I. Introduction

This appendix contains the Federal Motor Carrier Safety Administration's recommendations and guidance in the form of Medical Advisory Criteria to help medical examiners assess a driver's physical qualification. These recommendations and guidance are strictly advisory and do not have the force and effect of law. They were established after consideration of public comments and after consideration of recommendations from the Agency's Medical Review Board.

II. Interpretation of Medical Standards

Since the issuance of the regulations for physical qualifications of commercial motor vehicle drivers, the Federal Motor Carrier Safety Administration has published recommendations and guidance called advisory criteria to help medical examiners in determining whether a driver meets the physical qualification standards for commercial driving. These recommendations have been derived from the Medical Examiner's Handbook to provide information to medical examiners that is directly relevant to the physical qualification examination.

A. Medical Advisory Criteria for 49 CFR 391.41(b)(1)

1. Only individuals with loss of all five fingers are considered to have loss of a hand under § 391.41(b)(1).

2. Unless an individual possesses a skill performance evaluation certificate, loss of a foot, a leg, a hand, or an arm precludes physical qualification. Even if an individual has a prosthesis that replaces the foot, leg, hand, or arm, as applicable, certification is precluded without a skill performance evaluation certificate.

3. An individual may be eligible for a skill performance evaluation certificate under § 391.41(b)(1) or § 391.41(b)(2), or both.

B. Medical Advisory Criteria for 49 CFR 391.41(b)(2)

1. Individuals with loss of fewer than all five fingers or any number of toes should be evaluated under § 391.41(b)(2) to determine whether there is an impairment, defect, or limitation of a hand or foot that interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle.

2. A skill performance evaluation certificate is only available under § 391.41(b)(2) for impairment, defect, or limitation of a limb. A skill performance evaluation certificate is not available for impairment of the spine or torso that does not result in impairment, defect, or limitation of a limb.

3. An individual may be eligible for a skill performance evaluation certificate under § 391.41(b)(1) or § 391.41(b)(2), or both.

C. Medical Advisory Criteria for 49 CFR 391.41(b)(4)

1. The phrase “has no current clinical diagnosis of” is specifically designed to encompass a clinical diagnosis of a current cardiovascular condition, or a cardiovascular condition that has not fully stabilized. The phrase “known to be accompanied by” is designed to include a clinical diagnosis of a cardiovascular disease that is accompanied by, or is likely to cause, symptoms of syncope, dyspnea, collapse, or congestive cardiac failure.

2. Coronary artery bypass surgery and pacemaker implantation are remedial procedures and, thus, do not preclude medical certification. Implantable cardioverter-defibrillators are installed to address an ongoing underlying cardiovascular condition and are likely to cause syncope or collapse as a result of the underlying cardiovascular condition, as well as when they discharge.

3. Anticoagulation therapy is a medical treatment, which can improve the health and safety of the individual, and should not, by its use alone, preclude certification of the individual. The emphasis should be on the underlying medical condition(s) that requires treatment and the general health of the individual.

D. Medical Advisory Criteria for 49 CFR 391.41(b)(5)

1. Many conditions interfere with oxygen exchange and may interfere with the ability to control and drive a commercial motor vehicle safely. These include, but are not limited to, emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis, and obstructive sleep apnea.

2. If the medical examiner detects a possible undiagnosed or inadequately treated respiratory dysfunction that may be likely to interfere with the individual's ability to control and drive a commercial motor vehicle safely, the medical examiner should confer with the treating provider or should recommend that the individual be referred to a specialist for further evaluation and therapy.

E. Medical Advisory Criteria for 49 CFR 391.41(b)(6)

1. An elevated blood pressure finding should be confirmed by at least two subsequent measurements.

2. Hypertension alone is unlikely to interfere with the ability to operate a commercial motor vehicle safely; however, the likelihood increases when target organ damage, particularly cerebral vascular disease, is present. The guidance on the stages of hypertension below is based on the Federal Motor Carrier Safety Administration's Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers (October 2002), which adopted the sixth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (1997).

3. Stage 1 hypertension corresponds to a systolic blood pressure of 140-159 mmHg and/or a diastolic blood pressure of 90-99 mmHg. An individual with a blood pressure in this range is at low risk for a hypertension-related event that is likely to interfere with the ability to operate a commercial motor vehicle safely and may be medically certified to drive for a 1-year period. Certification examinations should be done annually thereafter and should be at or less than 140/90. If less than 160/100 but greater than 140/90 at the subsequent examinations, the individual may be given a one-time certification of 3 months to reduce the blood pressure to less than or equal to 140/90.

4. A blood pressure of 160-179 systolic and/or 100-109 diastolic is considered Stage 2 hypertension. A blood pressure in this range is an absolute indication for antihypertensive drug therapy. The individual may be given a one-time certification of 3 months to initiate or adjust antihypertensive drug therapy and to reduce the blood pressure to less than or equal to 140/90. Provided treatment is well tolerated and the driver demonstrates a blood pressure value of 140/90 or less, the individual may be certified for 1 year.

5. A blood pressure at or greater than 180 (systolic) and 110 (diastolic) is considered Stage 3 and carries a high risk for an acute blood pressure-related event that is likely to interfere with the ability to operate a commercial motor vehicle safely. The individual should not be qualified, even for a short period, until the blood pressure is reduced to 140/90 or less and treatment is well tolerated. The individual may be certified for 6 months and biannually (every 6 months) thereafter if at recheck blood pressure is 140/90 or less.

6. Annual certification is recommended if the medical examiner does not know the severity of hypertension prior to treatment.

7. Treatment includes non-pharmacologic and pharmacologic modalities as well as counseling to improve or eliminate the factors that contributed to the hypertension. Most antihypertensive medications also have side effects, such as somnolence or syncope. The importance of side effects must be evaluated on an individual basis and considering the underlying hypertension. Individuals should be alerted to the possibility that antihypertensive medications may interfere with the ability to operate a commercial motor vehicle safely.

8. Medical certification for secondary hypertension is based on the above stages. Evaluation is warranted if an individual is persistently hypertensive on maximal or near-maximal doses of two to three pharmacologic agents. Some causes of secondary hypertension may be amenable to surgical intervention or specific pharmacologic treatment.

F. Medical Advisory Criteria for 49 CFR 391.41(b)(7)

1. Once an individual has been diagnosed as having a rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease, then the individual has an established history of that disease.

2. The medical examiner, when examining an individual, should consider the following: the nature and severity of the individual's condition (such as sensory loss or loss of strength); the degree of limitation present (such as range of motion); the rate or stage of progression (symptoms may not be present initially but may manifest over time); and whether symptoms are likely to interfere with the ability to control and operate a commercial motor vehicle safely.

3. If severe functional impairment exists, the individual does not physically qualify. In cases where more frequent monitoring is required, a Medical Examiner's Certificate, Form MCSA-5876, for less than the maximum certification period may be issued.

G. Medical Advisory Criteria for 49 CFR 391.41(b)(8)

1. Epilepsy is a chronic functional disease characterized by seizures or episodes that usually occur without warning, resulting in loss of voluntary control that may lead to loss of consciousness. Therefore, the following individuals are not physically qualified:

• An individual who has a medical history of epilepsy or a seizure disorder, unless the individual satisfies the criteria described in paragraph 5 of the Medical Advisory Criteria for § 391.41(b)(8);

• An individual who has a current clinical diagnosis of epilepsy or a seizure disorder; or

• An individual who is taking antiseizure medication to prevent seizures.

2. When an individual has had a single unprovoked episode of loss of consciousness (i.e., the cause is unknown or there is no clear provoking trigger) that is determined not to have been a seizure, the medical examiner may certify the individual if the medical examiner determines recurrence of loss of consciousness or loss of ability to control a commercial motor vehicle is unlikely and the individual is not taking antiseizure medication. The determination should be made on an individual basis by the medical examiner in consultation with the treating provider. Before certification is considered, it is recommended that a 6-month waiting period elapse from the time of the episode.

3. When an individual has had a single unprovoked nonepileptic seizure (i.e., the cause is unknown or there is no clear provoking trigger) that was treated with antiseizure medication or left untreated, the medical examiner may certify the individual if the individual is both off antiseizure medication and seizure free for 5 years of more.

4. When an individual has had a single provoked nonepileptic seizure or episode of loss of consciousness (i.e., there is a known medical condition or a clear provoking trigger that is reversible or avoidable, such as a drug reaction, alcohol or illicit drug withdrawal, high temperature, acute infectious disease, dehydration, or acute metabolic disturbance), the medical examiner may certify the individual if the individual has fully recovered, has no existing residual complications, and is not taking antiseizure medication and seizure recurrence and exposure to the provoking trigger in the future is unlikely.

5. When an individual has a medical history of epilepsy or a seizure disorder, the medical examiner may certify the individual if the individual is both off antiseizure medication and seizure free for 10 years or more.

6. If a medical examiner is unsure about whether to qualify an individual with a diagnosis of epilepsy or a seizure disorder, or a single nonepileptic seizure, the medical examiner may refer the individual to the Federal Motor Carrier Safety Administration for evaluation under the criteria for a Federal seizure exemption.

H. Medical Advisory Criteria for 49 CFR 391.41(b)(9)

1. Emotional or adjustment disorders contribute directly to an individual's level of memory, reasoning, attention, and judgment, and are often caused by physical disorders. A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness, or paralysis that may lead to incoordination, inattention, or loss of functional control that may be likely to interfere with the ability to drive a commercial motor vehicle safely. Physical fatigue, headache, impaired coordination, recurring physical ailments, and chronic “nagging” pain may be present to such a degree that they may be likely to interfere with the ability to drive a commercial motor vehicle safely. Somatic and psychosomatic complaints should be thoroughly evaluated when examining an individual.

2. The degree to which an individual is able to appreciate, evaluate, and adequately respond to environmental strain and emotional stress is critical when assessing an individual's mental alertness and flexibility to cope with the stresses of commercial motor vehicle driving.

3. It is unlikely that individuals who are highly susceptible to frequent states of emotional instability (e.g., due to schizophrenia, affective psychoses, paranoia, severe anxiety, or depressive neuroses) would satisfy the physical qualification standard.

4. Careful consideration should be given to the side effects and interactions of medications in the overall qualification determination. Medications used to treat mental, nervous, organic, or functional disease or psychiatric disorder may be likely to interfere with the ability to drive a commercial motor vehicle safely.

I. Medical Advisory Criteria for 49 CFR 391.41(b)(11)

1. Since the prescribed standard under the Federal Motor Carrier Safety Regulations is from the American National Standards Institute (ANSI), formerly the American Standards Association, it may be necessary to convert the audiometric results from the International Organization for Standardization (ISO) standard to the ANSI standard. To convert audiometric test results from ISO to ANSI, subtract 14 decibels (dBs) from the ISO result for 500 Hertz (Hz), subtract 10 dBs for 1,000 Hz, and subtract 8.5 dBs for 2000 Hz. To average, add the readings for the 3 frequencies tested and divide by 3.

2. For the whispered voice test, the individual should be stationed at least 5 feet from the medical examiner with the ear being tested turned toward the medical examiner. The other ear is covered. Using the breath that remains after a normal expiration, the medical examiner whispers words or random numbers such as 66, 18, 3, etc. The medical examiner should then ask the individual to repeat the words or sequence. The medical examiner should not use only sibilants (“s” sounding materials). The opposite ear should be tested in the same manner. If the individual fails the whispered voice test in both ears, the audiometric test should be administered.

3. If an individual does not meet the requirements with the use of a hearing aid and requires a Federal hearing exemption, the box for “Wearing hearing aid” should NOT be selected on either the Medical Examination Report Form, MCSA-5875, or Medical Examiner's Certificate, Form MCSA-5876. Instead, only the box for accompanied by a hearing exemption is selected on the Medical Examination Report Form, MCSA-5875, and the Medical Examiner's Certificate, Form MCSA-5876.

4. To obtain an application for a hearing exemption, individuals who do not meet the Federal hearing standard may call (202) 366-4001, email [email protected], or go to https://www.fmcsa.dot.gov/medical/driver-medical-requirements/new-hearing-applicant-doc-email-version.

J. Medical Advisory Criteria for 49 CFR 391.41(b)(12)

1. Federal law prohibits Schedule I drugs or substances listed on 21 CFR 1308.11 from being prescribed for any purpose. Therefore, a medical examiner cannot physically qualify an individual who uses Schedule I drugs or substances.

2. A medical examiner may physically qualify an individual who uses an amphetamine, a narcotic, or other prescribed drug or substance listed on Schedules II through V in 21 CFR 1308.12 through 1308.15 if the prescription exception is met. A drug or substance that is prescribed by a licensed medical practitioner who is licensed under applicable Federal, State, local, or foreign laws to prescribe controlled drugs and substances, is familiar with the individual's medical history, and has advised the individual that the drug or substance will not adversely affect the individual's ability to safely operate a commercial motor vehicle meets the prescription exception in § 391.41(b)(12).

3. One of the ways for the medical examiner to obtain the information that shows the prescription exception is satisfied is to request a written communication from the prescribing licensed medical practitioner who satisfies the regulation's requirements. A voluntary form available on the Federal Motor Carrier Safety Administration's website (391.41 CMV Driver Medication Form, MCSA-5895) may be used, with the individual's consent, as an optional tool to obtain the required information.

4. The medical examiner may request a non-Department of Transportation drug test to aid in the physical qualification determination, including when signs exist indicating the individual may not have disclosed use of a scheduled drug or substance. Use of a substance abuse professional, see 49 CFR 40.3 and 40.281, is not required as part of a non-Department of Transportation drug test.

K. Medical Advisory Criteria for 49 CFR 391.41(b)(13)

1. The phrase “current clinical diagnosis of” alcoholism is specifically designed to encompass a current alcoholic illness or those instances where the individual's physical condition has not fully stabilized.

2. When in remission, the medical examiner may certify an individual who has a prior clinical diagnosis of alcoholism.

3. The medical examiner may request a non-Department of Transportation alcohol test to aid in the physical qualification determination, including when the individual discloses excessive use of alcohol or the medical examiner observes signs of alcoholism. The use of a substance abuse professional, see 49 CFR 40.3 and 40.281, is not required. The medical examiner may request that individuals provide documentation from a professional qualified to conduct an alcohol use assessment that includes an opinion concerning whether a current clinical diagnosis of alcoholism is present or the individual is in remission prior to making a medical certification determination.

[89 FR 3579, Jan. 19, 2024]