SSR 06-01p: Titles II and XVI: Evaluating Cases Involving Tremolite Asbestos-Related Impairments

Effective/Publication Date: 05/26/2006 [Federal Register: (Volume 71, Number 102), Page 30467-30469]

POLICY INTERPRETATION RULING

PURPOSE:

To provide guidance on the types of impairments that may

result from tremolite asbestos exposure and how to evaluate

disability claims under titles II and XVI of the Social Security

Act (the Act) based on these impairments. [1]

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 404.1502 , 404.1505 , 404.1508 - 404.1513 , 404.1519 - 1523 , 404.1525 - 404.1529 , 404.1545 , 404.1560 - 404.1569a * , 404.1593 - 404.1594 ,

and appendix 1 ;

and Regulations No. 16, subpart I, sections 416.902 , 416.905 , 416.906 , 416.908 - 416.913 , 416.919 , 416.920 , 416.921 - 416.929 , 416.945 , 416.960 - 416.969a , 416.993 - 416.994a .

PERTINENT HISTORY:

Tremolite is a type of asbestos sometimes found in the

mineral vermiculite. People may be exposed to tremolite from

vermiculite in mining and in work-related activities involving

the production of horticultural and agricultural items,

construction and insulation materials, brake pads, and other

items. People may also be exposed to tremolite from living in

an area where such mining or activities occur or from products

made from vermiculite. Exposure ** to tremolite asbestos has occurred in the Libby, Montana area and may

have occurred in other areas as well.

This ruling explains how we determine if impairments that

may be caused by exposure to tremolite asbestos meet our

definition of disability. [2] Sections 216(i) and 1614(a)(3) of the

Act define “disability” [3] as the inability to engage in any

substantial gainful activity 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. [4]

sability. [2] Sections 216(i) and 1614(a)(3) of the

Act define “disability” [3] as the inability to engage in any

substantial gainful activity 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. [4]

POLICY INTERPRETATION:

1. What Types of Impairments May Result from Exposure to

Tremolite Asbestos?

When tremolite asbestos is inhaled, it penetrates the lung

tissue by piercing the walls of the alveolar sacs and

permanently lodges in the pleural lining. The tremolite

accumulates in the pleural lining, and the affected lung and

pleural areas become inflamed and scarred. This process may

eventually result in chronic pulmonary insufficiency, such as

asbestosis, disorders of pulmonary circulation, pleural plaques,

pleural thickening, or pleural effusions. These impairments can

interfere with the lungs' ability to exchange oxygen and carbon

dioxide and can cause difficulty breathing by interfering with

the lungs' ability to expand and contract normally. Decrease in

blood flow to the lungs can result in prolonged right pulmonary

artery hypertension, enlargement of the heart, and failure of

the right ventricle (cor pulmonale).

Inhalation of tremolite asbestos can also cause several

types of cancers, primarily malignant mesothelioma of the pleura

and bronchogenic carcinoma of the lung.

Some factors that increase the chances of developing these

impairments include increased length of exposure to tremolite

asbestos, multiple routes of exposure to tremolite asbestos (for

example occupational contact and household contact), and

smoking. [5]

2. How Do We Consider Impairments Related to Tremolite Asbestos

Exposure in the Sequential Evaluation Process?

arcinoma of the lung.

Some factors that increase the chances of developing these

impairments include increased length of exposure to tremolite

asbestos, multiple routes of exposure to tremolite asbestos (for

example occupational contact and household contact), and

smoking. [5]

2. How Do We Consider Impairments Related to Tremolite Asbestos

Exposure in the Sequential Evaluation Process?

As with all impairments, we follow the five-step sequential

evaluation process in 20 CFR

404.1520 and 416.920 when we determine whether an individual is disabled.

Step 1. We first determine whether the individual is working

and whether the work is substantial gainful activity (SGA). If

the individual is working and the work is SGA, we will find that

the individual is not disabled, regardless of the individual's

medical condition, age, education, and work experience. If the

individual is not engaging in SGA, we go on to the next step.

Step 2. If the individual is not working or the work is not

SGA, we then establish whether the individual has a medically

determinable impairment that is “severe.”

The presence of chronic pulmonary insufficiency is

established based on the individual's medical history, findings

from a physical examination(s), and spirometric pulmonary

function tests. Chest x-rays or other appropriate radiographic

imaging techniques (for example, a computerized axial tomography

(CAT) scan) are often performed to support the presence of the

impairment. Measurement of diffusing capacity of the lungs for

carbon monoxide (DLCO), pulse oximetry, or resting or exercise

arterial blood gas studies (ABGS) may be performed to determine

if the impairment has resulted in gas exchange abnormalities.

In disorders of pulmonary circulation, a direct measurement of

pulmonary artery pressure may have been obtained with right

heart catheterization.

t. Measurement of diffusing capacity of the lungs for

carbon monoxide (DLCO), pulse oximetry, or resting or exercise

arterial blood gas studies (ABGS) may be performed to determine

if the impairment has resulted in gas exchange abnormalities.

In disorders of pulmonary circulation, a direct measurement of

pulmonary artery pressure may have been obtained with right

heart catheterization.

Malignant mesothelioma and bronchogenic carcinoma are

demonstrated by tissue biopsy. When a biopsy is performed, we

generally need a copy of both the operative note and pathology

report. If we cannot get these documents, we will accept the

summary of hospitalization(s) or other medical reports. This

evidence should include details of the findings at surgery and,

whenever appropriate, the pathological findings.

Once we determine that an impairment(s) exists, we evaluate

its severity. As with any other medical condition, we will find

that an impairment(s) caused by exposure to tremolite is a

“severe” impairment(s) when, alone or in combination with

another medically determinable physical or mental impairment(s),

it significantly limits an individual's physical or mental

ability to do basic work activities. When making a

determination about whether an impairment(s) is severe, we will

consider the effects of any symptoms (such as chest pain or

complaints of shortness of breath on exertion) that could limit

functioning. [6] We also recognize that limitations from

impairments caused by exposure to tremolite may be more

significant than would be expected based on objective findings

alone. 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.

also recognize that limitations from

impairments caused by exposure to tremolite may be more

significant than would be expected based on objective findings

alone. 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.

If the individual does not have a medically determinable

impairment that is “severe,” we will find that the individual is

not disabled. If the individual does have a “severe”

impairment, we will go on to the next step.

Step 3. If an individual has a severe impairment(s), we next

consider whether the impairment meets or medically equals a

listing in the Listing of Impairments contained in appendix 1, subpart P

of 20 CFR part 404 .

Chronic Pulmonary Insufficiency: We evaluate chronic pulmonary

insufficiency under listing 3.02. The listing contains criteria

based on spirometry, single breath DLCO, or ABGS. Chronic

pulmonary insufficiency caused by exposure to tremolite asbestos

may not have findings at rest that satisfy these criteria. If

exercise ABGS cannot be obtained in these situations, we

evaluate the impairment(s) at step 4, and if necessary, step 5

of the sequential evaluation process.

Cancer: Malignant mesothelioma of the pleura meets listing

13.15A. Bronchogenic carcinoma meets listing 13.14A if it is

inoperable, unresectable, recurrent, or has metastasized to or

beyond the hilar nodes.

If the individual has an impairment(s) that meets or

medically equals the criteria of one of the foregoing listings

or any other listing and meets the duration requirement, we will

find that the individual is disabled. If not, we will continue

with the sequential evaluation process.

13.14A if it is

inoperable, unresectable, recurrent, or has metastasized to or

beyond the hilar nodes.

If the individual has an impairment(s) that meets or

medically equals the criteria of one of the foregoing listings

or any other listing and meets the duration requirement, we will

find that the individual is disabled. If not, we will continue

with the sequential evaluation process.

Residual Functional Capacity. If we find that the impairment(s)

does not meet or medically equal a listing, or if we do not have

enough information for a determination or decision at Step 3, we

will assess the individual's residual functional capacity

(RFC). [7] We must consider all symptoms that result from the individual's

impairments, including those symptoms that result from

impairments that are not severe, when we evaluate how these

symptoms affect the individual's functional

capacity. [8]

In addition, if the individual's treating

source [9] has

provided an opinion about what the individual can still do

despite his or her impairment, we will give this opinion

controlling weight in determining the individual's RFC when the

opinion is well-supported by objective medical evidence and is

not inconsistent with the other substantial evidence in the case

record. [10] Even if the treating source's opinion is not given

“controlling weight” (for example it is not well-supported by

objective medical evidence), the opinion is still entitled to

deference and must be weighed using all of the factors in 20 CFR 404.1527 and 416.927 . In many cases,

a treating source's

medical opinion will be entitled to the greatest weight and

should be adopted even if it does not meet the test for

“controlling weight.”

n

“controlling weight” (for example it is not well-supported by

objective medical evidence), the opinion is still entitled to

deference and must be weighed using all of the factors in 20 CFR 404.1527 and 416.927 . In many cases,

a treating source's

medical opinion will be entitled to the greatest weight and

should be adopted even if it does not meet the test for

“controlling weight.”

Steps 4 and 5. After we determine the individual's RFC, we then

proceed to the fourth and, if necessary, the fifth step of the

sequential evaluation process. [11] If the individual can do past

relevant work, we will determine that the individual is not

disabled (step 4). If we determine 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 adjust to other work (step 5). The

usual vocational considerations must be applied in determining

the individual's ability to adjust to other

work. [12]

EFFECTIVE DATE:

This Ruling is effective on the date of its publication in the

Federal Register.

CROSS-REFERENCES:

SSR 85-28 ,

“Titles II and XVI: Medical Impairments That Are Not

Severe,” 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 96-7p ,

“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.”

,” SSR 96-3p ,

“Titles II and XVI: Considering Allegations of Pain and Other Symptoms

in Determining Whether a Medically Determinable Impairment is Severe,” SSR 96-7p ,

“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.”

[1] For simplicity, we refer in this Ruling only to initial adult claims for

disability benefits under titles II and XVI of the Act, and the steps of

the sequential evaluation process we use to determine disability in

those claims, 20 CFR 404.1520 and 416.920 . We use a different

sequential evaluation process for children who apply for benefits based

on disability under title XVI of the Act. We describe that sequential

evaluation process in 20 CFR

416.924 . We also use separate sequential

evaluation processes to determine whether an individual's disability has

ended when we conduct continuing disability reviews and when we

determine that an individual was disabled only for a specific period.

These rules are set out in 20

CFR 404.1594 , 416.994 ,

and 416.994a . The

guidance in this Ruling applies to all of the appropriate steps in those

regulations as well.

[2] The term “we” in this Social Security Ruling has the same

meaning as in 20 CFR

404.1502 and 416.902 .

“We” refers to

either the Social Security Administration or the State agency making the

disability determination; that is, our adjudicators at all levels of the

administrative review process and our quality reviewers.

[3] Except for statutory blindness.

in those

regulations as well.

[2] The term “we” in this Social Security Ruling has the same

meaning as in 20 CFR

404.1502 and 416.902 .

“We” refers to

either the Social Security Administration or the State agency making the

disability determination; that is, our adjudicators at all levels of the

administrative review process and our quality reviewers.

[3] Except for statutory blindness.

[4] For individuals under age 18 claiming benefits under title XVI,

disability will be established if the individual has a medically

determinable physical or mental impairment (or combination of

impairments) that results in “marked and severe functional

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

However, for simplicity, 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.

[5] With continuing scientific research, new medical information may

emerge to further clarify the causes and nature of impairments

related to tremolite asbestos exposure and to provide greater

specificity for clinical and laboratory diagnostic techniques to

document them.

[6] 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.”

[7] See 20 CFR 404.1520(e) and 416.920(e) .

[8] 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.”

[9] See 20 CFR 404.1502 and 416.902 .

[10] See 20 CFR 404.1527 and 416.927 ; SSR 96-2p ,

“Titles II and XVI: Giving Controlling Weight To Treating Source

Medical Opinions.”

[11] See 404.1545 and 416.945

[12] See 20 CFR 404.1560 - 404.1569a and 416.960 - 416.969a .

an Individual's

Statements” and SSR 96-8p ,

“Titles II and XVI: Assessing Residual Functional Capacity in

Initial Claims.”

[9] See 20 CFR 404.1502 and 416.902 .

[10] See 20 CFR 404.1527 and 416.927 ; SSR 96-2p ,

“Titles II and XVI: Giving Controlling Weight To Treating Source

Medical Opinions.”

[11] See 404.1545 and 416.945

[12] See 20 CFR 404.1560 - 404.1569a and 416.960 - 416.969a .

* FR Vol. 71, No. 110, p. 33342 (June 8, 2006) changed this from

"404.1560-404/1569a" to "404.1560-404.1569a".

** FR Vol. 71, No. 110, p. 33342 (June 8, 2006) changed this from

"exposure" to "Exposure".