DI 23010.005:
Failure to Follow Prescribed Treatment - Policies
Effective Dates: 03/27/2017 - Present- Effective Dates: 01/16/2018 - Present
- DI 23010.005 Failure to Follow Prescribed Treatment - Policies
- 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
-
- * If treatment can restore the ability to work- An individual must follow prescribed treatment to receive benefits.
- * 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:
- * The evidence establishes that the individual's impairment precludes substantial gainful activity (SGA) (or, age-appropriate activities for SSI children).
- * The impairment has lasted or is expected to last for 12 continuous months from onset of disability or is expected to result in death;
- * Prescribed treatment is clearly expected to restore capacity to engage in SGA (or gainful activity, as appropriate).
- * 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:
- * The specific medical treatment is contrary to the established teaching and tenets of the individual's religion.
- * The individual is unable to afford prescribed treatment, which he or she is willing to accept, but for which free community resources are unavailable.
- * An individual's fear of surgery is so intense that it is a contraindication for surgery.
- * 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.
- * Major surgery was previously performed with unsuccessful results and additional major surgery is prescribed for the same impairment.
- * 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.
- * The treatment involves amputation of an extremity, or a major part of an extremity.
- * An individual with a severe mental impairment is clearly unable to understand the consequences of failing to follow prescribed treatment.
- * 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.
- * 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).
- * 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:
- * 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).
- * 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.
- * 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 22505.001.A.4.- See DI 22505.001A.4.
- 2. Medical and Nonmedical Evidence
See DI 22505.001.A.1- See DI 22505.001A.1.
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