832 1,618 88.3 2070-Leukemias 6,166 5,408 87.7 1760-Malignant Kaposi’s sarcoma 40 35 87.5 1410-Malignant neoplasm/tongue 1,392 1,197 86.0 2990-Childhood origin psychosis (adult) 3,898 3,352 86.0 2030-Multiple myeloma 2,164 1,859 85.9 1590-Malignant neoplasm/other digestive organs, peritoneum 741 636 85.8 1990-Malignant neoplasm/unspecified sites 552 471 85.3 1830-Malignant neoplasm/ovary and other uterine adnexa 3,394 2,882 84.9 3180-Mental retardation 77,102 65,460 84.9 3360-Other disorders of the spinal cord 3,428 2,856 83.3 7600-Multiple body dysfunction 2,555 2,128 83.3 1920-Malignant neoplasm/other parts of the nervous system 280 230 82.1 1520-Malignant neoplasm/small intestine 552 449 81.3 1890-Malignant neoplasm/kidney, other urinary organs 2,740 2,206 80.5 0420-Malignant neoplasm/bone marrow or stem cell transplantation 5 4 80.0 7400-Anencephalus/catastrophic anomaly 569 453 79.6 2630-Malnutrition/weight loss 1,112 876 78.8 1640-Malignant neoplasm/thymus, heart, mediastinum 173 136 78.6 1700-Malignant neoplasm/bone and articular cartilage 1,550 1,207 77.9

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Improving the Social Security Disability Decision Process SSA Impairment Code Number of Decisions Number of Allowances Allowance Rate(percent) 3430-Cerebral palsy 9,864 7,546 76.5 3320-Parkinson’s disease 3,853 2,894 75.1 1950-Malignant neoplasm/other sites 5,399 4,049 75.0 8060-Vertebral fracture/cord lesion 4,699 3,449 73.4 1880-Malignant neoplasm/bladder 1,535 1,122 73.1 7840-Loss of voice 5,162 3,742 72.5 1380-Late effects of acute poliomyelitis 1,859 1,346 72.4 1710-Malignant neoplasm/connective and other soft tissue 902 650 72.1 7410-Spina bifida 1,867 1,344 72.0 1530-Malignant neoplasm/colon, rectum, anus 11,184 8,019 71.7 2950-Schizophrenic/paranoid functional disorders 56,218 40,308 71.7 3300-Cerebral degeneration/childhood 616 439 71.3 3750-Cardiac transplantation 319 226 70.8 1420-Malignant neoplasm/salivary glands 234 165 70.5 4380-Late effects of cerebrovascular disease 32,139 22,529 70.1 1790-Malignant neoplasm/uterus 2,566 1,783 69.5 4430-Peripheral vascular disease 8,979 6,240 69.5 4160-Chronic pulmonary heart disease 2,137 1,481 69.3 2840-Aplastic anemia 738 505 68.4 7830-Malnutrition, marasmus/growth impairment 2,388 1,631 68.3 3590-Muscular dystrophies 3,188 2,155 67.6 3150-Developmental/emotional disorders-infant 4,521 3,034 67.1 0300-Leprosy 3 2 66.7 4960-Cronic pulmonary insufficiency/COPD 40,287 26,348 65.4 1940-Malignant neoplasm/other endocrine glands and related 242 158 65.3 3310-Other cerebral degenerations 3,901 2,536 65.0 2940-Organic mental disorders 57,567 36,958 64.2 3210-Arachnoiditis 231 145 62.8 9070-Late effects/nervous system injuries 6,740 4,125 61.2 3690-Blindness/low vision 24,669 14,752 59.8 4280-Heart failure 15,865 9,440 59.5 1740-Malignant neoplasm/breast 17,865 10,558 59.1 3620-Other retinal disorders 3,455 2,038 59.0 3153-Speech and language delays 32,332 18,914 58.5 4460-Periarteritis nodosa/allied condition 296 171 57.8 1870-Malignant neoplasm/penis, male genital organs 158 91 57.6 7500-Congenital anomalies/upper alimentary tract 372 212 57.0 1850-Malignant neoplasm/prostate 3,233 1,827 56.5 4920-Emphysema 4,382 2,471 56.4 2760-Diabetic acidosis 222 123 55.4 4540-Varicose veins/low extremities 2,374 1,294 54.5 3570-Diabetic/peripheral neuropathy 13,714 7,460 54.4 2020-Lymphoma 7,075 3,799 53.7 3890-Deafness 15,352 8,183 53.3

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Improving the Social Security Disability Decision Process SSA Impairment Code Number of Decisions Number of Allowances Allowance Rate (percent) 7460-Congenital heart anomalies 5,542 2,910 52.5 0940-Neurosyphilis 25 13 52.0 0430-Symptomatic HIV positive 18,168 9,429 51.9 8540-Intracranial injury 5,785 2,968 51.3 1900-Malignant neoplasm/eye 194 99 51.0 2770-Disorders of metabolism/cystic fibrosis 1,426 719 50.4 3400-Multiple sclerosis 14,183 7,148 50.4 4250-Cardiomyopathy 15,472 7,581 49.0 1170-Skin/mucus membrane infections 720 351 48.7 7140-Rheumatoid & other inflammatory arthritis 19,437 9,330 48.0 3060-Somatoform disorders 1,425 681 47.8 1860-Malignant neoplasm/testis 791 375 47.4 2960-Mood disorders (children) 21,121 9,927 47.0 2390-Neoplasm/unspecified/unknown behavior 308 144 46.8 7050-Hidradenitis suppurativa 295 135 45.8 4410-Aortic aneurysm 1,341 607 45.3 1730-Other malignant neoplasm of skin 463 209 45.1 3610-Retinal detachment with retinal defects 1,592 716 45.0 2250-Benign neoplasm/brain, nervous system 3,049 1,332 43.7 4590-Other diseases of the circulatory system 7,004 3,061 43.7 3370-Disorders of the autonomic nervous system 1,408 614 43.6 1840-Malignant neoplasm/other female genital organs 1,141 496 43.5 4140-Chronic ischemic heart disease 44,127 19,195 43.5 4030-Hypertensive vascular/renal disease 376 162 43.1 7200-Ankylosing/inflamnatory spondylopathies 1,007 430 42.7 2820-Hereditary hemolytic anemias including sickle cell 4,167 1,771 42.5 5010-Asbestosis 289 122 42.2 7300-Osteomyelitis/other infections involving bone 1,837 775 42.2 1930-Malignant neoplasm/thyroid gland 782 327 41.8 5710-Chronic liver disease/cirrhosis 30,970 12,853 41.5 7150-Osteoarthritis/allied disorders 113,194 45,730 40.4 4480-Diseases of capillaries 145 57 39.3 0930-Cardiovascular syphilis 36 14 38.9 2730-Disorders of plasma protein metabolism 93 36 38.7 3490-Other nervous system disorders 15,534 5,996 38.6 3000-Anxiety-related disorders 46,037 17,724 38.5 3138-Oppositional/defiant disorder 7,776 2,955 38.0 3650-Glaucoma 2,958 1,121 37.9 3580-Myoneural disorders 3,118 1,160 37.2 5810-Nephrotic syndrome 2,447 903 36.9 3120-Conduct disorder 5,856 2,102 35.9 2960-Affective disorders (adult) 277,560 99,089 35.7 7590-Other congenital anomalies 3,324 1,160 34.9 2850-Other anemias 1,864 641 34.4

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Improving the Social Security Disability Decision Process SSA Impairment Code Number of Decisions Number of Allowances Allowance Rate (percent) 3660-Cataract 2,400 826 34.4 2790-Disorders immune mechanism (except HIV) 1,009 345 34.2 3010-Personality disorders 14,295 4,860 34.0 1360-Other infectious/parasitic diseases 1,488 487 32.7 5780-Gastrointestinal hemorrhage 979 311 31.8 9050-Late effects/musculoskeletal and connective tissue injuries 14,412 4,525 31.4 7100-Diffuse diseases of connective tissue 9,056 2,835 31.3 2880-Diseases of white blood cells 145 45 31.0 3140-Attention deficit hyperactivity disorder 94,862 29,312 30.9 3950-Diseases of aortic valve 3,889 1,190 30.6 4100-Acute myocardial infarction 5,254 1,608 30.6 3070-Eating and tic disorders 349 106 30.4 2870-Purpura/other hemorrhagic conditions 499 151 30.3 2380-Neoplasm/uncertain behavior 204 60 29.4 5190-Other diseases of respiratory system 8,111 2,385 29.4 1350-Sarcoidosis 1,904 554 29.1 5300-Diseases of esophagus 984 286 29.1 3860-Vertiginous syndromes 2,155 625 29.0 7330-Other bone/cartilage disorders 16,067 4,659 29.0 4940-Bronchiectasis 674 193 28.6 7649-Birth weight between 1,200 and 2,000 grams 6,951 1,981 28.5 2810-Deficiency anemias 1,365 388 28.4 4020-Hypertensive vascular disease 7,426 2,109 28.4 3980-Other rheumatic heart disease 629 177 28.1 9490-Burns 1,925 537 27.9 4510-Phlebitis/thrombophlebitis 1,012 280 27.7 4240-Valvular heart diseases/other stenotic defects 3,923 1,067 27.2 3910-Rheumatic fever/heart involvement 169 45 26.6 4270-Cardiac dysrhythmias 4,966 1,311 26.4 2890-Other diseases blood/blood forming organs 1,313 339 25.8 5050-Pneumoconiosis 240 61 25.4 5560-Idiopathic proctocolitis 1,369 344 25.1 6940-Bullous disease 517 128 24.8 4130-Angina pectoris 1,761 426 24.2 2860-Coagulation defects 826 199 24.1 2720-Hyperlipidemia 175 42 24.0 7160-Other and unspecified arthropathies 27,885 6,469 23.2 6960-Dermatitis 1,951 451 23.1 2780-Obesity 20,758 4,754 22.9 5550-Regional enteritis/granulomatous colitis 4,723 1,053 22.3 3680-Visual disturbances 6,158 1,324 21.5 8690-Internal injury 506 108 21.3 8940-Lower limb open wounds 3,117 664 21.3 3152-Learning disorder 36,123 7,622 21.1 8270-Lower limb fractures 34,015 7,075 20.8

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Improving the Social Security Disability Decision Process SSA Impairment Code Number of Decisions Number of Allowances Allowance Rate (percent) 2740-Gout 1,511 308 20.4 3195-Borderline intellectual functioning 31,621 6,356 20.1 7240-Back disorders 311,813 62,674 20.1 0110-Pulmonary tuberculosis 472 90 19.1 6950-Ichthyosis 567 103 18.2 7280-Muscle, ligament, fascia disorders 58,995 10,619 18.0 2550-Disorders of adrenal glands 386 69 17.9 2500-Diabetes mellitus 67,988 11,966 17.6 5690-Other disorders gastrointestinal system 13,943 2,440 17.5 9330-Chronic fatigue syndrome 1,974 342 17.3 2530-Disorders of pituitary gland 441 75 17.0 7800-Sleep-related disorder 2,371 403 17.0 7090-Other disorders skin/subcutaneous tissue 3,399 557 16.4 5330-Peptic ulcer 1,022 165 16.1 8390-Dislocations 2,435 392 16.1 3460-Migraine 8,011 1,282 16.0 3540-Carpal tunnel syndrome 5,627 889 15.8 8840-Upper limb open wounds 3,676 573 15.6 5530-Hernias 3,048 451 14.8 8180-Upper limb fractures 12,756 1,862 14.6 8290-Other fractures 8,432 1,214 14.4 4910-Chronic bronchitis 1,653 230 13.9 2510-Hypoglycemia 123 17 13.8 3780-Strabismus/disorders eye movements 557 76 13.6 3450-Epilepsy 37,165 4,980 13.4 7370-Curvature of spine 4,530 607 13.4 4010-Essential hypertension 32,188 3,863 12.0 6080-Disorders of male genital organs 434 49 11.3 5990-Other disorders of urinary tract 3,823 413 10.8 2520-Disorders of parathyroid 265 28 10.6 4930-Asthma 60,855 6,086 10.0 5350-Gastritis/Duodenitis 1,480 144 9.7 8790-Other open wounds 432 42 9.7 3880-Other ear disorders 3,019 281 9.3 8030-Skull fracture without intracranial injury 460 35 7.6 8480-Sprains & strains 19,846 1,111 5.6 2460-Disorders of thyroid 3,592 198 5.5 6290-Disorders of female genital organs 1,582 63 4.0 0440-Asymptomatic HIV positive 8,438 262 3.1 3040-Substance dependence/drugs (child) 100 1 1.0 3030-Addiction disorder/alcohol (adult) 8,069 0 0.0 3030-Substance dependence/alcohol (child) 39 0 0.0 3040-Addiction disorders/drugs (adult) 7,167 0 0.0 Unknown, missing, invalid codes 145,328 8,284 5.7 SOURCE: Unpublished table provided by the Office of Disability and Income Support Programs, SSA.

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