We will assess whether we would expect the prescribed treatment, if followed, to:

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  Restore the individual’s ability to engage in SGA – in adult disability claims;

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  Eliminate or improve a child’s impairment so that it no longer results in marked and severe functional limitations in Title XVI child disability claims; or

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  Restore vision to the extent that the individual will no longer be considered blind in statutory blindness claims.

At the Disability Determination Services (DDS), the medical or psychological consultant (MC/PC) makes this medical assessment. In other adjudicative levels, the adjudicator makes this assessment.

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  Consider all medical evidence received, including a medical source’s prognosis about prescribed treatment. For instance, you can consider and use a medical source’s opinion that an individual is currently unable to walk because the individual is not wearing a prosthetic, but they would be able to walk at least 2 hours in an 8-hour workday with use of a prosthetic. However, our administrative finding is not dependent upon receipt of, or determined by, a medical source’s prognosis.

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  Examples of evidence that might show that the prescribed treatment, if followed, would sufficiently improve the impairments includes evidence that:

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    The individual followed the prescribed treatment in the past, and it was sufficiently effective at that time.

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    The treatment is generally known to be sufficiently effective for the individual’s impairment.

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    Although it may be helpful to have evidence from a consultative examination (CE) or a medical expert (ME), we are not required to purchase a CE or obtain testimony from an ME to help us determine whether we expect a prescribed treatment, if followed, would restore the ability to engage in SGA.

At the DDS, the disability examiner makes this assessment. In other adjudicative levels, the adjudicator makes this assessment.

In adult claims, the individual has the burden to provide evidence showing that they have good cause for FTFPT. In child claims, the child’s parent or guardian has the burden to provide evidence showing that the child has good cause for FTFPT.

Accept any reasonable good cause explanation that is sufficiently supported by evidence as explained below. If needed, develop for the individual’s alleged reasons for FTFPT.

If the individual's alleged reasons for FTFPT are inconsistent with the existing evidence, ask the individual for an explanation. If the explanation you obtain continues to be inconsistent with the existing evidence, consider whether a recontact with the claimant’s medical source or a contact with a third party could resolve the inconsistency.

IMPORTANT: An individual’s mere assertions or allegations about the possible ineffectiveness of the prescribed treatment are not good cause.

The following are examples of what may be good cause for not following prescribed treatment:

If the child’s parent or guardian does not provide evidence showing good cause for FTFPT, follow established procedures specific to child cases before denying the claim or ceasing benefits. If the parent, guardian, or child asserts that the child would have followed prescribed treatment but for the actions of the child’s representative payee, return the claim to the field office (FO) as a “no determination” (ND) and ask the FO to pursue a new payee for the child. For more information about “no determination” claims, see DI 81020.127 Processing "No Determination" (ND) Claims (electronic processing) or DI 32005.020 Disability Determination Services “No Determination” Routing – Paper Case Only.

The FO will defer adjudication on the claim. After establishing a new representative payee, the FO will provide 6 additional months to allow the child time to follow the prescribed treatment. After 6 months, the FO will return the claim to DDS for adjudication.

For more information about determining if a payee sought medically necessary and available treatment, see DI 28005.031 Determining If a Representative Payee Sought Medically Necessary and Available Treatment for the Child When Conducting a Continuing Disability Review (CDR) for a Title XVI Disabled Child (DC) .

Refer child claims to the appropriate Vocational Rehabilitation (VR) agency or to the appropriate State agency administering the State program under Title V of the Act when medical evidence from a CE, MC, PC, or ME (but not from one of the child’s own medical sources) indicates a specific treatment if followed would result in the child no longer having marked or extreme limitations.

IMPORTANT: In States participating in the Ticket to Work Program (TWP), you are prohibited from referring any adult to a VR agency. See DI 26520.010 Initial Referrals and Re-referrals to the Vocational Rehabilitation (VR) Agency and Initial Referrals to Other Agencies and DI 55001.500 Repeal of Referral Authority for Rehabilitation Services after the Ticket to Work Program was Implemented.

A recent hospitalization admissions sheet lists the claimant’s insurance company, but the claimant indicates they do not have money for medications prescribed by the claimant’s medical source, and you have determined that the medications would restore the claimant's ability to perform SGA. The adjudicator should ask the claimant why the insurance listed on the recent hospitalization cover sheet does not cover the costs of their medication. If the claimant indicates their copay for the medication is an amount that they reasonably do not have the money to pay for (such as $65 a week in a Title XVI disability claim), the adjudicator should generally find good cause.

The claimant’s medical source indicates that they have prescribed a course of physical therapy after the claimant has had a knee replacement. You determine that the prescribed course of physical therapy would be expected to restore the claimant’s ability to perform SGA. The claimant alleges that they have no transportation to attend physical therapy although their insurance would cover the cost. The adjudicator should contact a third party who may be familiar with the claimant’s transportation issues. If the third party confirms that the claimant lives in an area with no public transportation and has no way to obtain transportation to the physical therapy, the adjudicator should generally find good cause.

The claimant is prescribed a lower limb prosthesis for a well-healed amputation. They have the prosthesis but does not wear it. They indicate they do not have any problem using the prosthesis, but believe they are more mobile using crutches and prefers them to using the prosthesis. You determine that the claimant’s use of the prosthesis would result in his ability to perform SGA. The adjudicator generally would not find good cause.