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New Social Security Ruling on Sickle Cell Disease

October 31, 2017

SSA issued Social Security Ruling (SSR) 17-3p, “Titles II and XVI: Evaluating Cases Involving Sickle Cell Disease (SCD),” effective September 15, 2017.  It provides basic background information about SCD and its variants and guidance on how SSA adjudicators should consider evidence regarding this impairment in a simple Q&A format.  In a footnote, SSA explains that this Ruling will be applied to new applications filed on or after September 15, as well as claims pending on or after this date.

SSR 17-3p first explains that SCD is “a type of hemolytic anemia and an inherited hematological disorder that affects the hemoglobin within a person’s red blood cells (RBC),” which has different variants that can indicate the severity of complications and the resulting functional limitations caused by the disease.  The Ruling lays out the most common variants of SCD, describing how each occurs and its prevalence and severity.  The Ruling then clarifies that sickle cell trait, which “occurs when a person inherits one sickle hemoglobin gene from one parent and a normal gene from the other parent,” is not a variant of SCD and will usually not meet the criteria for disability on its own. Since people with sickle cell trait “rarely have signs and symptoms associated with SCD and usually do not need treatment,” SSR 17-3p makes clear that sickle cell trait alone is not an impairment and cannot be a basis for disability without “medical signs or laboratory findings of complications from sickle cell trait” that meet the duration requirement.

SSR 17-3p next sets forth the common complications and symptoms of SCD, explaining that symptoms vary from person to person and can change over time, and then gives details of the most prevalent complications, including pain (vaso-occlusive) crisis, anemia, pulmonary complications, strokes and silent strokes, bacterial infections, and mental disorders.

The Ruling goes on to describe how SCD is evaluated under the hematological disorders listings, by simply reiterating what each of the following listings require:

  • Listings 7.05 and 107.05, Hemolytic anemias;
  • Listings 7.17 and 107.17, Hematological disorders treated by bone marrow or stem cell transplantation; and
  • Listing 7.18, Repeated complications of hematological disorders.

SSR 17-3p then explains how SCD is evaluated when assessing an adult’s residual functional capacity, which is based on all the relevant evidence of record, including the effects of treatment.  The Ruling provides two obvious examples: adults with SCD may have pain, fatigue, and shortness of breath that impact their ability to stand and walk; and persons who experience repeated acute pain crises may have difficulty maintaining concentration, completing tasks, or attending work without frequent absences.

Perhaps the most useful part of this Ruling is an explanation of how SCD is evaluated when assessing functional equivalence in child claims under each of the six domains of functioning, with specific examples of how SCD complications can impact each domain:

Acquiring and using information.  Some children with SCD may have limitations in acquiring and using information due to stroke, including silent stroke.  A stroke can cause brain injury that impairs a child’s ability to learn, concentrate, speak, and remember.

Attending and completing tasks.  Frequent pain crises can result in limitations in attending and completing tasks at school and at home.  If a child does not feel well due to pain, it may be difficult for him or her to stay focused on activities long enough to complete them in an age- appropriate manner.  A child with SCD who is experiencing pain may also have difficulty paying attention to details and may make mistakes on schoolwork due to an inability to concentrate.

Interacting and relating with others.  SCD can also cause limitations interacting and relating with others. The unpredictable nature of pain in SCD may cause anxiety and difficulty maintaining relationships.  Children suffering from complications of SCD may become withdrawn, uncooperative, or unresponsive.

Moving about and manipulating objects.  If SCD limits a child’s ability to move and manipulate objects, we evaluate those effects in the domain of ‘Moving about and manipulating objects.’  For example, sickling in the hip bones, knees, and ankles due to SCD may cause joint pain and problems with walking, running, and climbing up and down stairs.

Caring for yourself.  Caring for yourself involves a child’s basic understanding of his or her body’s normal functioning and the adequate emotional health for carrying out self-care tasks.  A child with SCD may avoid taking medication or ignore complications of the disease out of frustration with the limitations of SCD.

Health and physical well-being.  The ongoing effects of SCD and its treatment may affect a child’s health and physical well-being.  In this domain, we evaluate the effects of periodic exacerbations of pain crises due to sickle cell anemia.  We consider the frequency and duration of the exacerbations as well as the extent to which they affect a child’s ability to function physically.

SSR 17-3p is nothing novel: it does not make any changes in policy or otherwise, offers only easily accessible medical/diagnostic information on SCD, reiterates the hematological disorders listings criteria, and explains the well-known standard for assessing an adult’s RFC.  It may, however, be useful for evaluating complications of SCD under functional equivalence in child claims, as it does offer some specific guidance on that issue.

Thanks to NOSSCR for this excellent analysis of this important new Ruling.

 





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