Genitourinary Disorders

GU Disorder Comments

There are several questions requesting comment.

In regards to the first question, the main changes I would suggest for consideration are that eGFR be allowed to be calculated by the DDS Examiner/MC team just as occurs for VF efficiencies and other listings, where calculations are made available in the SSA Tools (such as with CLD Score for Adults/Children) for chronic liver disease as well as VF calculations using Humphreys VF MD scores, etc.

There are well known equations that can be used by SSA to calculate eGFR. Also the issue of differences in eGFR for African-Americans versus other non-African Americans needs to be clarified, when only one eGFR is given (even if SSA deems that calculations of eGFR by SSA will not be done, since for any creatinine, the eGFR is higher for African-Americans than for non-African-Americans based on medical evidence in the medical literature); and many labs give an eGFR for each, when they are reported on lab tests.

It seems that since SSA can calculate for other scores and VF efficiencies, then it potentially places a claimant with Chronic Renal Disease at a disadvantage, if they are younger and their creatinine is less than 4 and no 24 hour urine CrCl has been done, yet a calculated eGFR is "listing level" for the A part of 6.05, that SSA could calculate (just as a lab could on a test result yet do not); yet SSA does allow this to be done by the DDS, when no eGFR result is reported. SSA should consider clarifying this issue with different eGFRs between individuals, as noted above, when only one eGFR versus two results are given on lab results that are different as to meeting 6.05A; and when none is given yet is "listing level", when if calculated by SSA but the creatinine on lab result is not.

In addition, there are very few claimants in this modern era of medicine in the U.S., who have overt renal osteodystrophy as defined/described in 6.05B1. I presume SSA has looked at this listing over time and can determine the frequency it is used to at least meet a listing and refute my statement above if incorrect; but even in our area where Chronic Renal Failure is very common, we do not see Renal Osteodystrophy much if at all, as described in 6.05B1. However, even if there is not the weight loss with BMI down to 18 or less, if there is uremia with nausea and vomiting with marked fatigue, malaise, and/or weight loss of 10% that is unintentional in individuals that meet one of the 6.05A1 parts of Listing 6.05, I think the addition of this would consider those claimants, who are very severely limited and disabled from SGA. The requirement of imaging and "intractable pain" for Renal Osteodystrophy is uncommon, yet malaise and fatigue with weight loss of 10% or more unintentionally that causes a marked level of limit with ADLs, social functioning, or maintenance of persistence and pace is more common and severe enough to be disabling, just as it is with other MDIs as with Immune System and HIV, as examples with similar listings. It is also highly doubtful medically that a claimant's TP is going to wait on dialysis, until a claimant has become so severely anorexic or with N/V to lose weight to a BMI of 18 or less and certainly on two occasions 90 days apart in same 12 month period. SSA may argue, that well, they will be placed on dialysis and be an allowance or the DDS can equal a listing (which SSA despite training sessions on POMs on Equals is aware, I suspect, of the issues and problems that occur with equals and where different skilled Reviewers may disagree on this despite the POMs; or a newer DDS Examiner or Consultant may not understand or realize how to do an equals despite training and the POMs-which is another entirely different IdeaScale Commentary that is needed-i.e. how a highly skilled DDS Team may be able to write and rationalize an equals and another DDS Team does not that can potentially lead to different decisions on disability); but SSA already has listings that deal with similar findings and even functional limits that could be used in the 6.05B part once the A part is met of Listing 6.05 just, as is given in some of the Immune Listings and HIV listings with social, ADL limits, and/or persistence and pace limits at the marked level.

As to transplants, in this era of transplantation, it is not clear that with a single transplant that even a full 12 months is needed by many claimants based on a number of cases I see; but multiple transplants are in general medically for the most part, when without complications, would not be expected to require more than 12 months of being unable to do any SGA. Even if SSA is considering a longer period for multiple transplants, all transplants that are multiple would not necessarily be equal in the time of recovery. The way the transplant listings are currently structured, including the Renal Transplant Listing is that after 12 months, the residuals are considered. If a claimant has not adequately recovered and still disabled, even with multiple transplants, then another listing could be met or equaled without changing the 12 month transplant time. I think changing this to multiple transplants would require different periods potentially depending on the combination. (For example, would a renal/pancreas transplant recovery require the same period that a renal/lung transplant would based on extent of surgery; or that the multiple transplants would require with more than one surgical incision site to do the multiple transplants?). I see this as a highly complicated issue with SSA trying to determine what the recovery time is going to be depending on what multiple transplants are to be done, if changed from the current 12 months for a single transplant. Consensus on this, I predict, would be difficult, if changed to a longer time than 12 months, when the current "transplant listings" all take into account ongoing issues/MER to allow a claimant to be determined disabled long after the 12 month time from actual transplant has ended.

Finally in regards to Peritoneal dialysis, irrespective of the type, there are always potential complications and issues that may arise with either way of completing Peritoneal Dialysis, so that issues with SGA are not inconsistent with one form versus the other of Peritoneal Dialysis or for that matter hemo-dialysis in my opinion; and the listings should not be changed based on type of Peritoneal Dialysis given to a claimant related to disability and ability or inability to do SGA.

Thank you for allowing a response to the GU Disorder Questions posed by SSA.


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Idea No. 127