Citations:

20 C.F.R. Parts 404 and 416 Sections 404.1530, 404.1579(e)(4), 404.1586(c), 404.1594(e)(4), 416.930, 416.986(a)(3), 416.994(b)(4)(iv); SSR 82-59

A. Policy

1. Requirement

1. If treatment can restore the ability to work- An individual must follow prescribed treatment to receive benefits.

2. If prescribed treatment is not followed without good cause- An individual cannot be found:

   • Disabled.

   • Under a continuing disability, or blind, if currently receiving benefits.

2. Failure Determination

A failure to follow prescribed treatment determination may be made only where allof the following conditions are met:

1. The evidence establishes that the individual's impairment precludes substantial gainful activity (SGA) (or, age-appropriate activities for SSI children).

2. The impairment has lasted or is expected to last for 12 continuous months from onset of disability or is expected to result in death;

3. Prescribed treatment is clearly expected to restore capacity to engage in SGA (or gainful activity, as appropriate).

4. The evidence of record discloses that there has been refusal to follow prescribed treatment.

   NOTE: Where SSA makes a determination of “failure,” a determination must also be made as to whether or not failure to follow prescribed treatment is justified. See DI 23010.010A.2. regarding claimant contact.

3. Good Cause

Acceptable justifications for failing to follow prescribed treatment include, but are not limited to the following:

1. The specific medical treatment is contrary to the established teaching and tenets of the individual's religion.

2. The individual is unable to afford prescribed treatment, which he or she is willing to accept, but for which free community resources are unavailable.

3. An individual's fear of surgery is so intense that it is a contraindication for surgery.

4. The prescribed treatment is cataract surgery for one eye, when there is severe visual impairment of the other eye that cannot be improved through treatment.

5. Major surgery was previously performed with unsuccessful results and additional major surgery is prescribed for the same impairment.

6. The treatment because of its magnitude (e.g., open heart surgery), unusual nature (e.g., organ transplant), or for some other reason is very risky.

7. The treatment involves amputation of an extremity, or a major part of an extremity.

8. An individual with a severe mental impairment is clearly unable to understand the consequences of failing to follow prescribed treatment.

9. An individual’s own medical source advises against the treatment prescribed for the currently disabling condition.

4. Ability to Work

SSA is responsible for determining whether the prescribed treatment can clearly be expected to restore the ability to work.

1. An individual’s own medical source’s opinion will be considered per DI 24503.000 ff.

   • The individual’s own medical source’s opinion will be considered together with the rest of the evidence.

   • Where an individual’s own medical source’s opinion that the prescribed treatment will not restore the ability for SGA (or age-appropriate activities for SSI children) is not supported, the determination must include a citation of the facts of the case and a full rationalization of the findings. (See DI 26516.010).

2. Where an individual’s own medical source’s opinion recommends a treatment which SSA determines will not likely restore the ability to engage is SGA, there is no “failure” issue.

5. Prescribed Treatment

a. An Individual’s Own Medical Source

The treatment in question must be prescribed by the individual’s own medical source.

b. The Consultative Examiner

The case cannot be denied based on failure to pursue prescribed treatment where severity is established and a CE report, for the first time, raises the possibility that a specific treatment may restore the ability to perform SGA (or gainful activity, as appropriate).

6. Predetermination Notice

A predetermination notice must:

1. Be sent to the claimant or his/her representative, when:

   • Good cause for “failure” is not established, and

   • The treatment is expected to restore the ability to perform SGA (or gainful activity, as appropriate).

2. Inform the claimant or representative that:

   • Good cause for “failure” is not established; and

   • A determination will be made on this basis; and

   • He/she should advise us of any change in treatment participation; and

   • An adverse determination on this basis may mean entitlement requirements cannot be met at a later date, even if prescribed therapy is undergone.

3. Not make any recommendation for pursuing treatment or give any appearance of interference in the doctor-patient relationship.

B. Definitions

1. Medical Source

See DI 22505.001A.4.

2. Medical and Nonmedical Evidence

See DI 22505.001A.1.