The Medical Advisory Board shall follow the guidelines set forth in §§B—J of this regulation when making a recommendation to the Administration. Cardiovascular Impairments. Contraindications. Contraindications for the safe operation of a motor vehicle under any circumstance may include, but are not limited to: Unstable angina; Recovering from myocardial infarction of less than 4 weeks duration; Recovering from open heart surgery within the past 6 weeks; Recovering from heart transplantation surgery, 6 weeks after discharge; Placement of a left ventricular assist device discharge; Severe, uncontrolled congestive heart failure; Severe, uncontrolled hypertension; Cardiac infections not responding to appropriate therapy; Unoperated critical aortic stenosis or subaortic stenosis; Unoperated aneurysms of the aorta or cerebrovascular system; Loss of or impaired consciousness due to, but not limited to, uncontrolled arrhythmias, pacemaker failures, and cardiomyopathy; A symptom within 6 months after discharge of an automatic implantable cardioverter defibrillator (AICD); Any of the following arrhythmias: Alternating left or right bundle branch block (LBBB or RBBB) second degree AV; Mobitz II (distal AV block); or Acquired third degree AV block; and Survivors of sudden death with automatic implantable cardioverter defibrillator (AICD) devices still discharging at intervals of less than 3 months. An individual who has a condition listed in §B(1) of this regulation may be considered for a license by submitting evidence acceptable to the Medical Advisory Board that the condition: Has been modified, either medically or surgically; and Is well controlled without recurrence or relapse. Cases shall be evaluated on an individual basis by the Medical Advisory Board in doubtful or unclear circumstances. Additional or periodic follow-up reports may be required by the Administration for review by the Medical Advisory Board. Diseases of the Endocrine System. Diabetes Mellitus. An individual with diabetes mellitus requiring insulin may be reviewed by the Medical Advisory Board. Hypoglycemia. An individual who suffers from recurrent severe uncontrolled attacks of hypoglycemia may not operate any type of motor vehicle and may not be considered for any class license. Diseases of the Neuromusculoskeletal System. An individual who has a significant musculoskeletal impairment shall be evaluated by the Medical Advisory Board before being licensed initially or before having the individual's license to operate a motor vehicle renewed. Diseases of the Nervous System. Cerebral Hemorrhage, Infarction, or Traumatic Brain Injury (TBI). An individual who has had a cerebral hemorrhage, infarction, or TBI that has resulted in a marked change in personality, alertness, ability to make decisions, loss of coordination, motor power, visual acuity, visual field, or any other neurological deficit shall be reviewed by the Medical Advisory Board. Seizures. The driver's license or driving privilege of an individual with seizures may be suspended or refused for a period of 90 days or more from the date of the last seizure. An individual whose driver's license or driving privilege has been suspended or refused under §E(2)(a) of this regulation may request that the period of suspension or refusal be withdrawn or modified by submitting evidence of favorable modifiers acceptable to the Medical Advisory Board. The Medical Advisory Board shall consider favorable and unfavorable modifiers under §E(2)(e) and (f) of this regulation in determining whether to recommend that the suspension or refusal period be withdrawn or modified to more or less than 90 days. The withdrawal or reduction or increase of the suspension or refusal period shall be based upon the recommendation of the Medical Advisory Board. Favorable modifiers include: Seizures during medically directed medication changes; Simple partial seizures that do not interfere with consciousness or motor control; Seizures with consistent and prolonged auras; Established pattern of pure nocturnal seizures; and Favorable driving record. Unfavorable modifiers include: Noncompliance with medication or medical visits; Alcohol or drug abuse in the past 3 months; Unfavorable driving record; Structural brain lesion; Placement of a vagal nerve stimulator to control seizure activity; and Seizure control requiring three or more medications. Periodic follow-up reports may be required by the Administration for review by the Medical Advisory Board. At the conclusion of the suspension or refusal period, the Medical Advisory Board shall reevaluate the individual and recommend appropriate action. The procedures for the restoration of the driver's license following a period of ineligibility are set forth in COMAR 11.17.04. Narcolepsy. An individual under treatment for this condition may not be considered for any class of license until the individual has been free of symptoms for at least 6 months and is experiencing no side effects from medications. The individual shall be cleared by the Medical Advisory Board. Psychiatric Disorders. Psychopathic Personality. An individual who has a disregard for accepted social values, who has a history of impulsive or irresponsible behavior, and who is frequently rebellious to authority or openly aggressive, with consequent loss of caution and good judgment, may not be considered for any class of license. Personality, Character, and Psychotic Disorders. An individual with severe symptoms of personality, character, or psychotic disorders shall be evaluated by the Medical Advisory Board for a license on the basis of alertness, social behavior, psychomotor retardation, and side effects from drug therapy. Substance Use Disorders. In this section, a certified substance abuse treatment program means a program which has been certified by the Alcohol and Drug Abuse Administration of the Maryland Department of Health. A severe substance use disorder is characterized by physical or psychological dependence, or both, on certain psychoactive chemical substances, as shown through the continued use of these psychoactive chemical substances despite harmful or adverse circumstances. A mild or moderate substance use disorder involves harmful or hazardous use of substances which can be both licit, for example medication, and illicit. These substances include, but are not limited to: Central nervous system depressants such as alcohol, tranquilizers, and opiates and their derivatives; Hallucinogens; Stimulants; and Volatile solvents. Before being considered for a license, an individual who has been involved in two alcohol-related or other substance-related driving incidents during the past 5 years, or three or more alcohol-related or other substance-related driving incidents in a lifetime, is required to submit satisfactory evidence to the Administration of: Complete abstinence from substance use for 6 months or as determined by the Administration on a case-by-case basis; Enrollment in, or completion of a substance abuse treatment program for at least 90 days or longer as determined by the Administration on a case-by-case basis; and Participation in a self-help group for a period of time as determined by the Administration on a case-by-case basis. As a condition for approval, the Administration may impose certain restrictions, limitations, or other requirements determined to be appropriate to ensure an individual's safe driving of a motor vehicle, including enrollment in an ignition interlock program. Regardless of the number of incidents, if as the result of investigation, or assessment, an applicant is determined to have alcoholism or a chemical addiction that has not been addressed, the Administration may require evidence of at least 90 days of satisfactory completion of a certified substance abuse treatment program. An individual who is a paraplegic, quadriplegic, or has the loss of one or more limbs may be required by the Medical Advisory Board to submit to driver's reexamination to determine the individual's ability to safely operate a motor vehicle. Traumatic Brain Injury. After the review of medical reports submitted by a physician, a rehabilitation facility, or an occupational therapist, the Medical Advisory Board or Administration may require an examination or reexamination consisting of law, vision and driving tests.