Human immunodeficiency virus (HIV) infection SSDI Claims in Texas

Medical criteria

SSA Blue Book listing

14.11 Human immunodeficiency virus (HIV) infection

Listing criteria (20 CFR Appendix 1, Part A)

With documentation as described in 14.00F1 and one of the following: A. Multicentric (not localized or unicentric) Castleman disease affecting multiple groups of lymph nodes or organs containing lymphoid tissue (see 14.00F3a). OR B. Primary central nervous system lymphoma (see 14.00F3b). OR C. Primary effusion lymphoma (see 14.00F3c). OR D. Progressive multifocal leukoencephalopathy (see 14.00F3d). OR E. Pulmonary Kaposi sarcoma (see 14.00F3e). OR F. Absolute CD4 count of 50 cells/mm 3 or less (see 14.00F4). OR G. Absolute CD4 count of less than 200 cells/mm 3 or CD4 percentage of less than 14 percent, and one of the following (values do not have to be measured on the same date) (see 14.00F5): 1. BMI measurement of less than 18.5; or 2. Hemoglobin measurement of less than 8.0 grams per deciliter (g/dL). OR H. Complication(s) of HIV infection requiring at least three hospitalizations within a 12-month period and at least 30 days apart (see 14.00F6). Each hospitalization must last at least 48 hours, including hours in a hospital emergency department immediately before the hospitalization. OR I. Repeated (as defined in 14.00I3) manifestations of HIV infection, including those listed in 14.11A-H, but without the requisite findings for those listings (for example, Kaposi sarcoma not meeting the criteria in 14.11E), or other manifestations (including, but not limited to, cardiovascular disease (including myocarditis, pericardial effusion, pericarditis, endocarditis, or pulmonary arteritis), diarrhea, distal sensory polyneuropathy, glucose intolerance, gynecologic conditions (including cervical cancer or pelvic inflammatory disease, see 14.00F7), hepatitis, HIV-associated dementia, immune reconstitution inflammatory syndrome (IRIS), infections (bacterial, fungal, parasitic, or viral), lipodystrophy (lipoatrophy or lipohypertrophy), malnutrition, muscle weakness, myositis, neurocognitive or other mental limitations not meeting the criteria in 12.00, oral hairy leukoplakia, osteoporosis, pancreatitis, peripheral neuropathy) resulting in significant, documented symptoms or signs (for example, but not limited to, fever, headaches, insomnia, involuntary weight loss, malaise, nausea, night sweats, pain, severe fatigue, or vomiting) and one of the following at the marked level: 1. Limitation of activities of daily living. 2. Limitation in maintaining social functioning. 3. Limitation in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace.

Body system category

14.00 Immune System Disorders

Common denial reason

HIV claims are commonly denied when CD4 counts, opportunistic infections, or HIV manifestations do not meet listing criteria despite diagnosis.