106 CMR, § 703.192 - EAEDC Medical Standards

(A) Musculoskeletal System.

(1) Arthritis of Any Major Joint (Hips, Knees, Hands or Feet). Arthritis of any major joint must be substantiated by:

(a) the presence of three or more of the following clinical findings lasting for more than 15 days and expected to last for at least 30 days:

1. pain;

2. swelling;

3. tenderness;

4. warmth;

5. redness;

6. stiffness; or

7. limitation of motion; and

(b) corroboration of the diagnosis by at least two of the following:

1. positive serologic test for rheumatoid factor; or anti-nuclear antibody or HLAB antigen;

2. elevated sedimentation rate;

3. positive joint fluid culture;

4. elevation of white blood count;

5. significant anatomical deformity; or

6. x-ray evidence of significant joint space narrowing or bony destruction.

(2) Disorders of the Spine. Disorders of the spine must be demonstrated by one of the following:

(a) x-ray evidence of significant arthritic changes manifested by ankylosis, or fixation, or motion limitation (objective);

(b) Bone density evidence of significant osteoporosis manifested by pain and real motion limitation;

(c) evidence of other vertebragenic disorders (e.g., herniated nucleus pulposus or spinal stenosis), with:

1. pain and significant limitation of motion in the spine; and

2. appropriate radicular distribution of significant sensory, motor, or flex abnormalities; or

(d) evidence of acute back strain with pain and significant limitation of motion lasting more than 15 days and expected to last for at least 30 days.

(3) Fracture of a Major Bone. When solid union has not occurred and incapacity is expected to last for at least 30 days.

(4) Soft Tissue Injuries or Loss. Soft tissue injuries or loss, including burns, must be demonstrated by one of the following, which lasts more than 15 days and can be expected to last for at least 30 days:

(a) significant loss which prohibits function of an upper or lower extremity;

(b) significant body surface involvement; or

(c) involvement of critical areas such as hands and feet that prevents their use.

(B) Special Senses and Speech.

(1) Impairment of Central Visual Acuity. Remaining vision in the better eye after best correction must be 20/100 or less and must be expected to last for at least 30 days.

(2) Contraction of Peripheral Visual Fields. Contraction of peripheral visual fields in the better eye must be:

(a) to 20° or less from point of fixation;

(b) so the widest diameter subtends an angle no greater than 25°; or

(c) to 25% or less visual field efficiency; and must be expected to last at least 30 days.

(3) Hearing Impairments. Hearing must not be restorable by a hearing aid, and the impairment must be manifested by one of the following:

(a) average hearing threshold sensitivity for air conduction of 90 decibels or greater; and for bone conduction to corresponding maximal levels, in the better ear, determined by the simple average of hearing threshold levels at 500, 1000, and 2000 Hz; or

(b) speech discrimination scores of 40% or less in the better ear; and must be expected to last for at least 30 days.

(4) Disturbance of Labyrinthine-vestibular Function. Disturbance of labyrinthine-vestibular function (including Meniere's disease) must be demonstrated by one or more attacks of balance disturbance and tinnitus within the 30-day period immediately preceding application for EAEDC. The symptoms must persist for at least 30 days and affect daily functions and the diagnosis must be corroborated by:

(a) hearing loss established by audiometry; or

(b) standard vestibular test (ENG) with or without hearing loss established by audiometry.

(C) Respiratory System.

(1) Chronic Obstructive Airway Disease. Spirometric evidence of airway obstruction must be demonstrated by maximum voluntary ventilation (MVV) and one-second forced expiratory volume (FEV1) with both values equal to or less than those specified in Table I, corresponding to height and expected to last for at least 30 days.

Table I

Height (inches)	MVV equal to or less than (L/Min)	FEV1 equal to or less than And (L)
57 or less	42	1.5
58	43	1.5
59	44	1.5
60	45	1.6
61	46	1.6
62	47	1.6
63	48	1.6
64	49	1.7
65	50	1.7
66	51	1.7
67	52	1.8
68	53	1.8
69	54	1.8
70	55	1.9
71	56	1.9
72	57	1.9
73 or more	58	1.9

(2) Diffuse Pulmonary Fibrosis. Diffuse pulmonary fibrosis due to any cause must be demonstrated by both of the following, and expected to last for at least 30 days:

(a) Total vital capacity (VC) must be equal to or less than the values specified in Table II, corresponding to height; and Table II

Height or less than (inches)	VC equal to (L)
57 or less	1.7
58	1.8
59	1.8
60	1.9
61	1.9
62	2.0
63	2.0
64	2.1
65	2.1
66	2.2
67	2.2
68	2.3
69	2.3
70	2.4
71	2.4
72	2.5
73 or more	2.5

(b) Arterial oxygen tension (po2) at rest and simultaneously determined arterial carbon dioxide tension (PCO2) values must be equal to or less than those specified in Table III.

Table III

Arterial pco2 (mm Hg)	Arterial po2 equal to or less than (mm Hg)
30 or below	75
31	74
32	73
33	72
34	71
35	70
36	69
37	68
38	67
39	66
40 or above	65

(3) Other Restrictive Ventilatory Disorders. Other restrictive ventilatory disorders (such as kyphoscoliosis, thoracoplasty, and pulmonary resection) must be substantiated by total vital capacity (VC) equal to or less than the values specified in Table IV, corresponding to height and expected to last at least 30 days.

Table IV

Height (inches)	VC equal to or less than (L)
59	1.5
60	1.6
61	1.6
62	1.6
63	1.6
64	1.7
65	1.7
66	1.7
67	1.8
68	1.8
69	1.8
70	1.9

(4) Active Pulmonary Tuberculosis. Active pulmonary tuberculosis must be corroborated by either:

(a) positive culture; or

(b) x-ray evidence of increasing lesions or cavitation; and expected to last at least 30 days.

(5) Other Respiratory Disorders. Other respiratory disorders must be shown by the presence of at least two of the following 106 CMR 702.192(C)(5)(a), (b), or (c) for more than 15 days and expected to last at least 30 days:

(a) shortness of breath, wheezing, rhonchi, rales, cough, or fever;

(b) significant x-ray changes; or

(c) significant laboratory abnormalities.

(D) Cardiovascular System.

(1) Open Heart Surgery. The period of incapacity will be expected to last at least 30 days and meet the criteria in 106 CMR 703.192(D)(3) or (4).

(2) Ischemic Heart Disease.

(a) Ischemic heart disease, with chest pain of cardiac origin, must be corroborated by one of the following:

1. significantly diminished exercise tolerance corroborated by results of ETT;

2. significant ischemic changes on resting EKG;

3. EKG evidence of myocardial infarction at some time and symptoms if EKG evidence is more than six months old;

4. development of significant arrhythmia;

5. angiographic evidence (obtained independently) of coronary artery disease; or

6. development of left bundle branch block.

(b) If ischemic heart disease is ruled out after an extensive work-up the period of incapacity will be 90 days if:

1. symptoms lasted at least 15 days; or

2. substantial work activity is precluded by a physician's orders for at least 90 days.

(3) Congestive Heart Failure. Congestive heart failure must be manifested by evidence of vascular congestion such as hepatomegaly, or peripheral or pulmonary edema, with either of the following present, and expected to last at least 30 days.

(a) evidence of congestive heart failure on clinical examination; or

(b) significant x-ray or EKG changes.

(4) Arteriosclerosis Obliterans or Thromboangiitis. Arteriosclerosis obliterans or thromboangiitis must be substantiated by both:

(a) intermittent claudication; and

(b) absence of peripheral arterial pulsations below the knee; and be expected to last for at least 30 days.

(5) Venous Insufficiency of the Lower Extremity. Venous insufficiency of the lower extremity must be expected to last at least 30 days and be associated with two or more of the following:

(a) varicosities;

(b) brawny edema;

(c) stasis dermatitis; and

(d) ulceration

(E) Digestive System. Impairments affecting the digestive system that are considered incapacitating are listed:

(1) Gastrointestinal Disorders.

(a) Gastrointestinal disorders must be substantiated by the presence of three or more of the following symptoms lasting more than seven days and expected to last at least 30 days:

1. pain;

2. nausea;

3. vomiting;

4. diarrhea;

5. bloody stools; or

6. abdominal distension.

(b) Gastrointestinal disorders expected to last more than 90 days must demonstrate the presence of clinical findings under of significant pathology demonstrated by x-ray, endoscopy, barium enema, biopsy, or other objective criteria; or the presence of one of the following:

1. abscess or fistula formation;

2. hematocrit of 30% or less;

3. serum albumin of 3.0 g per deciliter (100 ml) or less;

4. serum calcium of 8.0 mg per deciliter;

5. fat in stool of 7.0 m or greater per 24-hour specimen;

6. nitrogen in stool of 3.0 g or greater per 24-hour specimen;

7. evidence of pancreatic dysfunction; or

8. systemic manifestations such as arthritis, iritis, or liver dysfunction not attributable to other causes.

(2) Diseases of the Liver.

(a) Acute Hepatitis (Viral A, B, Non-A, Non-B). Incapacity expected to last more than 90 days must meet the criteria in 106 CMR 703.192(E)(2)(b).

(b) Chronic Liver Disease. Chronic liver diseases (portal, postnecrotic, or biliary cirrhosis, chronic active hepatitis, Wilson's disease) must be substantiated by a history of significant and unresolved hyperbilirubinemia, ascites due to hypoalbuminemia, or mental confusion lasting more than 15 days and expected to last at least 30 days; or if the impairment persists is expected to last more than 90 days and is accompanied by confirmation of liver disease by liver biopsy and demonstration (clinical) of two of the following:

1. bleeding from esophageal varices; or

2. hepatic cell necrosis or inflammation;

3. hepatic encephalopathy.

(3) Weight Loss. Weight loss due to any gastrointestinal disorder must be substantiated by weight equal to or less than the values specified in Table V (for men) or Table VI (for women), corresponding to height and expected to last at least 30 days.

Table V - Men		Table VI - Women
Height (inches)	Weight (pounds)	Height (inches)	Weight (pounds)
61	95	61	82
62	98	62	84
63	100	63	87
64	103	64	89
65	106	65	92
66	109	66	94
67	112	67	97
68	116	68	100
69	119	69	104
70	122	70	107
71	126	71	111
72	129	72	114
73	133	73	117
74	136	74	121
75	139	75	124
76	143	76	128

Weight loss which continues for more than 90 days despite treatment and proper nutrition, must meet the criteria in 106 CMR 703.192(E)(1) or (2)(b).

(F) Genitourinary System.

Impairment of Renal Function. Impairment of renal function due to any cause must be substantiated by one of the following, which lasts more than 15 days and can be expected to last at least 30 days:

(1) elevation of serum creatinine;

(2) hematocrit of 30% or less;

(3) renal osteodystrophy manifested by bone pain and appropriate radiographic abnormalities;

(4) documented fluid overload syndrome;

(5) anorexia;

(6) hemodialysis or peritoneal dialysis; or

(7) proteinuria.

(G) Hemic and Lymphatic Systems.

(1) Anemia. Anemia must be substantiated by one of the following:

(a) hematocrit of 30% or less if, acute or not tolerated; or

(b) one or more blood transfusions required within the 30-day period immediately preceding application for EAEDC, and the incapacity is expected to last at least 30 days.

(2) Sickle Cell Disease. Sickle cell disease or one of its variants must be substantiated by a documented painful thrombotic crisis within the 30 day period immediately preceding application for EAEDC; and expected to last for at least 30 days.

(3) Hemorrhage. Hemorrhage due to any traumatic or nontraumatic cause must be substantiated by one or more blood transfusions required within the 30-day period immediately preceding application for EAEDC.

(H) Skin. All skin disorders and infections that last more than 15 days and that can be expected to last for at least 30 days will possibly be considered incapacitating when one of the following is present:

(1) Involvement of extensive body areas; or

(2) Involvement of critical areas such as hands, feet, axillae, perineum, or face.

(I) Endocrine System. Diabetes mellitus must be substantiated by one of the following:

(1) Peripheral neuropathy manifested by decreased sensation and loss of vibration and positional sense;

(2) Significant visual impairment according to the criteria in 106 CMR 703.192(B)(1) and (2), Special Senses and Speech;

(3) Amputation due to diabetic necrosis or peripheral vascular disease; or

(4) A documented episode of acidosis within the 30-day period immediately preceding application for EAEDC, and the incapacity is expected to last for at least 30 days.

(J) Multiple Body Systems.

(1) Lupus Erythematosus. Disseminated lupus erythematosus must be established by a positive LE preparation or biopsy or positive ANA test. Exacerbation (involving renal, cardiac, pulmonary, gastrointestinal, or central nervous systems) must have occurred within the 30-day period immediately preceding application for EAEDC, and have lasted more than 15 days and be expected to last for at least 30 days.

(2) Obesity. Obesity must be substantiated by weight equal to or greater than the values specified in Table VII for males or Table VIII for females and one of the following:

(a) a history of significant pain and limitation of motion in any weight-bearing joint or the spine;

(b) significant hypertension;

(c) a history of significant cardiovascular difficulties;

(d) chronic venous insufficiency with pain or superficial varicosities; or

(e) significant respiratory difficulties; and The incapacity is expected to last for at least 30 days.

Table VII - Men		Table VIII - Women
Height (inches)	Weight (pounds)	Height (inches)	Weight (pounds)
60	246	56	208
61	252	57	212
62	258	58	218
63	264	59	224
64	270	60	230
65	276	61	236
66	284	62	242
67	294	63	250
68	302	64	258
69	310	65	266
70	318	66	274
71	328	67	282
72	336	68	290
73	346	69	298
74	356	70	306
75	364	71	314
76	374	72	322

(K) Neurological System.

(1) Central Nervous System Vascular Accident. The period of incapacity is expected to last for at least 30 days and two of the following persists:

(a) ineffective speech or communication;

(b) significant disorganization of motor function in one or more extremities interfering with locomotion or use of fingers, hands and arms; and

(c) significant mental status abnormalities.

(2) Epilepsy. Major motor seizures (or partial complex), documented by EEG and by clinically detailed description of a typical seizure pattern, including all associated phenomena; occurring more frequently than once a month, in spite of at least one month of prescribed treatment; expected to last at least 30 days with:

(a) Daytime episodes (loss of consciousness and convulsive seizures); or

(b) Nocturnal episodes manifesting residuals which interfere significantly with activity during the day.

(3) Epilepsy. Minor seizures (petit mal, psychomotor, or focal), documented by EEG and by detailed description of a typical seizure pattern, including all associated phenomena; occurring more frequently than once weekly in spite of at least one month of prescribed treatment: with alteration of awareness or loss of consciousness and transient postictal manifestations of unconventional behavior or significant interference with activity during the day; and expected to last for at least 30 days.

(4) Parkinsonian Syndrome. This must include the following signs: significant rigidity; bradykinesia, or tremor in two extremities or one, if in dominant hand with significant loss of dexterity which, singly or in combination, result in sustained disturbance of gross and dexterous movements, or gait and station; and expected to last for at least 30 days.

(5) Spinal Cord or Nerve Root Lesions. This must be due to any course with disorganization of motor function expected to last for at least 30 days with significant and persistent disorganization of motor function in a single extremity, resulting in sustained disturbance of gross and dexterous movements, or gait and station.

(6) Multiple Sclerosis. With disorganization of motor function expected to last for at least 30 days with:

(a) significant and persistent disorganization of motor function in two extremities, or one dominant upper extremity, resulting in sustained disturbance of gross and dexterous movements, or gait and station; or marked motor fatiguability;

(b) impairment of central visual acuity. Remaining vision in the better eye after best correction must be 20/100 or less and must be expected to last at least 30 days.

(c) contraction of peripheral visual fields. Contraction of peripheral vision fields in the better eye that is expected to last at least 30 days must be:

1. To 20° or less from the point of fixation; or

2. So the widest diameter subtends an angle no greater than 25°; or

3. To 25% or less visual field efficiency; or

(7) Myasthenia Gravis. This must be expected to last for at least 30 days with:

(a) significant difficulty with speaking, swallowing, or breathing while on prescribed therapy; or

(b) significant motor weakness of muscles of extremities on repetitive activity against resistance while on prescribed therapy.

(8) Myotonic Muscular Dystrophy. This must include disorganization of motor function expected to last for at least 30 days with significant and persistent disorganization of motor function in two extremities, resulting in sustained disturbance of gross and dexterous movements, or gait and station.

(9) Peripheral Neuropathies. With disorganization of motor function in spite of prescribed treatment expected to last for at least 30 days with significant and persistent disorganization of motor function in one extremity, resulting in sustained disturbance of gross and dexterous movements, or gait and station.

(10) Subacute Combined Cord Degeneration (Pernicious Anemia). This must include disorganization of motor function as descried below not significantly improved by prescribed treatment and expected to last for at least 30 days with:

(a) significant and persistent disorganization of motor function in one extremity, resulting in sustained disturbance of gross and dexterous movements, or gait and station; and

(b) unsteady, broad-based or ataxic gait causing significant restriction of mobility substantiated by appropriate posterior column signs.

(11) Cerebral Trauma. Evaluate under the provisions for epilepsy - Major motor, epilepsy -minor motor, cerebral nervous system vascular accident or organic mental disorders.

(L) Mental Disorders.

(1) The following definitions should be used when referencing 106 CMR 703.192.

(a) Need for Medical Evidence. The existence of a medically determinable impairment must be established by medical evidence consisting of clinical signs, symptoms and/or laboratory test findings. These findings may be intermittent or persistent depending on the nature of the disorder. Clinical signs are medically demonstrable phenomena which reflect specific abnormalities of behavior, affect, thought, memory, orientation or contact with reality. These signs are typically assessed by a psychiatrist. Symptoms or complaints are presented by the individual. Signs and symptoms generally cluster together to constitute recognizable clinical syndromes (mental disorders). Both symptoms and signs which are part of any diagnosed mental disorder must be considered in evaluating severity.

(b) Assessment of Severity. For mental disorders, severity is assessed in terms of the functional limitations imposed by the impairment. Where "marked" is used as a standard for measure the degree of limitation, it means more than moderate, but less than extreme. A marked limitation may arise when several activities or functions are impaired or even when only one is impaired, so long as the degree of limitation is such as to seriously interfere with the ability to function independently, appropriately and effectively.

1. Activities of daily living including adaptive activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, caring appropriately for one's grooming and hygiene, using telephones and directories, using a post office, etc. In the context of the individual's overall situation, the quality of these activities is judged by their independence, appropriateness and effectiveness. It is necessary to define the extent to which the individual is capable of initiating and participating in activities independent of supervision or direction.

"Marked" is not the number of activities which are restricted but the overall degree of restriction or combination of restrictions which must be judged.

2. Social functioning refers to an individual's capacity to interact appropriately and communicate effectively with other individuals. "Marked" is not the number of areas in which social functioning is impaired, but the overall degree of interference in a particular area or combination of areas of functioning.

3. Concentration, persistence and pace refer to the ability to sustain focused attention sufficiently long to permit the timely completion of tasks commonly found in work settings. In activities of daily living, concentration may be reflected in terms of ability to complete tasks in everyday household routines. Deficiencies in concentration, persistence and pace are best observed in work and work-like settings. 4. Documentation. The presence of a mental disorder should be documented primarily on the basis of reports from individual providers, such as psychiatrists, and facilities such as hospitals and clinics. Adequate descriptions of functional limitations must be obtained from these or other sources which may include programs and facilities where the individual has been observed over a considerable period of time.

Information from both medical and nonmedical sources may be used to obtain detailed descriptions of the individual's activities of daily living; social functioning; concentration, persistence and pace; or ability to tolerate increased mental demands (stress). This information can be provided by programs such as community mental health centers, day care centers, sheltered workshops, etc. It can also be provided by others, including family members, who have knowledge of the individual's functioning. In some cases descriptions of activities of daily living or social functioning given by individuals or treating sources may be insufficiently detailed and/or may be in conflict with the clinical picture otherwise observed or described in the examination or reports. Evidence may include treatment notes, hospital discharge summaries, and work evaluation or rehabilitation progress notes if these are available. It is necessary to resolve any inconsistencies or gaps that may exist in order to obtain a proper understanding of the individual's functional restrictions.

Some individuals may have attempted to work or may actually have worked during the period of time pertinent to the determination of disability. This may have been an independent attempt at work, or it may have been in conjunction with a community mental health or other sheltered program which may have been of either short or long duration. Information concerning the individual's behavior during any attempt to work and the circumstances surrounding termination of the work effort are particularly useful in determining the individual's ability or inability to function in a work setting.

5. Chronic Mental Impairments. Particular problems are often involved in evaluating mental impairments in individuals who have long histories of repeated hospitalizations or prolonged outpatient care with supportive therapy and medication. Individuals with chronic psychotic disorders commonly have their lives structured in such a way to minimize stress and reduce their signs and symptoms. Such individuals may be much more impaired for work than their signs and symptoms would indicate. The results of a single examination may not adequately describe these individuals' sustained ability to function. It is therefore, vital to include all pertinent and available information relative to the individual's condition, especially at times of increased stress.

6. Effect of Medication. Attention must be given to the effect of medication on the individual's signs, symptoms and ability to function. While psychotropic medications may control certain primary manifestations of a mental disorder, e.g., hallucinations, such treatment may or may not affect the functional limitations imposed by the mental disorder. In such cases where overt symptomatology is attenuated by the psychotropic medications, particular attention should be included on the functional restrictions which may persist. These functional restrictions are important for the measure of impairment severity.

Neuroleptics, the medicines used in the treatment of some mental illnesses, may cause drowsiness, blunted effect, or other side effects involving other body systems. Such side effects must be considered in evaluating overall impairment severity. Where adverse effects of medications contribute to the impairment severity and the impairment does not meet the listings but is nonetheless severe, such adverse effects must be considered in the assessment of the disability.

7. Effect of Treatment. It must be remembered that with adequate treatment some individuals suffering with chronic mental disorders not only have their symptoms and signs ameliorated but also return to a level of function close to that of their premorbid status.

(2) Dementia with or without Delirium. Psychological, cognitive or behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of specific organic factor judges to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities.

The required level of severity for these disorders is met when the requirements in 106 CMR 703.192(L)(2)(a) and (b) are satisfied, and they are expected to last for at least 30 days.

(a) Demonstration of loss of specific cognitive abilities or affective changes and the medically documented persistence of at least one of the following:

1. disorientation to time and place;

2. substantial memory loss impairment;

3. perceptual or thinking disturbances (e.g., hallucinations, delusions);

4. change in personality;

5. disturbance in mood;

6 emotional liability (e.g., explosive temper outbursts, sudden crying, etc.) and impairment in impulse control; or

7. loss of measured intellectual ability of at least 15 I.Q. points from premorbid levels or overall impairment index clearly within the moderately to severely impaired range on neuropsychological testing, e.g., the Luria-Nebraska, Halstead-Reitan, etc.; and

(b) Resulting in at least one of the following:

1. marked restriction of activities of daily living;

2. marked difficulties in maintaining social functioning;

3. deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or

4. repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors).

(3) Schizophrenic, Paranoid and Other Psychotic Disorders. Characterized by the onset of psychotic features with deterioration from a previous level of functioning.

The required level of severity for these disorders is met when the requirements in 106 CMR 703.192(L)(3)(a) and (b) are satisfied, or when the requirements in 106 CMR 703.192(L)(3)(c) are satisfied; and they are expected to last for at least 30 days.

(a) Medically documented persistence, either continuous or intermittent, of one or more of the following:

1. delusions or hallucinations;

2. catatonic or other grossly disorganized behavior;

3. incoherence, loosening of associations, illogical thinking, or poverty of content of speech if associated with one of the following:

a. blunt affect;

b. flat affect; or c. inappropriate affect; or

4. emotional withdrawal and/or isolation; and

(b) Resulting in at least one of the following:

1. marked restriction of activities of daily living; or

2. marked difficulties in maintaining social functioning; or

3. deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or

4. repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors); or

(c) Medically documented history of one or more episodes of acute symptoms, signs and functional limitations which at the time met the requirements in 106 CMR 703.192 (L0(3)(a) and (b), although these symptoms or signs are currently attenuated by medication or psychosocial support, and one of the following:

1. repeated episodes of deterioration or decompensation in situations which cause the individual to withdraw from the situation or to experience exacerbation of signs or symptoms (which may include deterioration of adaptive behaviors); or

2. documented current history of two or more years inability to function outside of a highly supportive living situation.

(4) Affective Disorders. Characterized by a disturbance of mood, accompanied by a full or partial manic or depressive syndrome. Mood refers to a prolonged emotion that colors the whole psychic life, generally involving either depression or elation.

The required level of severity for these disorders is met when the requirements in 106 CMR 703.192(L)(4)(a) and (b) are satisfied, and they are expected to last at least 30 days.

(a) Medically documented persistence, either at least one of the following:

1. depressive syndrome characterized by at least three of the following:

a. anhedonia or pervasive loss of interest in almost all activities;

b. appetite disturbance with change in weight;

c. sleep disturbance;

d. psychomotor agitation or retardation;

e. decreased energy;

f. feelings of guilt or worthlessness;

g. difficulty concentrating or thinking;

h. thoughts of suicide; or

i. hallucinations, delusions or paranoid thinking; or

2. Manic syndrome characterized by at least two of the following:

a. hyperactivity;

b. pressure of speech;

c. flight of ideas;

d. inflated self-esteem;

e. decreased need for sleep;

f. easy distractibility;

g. involvement in activities that have a high probability of painful consequences which are not recognized; or

h. hallucinations, delusions or paranoid thinking; or

3. Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both manic and depressive syndromes (and currently characterized by either or both syndromes); and

(b) Resulting in at least one of the following:

1. marked restriction of activities of daily living;

2. marked difficulties in maintaining social functioning;

3. deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in working settings or elsewhere); or

4. repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors).

(5) Mental Retardation and Autism. Mental retardation refers to a significantly subaverage general intellectual functioning with deficits in adaptive behavior initially manifested during the developmental period (before 22 years of age). (Note: The scores specified in 106 CMR 703.192(L)(5)(a) through (d) refer to those obtained on the WAIS, and are used only for reference purposes. Scores obtained on other standardized and individually administered tests are acceptable, but the numerical values obtained must indicate a similar level of intellectual functioning.) Autism is a pervasive developmental disorder characterized by social and significant communication deficits originating in the developmental period.

The required level of severity for this disorder is met when the requirements in 106 CMR 703.192(L)(5)(a), (b), (c), or (d) are satisfied.

(a) Mental incapacity evidenced by dependence upon others for personal needs, e.g., toileting, eating, dressing, or bathing, an inability to follow directions, such that the use of standardized measures of intellectual functioning is precluded;

(b) A valid verbal, performance, or full scale IQ of 59 or less;

(c) A valid verbal, performance, or full scale IQ of 60 through 69 and a physical or other mental impairment imposing additional and significant work-related limitation of function; or

(d) A valid verbal, performance, or full scale IQ of 60 through 69 or in the case of autism, gross deficits of social and communicative skills with one of the following:

1. marked restriction of activities of daily living;

2. marked difficulties in maintaining social functioning;

3. deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or

4. repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration or adaptive behaviors).

(6) Anxiety Related Disorders. In these disorders, anxiety is either the predominant disturbance or it is experienced if the individual attempts to master symptoms; for example, confronting the dreaded object or situation in a phobic disorder or resisting the obsessions or compulsions in obsessive compulsive disorders.

The required level of severity for these disorders is met when the requirements in 106 CMR 703.192(L)(6)(a) and (b) are satisfied, or when the requirements in 106 CMR 703.192(L)(6)(a) and (c) are satisfied, and the incapacity is expected to last at least 30 days.

(a) Medically documented findings of at least one of the following:

1. generalized persistent anxiety accompanied by two out of four of the following signs or symptoms:

a. motor tension;

b. autonomic hyperactivity;

c. apprehensive expectation; or

d. vigilance and scanning; or

2. a persistent irrational fear of a specific object, activity, or situation;

3. recurrent severe panic attacks manifested by a sudden unpredictable onset of intense apprehension, fear, terror and sense of impending doom occurring on the average of at least once a week;

4. recurrent obsessions or compulsions which are a source of marked distress; or

5. recurrent and intrusive recollections of a traumatic experience, which are a source of marked distress; and

(b) Resulting in at least one of the following:

1. marked restriction of activities of daily living;

2. marked difficulties in maintain social functioning;

3. deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or

4. repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors); or

(c) resulting in complete inability to function independently outside the area of one's home.

(7) Psychophysiological Disorders. Physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms.

The required level of severity for these disorders is met when the requirements of 106 CMR 703.192(L)(7)(a) and (b) are satisfied, and the incapacity is expected to last for at least 30 days.

(a) Medically documented by evidence of one of the following:

1. a history of multiple physical symptoms of several years duration, beginning before age 30, that have caused the individual to take medicine frequently, see a physician often and alter life patterns significantly;

2. persistent nonorganic disturbance of one of the following:

a. vision;

b. speech;

c. hearing;

d. use of a limb;

e. movement and its control (e.g., coordination disturbance, psychogenic seizures, akinesia, dyskinesia); or f. sensation (e.g., diminished or heightened); or

3. Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury; and

(b) Resulting in two of the following:

1. marked restriction of activities of daily living;

2. marked difficulties in maintaining social functioning;

3. deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or

4. repeated episodes of deterioration or decompensation on work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behavior).

(8) Personality Disorders. A personality disorder exists when personality traits are inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress. Characteristic features are typical of the individual's long term functioning and are not limited to discrete episodes of illness.

The required level of severity for these disorders is met when the requirement of 106 CMR 703.192(L)(8)(a) and (b) are satisfied, and the incapacity is expected to last at least 30 days.

(a) Deeply ingrained, maladaptive patterns of behavior associated with one of the following:

1. seclusiveness or autistic thinking;

2. pathologically inappropriate suspiciousness or hostility;

3. oddities of thought, perception, speech and behavior;

4. persistent disturbances of mood or affect;

5. pathological dependence, passivity, or aggressivity; or

6. intense and unstable interpersonal relationships and impulsive and damaging behavior; and

(b) Resulting in two of the following:

1. marked restriction of activities of daily living;

2. marked difficulties in maintaining social functioning;

3. deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or

4. repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behavior).

(9) Substance Addiction Disorders. Physical changes or behavioral changes associated with the regular use of legal substances that affect the central nervous system when accompanied by an impairment listed elsewhere in these standards.

The required level of severity for these substance addiction disorders is met when the requirements in any of the following disorders in 106 CMR 703.192(L)(9)(a) through (i) are satisfied, and the incapacity is expected to last for at least 30 days.

(a) Organic Mental Disorders. Evaluate under Dementia with or without Delirium (106 CMR 703.192(L)(2)) .

(b) Depressive Syndrome. Evaluate under Affective Disorders (106 CMR 703.192(L)(4)) .

(c) Anxiety Disorders. Evaluate under Anxiety Related Disorders (106 CMR 703.192(L)(6)) .

(d) Personality Disorders. Evaluate under Personality Disorders (106 CMR 703.192(L)(8)) .

(e) Peripheral Neuropathies. Evaluate under Neurological System Impairments (106 CMR 703.192(K)) .

(f) Liver Damage. Evaluate under Digestive System Impairments (Diseases of the Liver) (106 CMR 703.192(E)(2)) .

(g) Gastritis. Evaluate under Digestive System Impairments (Diseases of the Liver) (106 CMR 703.192(E)(2)) .

(h) Pancreatitis. Evaluate under Digestive System Impairments (Gastrointestinal Disorders) (106 CMR 703.192(E)(1)) .

(i) Seizures. Evaluate under Neurological System Impairments (Epilepsy - Major Motor Seizure and Epilepsy - Minor Motor Seizure) (106 CMR 703.192(K)(2) and (3)) .

(M) Immuno-suppressive Disorders.

(1) Indicator Diseases Diagnosed Definitively. The required level of incapacity associated with the following is met when the incapacity is expected to last for at least 30 days.

(a) Candidiasis of the esophagus, trachea, bronchi, or lungs.

(b) Coccidioidomycosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes).

(c) Cryptococcosis, extrapulmonary.

(d) Cryptosporidiosis with diarrhea persisting over one month.

(e) Cytomegalovirus disease of an organ other than liver, spleen, lymph nodes in an individual over one month of age.

(f) Genital Herpes, chronic, recurrent, wide spread, resistant to therapy.

(g) Herpes Simplex virus infection causing a mucocutaneous ulcer that persists longer than one month, or bronchitis, pneumonitis, or esophagitis for any duration affecting an individual over one month of age.

(h) HIV Encephalopathy (also called "HIV dementia", "AIDS dementia", or "subacute encephalitis due to HIV").

(i) Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes).

(j) Isoporiasis with diarrhea persisting over one month.

(k) Kaposi's Sarcoma at any age.

(l) Leukoencephalopathy, progressive multifocal leukoencephalopathy.

(m) Lymphoma of the Brain (primary) at any age.

(n) Lymphoid Interstitial Pneumonia and/or Pulmonary Lymphoid Hyperplasia (LIP/PLH complex) affecting a child younger than 13 years old.

(o) Any Mycobacterial Disease caused by mycobacteria other than M. Tuberculosis, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes).

(p) Pneumocystis Carinii Pneumonia.

(q) Pelvic Inflammatory Disease, chronic, recurrent, resistant to therapy.

(r) Salmonella (Nontyphoid) septicemia, recurrent.

(s) Systemic Toxoplasmosis.

(t) Toxoplasmosis of the brain.

(u) One of the following with documented HIV infection:

1. Anal Squamous Cell Carcinoma;

2. Invasive Carcinoma of Cervix FIGO stage II or more;

3. Nocardiosis;

4. Non-Hodgkins Lymphoma; or

5. Strongyloidiasis, extra-intestinal.

(2) Individuals should be considered to have an impairment that equals the severity of the listings with or without documented evidence of HIV infection and must have the following laboratory and clinical features:

(a) A T4 Lymphocyte Count of Less than or Equal to 200 Cells/mm3 (or 25% or less T4 lymphocytes); or

(b) One or more of the following persisting over a two-month period:

1. Anemia (Hematocrit value less than 30%);

2. Granulocytopenia (absolute neutrophil count less than or equal to 1000/mm3);

3. Thrombocytopenia (platelet count less than or equal to 40,000/mm3);

4. Documented Fever (daily greater than or equal to 100.4°F or 38°C);

5. Undesired Weight loss greater than or equal to 10% of baseline;

6. Oral Recurrent Candidiasis;

7. Oral hairy leukoplakia;

8. Recurrent Herpes Zoster;

9. Persistent, Unresponsive Diarrhea;

10. Mucosal (including vulvovaginal candidiasis other than listed in 106 CMR 703.192(M)(1)(a) or new added vulvovaginal conditions);

11. Persistent dermatological conditions such as Eczema or psoriasis; or

12. Persistent or recurrent radiographically documented Sinusitis; and

(c) Interference with activities of daily living resulting in marked restriction of activities such that the individual needs help with most activity including climbing stairs, shopping, cooking and housework.

(N) Neoplastic Diseases - Malignant. Intractable pain, and/or ongoing therapy side effects, disease process or treatment which has caused a disability covered elsewhere in these standards.

(O) Medically Equivalent Impairment(s) and Combinations of Impairments.

(1) If an applicant or client has an anatomical, physiological or psychological impairment(s) that is not specifically included in the medical standards specified in 106 CMR 703.192(A) through (N) but is documented by medically acceptable clinical and/or diagnostic techniques and is medically equal in severity to a medical standard, the applicant or client shall be considered as having impairment that meets a medical standard for purposes of 106 CMR 703.191. For purposes of determining if an impairment is medically equal in severity to a medical standard, the medical standard that is most closely analogous to the impairment shall be used.

(2) In making the determination required by 106 CMR 703.192(O)(1), the applicant's or client's description of his or her symptoms (including pain) shall be taken into consideration to the extent that:

(a) such symptoms are the result of a physical or mental impairment(s) as defined in 106 CMR 703.192 that is confirmed by acceptable clinical and/or laboratory diagnostic techniques; and

(b) such physical or mental impairments could reasonably produce such symptoms.

An applicant or client must have a physical or mental impairment to be determined disabled. Symptoms alone are not sufficient.

(3) If a specific medical finding required to meet a medical standard specified in 106 CMR 703.192(A) through (N) is not indicated by the competent medical authority (see 106 CMR 701.600: Definition of Terms) on the medical report but a medical finding of equal clinical significance is indicated, the latter medical finding may be substituted for the required medical finding.

(4) If an applicant or client has more than one impairment and none of the impairments separately are medically equivalent to a medical standard specified in 106 CMR 703.192(A) through (N), the impairments shall be considered to meet a medical standard if they, in combination with each other, are medically equivalent to a medical standard. For purposes of determining if an impairment is medically equal in severity to a medical standard, the medical standard that is most closely analogous to the combined impairments shall be used.

Notes

106 CMR, § 703.192

Adopted by Mass Register Issue 1360, eff. 3/9/2018.