[Federal Register: September 12, 2002 (Volume 67, Number 177)]
[Notices]
[Page 57859-57864]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr12se02-128]
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SOCIAL SECURITY ADMINISTRATION
Social Security Ruling, SSR 02-1p; Titles II and XVI: Evaluation
of Obesity
AGENCY: Social Security Administration.
ACTION: Notice of Social Security ruling.
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SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of
Social Security gives notice of Social Security Ruling, SSR 02-1p. This
Ruling supersedes SSR 00-3p and provides guidance on the evaluation of
disability claims involving obesity following our deletion of listing
9.09, Obesity, from the Listing of Impairments (the listings). The
final rule deleting listing 9.09 was effective on October 25, 1999 (64
FR 46122 (1999)).
EFFECTIVE DATE: September 12, 2002.
FOR FURTHER INFORMATION CONTACT: Bonnie Davis, Office of Disability,
Social Security Administration, 6401 Security Boulevard, Baltimore, MD
21235-6401, (410) 965-4172 or TTY (410) 966-5609. For information on
eligibility or filing for benefits, call our national toll-free number,
1-800-772-1213 or TTY 1-800-325-0778, or visit our Internet Web site,
Social Security Online, at http://www.ssa.gov.
SUPPLEMENTARY INFORMATION: Although we are not required to do so
pursuant
[[Page 57860]]
to 5 U.S.C. 552(a)(1) and (a)(2), we are publishing this Social
Security Ruling in accordance with 20 CFR 402.35(b)(1). Social Security
Rulings make available to the public precedential decisions relating to
the Federal old-age, survivors, disability, supplemental security
income, and black lung benefits programs. Social Security Rulings may
be based on case decisions made at all administrative levels of
adjudication, Federal court decisions, Commissioner's decisions,
opinions of the Office of the General Counsel, and policy
interpretations of the law and regulations.
Although Social Security Rulings do not have the same force and
effect as the statute or regulations, they are binding on all
components of the Social Security Administration, in accordance with 20
CFR 402.35(b)(1), and are to be relied upon as precedents in
adjudicating cases.
If this Social Security Ruling is later superseded, modified, or
rescinded, we will publish a notice in the Federal Register to that
effect.
We previously published SSR 00-3p on May 15, 2000 (65 FR 31039
(2000)), which provided guidance on the evaluation of claims involving
obesity. However, since the date we published SSR 00-3p we have revised
several of the rules that we apply under the SSR. The rules that we
have revised since we published SSR 00-3p include the adult mental
disorders listings (65 FR 50746 (2000)), the musculoskeletal listings
for adults and children (66 FR 58010 (2001)), and the regulations that
we use to evaluate disability in children claiming Supplemental
Security Income benefits under title XVI of the Social Security Act (65
FR 54747 (2000)). We are superseding SSR 00-3p with this new ruling to
reflect the changes to our rules that we have made since we published
SSR 00-3p. We are not making any other substantive changes to the
guidance that was contained in SSR 00-3p.
(Catalog of Federal Domestic Assistance, Programs 96.001 Social
Security--Disability Insurance; 96.006 Supplemental Security Income)
Dated: September 5, 2002.
Jo Anne B. Barnhart,
Commissioner of Social Security.
Policy Interpretation Ruling
Titles II and XVI: Evaluation of Obesity
This Ruling supersedes SSR 00-3p, Titles II and XVI: Evaluation of
Obesity (65 FR 31039, May 15, 2000).
Purpose: To provide guidance on SSA policy concerning the
evaluation of obesity in disability claims filed under titles II and
XVI of the Social Security Act (the Act).
Citations: Sections 216(i), 223(d), 223(f), 1614(a), and 1614(c) of
the Act, as amended; Regulations No. 4, subpart P, sections 404.1502,
404.1508, 404.1509, 404.1512, 404.1520, 404.1521, 404.1523, 404.1525,
404.1526, 404.1528, 404.1529, 404.1530, 404.1545, 404.1546, 404.1561,
404.1594, and appendix 1; and Regulations No. 16, subpart I, sections
416.902, 416.908, 416.909, 416.912, 416.920, 416.921, 416.923, 416.924,
416.925, 416.926, 416.926a, 416.928, 416.929, 416.930, 416.933,
416.945, 416.946, 416.961, 416.994, and 416.994a.
Introduction: On August 24, 1999, we\1\ published a final rule in
the Federal Register deleting listing 9.09, Obesity, from the Listing
of Impairments in 20 CFR, subpart P, appendix 1 (the listings). The
final rule was effective on October 25, 1999. 64 FR 46122 (1999).
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\1\ The terms we and us in this Social Security Ruling have the
same meaning as in 20 CFR 404.1502 and 416.902. We or us refers to
either the Social Security Administration or the State agency making
the disability or blindness determination; i.e., our adjudicators at
all levels of the administrative review process and our quality
reviewers.
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We stated in the preamble to the final rule that we deleted listing
9.09 because our experience adjudicating cases under this listing
indicated that the criteria in the listing were not appropriate
indicators of listing-level severity. In our experience, the criteria
in listing 9.09 did not represent a degree of functional limitation
that would prevent an individual from engaging in any gainful activity.
However, even though we deleted listing 9.09, we made some changes
to the listings to ensure that obesity is still addressed in our
listings. In the final rule, we added paragraphs to the prefaces of the
musculoskeletal, respiratory, and cardiovascular body system listings
that provide guidance about the potential effects obesity has in
causing or contributing to impairments in those body systems. See
listings sections 1.00Q, 3.00I, and 4.00F. The paragraphs state that we
consider obesity to be a medically determinable impairment and remind
adjudicators to consider its effects when evaluating disability. The
provisions also remind adjudicators that the combined effects of
obesity with other impairments can be greater than the effects of each
of the impairments considered separately. They also instruct
adjudicators to consider the effects of obesity not only under the
listings but also when assessing a claim at other steps of the
sequential evaluation process, including when assessing an individual's
residual functional capacity.
When we published that final rule, in response to public comments,
we stated that we would provide additional guidance in a Social
Security Ruling (SSR). (64 FR at 46126) On May 15, 2000, we published
SSR 00-3p (65 FR 31039) to provide that additional guidance by
discussing how we evaluate obesity in disability claims filed by adults
and children under titles II and XVI of the Act. Since then, we have
published several final rules that revise some of the criteria we use
to evaluate disability claims under titles II and XVI of the Social
Security Act. We are issuing this SSR to reflect the changes to the
rules that we have published since we published SSR 00-3p.
Policy Interpretation
General
1. What Is Obesity?
Obesity is a complex, chronic disease characterized by excessive
accumulation of body fat. Obesity is generally the result of a
combination of factors (e.g., genetic, environmental, and behavioral).
In one sense, the cause of obesity is simply that the energy (food)
taken in exceeds the energy expended by the individual's body. However,
the influences on intake, the influences on expenditure, the metabolic
processes in between, and the overall genetic controls are complex and
not well understood.
The National Institutes of Health (NIH) established medical
criteria for the diagnosis of obesity in its Clinical Guidelines on the
Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults (NIH Publication No. 98-4083, September 1998). These guidelines
classify overweight and obesity in adults according to Body Mass Index
(BMI). BMI is the ratio of an individual's weight in kilograms to the
square of his or her height in meters (kg/m2). For adults,
both men and women, the Clinical Guidelines describe a BMI of 25-29.9
as ``overweight'' and a BMI of 30.0 or above as ``obesity.''
The Clinical Guidelines recognize three levels of obesity. Level I
includes BMIs of 30.0-34.9. Level II includes BMIs of 35.0-39.9. Level
III, termed ``extreme'' obesity and representing the greatest risk for
developing obesity-related impairments, includes BMIs greater than or
equal to 40. These levels describe the extent of obesity, but they do
not correlate with any specific degree of functional loss.
[[Page 57861]]
In addition, although there is often a significant correlation
between BMI and excess body fat, this is not always the case. The
Clinical Guidelines also provide for considering whether an individual
of a given height and weight has excess body fat when determining
whether he or she has obesity. Thus, it is possible for someone whose
BMI is below 30 to have obesity if too large a percentage of the weight
is from fat. Likewise, someone with a BMI above 30 may not have obesity
if a large percentage of the weight is from muscle. However, in most
cases, the BMI will show whether the individual has obesity. It also
will usually be evident from the information in the case record whether
the individual should not be found to have obesity, despite a BMI of
30.0 or above. See question 4, below.
The Clinical Guidelines do not provide criteria for diagnosing
obesity in children. However, a BMI greater than or equal to the 95th
percentile for a child's age is generally considered sufficient to
establish the diagnosis of obesity. (BMIs in the 95th percentile vary
by age and sex of the child.) BMI-for-age-and-gender charts are
published in medical textbooks or professional journals and by the
National Center for Health Statistics. As with adults, the amount of
body fat is considered in making the diagnosis of obesity in children.
Treatment for obesity is often unsuccessful. Even if treatment
results in weight loss at first, weight lost is often regained, despite
the efforts of the individual to maintain the loss. See question 13,
below, for additional discussion of obesity treatment.
2. How Does Obesity Affect Physical and Mental Health?
Obesity is a risk factor that increases an individual's chances of
developing impairments in most body systems. It commonly leads to, and
often complicates, chronic diseases of the cardiovascular, respiratory,
and musculoskeletal body systems. Obesity increases the risk of
developing impairments such as type II (so-called adult onset) diabetes
mellitus-even in children; gall bladder disease; hypertension; heart
disease; peripheral vascular disease; dyslipidemia (abnormal levels of
fatty substances in the blood); stroke; osteoarthritis; and sleep
apnea. It is associated with endometrial, breast, prostate, and colon
cancers, and other physical impairments. Obesity may also cause or
contribute to mental impairments such as depression. The effects of
obesity may be subtle, such as the loss of mental clarity and slowed
reactions that may result from obesity-related sleep apnea.
The fact that obesity is a risk factor for other impairments does
not mean that individuals with obesity necessarily have any of these
impairments. It means that they are at greater than average risk for
developing the other impairments.
3. How Do We Consider Obesity in the Sequential Evaluation Process?\2\
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\2\ For ease of reading, we refer in this Ruling only to the
steps of the sequential evaluation processes for initial adult and
childhood claims. 20 CFR 404.1520, 416.920, and 416.924. We use
separate sequential evaluation processes when we do continuing
disability reviews; i.e., reviews to determine whether individuals
who are receiving disability benefits are still disabled or when we
determine whether an individual has a ``closed period of
disability.'' These rules are set out in 20 CFR 404.1594, 416.994,
and 416.994a, and the guidance in this Ruling applies to all of the
appropriate steps in those regulations as well. However, in some
continuing disability review cases, we will still consider the
provisions of former listings 9.09 and 10.10. See question 11.
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We will consider obesity in determining whether:
[sbull] The individual has a medically determinable impairment. See
question 4.
[sbull] The individual's impairment(s) is severe. See question 6.
[sbull] The individual's impairment(s) meets or equals the
requirements of a listed impairment in the listings. See question 7.
(We use special rules for some continuing disability reviews. See
question 11.)
[sbull] The individual's impairment(s) prevents him or her from
doing past relevant work and other work that exists in significant
numbers in the national economy. However, these steps apply only in
title II and adult title XVI cases. See questions 8 and 9.
4. How Is Obesity Identified as a Medically Determinable Impairment?
When establishing the existence of obesity, we will generally rely
on the judgment of a physician who has examined the claimant and
reported his or her appearance and build, as well as weight and height.
Thus, in the absence of evidence to the contrary in the case record, we
will accept a diagnosis of obesity given by a treating source or by a
consultative examiner. However, if there is evidence that indicates
that the diagnosis is questionable and the evidence is inadequate to
determine whether or not the individual is disabled, we will contact
the source for clarification, using the guidelines in 20 CFR
404.1512(e) and 416.912(e).
When the evidence in a case does not include a diagnosis of
obesity, but does include clinical notes or other medical records
showing consistently high body weight or BMI, we may ask a medical
source to clarify whether the individual has obesity. However, in most
such cases we will use our judgment to establish the presence of
obesity based on the medical findings and other evidence in the case
record, even if a treating or examining source has not indicated a
diagnosis of obesity. Generally, we will not purchase a consultative
examination just to establish the diagnosis of obesity.
When deciding whether an individual has obesity, we will also
consider the individual's weight over time.\3\ We will not count minor,
short-term weight loss. We will consider the individual to have obesity
as long as his or her weight or BMI shows essentially a consistent
pattern of obesity. (See question 13 for a discussion of weight loss
and medical improvement.)
Finally, there are a number of methods for measuring body fat and,
if such information is in a case record, we will consider it. However,
we will not purchase such testing. In most cases, the medical and other
evidence in the case record will establish whether the individual has
obesity.
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\3\ As with all impairments, to establish a finding of
disability based on obesity, in whole or in part, the statutory
duration requirement must be satisfied. See 20 CFR 404.1509 or
416.909, and SSR 82-52, ``Titles II and XVI: Duration of the
Impairment'' (superseded in part by SSR 91-7c).
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5. Can We Find an Individual Disabled Based on Obesity Alone?
If an individual has the medically determinable impairment obesity
that is ``severe'' as described in question 6, we may find that the
obesity medically equals a listing. (In the case of a child seeking
benefits under title XVI, we may also find that it functionally equals
the listings.) We may also find in a title II claim, or an adult claim
under title XVI, that the obesity results in a finding that the
individual is disabled based on his or her residual functional capacity
(RFC), age, education, and past work experience. However, we will also
consider the possibility of coexisting or related conditions,
especially as the level of obesity increases. We provide an example of
when we may find obesity to medically equal a listing in question 7.
Sequential Evaluation: Step 2, Severe Impairment
6. When Is Obesity a ``Severe'' Impairment?
As with any other medical condition, we will find that obesity is a
``severe'' impairment when, alone or in combination with another
medically
[[Page 57862]]
determinable physical or mental impairment(s), it significantly limits
an individual's physical or mental ability to do basic work activities.
(For children applying for disability under title XVI, we will find
that obesity is a ``severe'' impairment when it causes more than
minimal functional limitations.) We will also consider the effects of
any symptoms (such as pain or fatigue) that could limit functioning.
(See SSR 85-28, ``Titles II and XVI: Medical Impairments That Are Not
Severe'' and SSR 96-3p, ``Titles II and XVI: Considering Allegations of
Pain and Other Symptoms In Determining Whether a Medically Determinable
Impairment Is Severe.'') Therefore, we will find that an impairment(s)
is ``not severe'' only if it is a slight abnormality (or a combination
of slight abnormalities) that has no more than a minimal effect on the
individual's ability to do basic work activities (or, for a child
applying under title XVI, if it causes no more than minimal functional
limitations).
There is no specific level of weight or BMI that equates with a
``severe'' or a ``not severe'' impairment. Neither do descriptive terms
for levels of obesity (e.g., ``severe,'' ``extreme,'' or ``morbid''
obesity) establish whether obesity is or is not a ``severe'' impairment
for disability program purposes. Rather, we will do an individualized
assessment of the impact of obesity on an individual's functioning when
deciding whether the impairment is severe.
Sequential Evaluation
Step 3, The Listings
7. How Do We Evaluate Obesity at Step 3 of Sequential Evaluation, the
Listings?
Obesity may be a factor in both ``meets'' and ``equals''
determinations.
Because there is no listing for obesity, we will find that an
individual with obesity ``meets'' the requirements of a listing if he
or she has another impairment that, by itself, meets the requirements
of a listing. We will also find that a listing is met if there is an
impairment that, in combination with obesity, meets the requirements of
a listing. For example, obesity may increase the severity of coexisting
or related impairments to the extent that the combination of
impairments meets the requirements of a listing. This is especially
true of musculoskeletal, respiratory, and cardiovascular impairments.
It may also be true for other coexisting or related impairments,
including mental disorders.
For example, when evaluating impairments under mental disorder
listings 12.05C, 112.05D, or 112.05F, obesity that is ``severe,'' as
explained in question 6, satisfies the criteria in listing 12.05C for a
physical impairment imposing an additional and significant work-related
limitation of function and in listings 112.05D and 112.05F for a
physical impairment imposing an additional and significant limitation
of function. We will find the requirements of listing 12.05 are met if
an individual's impairment satisfies the diagnostic description in the
introductory paragraph of listing 12.05 and any one of the four sets of
criteria in the listing. In the case of an individual under age 18, we
will find that the requirements of listing 112.05 are met if the
child's impairment satisfies the diagnostic description in the
introductory paragraph of listing 112.05 and any one of the six sets of
criteria in the listing. (See sections 12.00A and 112.00A of the
listings.)
We may also find that obesity, by itself, is medically equivalent
to a listed impairment (or, in the case of a child applying under title
XVI, also functionally equivalent to the listings). For example, if the
obesity is of such a level that it results in an inability to ambulate
effectively, as defined in sections 1.00B2b or 101.00B2b of the
listings, it may substitute for the major dysfunction of a joint(s) due
to any cause (and its associated criteria), with the involvement of one
major peripheral weight-bearing joint in listings 1.02A or 101.02A, and
we will then make a finding of medical equivalence. (See question 8 for
further discussion of evaluating the functional effects of obesity,
including functional equivalence determinations for children applying
for benefits under title XVI.)
We will also find equivalence if an individual has multiple
impairments, including obesity, no one of which meets or equals the
requirements of a listing, but the combination of impairments is
equivalent in severity to a listed impairment. For example, obesity
affects the cardiovascular and respiratory systems because of the
increased workload the additional body mass places on these systems.
Obesity makes it harder for the chest and lungs to expand. This means
that the respiratory system must work harder to provide needed oxygen.
This in turn makes the heart work harder to pump blood to carry oxygen
to the body. Because the body is working harder at rest, its ability to
perform additional work is less than would otherwise be expected. Thus,
we may find that the combination of a pulmonary or cardiovascular
impairment and obesity has signs, symptoms, and laboratory findings
that are of equal medical significance to one of the respiratory or
cardiovascular listings.\4\
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\4\ For our regulations and rulings on the consideration of
medical or psychological consultant opinions in determining medical
equivalence, see 20 CFR 404.1526(c) and 416.926(c), and SSR 96-6p,
``Titles II and XVI: Consideration of Administrative Findings of
Fact by State Agency Medical and Psychological Consultants and Other
Program Physicians and Psychologists at the Administrative Law Judge
and Appeals Council Levels of Administrative Review; Medical
Equivalence.''
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However, we will not make assumptions about the severity or
functional effects of obesity combined with other impairments. Obesity
in combination with another impairment may or may not increase the
severity or functional limitations of the other impairment. We will
evaluate each case based on the information in the case record.
Sequential Evaluation
Steps 4 and 5, Assessing Functioning in Adults
Step 3, Assessing Functional Equivalence in Children
8. How Do We Evaluate Obesity in Assessing Residual Functional Capacity
in Adults and Functional Equivalence in Children?
Obesity can cause limitation of function. The functions likely to
be limited depend on many factors, including where the excess weight is
carried. An individual may have limitations in any of the exertional
functions such as sitting, standing, walking, lifting, carrying,
pushing, and pulling. It may also affect ability to do postural
functions, such as climbing, balance, stooping, and crouching. The
ability to manipulate may be affected by the presence of adipose
(fatty) tissue in the hands and fingers. The ability to tolerate
extreme heat, humidity, or hazards may also be affected.
The effects of obesity may not be obvious. For example, some people
with obesity also have sleep apnea. This can lead to drowsiness and
lack of mental clarity during the day. Obesity may also affect an
individual's social functioning.
An assessment should also be made of the effect obesity has upon
the individual's ability to perform routine movement and necessary
physical activity within the work environment. Individuals with obesity
may have problems with the ability to sustain a function over time. As
explained in SSR 96-8p (``Titles II and XVI: Assessing Residual
Functional Capacity in Initial Claims''), our RFC assessments must
consider an individual's maximum remaining ability to do sustained work
activities in an ordinary work setting on
[[Page 57863]]
a regular and continuing basis. A ``regular and continuing basis''
means 8 hours a day, for 5 days a week, or an equivalent work
schedule.\5\ In cases involving obesity, fatigue may affect the
individual's physical and mental ability to sustain work activity. This
may be particularly true in cases involving sleep apnea.
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\5\ However, see footnote 2 of SSR 96-8p. That footnote explains
that the ability to work 8 hours a day for 5 days a weeks is not
always required for a finding at step 4 of the sequential evaluation
process for adults when an individual can do past relevant work that
was part-time work, if that work was substantial gainful activity,
performed within the applicable period, and lasted long enough for
the person to learn to do it.
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The combined effects of obesity with other impairments may be
greater than might be expected without obesity. For example, someone
with obesity and arthritis affecting a weight-bearing joint may have
more pain and limitation than might be expected from the arthritis
alone.
For a child applying for benefits under title XVI, we may evaluate
the functional consequences of obesity (either alone or in combination
with other impairments) to decide if the child's impairment(s)
functionally equals the listings. For example, the functional
limitations imposed by obesity, by itself or in combination with
another impairment(s), may establish an extreme limitation in one
domain of functioning (e.g., Moving about and manipulating objects) or
marked limitations in two domains (e.g., Moving about and manipulating
objects and Caring for yourself).
As with any other impairment, we will explain how we reached our
conclusions on whether obesity caused any physical or mental
limitations.
9. How Can We Consider Obesity in the Assessment of RFC When SSR 96-8p
says, ``Age and Body Habitus Are Not Factors in Assessing RFC''?
The SSR goes on to say that ``[i]t is incorrect to find that an
individual has limitations beyond those caused by his or her medically
determinable impairment(s) and any related symptoms, due to such
factors as age and natural body build, and the activities the
individual was accustomed to doing in his or her previous work.''
(Emphasis added.) We included the italicized statement in the SSR to
distinguish between individuals who have a medically determinable
impairment of obesity and individuals who do not. When we identify
obesity as a medically determinable impairment (see question 4, above),
we will consider any functional limitations resulting from the obesity
in the RFC assessment, in addition to any limitations resulting from
any other physical or mental impairments that we identify.
Effect of the Rules Change: Claims in Which Prior Listings Apply and Do
Not Apply
10. How Does the Deletion of Listing 9.09 Affect Claims Pending on
October 25, 1999?
The final rules that deleted the listing became effective on
October 25, 1999. The final rules deleting listing 9.09 apply to claims
that were filed before October 25, 1999, and that were awaiting an
initial determination or that were pending appeal at any level of the
administrative review process or that had been appealed to court. The
change affected the entire claim, including the period before October
25, 1999. This is our usual policy with respect to any change in our
listings.
However, different rules apply to individuals who were already
found eligible to receive benefits prior to October 25, 1999. For an
explanation of how we apply listing 9.09 in continuing disability
reviews, see question 11.
11. How Does Deletion of Listing 9.09 Affect Claims Already Allowed?
Deletion of listing 9.09 does not affect the entitlement or
eligibility of individuals receiving benefits because their
impairment(s) met or equaled that listing. We will not find that their
disabilities have ended just because we deleted listing 9.09.
We must periodically review all claims to determine whether the
individual's disability continues. When we conduct a periodic
continuing disability review (CDR), we will not find that an
individual's disability has ended based on a change in a listing. For
individuals receiving disability benefits under title II and adults
receiving payments under title XVI, we apply the medical improvement
review standard described in 20 CFR 404.1594 and 416.994.
We will first evaluate whether the individual's impairment(s) has
medically improved and, if so, whether any medical improvement is
related to the ability to work. If the individual's impairment(s) has
not medically improved, we will find that he or she is still disabled,
unless we find that an exception to the medical improvement standard
applies. Even if the impairment(s) has medically improved, we will find
that the improvement is not related to the ability to work if the
impairment(s) continues to meet or equal the same listing section used
to make our most recent favorable decision. This is true even if we
have since deleted the listing section that we used to make the most
recent favorable decision. See 20 CFR 404.1594(c)(3)(i) and
416.994(b)(2)(iv)(A). We apply a similar provision when we do CDRs for
individuals who have not attained age 18 and who are eligible for title
XVI benefits based on disability (20 CFR 416.994a(b)(2)).
Even if the individual's impairment(s) has medically improved and
no longer meets or equals prior listing 9.09, we must still determine
whether he or she is currently disabled, considering all of the
impairments.
12. What Amount of Weight Loss Would Represent ``Medical Improvement''?
Because an individual's weight may fluctuate over time and minor
weight changes are of little significance to an individual's ability to
function, it is not appropriate to conclude that an individual with
obesity has medically improved because of a minor weight loss. A loss
of less than 10 percent of initial body weight is too minor to result
in a finding that there has been medical improvement in the obesity.
However, we will consider that obesity has medically improved if an
individual maintains a consistent loss of at least 10 percent of body
weight for at least 12 months. We will not count minor, short-term
changes in weight when we decide whether an individual has maintained
the loss consistently.
If there is a coexisting or related condition(s) and the obesity
has not improved, we will still consider whether the coexisting or
related condition(s) has medically improved.
If we find that there has been medical improvement in obesity or in
any coexisting or related condition(s), we must also decide whether the
medical improvement is related to the ability to work. If necessary, we
will also decide whether any exceptions to the medical improvement
review standard apply and, if appropriate, whether the individual is
currently disabled.
13. What Are the Goals and Methods of Treatment for Obesity?
Obesity is a disease that requires treatment, although in most
people the effect of treatment is limited. However, if untreated, it
tends to progress.
A common misconception is that the goal of treatment is to reduce
weight to a ``normal'' level. Actually, the goal of realistic medical
treatment for obesity is only to reduce weight by a reasonable amount
that will improve health and quality of life. People with extreme
obesity, even with treatment, will
[[Page 57864]]
generally continue to have obesity. Despite short-term progress, most
treatments for obesity do not have a high success rate.
Recommended treatment for obesity depends upon the level of
obesity. At levels I and II (BMI 30.0-39.9), treatment usually consists
of behavior modification (diet and exercise) with the option of
medication, usually either in the form of a fat-blocking drug or an
appetite suppressant. Some people do not respond to medication, while
others experience negative side effects. (In making our decision, we
will also consider any side effects of medication the individual
experiences.) Individuals with coexisting or related conditions may not
be able to take medication because of its effects on their other
conditions.
Generally, physicians recommend surgery when obesity has reached
level III (BMI 40 or greater). However, surgery may also be an option
at level II (BMI 35-39.9) if there is a serious coexisting or related
condition. Obesity surgery modifies the stomach, the intestines, or
both in order to reduce the amount of food that the individual can eat
at one meal or the time food is available for digestion and absorption.
Surgery is generally a last resort with individuals for whom other
forms of treatment have failed. Some individuals also experience
significant negative side effects from surgery (e.g., ``dumping
syndrome''--that is, rapid emptying of the stomach's contents marked by
various signs and symptoms).
Obesity is a life-long disease. Even when treatment has been
successful, individuals with obesity generally need to stay in
treatment or they will gain weight again, just as individuals with
other impairments may need to stay in treatment. Individuals who have
had surgery should receive continuing follow-up care because of health
risks related to the surgery. As with other chronic disorders,
effective treatment of obesity requires regular medical follow-up.
14. How Do We Evaluate Failure To Follow Prescribed Treatment in
Obesity Cases?
Before failure to follow prescribed treatment for obesity can
become an issue in a case, we must first find that the individual is
disabled because of obesity or a combination of obesity and another
impairment(s). Our regulations at 20 CFR 404.1530 and 416.930 provide
that, in order to get benefits, an individual must follow treatment
prescribed by his or her physician if the treatment can restore the
ability to work, unless the individual has an acceptable reason for
failing to follow the prescribed treatment. We will rarely use
``failure to follow prescribed treatment'' for obesity to deny or cease
benefits.
SSR 82-59, ``Titles II and XVI: Failure To Follow Prescribed
Treatment,'' explains that we will find failure to follow prescribed
treatment only when all of the following conditions exist:
[sbull] The individual has an impairment(s) that meets the
definition of disability, including the duration requirement, and
[sbull] A treating source has prescribed treatment that is clearly
expected to restore the ability to engage in substantial gainful
activity, and
[sbull] The evidence shows that the individual has failed to follow
prescribed treatment without a good reason.
If an individual who is disabled because of obesity (alone or in
combination with another impairment(s)) does not have a treating source
who has prescribed treatment for the obesity, there is no issue of
failure to follow prescribed treatment.
The treatment must be prescribed by a treating source, as defined
in our regulations at 20 CFR 404.1502 and 416.902, not simply
recommended. A treating source's statement that an individual
``should'' lose weight or has ``been advised'' to get more exercise is
not prescribed treatment.
When a treating source has prescribed treatment for obesity, the
treatment must clearly be expected to improve the impairment to the
extent that the person will not be disabled. As noted in question 13,
the goals of treatment for obesity are generally modest, and treatment
is often ineffective. Therefore, we will not find failure to follow
prescribed treatment unless there is clear evidence that treatment
would be successful. The obesity must be expected to improve to the
point at which the individual would not meet our definition of
disability, considering not only the obesity, but any other
impairment(s).
Finally, even if we find that a treating source has prescribed
treatment for obesity, that the treatment is clearly expected to
restore the ability to engage in SGA, and that the individual is not
following the prescribed treatment, we must still consider whether the
individual has a good reason for doing so. In making this finding, we
will follow the guidance in our regulations and SSR 82-59, which
provide that acceptable justifications for failing to follow prescribed
treatment include, but are not limited to, the following:
[sbull] The specific medical treatment is contrary to the teaching
and tenets of the individual's religion.
[sbull] The individual is unable to afford prescribed treatment
that he or she is willing to accept, but for which free community
resources are unavailable.
[sbull] The treatment carries a high degree of risk because of the
enormity or unusual nature of the procedure.
In this regard, most health insurance plans and Medicare do not
defray the expense of treatment for obesity. Thus, an individual who
might benefit from behavioral or drug therapy might not be able to
afford it. Also, because not enough is known about the long-term
effects of medications used to treat obesity, some people may be
reluctant to use them due to the potential risk.
Because of the risks and potential side effects of surgery for
obesity, we will not find that an individual has failed to follow
prescribed treatment for obesity when the prescribed treatment is
surgery.
EFFECTIVE DATE: This Ruling is effective upon publication in the
Federal Register.
Cross-References: SSR 82-52, ``Titles II and XVI: Duration of the
Impairment;'' SSR 82-59, ``Titles II and XVI: Failure To Follow
Prescribed Treatment;'' SSR 85-28, ``Titles II and XVI: Medical
Impairments That Are Not Severe;'' SSR 96-3p, ``Titles II and XVI:
Considering Allegations of Pain and Other Symptoms In Determining
Whether a Medically Determinable Impairment Is Severe;'' SSR 96-6p,
``Titles II and XVI: Consideration of Administrative Findings of Fact
by State Agency Medical and Psychological Consultants and Other Program
Physicians and Psychologists at the Administrative Law Judge and
Appeals Council Levels of Administrative Review; Medical Equivalence;''
SSR 96-8p, ``Titles II and XVI: Assessing Residual Functional Capacity
in Initial Claims;'' and Program Operations Manual System sections DI
23010.005 ff., DI 24510.006, DI 24570.001, DI 34001.010, DI 34001.014,
and DI 34001.016.
[FR Doc. 02-23148 Filed 9-11-02; 8:45 am]
BILLING CODE 4191-02-P