To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your breathing difficulties are severe enough to meet or equal the chronic pulmonary insufficiency listing. The Social Security Administration has developed rules called Listing of Impairments for most common impairments. The listing for a particular impairment describes a degree of severity that Social Security Administration presumes would prevent a person from performing substantial work. If your lung disease is severe enough to meet or equal the chronic pulmonary insufficiency listing, you will be considered disabled.
The listing that applies to chronic pulmonary insufficiency is 3.02. It has 3 parts, A, B, and C.
Part A applies to chronic obstructive pulmonary disease. Part B applies to chronic restrictive ventilator disease. Part C applies to chronic impairment of gas exchange.
Important to note for all three parts of the listing is that:
1) Chronic impairment must be present, and
2) All pulmonary diseases can potentially qualify.
The Social Security Administration will first consider whether your lung disorder will satisfy the 12-month duration requirement that all impairments must meet. Once impairment duration is established or expected, the severity of your impairment can be determined by several methods of testing. The real question that all these tests seek to answer is how well you can oxygenate your blood and remove waste carbon dioxide gas. If your lung disease meets or equals a listing, the Social Security Administration presumes that these vital respiratory functions would be too severely impaired to permit you to carry out even sedentary work activities. The nature of your respiratory disorder determines which part of this listing is most appropriate to evaluate the severity of the impairment.
Meeting Social Security Administration Listing 3.02A for Chronic Pulmonary Insufficiency
Part A involves evaluation of the results of spirometric testing of chronic obstructive pulmonary disease. According to this listing, if you are diagnosed with chronic obstructive pulmonary disease due to any cause, you will be disabled if you have an FEV1 equal to or less than the values specified in Table I corresponding to your height without shoes. FEV stands for forced expiratory volume. FEV1 is the amount of air you can exhale with force in one breath measured at 1 second.
FEV1 is the important measurement for COPD and it decreases in proportion to the severity of the lung disease.
In reality, gender and age affect normal values but they are not taken into account in part A. Since older women have somewhat lower normal predicted values for a given height than men, failure of the table to make a distinction is to the advantage of older women.
For the test results to be valid, your height must be measured without shoes. Taller people have larger lungs, so normal values for FEV1 are higher for those individuals and this fact is reflected in the spirometric tables. It is not unusual for the Social Security Administration to have to send a claimant to a consultative examination just to get an accurate height.
If your height measured in inches falls between the whole number values in the respective tables, it should be rounded off to the nearest inch by whole number. If the fraction is precisely one-half inch, the height measured should be rounded off to the next highest whole number. The importance of the above rounding policy cannot be over-stated. This is a perfect example of how attention to detail can make the difference between allowance and denial of benefits, since FEV1 values are exactly specified.
Meeting Social Security Administration Listing 3.02B for Chronic Pulmonary Insufficiency
Part B involves evaluation of the results of spirometric testing of restrictive pulmonary disease. You will meet part B of the listing if you have chronic restrictive ventilatory disease due to any cause, with the FVC equal to or less than the values specified in Table II corresponding to your height without shoes. FVC stands for forced vital capacity. It is the amount of air you can exhale with force after you inhale as deeply as possible.
FVC is the most important measurement for restrictive lung disease and it decreases in proportion to the severity of the lung disease. The FEV1 used to determine severity in COPD may be normal in restrictive lung diseases.
In reality, gender affects normal values but that is not taken into account. Women have somewhat lower normal predicted values for a given height than men, so failure of the table to make a distinction is to the advantage of women.
If your height measured in inches falls between the whole number values in the respective tables, it should be rounded off to the nearest inch by whole number. If the fraction is precisely one-half inch, the height measured should be rounded off to the next highest whole number. The importance of the above rounding policy cannot be over-stated. This is a perfect example of how attention to detail can make the difference between allowance and denial of benefits, since FVC values are exactly specified.
Meeting Social Security Administration Listing 3.02C for Chronic Pulmonary Insufficiency
You will meet part C of the listing if you have chronic impairment of gas exchange due to clinically documented pulmonary disease. With:
1. Single breath carbon monoxide diffusing capacity (DLCO) less than 10.5 ml/min/mm Hg or less than 40 percent of the predicted normal value. (Predicted values must either be based on data obtained at the test site or published values from a laboratory using the same technique as the test site. The source of the predicted values should be reported. If they are not published, they should be submitted in the form of a table or nomogram); or
2. Arterial blood gas values of PO2 and simultaneously determined PCO2 measured while at rest (breathing room air, awake and sitting or standing) in a clinically stable condition on at least two occasions, three or more weeks apart within a 6-month period, equal to or, less than the values specified in the applicable Table III-A or III-B or III-C:
3. Arterial blood gas values of PO2 and simultaneously determined PCO2 during steady state exercise breathing room air (level of exercise equivalent to or less than 17.5 ml O2 consumption/kg/min or 5 METs) equal to or less than the values specified in the applicable Table III-A or III-B or III-C in listing 3.02 C2.
ABGS done during acute respiratory distress of any kind are not reliable for determination of chronic impairment and cannot be used to evaluate severity under the listing.
The three tables in part C have different values, because normal arterial oxygen pressure decreases with altitude. In medical records or elsewhere, reports of ABGS should always specify the percentage of oxygen the patient is breathing (FIO2) when the ABGS is done. The normal atmosphere consists of about 21% oxygen. FIO2 21% or 0.21 means the person is breathing normal air without oxygen supplementation. RA (room air) means the same thing, and is a commonly used abbreviation.
Part C.1 is satisfied if 10.5 milliliters of carbon monoxide gas per minute, or less, diffuses into the blood for each millimeter of pressure. Alternatively, if the result is 40% or less than the predicted normal value used by the testing laboratory, then part C.1 is fulfilled. Failure to satisfy one of these criteria does not preclude allowance under the other.
Part C.2 can be satisfied by resting oxygen and carbon dioxide pressures adjusted for altitude. The Social Security Administration may send you for a resting ABGS when there is a question of whether your impairment meets or is equivalent in severity to a listing, and the claim cannot otherwise be favorably decided. If the results of a DLCO study are greater than 40% of predicted normal but less than 60% of predicted normal, the Social Security Administration should consider a resting ABGS. In other words, you must have had spirometry and DLCO testing prior to the resting ABGS, and there must be no possibility that your claim will be allowed based on these tests. A further restriction is that the DLCO must be greater than 40%, since lower values would qualify under part C.1. Finally, values of 60% or more for the DLCO would generally preclude purchase of ABGS, because values that high would not be expected to be associated with abnormal ABGS.
Part C.3 Exercise ABGS
Part C.3 provides for ABGS to be done during exercise. Individuals with a DLCO greater than 60% of predicted normal would not usually be considered for exercise testing with measurement of arterial blood gas studies; they are unlikely to have an abnormal exercise result. Exercise ABGS are not often done by the Social Security Administration, but represent an important testing procedure in selected cases. With a parenchymal restrictive lung disease like idiopathic fibrosis, exercise puts a demand on the lungs for more oxygen to supply the muscles but the disease limits gas exchange. Direct measurement of PaO2 is done during exercise as specified by methodology in part C.1.
Exercise ABGS should not be ordered if you have the following conditions:
How does the Social Security Administration decide when purchase of exercise ABGS is relevant to the disability determination? Claimants with DLCO values of 41–60% of predicted normal and not allowable with resting ABGS, or by any other means, should be considered for exercise ABGS. Such a decision is not automatic; most relevant are cases in which the evidence indicates symptomatology significantly worse than would otherwise be expected from the objective findings. In these instances, exercise can expose underlying severity that otherwise would not be documented.
Further Considerations Regarding Part C.3
Exercise ABGS testing should never be administered by anyone other than a sub-specialist in pulmonary medicine with the requisite expertise. That physician has the final decision about whether it is medically appropriate to carry out testing. The test is invasive; an indwelling arterial catheter must be placed. Therefore, there is some pain, some risk that a piece of the catheter could break in the radial artery, some risk that the artery may be permanently damaged, and some risk of infection. In addition to making a medical determination about the safety of testing, that examining specialist will inform you of any risk and obtain informed consent.
There are also the risks associated with exercise testing of any kind, such as cardiac arrhythmias. Although the low level of exercise makes such cardiac complications unlikely, the presence of dropping arterial oxygen as a result of lung disease (development of hypoxemia) during exercise increases the risk of arrhythmias beyond what would be present in a normal individual. These risks are not great with appropriate pre-test physical examination, review of medical records by a pulmonologist, and expert monitoring during testing.
If exercise ABGS has been done by your treating physician prior to application for disability benefits, that information should be used, if possible. If your treating physician states to the Social Security Administration that exercise ABGS testing is contraindicated, there is a good chance the Social Security Administration will not request such testing. However, the treating physician should be willing to provide an explanation for that judgment.
Use of Supplemental Oxygen
Use of supplemental oxygen is common among claimants with lung disease. Your use of oxygen in itself is not proof of impairment, just as use of a crutch does not demonstrate inability to walk. The Social Security Administration will need to obtain your doctor’s reasons for prescribing supplemental oxygen to determine if you truly need it.
A claimant truly needing supplemental oxygen would easily qualify under part C.2 of the listing. The use of supplemental oxygen becomes mandatory at a resting PaO2 of about 55 mm Hg. In individuals with severe co-existing heart disease, supplemental oxygen might be needed for values up to 59 mm Hg. Such values are not absolutes, but must be tailored to the individual.
If you need oxygen you should not be sent for spirometry or DLCO testing.
To obtain resting ABGS, your oxygen would need to be terminated for a few minutes to determine your natural PaO2. If the Social Security Administration is contemplating sending you for ABGS and you use oxygen, the Social Security Administration should contact your treating physician and ask:
1) Why you are receiving oxygen;
2) For clinical and laboratory evidence regarding your pulmonary disease; and
3) Whether it is safe for you to receive ABGS without oxygen flow if this information has not already been received into the file.
If your treating physician does not cooperate or the information obtained is vague, the Social Security Administration can send you to an internal medicine specialist, preferably a pulmonary sub-specialist, who can provide a professional evaluation of your pulmonary condition and appropriateness of further testing without the use of oxygen.
Determination of Equivalence in COPD
The FEV1 is the most important test for assessment of chronic severity of emphysema, chronic bronchitis, asthma, and other forms of obstructive pulmonary disorders. However, claimants with advanced lung disease—particularly emphysema—can demonstrate severity equivalent to the requirements of the listing without spirometry. These individuals have had numerous ABGS done that reflect their chronic condition and are associated with adjustments in supplemental oxygen requirements. They are also usually malnourished, because of loss of appetite associated with chronic disease and the added respiratory effort required to ventilate. They very well may have heart disease associated with their lung disease (cor pulmonale). Additionally, they frequently have ischemic heart disease associated with a history of cigarette smoking.
These types of claims characteristically include volumes of medical records. But the file may lack any spirometric results—or the actual breathing curves may not be in the file, if spirometry was done. It is not necessary for the Social Security Administration to send such claimants to spirometric testing, and it is important to bear in mind that ABGS need not necessarily satisfy part C.2 of the listing for a finding of equivalence. Other medical conditions, such as malnutrition, can often provide the basis for a finding of additional severity. Malnutrition in chronic lung disease is an important and common problem.
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