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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