Chronic Fatigue Syndrome and Fibromyalgia

[Guest guest]

All of us who have been affected by molds know the severe fatigue <CFS>

and pain <fibromyalgia>

This is a few years old but thought it may be of use to those whom are

unable to work a full time job. Much less a part time job. The ole

Mold Fog! And when we can't at times add 2+2 , etc. The government is

good at denying disability.

_______________

New Ruling Should Improve Disabled CFIDS Patients' Access to Benefits

On April 30, 1999, the Social Security Administration (SSA) issued a

ruling clarifying that persons with medically documented CFS can be

found to have a " medically determinable impairment. " The ruling provides

guidance to disability claims processors for applying SSA policy to

applications for Social Security Disability Income (SSDI) benefits that

result from disability due to CFS. While the new ruling will hardly

" open the floodgates " for CFIDS patients to garner disability benefits,

it should make it easier for disabled CFIDS patients to acquire benefits

at an earlier stage in the SSA appeals process.

The ruling had been in development for over a year. A unique aspect of

this ruling was that SSA's Office of Disability appropriately involved

The CFIDS Association of America from the earliest stages in drafting

and refining the ruling. SSA became convinced of the need for the ruling

when an internal survey of CFS-related applications revealed that

numerous awards made at the hearing level could have been approved

earlier in the review process. The inappropriate delays not only posed

serious problems for the applicant, but created unnecessary expense for

the agency. The POMS manual, the " bible " of SSA adjudicators, will be

revised soon to reflect the policy stated in the ruling. In July SSA

will begin training its personnel to ensure that the ruling is used

correctly at all stages of the disability process.

Overall the new Social Security Ruling should improve disabled CFIDS

patients' outcomes in the SSDI process. It is binding on adjudicators at

all levels -- initial application, reconsideration, and administrative

law hearings -- and it applies when SSDI recipients are periodically

reviewed (for Continuing Disability Reviews or CDRs). " Social Security

Ruling, SSR 99-2p.; Titles II and XVI: Evaluating Cases Involving

Chronic Fatigue Syndrome (CFS) " should become a critical reference in

any CFIDS patient's application for federal disability benefits.

The full text of the Social Security Ruling appears below:

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.

SUMMARY: In accordance with 20 CFR 402.35((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((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((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.

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; 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'' (ls 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:

*

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;

*

Sore throat;

*

Tender cervical or axillary lymph nodes;

*

Muscle pain;

*

Multi-joint pain without joint swelling or redness;

*

Headaches of a new type, pattern, or severity;

*

Unrefreshing sleep; and

*

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''<1> 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.<2> 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.

Under the CDC definition, the diagnosis of CFS can be made based on an

individual's reported symptoms alone once other possible causes for the

symptoms have been ruled out. However, the foregoing statutory and

regulatory provisions require that, for evaluation of claims of

disability under the Act, there must also be medical signs or laboratory

findings before the existence of a medically determinable impairment may

be established.

Establishing the Existence of a Medically Determinable Impairment

The following medical signs and laboratory findings establish the

existence of a medically determinable impairment in individuals who have

CFS. Although no specific etiology or pathology has yet been established

for CFS, many research initiatives continue, and some progress has been

made in ameliorating symptoms in selected individuals. With continuing

scientific research, new medical evidence may emerge that will further

clarify the nature of CFS and provide greater specificity regarding the

clinical and laboratory diagnostic techniques that should be used to

document this disorder.

Because of this, the medical criteria discussed below are only examples

of signs and laboratory findings that will establish the existence of a

medically determinable impairment; they are not all- inclusive. As

progress is made in medical research into CFS, additional signs and

laboratory findings may also be found that can be used to establish that

individuals with CFS have a medically determinable impairment. The

existence of CFS may be documented with medical signs or laboratory

findings other than those listed below, provided that such documentation

is consistent with medically accepted clinical practice and is

consistent with the other evidence in the case record.

Examples of Medical Signs That Establish the Existence of a Medically

Determinable Impairment

For purposes of Social Security disability evaluation, one or more of

the following medical signs clinically documented over a period of at

least 6 consecutive months establishes the existence of a medically

determinable impairment for individuals with CFS:

*

Palpably swollen or tender lymph nodes on physical examination;

*

Nonexudative pharyngitis;

*

Persistent, reproducible muscle tenderness on repeated

examinations, including the presence of positive tender points<3>; or,

*

Any other medical signs that are consistent with medically

accepted clinical practice and are consistent with the other evidence in

the case record.

Examples of Laboratory Findings That Establish the Existence of a

Medically Determinable Impairment

At this time, there are no specific laboratory findings that are widely

accepted as being associated with CFS. However, the absence of a

definitive test does not preclude reliance upon certain laboratory

findings to establish the existence of a medically determinable

impairment in persons with CFS. Therefore, the following laboratory

findings establish the existence of a medically determinable impairment

in individuals with CFS:<4>

*

An elevated antibody titer to Epstein-Barr virus (EBV) capsid

antigen equal to or greater than 1:5120, or early antigen equal to or

greater than 1:640; · An abnormal magnetic resonance imaging (MRI) brain

scan;

*

Neurally mediated hypotension as shown by tilt table testing or

another clinically accepted form of testing; or,

*

Any other laboratory findings that are consistent with medically

accepted clinical practice and are consistent with the other evidence in

the case record; for example, an abnormal exercise stress test or

abnormal sleep studies, appropriately evaluated and consistent with the

other evidence in the case record.

Mental Findings That Establish the Existence of a Medically Determinable

Impairment

Some individuals with CFS report ongoing problems with short-term

memory, information processing, visual-spatial difficulties,

comprehension, concentration, speech, word-finding, calculation, and

other symptoms suggesting persistent neurocognitive impairment. When

ongoing deficits in these areas have been documented by mental status

examination or psychological testing, such findings constitute medical

signs or (in the case of psychological testing) laboratory findings that

establish the presence of a medically determinable impairment.

Individuals with CFS may also exhibit medical signs, such as anxiety or

depression, indicative of the existence of a mental disorder. When such

medical signs are present and appropriately documented, the existence of

a medically determinable impairment is established.

Evaluation

1. General

Claims involving CFS are adjudicated using the sequential evaluation

process, just as for any other impairment. Once a medically determinable

impairment has been found to exist (see discussion above), the severity

of the impairment(s) must be established. The severity of an

individual's impairment(s) is determined based on the totality of

medical signs, symptoms, and laboratory findings, and the effects of the

impairment(s), including any related symptoms, on the individual's

ability to function.

Also, several other disorders (including, but not limited to, FMS,

multiple chemical sensitivity, and Gulf War Syndrome, as well as various

forms of depression, and some neurological and psychological disorders)

may share characteristics similar to those of CFS. When there is

evidence of the potential presence of another disorder that may

adequately explain the individual's symptoms, it may be necessary to

pursue additional medical or other development.

2. Step 2

When an adjudicator finds that an individual with CFS has a medically

determinable impairment, he or she must consider that the individual has

an impairment that could reasonably be expected to produce the

individual's symptoms associated with CFS, as required in 20 CFR

404.1529( and 416.929(, and proceed to evaluate the intensity and

persistence of the symptoms. Thus, if an adjudicator concludes that an

individual has a medically determinable impairment, and the individual

alleges fatigue, pain, symptoms of neurocognitive problems, or other

symptoms consistent with CFS, these symptoms must be considered in

deciding whether the individual's impairment is ``severe'' at step 2 of

the sequential evaluation process and at any later steps reached in the

sequential evaluation process. If fatigue, pain, neurocognitive

symptoms, or other symptoms are found to cause a limitation or

restriction having more than a minimal effect on an individual's ability

to perform basic work activities, the adjudicator must find that the

individual has a ``severe'' impairment. See SSR 96-3p, ``Titles II and

XVI: Considering Allegations of Pain and Other Symptoms in Determining

Whether a Medically Determinable Impairment is Severe.''

3. Step 3

When an individual is found to have a severe impairment, the adjudicator

must proceed with the sequential evaluation process and must next

consider whether the individual's impairment is of the severity

contemplated by the Listing of Impairments contained in appendix 1,

subpart P of 20 CFR 404. Inasmuch as CFS is not a listed impairment, an

individual with CFS alone cannot be found to have an impairment that

meets the requirements of a listed impairment; however, the specific

findings in each case should be compared to any pertinent listing to

determine whether medical equivalence may exist.<5>

Further, in cases in which individuals with CFS have psychological

manifestations related to CFS, consideration should always be given to

whether the individual's impairment meets or equals the severity of any

impairment in the mental disorders listings in 20 CFR, part 404, subpart

P, appendix 1, sections 12.00 ff. or 112.00 ff.

4. Steps 4 and 5

For those impairments that do not meet or equal the severity of a

listing, an assessment of residual functional capacity (RFC) must be

made, and adjudication must proceed to the fourth and, if necessary, the

fifth step of the sequential evaluation process.<6> In assessing RFC,

all of the individual's symptoms must be considered in deciding how such

symptoms may affect functional capacities. See 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 Residual Functional Capacity in Initial Claims.''

If it is determined that the individual's impairment(s) precludes the

performance of past relevant work (or if there was no past relevant

work), a finding must be made about the individual's ability to perform

other work. The usual vocational considerations (see 20 CFR 404.1560-

404.1569a and 416.960-416.969a) must be applied in determining the

individual's ability to perform other work.

Many individuals with CFS are ``younger individuals,'' ages 18 through

49 (see 20 CFR 404.1563 and 416.963). Age, education, and work

experience are not usually considered to limit significantly the ability

of individuals under age 50 to make an adjustment to other work,

including unskilled sedentary work.<7> However, a finding of

``disabled'' is not precluded for those individuals under age 50 who do

not meet all of the criteria of a specific rule and who do not have the

ability to perform a full range of sedentary work. The conclusion about

whether such individuals are disabled will depend primarily on the

nature and extent of their functional limitations or restrictions. Thus,

if it is found that an individual is able to do less than the full range

of sedentary work, refer to 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.'' As explained in

that Ruling, whether the individual will be able to make an adjustment

to other work requires adjudicative judgment regarding factors such as

the type and extent of the individual's limitations or restrictions and

the extent of the erosion of the occupational base for sedentary work.

5. Duration

The medical signs and symptoms of CFS fluctuate in frequency and

severity and often continue over a period of many months or years. Thus,

appropriate documentation should include a longitudinal clinical record

of at least 12 months prior to the date of application, unless the

alleged onset of CFS occurred less than 12 months in the past, or unless

a fully favorable determination or decision can be made without

additional documentation. The record should contain detailed medical

observations, treatment, the individual's response to treatment, and a

detailed description of how the impairment limits the individual's

ability to function over time.

When the alleged onset of disability secondary to CFS occurred less than

12 months before adjudication, the adjudicator must evaluate the medical

evidence and project the degree of impairment severity that is likely to

exist at the end of 12 months.<8> Information about treatment and

response to treatment as well as any medical source opinions about the

individual's prognosis at the end of 12 months are helpful in deciding

whether the medically determinable impairment(s) is expected to be of

disabling severity for at least 12 consecutive months.

6. Continuing Disability Reviews

In those cases in which an individual is found to have a disability

based on CFS but medical improvement is anticipated, an appropriate

continuing disability review should be scheduled based on the

probability of cessation under the Medical Improvement Review Standard.

This standard takes into account relevant individual case facts such as

the combined severity of other chronic or static impairments and the

individual's vocational factors.

Documentation

1. General

As with all claims for disability under both title II and title XVI,

documentation of medical signs or laboratory findings in cases involving

CFS is critical to establishing the presence of a medically determinable

impairment. In cases in which CFS is alleged, longitudinal clinical

records reflecting ongoing medical evaluation and treatment from the

individual's medical sources, especially treating sources, are extremely

helpful in documenting the presence of any medical signs or laboratory

findings, as well as the individual's functional status over time. Every

reasonable effort should be made to secure all available, relevant

evidence in cases involving CFS to ensure appropriate and thorough

evaluation.

Generally, evidence for the 12-month period preceding the month of

application should be requested unless there is reason to believe that

development of an earlier period is necessary, or unless the alleged

onset of disability is less than 12 months before the date of the

application.

2. Recontacting Medical Sources/Consultative Examinations

If the adjudicator finds that the evidence is inadequate to determine

whether the individual is disabled, he or she must first recontact the

individual's treating or other medical source(s) to determine whether

the additional information needed is readily available, in accordance

with 20 CFR 404.1512 and 416.912.<9> Only after the adjudicator

determines that the information needed is not readily available from the

individual's health care provider(s), or that the necessary information

or clarification cannot be sought from the individual's health care

provider(s), should the adjudicator proceed to arrange for a

consultative examination(s) in accordance with 20 CFR 404.1519a and

416.919a. The type

of consultative examination(s) purchased will depend on the nature of

the individual's symptoms and the extent of the evidence already in the

case record.

3. Resolution of Conflicts

It should be noted that conflicting evidence in the medical record is

not unusual in cases of CFS due to the complicated diagnostic process

involved in these cases. Clarification of any such conflicts in the

medical evidence should be sought first from the individual's treating

or other medical sources.

Medical opinions from treating sources about the nature and severity of

an individual's impairment(s) are entitled to deference and may be

entitled to controlling weight. If we find that a treating source's

medical opinion on the issue(s) of the nature and severity of an

individual's impairment(s) is well-supported by medically acceptable

clinical and laboratory diagnostic techniques and is not inconsistent

with the other substantial evidence in the case record, the adjudicator

will give it controlling weight. (See SSR 96-2p, ``Titles II and XVI:

Giving Controlling Weight to Treating Source Medical Opinions,'' and SSR

96-5p, ``Titles II and XVI: Medical Source Opinions of Issues Reserved

to the Commissioner.'')<10>

4. Assessing Credibility

In accordance with SSR 96-7p, if the existence of a medically

determinable impairment that could reasonably be expected to produce the

symptoms has been established, as outlined above, but an individual's

statements about the intensity, persistence, or functionally limiting

effects of symptoms are not substantiated by objective medical evidence,

the adjudicator must consider all of the evidence in the case record,

including any statements by the individual and other persons concerning

the individual's symptoms. The adjudicator must then make a finding on

the credibility of the individual's statements about symptoms and their

functional effects. When additional information is needed to assess the

credibility of the individual's statements about symptoms and their

effects, the adjudicator must make every reasonable effort to obtain

available information that could shed light on the credibility of the

individual's statements.

5. Treating and other medical sources

In evaluating credibility, the adjudicator should ask the treating or

other medical source(s) to provide information about the extent and

duration of an individual's impairment(s), including observations and

opinions about how well the individual is able to function, the effects

of any treatment, including side effects, and how long the impairment(s)

is expected to limit the individual's ability to function. Opinions from

an individual's medical sources, especially treating sources, concerning

the effects of CFS on the individual's ability to function in a

sustained manner in performing work activities or in performing

activities of daily living are important in enabling adjudicators to

draw conclusions about the severity of the impairment(s) and the

individual's RFC. In this regard, any information a medical source is

able to provide contrasting the individual's impairment(s) and

functional capacities since the alleged onset of CFS with the

individual's status prior to the onset of CFS will be helpful in

evaluating the individual's impairment(s) and its functional consequences.

Third-party information, including evidence from medical sources who are

not ``acceptable medical sources'' for the purpose of establishing the

existence of a medically determinable impairment, but who have provided

services to the individual, may be very useful in deciding the

individual's credibility. Information other than an individual's

allegations and reports from the individual's treating sources helps to

assess an individual's ability to function on a day- to-day basis and to

depict the individual's capacities over a period of time. Such evidence

includes, but is not limited to:

*

Information from neighbors, friends, relatives, or clergy;

*

Statements from such individuals as past employers, rehabilitation

counselors, or school teachers about the individual's impairment(s) and

the effects of the impairment(s) on the individual's functioning in the

work place, rehabilitation facility, or educational institution;

*

Statements from other practitioners with knowledge of the

individual, e.g., nurse-practitioners, physicians' assistants,

naturopaths, therapists, social workers, and chiropractors;

*

Statements from other sources with knowledge of the individual's

ability to function in daily activities; and

*

The individual's own record (such as a diary, journal, or notes)

of his or her own impairment(s) and its impact on function over time.

The adjudicator should carefully consider this information when making

findings about the credibility of the individual's allegations regarding

functional limitations or restrictions.

EFFECTIVE DATE: This Ruling is effective on April 30, 1999.

CROSS-REFERENCES: SSR 96-2p, ``Titles II and XVI: Giving Controlling

Weight to Treating Source Medical Opinions,'' 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

96-5p, ``Titles II and XVI: Medical Source Opinions on Issues Reserved

to the Commissioner,'' 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. 99-10840 Filed 4-29-99; 8:45 am]

BILLING CODE 4190-29-P

Footnotes

1. Except for statutory blindness

2. For individuals under age 18 claiming benefits under title XVI,

disability will be established if the individual is suffering from a

medically determinable physical or mental impairment (or combination of

impairments) that results in ``marked and severe functional

limitations.'' See section 1614(a)(3)© of the Act and 20 CFR 416.906.

However, for clarity, the following discussions refer only to claims of

individuals claiming disability benefits under title II and individuals

age 18 or older claiming disability benefits under title XVI. The

concepts in this ruling, however, are also intended to apply in

determining disability based on CFS for individuals under age 18 under

title XVI.

3. There is considerable overlap of symptoms between CFS and

Fibromyalgia Syndrome (FMS), but individuals with CFS who have tender

points have a medically determinable impairment. Individuals with

impairments that fulfill the American College of Rheumatology criteria

for FMS (which includes a minimum number of tender points) may also

fulfill the criteria for CFS. However, individuals with CFS who do not

have the specified number of tender points to establish FMS, will still

be found to have a medically determinable impairment.

4. It should be noted that standard laboratory test results in the

``normal'' range are characteristic for many individuals with CFS, and

should not be relied upon to the exclusion of all other clinical

evidence in decisions regarding the presence and severity of a medically

determinable impairment.

5. In evaluating title XVI claims for disability benefits for

individuals under age 18, consideration must also be given to the

possibility of functional equivalence. See 20 CFR 416.926a.

6. These steps of the sequential evaluation process are not applicable

to claims for benefits under title XVI for individuals under age 18. See

20 CFR 416.924.

7. However, ``younger individuals'' ages 45-49 who are illiterate in

English or unable to communicate in English, whose past work was

unskilled (or who had no past relevant work), or who have no

transferable skills, and who are limited to a full range of sedentary

work, must be found disabled under rule 201.17 in Table No. 1 of

appendix 2 of the Medical-Vocational Guidelines in 20 CFR part 404.

8. To meet the statutory requirement for ``disability,'' an individual

must have been unable to engage in any SGA by reason of any medically

determinable physical or mental impairment which is 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. Thus, the existence of an impairment

for 12 continuous months is not controlling; rather, it is the existence

of a disabling impairment which has lasted or can be expected to last

for at least 12 months that meets the duration requirement of the Act.

9. We may not seek additional evidence or clarification from a medical

source when we know from past experience that the source either cannot

or will not provide the necessary findings.

10. A medical source opinion that an individual is ``disabled'' or

``unable to work,'' has an impairment(s) that meets or is equivalent in

severity to the requirements of a listing, has a particular residual

functional capacity (RFC), that concerns whether an individual's RFC

prevents him or her from doing past relevant work, or that concerns the

application of vocational factors, is an opinion on an issue reserved to

the Commissioner. Every such opinion must still be considered in

adjudicating a disability claim; however, the adjudicator will not give

any special significance to such an opinion because of its source. See

SSR 96-5p, ``Titles II and XVI: Medical Source Opinions on Issues

Reserved to the Commissioner.''

The CFIDS Association of America

Advocacy, Information, Research and Encouragement for the CFIDS Community

PO Box 220398

Charlotte NC 28222-0398

Toll-free Info Line: 800/442-3437

Resource Line: 704/365-2343

Fax: 704/365-9755

General e-mail: info@...

_____________________________