TN 2 (11-02)

DI 13005.080 Resolving Issue of Whether Child Is and Has Been Receiving Medically Necessary and Available Treatment In Childhood Disability SSI Claims

A. Policy (416.994a(i))

1. Requirement for Treatment That Is Medically Necessary and Available

If you have a representative payee, the representative payee must, at the time of the continuing disability review, present evidence demonstrating that you are and have been receiving treatment, to the extent considered medically necessary and available, for the condition(s) that was the basis for providing you with SSI benefits, unless we determine that requiring such evidence would be inappropriate or unnecessary considering the nature of your impairment(s). If your representative payee refuses without good cause to comply with this requirement, and if we decide that it is in your best interests, we may pay your benefits to another representative payee or to you directly.

2. What We Mean By Treatment That Is Medically Necessary

Treatment that is medically necessary means treatment that is expected to improve or restore your functioning and that was prescribed by a medical source (MS), as defined in DI 22505.001A.4. If you do not have a MS, we will decide whether there is treatment that is medically necessary that could have been prescribed by a MS. The treatment may include (but is not limited to):

  1. medical management;

  2. psychiatric, psychological or psychosocial counseling;

  3. physical therapy; and

  4. home therapy, such as administering oxygen or giving injections.

3. How We Will Consider Whether Medically Necessary Treatment Is Available

When we decide whether medically necessary treatment is available, we will consider such things as (but not limited to):

  1. The location of an institution or facility or place where treatment, services, or resources could be provided to you in relationship to where you reside;

  2. The availability and cost of transportation for you and your payee to the place of treatment;

  3. Your general health, including your ability to travel for the treatment;

  4. The capacity of an institution or facility to accept you for appropriate treatment;

  5. The cost of any necessary medications or treatments that are not paid for by Medicaid or another insurer or source; and

  6. The availability of local community resources (e.g., clinics, charitable organizations, public assistance agencies) that would provide free treatment or funds to cover treatment.

4. When We Will Not Require Evidence of Treatment That Is Medically Necessary and Available

We will not require your representative payee to present evidence that you are and have been receiving treatment if we find that the condition(s) that was the basis for providing you benefits is not amenable to treatment.

5. Removal of a Payee Who Does Not Provide Evidence That a Child Is and Has Been Receiving Treatment That Is Medically Necessary and Available

If your representative payee refuses without good cause to provide evidence that you are and have been receiving treatment that is medically necessary and available, we may, if it is in your best interests, suspend payment of benefits to the representative payee, and pay benefits to another payee or to you. When we decide whether your representative payee had good cause, we will consider factors such as the acceptable reasons for failure to follow prescribed treatment in DI 23010.005A.3. and other factors similar to those describing good cause for missing deadlines in GN 03101.020A.

6. If You Do Not Have a Representative Payee

If you do not have a representative payee and we make your payments directly to you, the provisions of this paragraph do not apply to you. However, we may still decide that you are failing to follow prescribed treatment under the provisions of DI 23010.005, if the requirements of that section are met.

B. Procedure

1. General

For a continuance in which the child has a representative payee, the DDS will decide whether the child is and has been receiving medically necessary and available treatment for the condition(s) that was the basis for providing benefits. In the event the payee does not obtain such treatment for the child, the DDS will also decide whether good cause exists for failing to obtain the treatment. The DDS will place a remark in item 24 and a list code in item 34 of the SSA-832-C2/U3 that describes the situation for each case. If some action is required of the FO, the DDS will provide the necessary information on an SSA-883-U3 (Request for Assistance (Disability Case)) to facilitate your handling of the matter. If, for any reason, the information is not sufficient, contact the DDS for a further clarification.

2. Remarks and List Codes on the SSA-832-C2/U3 (See Exhibit at DI 13005.080C.)

The following summarizes the situations the DDS will encounter, the remarks and list codes that will appear in item 24 of the SSA-832-C2/U3, depending on what the DDS finds, and what the FO action will be:

  • Child Receiving Medically Necessary Treatment

For those cases in which the evidence shows that the child is and has been receiving treatment prescribed by a MS for the disabling condition(s), the treatment will be considered medically necessary and available. Provided the payee is and has been making a good-faith effort to follow the requirements of the treatment, the following remark will have been entered in item 24 of the SSA-832-C2/U3:
"In treatment." The list code in item 34 will be “281.”
The DDS also will have entered this remark if the payee is and has been making a good-faith effort to follow the requirements of treatment prescribed by a medical source as defined in DI 22505.001A.4., with which there is no ongoing treatment relationship between the child and a particular physician, psychologist, or other acceptable medical source, provided the treatment is medically necessary and available.
In either case, the FO will process the continuance in the usual manner.

  • Medically Necessary Treatment Prescribed But Not Available

If the evidence shows that the payee attempted to get the treatment that was prescribed for the child or independently sought treatment but was not able to obtain the prescribed treatment for a justifiable reason (see the criteria set forth in DI 13005.080A.3.), the following remark will have been entered in item 24 of the SSA-832-C2/U3:
"Treatment unavailable or other good cause." The list code in item 34 will be “284.”
The DDS has been instructed not to consider experimental treatment modalities or treatment that is not generally available as medically necessary treatment. Accordingly, should such treatment be all that might improve or restore the child's functioning or should the payee choose not to have the child undergo such treatment, even if prescribed by a MS, the DDS will have entered the above remark in item 24.
Regardless, whenever this entry appears in item 24, the FO will process the continuance in the usual manner.

  • Medically Necessary Treatment Prescribed and Available But Not Obtained

a. When Rules on Failure to Follow Prescribed Treatment Will Apply

If the evidence shows that a MS prescribed treatment, but it was not obtained, the DDS will have determined whether there was good cause for not obtaining this treatment.

b. Good Cause Found

If, due to good cause as defined in DI 23010.010A, the payee has not sought or obtained the treatment for the child the following remark again will have been entered in item 24 of the SSA-832-C2/U3:

"Treatment unavailable or other good cause." The list code in item 34 will be “284.”

In this case, the DDS will forward the continuance to the FO for processing in the usual manner.

c. Good Cause Not Found

If the payee has not sought or obtained the treatment and there is no good cause for the failure, the following remark will have been entered in item 24 of the SSA-832-C2/U3:

"Treatment medically necessary--Good cause not found." The list code in item 34 will be “285.”

In this situation, the DDS will send the case to the FO to take the necessary action as discussed in section 3 below and, if necessary, to develop for another representative payee in accordance with GN 00504.100. The DDS will explain on an SSA-883-U3, what the treatment is that has been prescribed and why the DDS has found that the payee does not have good cause for failing to obtain the treatment for the child. If there are local community resources (e.g., clinics, charitable organizations, public assistance agencies) available that would provide free treatment or funds to cover treatment, the DDS will enter the names and addresses of these resources on the SSA-883-U3, in case the payee is unable to afford the treatment.

d. No MS and the Condition(s) Requires Medically Necessary Treatment

If the child does not have a MS, the DDS medical or psychological consultant will make a medical judgment to determine whether any generally accepted medical treatment would improve or restore the child's functioning. Whenever it is determined that such treatment is medically necessary and available, the following remark will have been entered in item 24 of the SSA-832-C2/U3:

"Treatment medically necessary and available." The list code in item 34 will be “286.”

The DDS will then forward the case with an SSA-883-U3 to the FO with an explanation of what the treatment is that would be expected to improve or restore the child's functioning and whether the treatment would need to be ongoing or would be necessary only for a limited amount of time. (If the treatment would be necessary for a limited duration, the DDS would state what the duration would be.) Again, the DDS should provide the names and addresses of available community resources in case they are necessary. The FO will take necessary action as discussed in DI 13005.080B.3. and develop for another representative payee if necessary and in the best interest of the child, in accordance with GN 00504.100.

e. No Treatment Necessary

If the DDS determines that a child's impairment is not amenable to treatment or if for any other reason, treatment is not necessary and available, the following remark will have been entered in item 24 of the SSA-832-C2/U3:

"No treatment issue." The list code in item 34 will be “282” or “283.”

In these situations, the DDS will forward the cases to the FO for processing in the usual manner.

3. FO Action - Payee Contact Necessary

NOTE: Before the FO takes any action to develop for a new payee, the DDS necessarily will have found that treatment is medically necessary and available, and the DDS will have found that there was no good cause for failing to obtain the treatment. Nevertheless, it is possible that the payee will submit additional evidence that may change or call into question the finding by the DDS. Accordingly, the FO should follow the procedures below as applicable. If the payee submits new evidence to the FO that does call into question the DDS's finding, the FO should consult with the DDS, if necessary, to decide whether there still is no good cause for failing to obtain the treatment.

a. General

The FO should contact the payee and advise him/her of the facts as described by the DDS on the SSA-883-U3 when:

  • medically necessary treatment prescribed by a MS is available that could improve or restore the child's functioning, and without good cause, the child either did not receive it or did not receive it as prescribed, or

  • if there is no MS, medically necessary treatment is available that could improve or restore the child's functioning.

Remind the payee that we previously notified him/her that, when the child's claim required a review, he or she might be required to show proof that the child is and has been receiving treatment to the extent considered medically necessary and available for the condition(s) that was the basis for awarding benefits. Also, explain to the payee that, in the evidence in the initial claim and the CDR about the child's condition(s):

  • there is no proof that the child is or has been receiving treatment for the medical condition(s) that formed the basis for his/her disability;

  • there is evidence that a MS prescribed treatment, but it was not obtained for the child; or

  • the child was not being given the treatment as prescribed, depending on the particular circumstances of the case. If there is no MS and you are providing information based on the DDS's discussion of medically necessary and available treatment, be careful to explain to the payee that SSA does not prescribe treatment but that it appears that treatment as described or similar treatment should be sought.

State that, while we have found that the child's disability continues, we must decide whether it is in the best interests of the child to:

  • select another payee, at which time the child's record may be placed in administrative suspense until another payee can be found, or

  • pay the child directly if the payee does not obtain the treatment described by the DDS or provide good cause for not seeking the treatment.

Have the payee provide:

  • proof that the prescribed treatment or, when there is no MS, that the medically necessary and available treatment identified by the DDS on an SSA-883-U3 is being received, and

  • the name and address of the health care provider who prescribed it.

If the child still is not receiving medically necessary treatment, the payee must provide an explanation why the treatment is not being received.

b. Payee Requests Assistance

If the payee cannot afford the treatment and there are local community resources (e.g., clinics, charitable organizations, public assistance agencies) available that would provide free treatment or funds to cover treatment, advise the payee of these resources as a possible source of treatment.

NOTE: The DDS should provide the names and addresses of these resources on the SSA-883-U3. If the information is not provided, consult with the DDS as necessary.

c. MS Advises No Treatment Necessary

If the payee submits proof that a MS believes no treatment is necessary for the child or treatment would not change the severity or progression of the condition(s), you may accept this opinion. If you cannot decide on your own whether the MS advises that no treatment is necessary or that treatment would not improve the child's functioning, contact the DDS for appropriate guidance. If necessary, return the case to the DDS with an SSA-883-U3 explaining what guidance is needed.

d. Medically Necessary Treatment Not Available

If the payee submits proof that treatment is not available for a justifiable reason (see the criteria set forth in DI 13005.080A.3.), continue that individual as payee. If the payee does not have an acceptable reason for not providing the child with treatment, see DI 13005.080B.3.e.

e. Payee Does Not Comply With Request for Evidence

If the payee does not comply with the request to provide the necessary evidence that the child is and has been receiving medically necessary and available treatment or does not provide good cause for failing to take the child for treatment that is medically necessary and available:

  • consider paying the child directly in accordance with GN 00502.070 (if the child is age 15 or older); or

  • develop for change of payee provided this is in the child's best interests.

While developing for a new representative payee consider continuing payment through the current payee. If that is not appropriate, put the record into administrative suspense (payment status code S08) until the new payee is established. Bear in mind that part of the role of the new payee, if it is a source other than the child, will be to ensure the child receives the medically necessary and available treatment.

C. Procedure - Continuance - Situations and Actions

Remarks in Item 24

List Code

FO Action

1. "In treatment"

2. "No treatment issue"

3. "Treatment unavailable or other good cause"

"281"

"282" & "283"

"284"

No FO payee action necessary

4. "Treatment medically necessary -- Good cause not found"

5. "Treatment medically necessary"

"285"

"286"

Contact payee and follow the guidelines in DI 13005.080B.3. (FO Action Payee Contact Necessary"


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0413005080
DI 13005.080 - Resolving Issue of Whether Child Is and Has Been Receiving Medically Necessary and Available Treatment In Childhood Disability SSI Claims - 03/30/2017
Batch run: 03/30/2017
Rev:03/30/2017