If evidence already in a claim is insufficient to make a failure to follow prescribed treatment (FTFPT) determination, you must develop the evidence until it is sufficient to complete the FTFPT determination. You may contact the individual, the individual’s medical source(s), and third parties using the procedures in this section.

Always document the content of your contact in the claim communication section of eCAT. For paper cases, use an SSA-5002 (Report of Contact).

If there is inconsistency or conflict within information gathered during development conflict, attempt to resolve the inconsistency or conflict. For example, if an individual states that he or she is following the prescribed treatment but his or her medical source(s) contradicts the individual’s statements, attempt to resolve the discrepancy. We may also rely on expert medical judgment. If appropriate, evaluate the claim using the procedures for fraud or similar fault.

IMPORTANT: Do not purchase a consultative examination to obtain a prognosis or to resolve a conflict about whether good cause exists.

You may develop evidence for a potential FTFPT determination anytime during normal case development procedures. However, if FTFPT is an issue in the case, you must make every reasonable effort to complete this development in order to make a FTFPT determination prior to issuing an allowance or continuance determination. If the case is a denial or cessation for any other reason, you may stop development for the FTFPT and issue the denial or cessation. However, include all FTFPT development in the folder to help subsequent reviewers on appeal. For the definition of every reasonable effort, see DI 22505.001 Medical and Nonmedical Evidence.

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  DI 22505.030 Obtaining Medical Evidence by Telephone

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  DI 23007.005 Failure to Cooperate With Requests to the Claimant for Evidence or Action

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  DI 23010.030 Exhibit - Predetermination Notice