Medical/Professional Relations

Providing Medical Evidence For Individuals With HIV Infection

A Guide For Health Professionals

We developed the following guidelines to assist health care professionals in providing the kinds of medical evidence we need to evaluate disability claims filed by individuals with HIV infection. Although these guidelines do not address every possible situation, they should help you understand the documentation we need to evaluate the disability applicant's condition.

As you may know, Disability Determination Services (DDSs) in each State evaluate disability claims for Social Security. Most requests for medical evidence you receive will be from a DDS, and the request will ask you to return the evidence to the DDS. However, there are exceptions.

In certain circumstances, we can make payments to needy individuals before making a final disability determination if there is a high degree of probability that the individual is disabled. In order to decide if the individual qualifies for these "presumptive disability" payments, we need some medical information as soon as the individual files a claim. You may receive a check-block form (or, in certain cases, a telephone call) from a Social Security field office to verify the presence of HIV disease manifestations in a patient. The request will include complete instructions, and will tell you to return the form to the Social Security field office. In these situations, the field office's request may be followed by DDS's request for additional evidence. The important thing to remember is to return the check-block form as quickly as possible to the location specified.

You may wish to have a stock of these forms in your office that you can complete and give to a patient to bring to the Social Security office when he or she files a claim. You can request supplies of the forms (Form SSA-4814 for adults and SSA-4815 for children) by contacting your local Social Security office or by calling 1-800-SSA-1213.

As always, we appreciate your assistance in providing timely reports and other medical records.

EVALUATION OF CLAIMS INVOLVING HIV INFECTION

Under Social Security law, an individual is considered disabled if he or she is unable to do any substantial gainful work activity because of a medical condition. The inability to work must last, or be expected to last, for at least 12 months unless the condition will result in death. (This is called the "duration requirement.")

Many individuals with HIV infection have a condition that prevents them from being able to work. If their impairment(s) meet the duration requirement, they may be found disabled. On the other hand individuals with HIV infection who are asymptomatic, or who have less severe HIV manifestations, may be found not disabled. Therefore, we evaluate each case on an individual basis, and rely on the signs, symptoms, laboratory findings, and other information unique to that person's case in order to make a decision.

As in all disability claims, we first try to resolve the issue of disability based on the medical information alone. If the medical information shows either that the individual is clearly disabled, or that the individual is clearly not disabled, we decide the case based on that information. Otherwise, we go on to consider other factors, such as (in the case of adults) work capacity, age, education, and work background or (in the case of most children) the individual's ability to function independently, appropriately, and effectively in an age-appropriate manner.

The medical evidence required to evaluate cases involving HIV infection is similar to that required for cases involving other medical conditions. The evidence must be sufficiently complete to permit the DDS medical consultant to make an independent determination about the nature, severity, and probable duration of the individual's impairment(s). A complete medical report should include medical history, clinical and laboratory findings, diagnosis, prognosis, and a statement about what the individual can still do despite his or her impairments. However, we will accept and evaluate any medical evidence, even if it is not a complete report.

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MEDICAL HISTORY

The medical history should be thorough, and discuss the onset and duration of the individual's illness. It is important to describe the full clinical course of the illness to assist in determining when the illness became disabling (the disability "onset"). Establishing the correct disability onset date is important because it may affect when cash benefits and Medicare coverage begin.

FINDINGS, DIAGNOSIS, AND PROGNOSIS

A medical report should also describe the standard positive and negative findings of a thorough physical or mental examination. Progress notes that document findings are also helpful.

Copies of laboratory findings, including HIV testing, should also be included, if available. (The DDSs have an appropriate release form for HIV test results.)

A diagnosis and prognosis consistent with the medical data should be included. A diagnosis of HIV infection that is not supported by laboratory test results should be explained.

A STATEMENT ABOUT WHAT THE INDIVIDUAL CAN STILL DO

Finally, a medical report should include a statement of the individual's ability to do work-related physical and mental activities (described below).

The following outline describes the type of information that is particularly useful to us. The outline lists frequently encountered changes due to HIV infection but it is, by no means, an exhaustive list.

SYMPTOMS

Symptoms may include an individual's statements about:

1. Low energy, fatigue, weakness
2. Fever, night sweats
3. Weight loss
4. Shortness of breath
5. Persistent cough
6. Persistent diarrhea
7. Depression, anxiety
8. Forgetfulness, loss of concentration, slowness of thought
9. Other symptoms (e.g., headaches, nausea, vomiting)

SIGNS

Signs may include:

1. Muscle weakness
2. Documented fever or weight loss
3. Dyspnea
4. Neurological deficits
5. Mental abnormalities

LABORATORY FINDINGS

Laboratory findings may include:

1. Positive HIV antibody test (including any confirming test)
2. Depressed T4 (CD4) lymphocyte count; inverted helper/suppressor    ratio
3. Abnormal blood counts (e.g., hematocrit)
4. Other markers for HIV infection (e.g., beta-2 microglobulins, detectable
    p24 antigen)
5. Radiographic or other imaging abnormalities
6. Pertinent microbiology or pathology reports

WORK-RELATED PHYSICAL AND MENTAL ACTIVITIES
 
An individual may have limitation(s) in the ability to:

1. Perform physical functions such as walking, standing, sitting, lifting,
    pushing, pulling, reaching, carrying, or handling
2. See, hear, and speak
3. Understand, carry out, and remember simple instructions
4. Use judgment
5. Respond appropriately to supervision, co-workers, and usual work
    situations
6. Deal with changes in a routine work setting

NOTE: If you provide specific details about the individual's abilities and limitations, it will be easier for us to make a sound decision.

SSA Publication No. 64-037
ICN 953600
August 1993

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