SSA Amends Medical Rules for Evaluating Cancer in Children and Adults

SSA Amends Medical Rules for Evaluating Cancer in Children and Adults

The Social Security Administration has recently implemented changes in their Medical Listings for the child and adult listings formally “Malignant Neoplastic Diseases”, now simplified to “Cancer” in order make the name more recognizable to the public. 

The final rule for the new Listing for Cancer: 13.00 (for adults) and 113.00 (for children) was published at 80 Fed. Reg. 28821 on May 20, 2015.  It will be effective beginning on July 20, 2015. The Federal Register final rule is available at https://www.gpo.gov/fdsys/pkg/FR-2015-05-20/pdf/2015-11923.pdf.

These cancer listings, like all listings, are the medical rules SSA follows to determine whether a claim can be approved based on medical considerations alone, regardless of the age or vocational profile of the individual.

In our experience, clients who qualify for disability under the SSA cancer listings generally are approved when their cancer is not treatable because of its location; or the cancer itself or the surgical, chemical, or radiation treatment for the cancer exists at a disabling level at least 12 months, or is expected to result in death.

Among some of the most significant inclusions, the new listing has incorporated mantle cell lymphoma to section 13.05 which evaluates Lymphoma and small-cell (oat cell) carcinoma to section 13.10 for breast cancer. 

Under section 13.10E, it is now established that when secondary lymphedema occurs from anticancer therapy, the onset of disability can be found earlier than the date of surgery as long as it is fully supported in the medical evidence, 12 months from surgery date. 

Section 13.00 also now states that primary peritoneal carcinoma is evaluated under 13.23E for women and 13.15A for men.

Listing 13.03 for skin cancer excludes “malignant melanoma”, and it is now evaluated under a new Listing, 13.29 for adults and 113.29 for children. To qualify for disability benefits under these regulations (section 13.29 evaluates malignant melanomas of the skin, ocular, or mucosal areas) a person would require one of the following A to B categories:

A) Recurrent melanoma following either a wide excision (skin melanoma) or an enucleation of the eye (ocular melanoma); B) Melonoma with metastases with either one or more clinically apparent nodes detected by imaging studies or by clinical evaluation; if the nodes are not clinically apparent, with metastases to four or more nodes; or metastases to adjacent skin or distant sites such as in the liver, lung, or brain; or C) Mucosal melanoma.

Section 13.00I.6 and 113.00I.5 of the updated listings add to the definition of “progressive” cancer explaining that “progressive means the cancer becomes more extensive after treatment; that is, there is evidence that your cancer is growing after you have completed at least half of your planned initial anticancer therapy.”

The Listings for nervous system tumors (13.13, 113.13) have also added several changes including indications that glioblastoma multiforme, ependymoblastoma, and diffuse intrinsic brain stem gliomas no longer require metastases or grade of III or IV to meet the requirements of the listing. It is now established that any central nervous system cancer that is grade III or IV meets the listing severity. Therefore, for both adults and children, cancer of the primary central nervous system now meets the listing if it is metastatic or if it is progressive or recurrent after initial treatment. The adult listing also applies this policy to cancers of the peripheral nerve and spinal root.

Another Listing that has recently been amended is for Hematological Disorders. The final rules for the Hematological Disorders (7.00 and 107.00) were published at 80 Fed. Reg. 21159 (Apr. 17, 2015) and went into effect on May 18, 2015. It is also available at https://www.gpo.gov/fdsys/pkg/FR-2015-04-17/pdf/2015-08849.pdf