SSR 87-6: TITLES II AND XVI: THE ROLE OF PRESCRIBED TREATMENT IN THE EVALUATION OF EPILEPSY
"This supersedes Program Policy Statement (PPS) No. 115 (Social Security Ruling (SSR) 84-27), Titles II and XVI: The Role of Prescribed Treatment in the Evaluation of Epilepsy."
PURPOSE: To explain the policy for evaluating epilepsy when determining disability on this impairment under titles II and XVI of the Social Security Act.
CITATIONS (AUTHORITY): Sections 223(d), 216(i) and 1614(a) of the Social Security Act, as amended; Regulations No. 4, Subpart P, sections 404.1525 and 404.1530, and Appendix 1, Part A, sections 11.00A, 11.02 and 11.03; and Regulations No. 16, Subpart I, sections 416.925 and 416.930.
INTRODUCTION: During the past decade, rapid growth in the knowledge of more effective clinical approaches to epilepsy has taken place. Potent anticonvulsants are available and reliable methods to determine blood anticonvulsant levels have been developed. This has made possible the more precise "tailoring" of anticonvulsant drugs to the patient's needs. Due to these advances, most epileptic seizures are controllable and individuals who receive appropriate treatment are able to work. Therefore, the Listing of Impairments (Regulations No. 4, Subpart P, Appendix 1) was revised (effective March 27, 1979) to more specifically require that before disability can be found under Listings 11.02 and 11.03, the individual must have major motor seizures occurring more frequently than once a month or minor motor seizures occurring more frequently then once weekly in spite of being on prescribed treatment for at least 3 months. The Listing of Impairments was again revised (effective January 6, 1986) to require consideration of the serum drug levels in the evaluation of severity when seizures are occurring at the frequency specified in Listing 11.02 or Listing 11.03. This PPS explains the documentary and adjudicative requirements necessary for a finding of disability.
PPS No. 115 (SSR 84-27) is being revised to clarify that when epileptic seizures are occurring at the frequency specified in the criteria of the epilepsy listings, current evidence showing blood drug levels is necessary before a favorable decision can be made.
POLICY STATEMENT: As a result of a modern treatment which is widely available, only a small percentage of epileptics, who are under appropriate treatment, are precluded from engaging in substantial gainful activity (SGA). Situations where the seizures are not under good control are usually due to the individual's noncompliance with the prescribed treatment rather than the ineffectiveness of the treatment itself. Noncompliance is usually manifested by failure to continue ongoing medical care and to take medication at the prescribed dosage and frequency. Determination of blood levels of anticonvulsive drugs may serve to indicate whether the prescribed medication is being taken. In a substantial number of cases, use of alcohol has been found to be a contributory basis for the individual's failure to properly follow prescribed treatment. In such cases, the individual's alcohol abuse should be evaluated. (See SSR 82-60, PPS No. 83, Titles II and XVI: Evaluation of Drug Addiction and Alcoholism.)
Evidence of Seizures Occurring Despite Treatment
When seizures are alleged to be occurring at a disabling frequency, the following is essential to a sound determination:
- 1. An ongoing relationship with a treatment source is necessary. "Treatment source" for purposes of application of this provision is a licensed physician, irrespective of specialty. To achieve good control of epilepsy, there must be close rapport between doctor and patient so that the doctor can "tailor" anticonvulsant drugs to the patient's needs. There must be a constant treating source to whom the patient turns for advice and treatment, especially when seizure control wavers. It is not necessary that the claimant see the same physician on each visit e.g., regular visits to an outpatient clinic would be considered on "ongoing relationship." Also, evaluation must be made, in light of treatment prescribed by the treating source, irrespective of whether that treatment is necessarily optimal.
- For epilepsy to be accurately evaluated for disability program purposes, the individual's file must contain adequate information regarding the history of the treatment regimen and his or her response to it. If an individual does not have an ongoing treatment relationship, it would be unreasonable to assume that the seizures cannot be controlled with medication, at least to the level at which the listing would not be met or equaled. Therefore, in the absence of an ongoing treatment relationship, the individual's impairment cannot be found to meet or equal the listings for epilepsy. If the listings are not met or equaled, the particular findings in the case must be evaluated to determine the impairment severity and the expected residual functional capacity (RFC). In such cases, if the evaluation of the medical impairment findings in conjunction with consideration of the vocational factors would lead to a determination that the individual is disabled, it is necessary to consider the issue of failure to follow prescribed therapy.
- 2. There must be a satisfactory description by the treating physician of the treatment regimen and response, in addition to corroboration of the nature and frequency of seizures, to permit an informed judgment on impairment severity. (A purchased examination cannot provide authoritative description of these findings.)
- 3. In every instance, the record of anticonvulsant blood levels is required before a claim can be allowed.
Development Required When There is an Ongoing Treatment
Relationship and the Treating Source Indicates that Frequent
Seizures are Occurring
When the treating source indicates that frequent seizures are occurring (or continuing to occur) despite anticonvulsant therapy, detailed information is necessary to establish whether the seizures are due to factors beyond the individual's control or to noncompliance with prescribed therapy. If the required information is not included in the initial report, it may be necessary to recontact the treating medical source for information on the treatment regimen and the claimant's compliance with it (e.g., whether there have been missed appointments, alcohol abuse, etc.). If satisfactory information on blood drug levels is not available in the treating physician's records, it must be obtained through a purchased examination.
Evaluation of Low Anticonvulsant Blood Levels
The predominant reason for low anticonvulsant blood levels is that the individual is not taking the drugs as prescribed. In extremely rare cases, individual idiosyncrasy in absorption or metabolism of the drug causes therapeutically inadequate anticonvulsant blood levels. The reasons for abnormal absorption or metabolism of these drugs is linked to the individual's clinical condition and would have to be recognized by the treating physician in his or her efforts to obtain control of the seizures. Therefore, a finding that low anticonvulsant blood levels are caused by idiosyncrasy in absorption or metabolism must be based on specific descriptive evidence provided by the treating physician.
When reported blood drug levels are low, therefore, the information obtained from the treating physician should include an explanation as to why the levels are low and the results of any relevant diagnostic studies concerning the blood levels. Unless convincing evidence is provided that subtherapeutic blood drug levels are due to abnormal absorption or metabolism, and the prescribed drug dosage is not itself inadequate, the conclusion should follow that the individual is not complying with the treatment regimen. Similarly, in cases in which there is convincing evidence of intermittent noncompliance, including seizure activity because of alcohol abuse, little weight should be given to sporadically obtained anticonvulsant blood levels, even if they are in the therapeutic range. In all cases, however, blood drug levels should be evaluated in conjunction with all the other evidence to determine the extent of compliance with the prescribed treatment.
Blood drug levels reported during the regular course of treatment are usually of more probative value than evidence obtained for the purpose of disability evaluation which shows the blood drug level at one point in time. However, information concerning current blood levels should be purchased when the existing evidence does not contain blood drug levels and a favorable decision appears to be indicated.
As set forth in the Listing of Impairments (section 11.00A) epilepsy is evaluated according to the type, frequency, duration and sequelae of seizures. Documentation must include at least one electroencephalogram, and at least one detailed description of a typical seizure pattern, including all associated phenomena. Due to the nature of the impairment, a complete description of a seizure cannot be obtained from the claimant. Therefore, if professional observation is not available, it is essential that a description be obtained from a third party (i.e., family member, neighbor, etc.). However, before such contact is made, the claimant's permission must be obtained.
To meet the listing criteria, major motor seizures must be occurring more frequently than once a month (Listing 11.02), or minor motor seizures must occur more frequently than once weekly (Listing 11.03), in spite of at least 3 months of prescribed treatment. Adequate documentation as to cooperation with prescribed treatment is vital to the assessment of impairment severity of seizure disorders. The evidence must reflect the current treatment regimen and information about any recent changes in drug dosage. An allowance on the basis of meeting listing level severity is warranted only when the individual is following a treatment regimen prescribed by his or her treating source and continues to have seizures at the specified frequency.
The Impairment Does Not Meet or Equal the Listing
If the individual is following prescribed treatment and the listing is not met or equaled, the sequential evaluation process requires an assessment of RFC. If the claimant is unable to do past relevant work, his or her age, education, training, and work experience, as they relate to the ability to perform any other work, must be considered.
As previously explained, if functional limitations are imposed by seizures but there is no ongoing treatment relationship, the impairment cannot be found to meet or equal the listings. In such cases, the impairment severity and expected RFC must be considered in conjunction with vocational factors. If the individual is found to be disabled, the issue of failure to follow prescribed treatment must be addressed. (See SSR 82-59, PPS No. 78, Titles II and XVI: Failure to Follow Prescribed Treatment.)
It should be noted that there does not have to be an "ongoing treatment relationship" for there to have been "prescribed treatment." In the vast majority of cases where epilepsy has been diagnosed, treatment including drugs has been prescribed.
EFFECTIVE DATE: The policy explained herein is effective on publication.
CROSS-REFERENCE: Program Operations Manual System, section DI 24580.001.