dition of eligibility for aid under such State plan he was required to undergo treatment for drug addiction or alcoholism at an institution or facility accepted by the State for such purpose, such institution or facility will be deemed to be approved by the Secretary for such individuals.

(2) Other cases. Any institution or facility utilized by a State vocational rehabilitation agency for treatment of drug addicts or alcholics in connection with their rehabilitation programs under the Rehabilitation Act of 1973, or any institution or facility utilized or licensed by any other appropriate State agency will be deemed to be approved by the Secretary for treatment of medically determined drug addicts or alcoholics. Utilization of appropriate treatment facilities other than those utilized by the State Vocational Rehabilitation agency means the referral of an individual by any State agency empowered to make such referrals to any institution or facility for treatment of drug addiction or alcoholism.

§ 416.985

Availability of treatment.

Whether treatment is available to a particular individual shall depend on the existence of an obtainable treatment vacancy in an approved institution or facility (see § 416.984) and the condition and circumstances of the individual, the treatment required, and the location of the treatment institution or facility, or the services or resources provided by the institution or facility. In determining the availability of treatment, consideration will also be given to the individual's general health, including his mobility and capacity to comprehend the essential specifications of appropriate treatment and the availability and cost of public and private transportation. The individual is not expected to pay for the treatment provided.

1.00

MUSCULOSKELETAL SYSTEM

A. Functional loss may be due to an anatomical loss or to a loss of use of a part due to deformity, adhesions, defective innervation, or other pathology. Pain may be an important factor in causing functional loss, but it must be associated with relevant abnormal findings. Evaluations of musculoskeletal impairments should be supported where applicable by detailed descriptions of ranges of motion, status of the musculature and any sensory, reflex or circulatory deficits and pertinent X-ray findings.

B. Major joints as used herein refer to hip, knee, ankle, shoulder, elbow or wrist and hand. (Wrist and hand considered together as one major joint.)

C. The measurements of restricted motion and ankylosis are based on the technic of measurements described in "Guides to the Evaluation of Permanent Impairment Extremities and Back" by the Committee on Rating of Mental and Physical Impairment, Special Edition, JAMA, February 15, 1958.

1.01 CATEGORY OF IMPAIRMENTS,
MUSCULOSKELETAL

1.02 Rheumatoid arthritis. With: A. History of joint pain and swelling in two or more major joints and morning stiffness persistent on activity; and

B. Signs of joint enlargement or effusion, and motion limitation with periarticular muscle wasting in two or more major joints; and

C. X-ray evidence of abnormality of a major joint (i.e., osteoporosis or decalcification or narrowing of joint space) and one of the following:

1. Anatomical deformity in one major joint, such as joint subluxation, contracture, bony or fibrous ankylosis, joint instability, ulnar deviation, or hyperextension, with resultant limitation of motion; or

2. Positive serologic test for rheumatoid factor; or

3. Elevated sedimentation rate (Wintrobe) greater than 20 mm. per hour in females or 10 mm. per hour in males; cr

4. Positive C-reactive protein; or

5. Polymorphonuclear leukocytosis in synovial fluid aspirate; or

6. Characteristic histologic changes in biopsy of synovial membrane or subcutaneous nodule.

1.03 Neurogenic arthropathy (e.g., Charcot) affecting at least one major weight-bear

ing joint or one major joint in each of the upper extremities. With:

A. Instability or subluxation; and

B. Associated loss of sensory modalities in appropriate distribution.

1.04 Hypertrophic (osteo or degenerative), gouty, infectious or traumatic arthritis. With:

A. History of pain and stiffness in the involved joints; and

B. X-ray evidence of joint space narrowing with osteophytosis (exostosis) or bony destruction with erosicns and cysts, or subluxation, or ankylosis of involved joints and one of the following:

1. Abduction of both arms at shoulders restricted to less than 90 degrees; or

2. Ankylosis (fibrous or bony consolidation cr fixation) of hip at less than 20 degrees cr more than 30 degrees of flexion, measured from neutral position; or

3. Ankylosis or fixation of knee at more than 10 degrees from neutral position; or

4. Limitation of flexion of both hips to 50 degrees or less from neutral position (including ankylosis of both hips at any angle);

or

5. Limitation of flexion of both knees to 30 degrees or less from the neutral position (including ankylosis of both knees at any angle); or

6. Combined involvement of single hip and knee in contralateral extremity, with impairment in each as in 4 or 5 above; or 7. Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint (hip, knee, ankle, or tarsal region) and return to full weight-bearing status did not occur, or is not expected to occur within 12 months of onset of disability; or

8. X-ray evidence of lumbar spine abnormalities as in B above with motion of dorsolumbar spine limited to 5 degrees or less from neutral position and impairment of single hip or knee as in 4 or 5 above. 1.05 Disorders of spine. With:

A. Fracture of vertebra, residuals of. With cord involvement with appropriate sensory and motor loss; or

B. Generalized osteoporosis with pain, limitation of back motion, paravertebral muscle spasm, and compression fracture of a vertebra; or

B. Cervical or lumbar nerve root compression as evidenced by appropriate radicular distribution of sensory, motor, and reflex abnormalities.

by

1.08 Osteomyelitis (demonstrated X-ray). A. Pelvis, vertebra, femur, tibia or a major joint of an upper or lower extremity, with persistent activity or occurrence of at least 2 episodes in the 6 months since onset of disability manifested by local or systemic signs or laboratory findings (e.g., heat, redness, swelling, drainage, leucocytosis, or increased sedimentation rate); or

B. With multiple localizations and systemic manifestations such as anemia (hematocrit of 30 percent or less) or amyloid changes.

1.09 Amputation of; or anatomical deformity of (i.e., loss of major function due to degenerative changes associated with vascular or neurological deficits, traumatic loss of muscle mass or tendons and X-ray evidence of bony or fibrous ankylosis at an unfavorable angle, joint subluxation instability). A. Both hands; or

B. Both feet; or

C. One hand and one foot.

от

1.10 Amputation of lower extremity (at or above the tarsal region). A. Hemipelvectomy or hip disarticulation; or

B. Evaluate an amputation associated with peripheral vascular disease or diabetes mellitus under the criteria in § 4.13 or § 9.08; or C. Inability to use prosthesis effectively, without other assistive devices, due to:

1. Vascular disease; or

2. Neurological complications (e.g., loss of position sense); or

3. Stump complications persisting, or expected to persist, for at least 12 months from onset of disability; or

4. Disorder of contralateral lower extremity causing mobility restriction.

1.11 Fracture of femur, tibia, tarsal bone or pelvis. With solid union not evident on X-ray and return to full weight-bearing status did not occur, or is not expected to occur, within 12 months of onset.

1.12 Fractures and/or soft tissue injuries of an upper extremity. A. With non-union of a fracture of the shaft of the humerus, radius, or ulna under continuing surgical management directed toward restoration of functional use of the extremity and such function was not restored or expected to be restored within 12 months after onset; or B. Requiring a series of staged surgical procedures within 12 months after onset for salvage and/or restoration of major function of the extremity, and such major function was not restored or expected to be restored within 12 months after onset; or

C. After maximum benefit from surgical therapy has been achieved (i.e., there have been no significant changes in physical findings and/or X-ray findings for any 6-month period after the last definitive surgical procedure), the residual of fractures and/or

soft tissue injuries of an upper extremity should be evaluated under the criteria in 8 1.09 when associated with residual impairment or another extremity.

2.00 SPECIAL SENSE ORGANS

Disease

or in

A. Causes of disability. jury of the special sense organs may produce disability by reduction of the ability to see or hear. Loss of central vision results in inability to distinguish detail and prevents reading and fine work. Loss of peripheral vision restricts the ability of an individual to move about freely. Loss of hearing impairs ability to communicate with others by misinterpretation of ideas and orders and results in lack of awareness to danger. The extent of impairment of sight or hearing should be determined by visual or auditory testing.

B. Central visual acuity. A loss of central visual acuity may be caused by impaired distant and/or near vision. However, for an individual to meet the level of severity described in § 2.02 and 2.04 only the remaining central visual acuity for distance of the better eye with best correction using the Snellen test chart may be used. Correction obtained by special visual aids (e.g., contact lenses) will be considered only if the individual has the abilly to wear such aids.

C. Field of vision. Disability due to loss of peripheral vision may result if there is contraction of the visual fields. The contraction may be either symmetrical or irregular. For the phakic eye (the eye with a lens), the extent of the remaining visual field will be determined by usual perimetric methods, utilizing a 3 mm. white disc target at a distance of 330 mm. under illumination of not less than 7 foot-candles. For the aphakic eye the eye without a lens), the visual field must be determined by utilizing a 6 mm. white disc at a distance of 330 mm. without corrective lenses.

Field measurements must be accompanied by notated field charts, a description of the type and size of the target and the test distance. If corrective lenses have been used, this fact must be stated.

D. Muscle function. Paralysis of the third cranial nerve producing ptosis, paralysis of accommodation, and dilation and immobility of the pupil may cause significant visual impairment. When all the muscles of the eye are paralyzed, including the iris and ciliary body (total ophthalmoplegia), the condition is disabling provided it is bilateral. A finding of disability based primarily on impaired muscle function must be supported by a report of an actual measurement of ocular motility.

E. Visual efficiency. Loss of visual efficiency may be caused by disease or injury resulting in a reduction of central visual acuity and/or visual field. The visual efficiency of one eye is the product of the percentage of central visual efficiency and the

percentage of visual field efficiency. (See Tables No. 1 and 2, § 2.09).

F. Special situations. Aphakia represents a visual handicap in addition to the loss of central visual acuity. The term monocular aphakia would apply to an individual who has had the lens removed from one eye, and who still retains the lens in his other eye of to an individual who has only one eye which is aphakic. The terms binocular aphakia would apply to an individual who has had both lenses removed. In cases of binocular aphakia, the central visual efficiency of the better eye will be accepted as 75 percent of its value. In cases of monocular aphakia where the better eye is aphakic, the centra visual efficiency will be accepted as 50 per cent of its value. (If an individual ha binocular aphakia, and the central visual acuity in the poorer eye can be corrected only to 20/200, or less, the central visual efficiency of the better eye will be accepted as 50 percent of its value.)

Ocular symptoms of systemic disease may or may not produce a disabling visual in pairment. These manifestations should be evaluated as part of the underlying disease entity by reference to the particular body system involved.

G. Deafness. Deafness should be evaluated in terms of the person's ability to hear and distinguish speech. The degree of functional hearing loss is that loss of hearing and discrimination for speech which is not restorable by a hearing aid. Loss of hearing may be determined with an audiometer or by other appropriate auditory testing. Discrimination for speech may be determined with a speech audiometer or a hearing aid and the use of phonetically balanced word lists (e.g., the PB-50's prepared at Harvard University of the W-22 recordings developed by the Central Institute for the Deaf). These special test lists consist of words selected so that the frequency of speech sounds in the group is the same as the frequency of the same sounds in an average vocabulary of conventional American English.

2.01 CATEGORY OF IMPAIRMENTS, SPECIAL
SENSE ORGANS

2.02 Impairment of central visual acuity. Remaining vision in the better eye after best correction is 20/200 or less.

2.03 Contraction of visual fields. A. To 10 degrees or less from the point of fixation; or B. So the widest diameter subtends an angle no greater than 20 degrees; or

C. To 20 percent or less visual field efficiency.

2.04 Loss of visual efficiency. Visual efficiency of better eye after best correction, 20 percent or less. (The percent of remaining visual efficiency=the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.

2.05 Complete homonymous hemianopsia. 2.06 Total bilateral ophthalmoplegia.