TN 2 (11-02)

DI 28005.031 CDR Evaluation Process -- Title XVI DC Under Age 18 --Determining If Payee Sought Medically Necessary and Available Treatment for the Child

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 treating source (TS), as defined in DI 22505.001B.1. If you do not have a TS, we will decide whether there is treatment that is medically necessary that could have been prescribed by a TS. 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. Basic Approach

a. Medically Necessary Treatment

For continuances in which the child has a payee, it must be determined whether 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 providing benefits, unless requiring such evidence would be inappropriate or unnecessary considering the nature of the child's impairment(s). Treatment that is “medically necessary” is treatment that is expected to improve or restore the child's functioning. The law does not specify the degree of improvement necessary to satisfy this requirement, nor does it specify that improvement or restoration of functioning must occur within a specified time period. Thus, if the treatment can be expected to improve the child's functioning at all and at any time in the future, you should consider the requirement met. The improvement or restoration of functioning need not be to the point that the child no longer has marked and severe functional limitations. If the child's condition(s) is not amenable to treatment, the treatment provisions of the law do not apply.

b. Role of Medical or Psychological Consultant

The medical or psychological consultant (MC/PC) should decide whether the child's condition is amenable to treatment, and, if so, a member of the adjudicative team will need to decide whether the treatment that the MC/PC determined to be medically necessary is available based on the longitudinal record from the initial claim and the evidence developed for the CDR. In most cases, there will be sufficient evidence available from this record, including reports from the TS or other sources of medical evidence to make these judgments. In the event that the MC/PC cannot make these judgments from the evidence in file, a telephone call to the TS or, when there is no TS, to another source (e.g., a consultative examiner or other nontreating source), should be sufficient to obtain this information. Purchase of additional evidence for the sole purpose of making this decision should not be undertaken.

c. If There is a TS

If the child's condition is amenable to treatment and the child is and has been receiving treatment, you must first determine whether it is from a TS, as defined in DI 22505.001B.1. If the treatment is from a TS, assume it is medically necessary. In such a case, no further development will be necessary.

NOTE: If the TS has not prescribed any treatment, as determined from the longitudinal record including any necessary telephone inquiries, assume that the impairment is not amenable to treatment. It would be inappropriate to suggest treatment not prescribed by a TS. It is appropriate for an MC/PC to make a medical judgment about whether any generally accepted medical treatment would improve or restore the child's functioning only if there is no TS. Bear in mind that routine or recommended examinations and evaluations can be considered “medically necessary treatment” if they are consistent with accepted medical practice; so, if the only “prescribed treatment” is that the child should have these kinds of examinations, and if the payee takes the child for them, this would be considered complying with treatment.

d. If There Is No TS

If the child has no TS or other medical source, the MC/PC will need to decide whether there is treatment that is medically necessary that could have been prescribed by a TS. Because there will be no current TS evidence upon which to draw in these cases, the MC/PC will need to review the longitudinal record from the initial claim and the evidence developed for the CDR. This will include reports from prior TSs or other sources of medical evidence. Based on this record, the MC/PC must make a medical judgment to determine if any generally accepted medical treatment would improve or restore the child's functioning. Do not consider experimental treatment modalities or treatment that is not generally available as medically necessary treatment. If there is any generally accepted medical treatment that would improve or restore the child's functioning, DDS adjudicators must determine the availability of the medically necessary treatment in the local community.

Analogous to the discussion in the note under 1.c. above, if there is no TS and the MC/PC believes the child should be receiving routine examinations or evaluations to improve or restore functioning, it would be reasonable to recommend such “treatment.”

NOTE: If the child's regular health care provider is a medical facility that is a “medical source” (e.g., a hospital, clinic, or health maintenance organization), as defined in DI 22505.001B.2., with which there is no ongoing treatment relationship between the child and a particular physician, psychologist, or other acceptable medical source, the MC/PC normally will not need to make an extensive judgment about what treatment the child should be receiving and ordinarily can accept the medical source's treatment as medically necessary, unless there is reason to question the medical source's treatment plan. The same holds true if the source of record is a physician, psychologist, or other acceptable medical source that has treated or evaluated the claimant, but does not or did not have an ongoing treatment relationship with the child. In any case, the MC/PC will need to determine whether the treatment could improve or restore the child's functioning. If it can, the DDS will need to initiate action to determine whether a change of payee is necessary (provided the treatment is available in the local community and the payee does not, otherwise, have good cause for failing to follow the treatment).

e. Determining Availability of Medically Necessary Treatment

In determining the availability of medically necessary treatment, explore the availability of all local community resources (e.g., clinics, charitable organizations, public assistance agencies) in the same way as in a situation involving failure to follow prescribed treatment as described in DI 23010.010A.5.

2. SSA-832-C2/U3 Remarks, List Codes and Additional Actions After Deciding Whether Treatment Is Medically Necessary and Available (See Exhibit at DI 28005.031C.)

a. Child Received Medically Necessary Treatment

It will be necessary to contact the payee or others to determine whether the child is receiving treatment only if there is no evidence in the file to this effect. The file will often contain sufficient evidence to eliminate the need for such contacts. Examples of sources of evidence that the treatment is being received include, but are not limited to, reports from medical sources, reports from the payee or other third parties, and photocopied prescription receipts. Of course, if you know that treatment is unavailable (see paragraph 2.b.) or if the condition is not amenable to treatment (see paragraph 2.e.), you would not need to develop this issue either.

For those cases in which the evidence shows that the child is and has been receiving treatment prescribed by a TS for the disabling condition(s), consider the treatment to be medically necessary and available. Provided the payee is and has been making a good-faith effort to follow the requirements of the treatment, enter the following remark in item 24 of the SSA-832-C2/U3:

“In treatment.” Also enter list code “281” in item 34.

Also enter 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 22505.001B.2. (See also the “NOTE” under DI 28005.031B.1.d.)

b. Medically Necessary Treatment Prescribed But Not Available

If the evidence shows that the payee attempted to get the treatment that was prescribed by a TS for the child or independently sought treatment from a TS but was not able to obtain the prescribed treatment for a justifiable reason (see the criteria set forth in DI 28005.031A.3.), enter the following remark in item 24 of the SSA-832-C2/U3:

“Treatment unavailable or other good cause.” Also enter list code “284” in item 34.

NOTE: As stated in DI 28005.031B.1.d., do not 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 TS, the above remark would apply and no further development would be necessary.

c. Medically Necessary Treatment Prescribed and Available But Not Obtained

  • When Rules on Failure to Follow Prescribed Treatment Will Apply

    If the evidence shows that a TS prescribed treatment, but it was not obtained for the child, the rules on failure to follow prescribed treatment in DI 23010.010 will apply in making the decision whether you should recommend to the FO that it develop for another representative payee, provided the FO finds this is in the best interests of the child. Follow the rules in DI 23010.020, which discusses special Title XVI issues for individuals under age 18, and determine whether a change of payee may be necessary.

  • Good Cause Found

    If, due to good cause as defined in DI 23010.005A.3., the payee has not sought or obtained the treatment for the child, enter the same remark in item 24 of the SSA-832-C2/U3 as in paragraph 2.b.:

    “Treatment unavailable or other good cause.” Also enter list code “284.”

  • Good Cause Not Found

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

    “Treatment medically necessary -- Good cause not found.” Also enter list code “285.”

    In this case, send the claim to the FO to develop for another representative payee, provided the FO finds obtaining a new payee to be in the best interests of the child. Explain to the FO on an SSA-883-U3 (Request for Assistance (Disability Case)) what treatment has been prescribed and why you find that the payee does not have good cause for failing to obtain the treatment for the child. Remember that FO staff are not likely to be trained in medical areas, so your explanation should be presented in lay terms to the degree possible. If you know of local community resources (e.g., clinics, charitable organizations, public assistance agencies) that would provide free treatment or funds to cover treatment, enter the names and addresses of these resources on the SSA-883-U3, in case the payee is unable to afford the treatment.

    Bear in mind that, if the treatment could be expected to improve or restore the child's functioning to the point that the child would no longer have marked and severe functional limitations, he issue becomes more complicated because of the potential for cessation of benefits. In this event, you will need to contact the payee and initiate development, per DI 23010.005 and DI 23010.010; then, consider returning the case to the FO for development of a new payee or referring the case to an appropriate social agency for assistance instead of to the FO. In addition, if the payee does not comply with treatment requirements, you will need to send a predetermination notice per DI 23010.015 and DI 23010.020.

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

As discussed in paragraph 1.d., if the payee did not take the child for any kind of treatment and the child does not have a TS, the MC/PC 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 treatment is medically necessary and available, enter the following remark in item 24 of the SSA-832-C2/U3:

“Treatment medically necessary and available.” Also enter list code “286” in item 34.

As with paragraph 2.c., forward the case to the FO, and explain on an SSA-883-U3 what treatment 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, state what the duration would be.) Again, your explanation should be presented in lay terms to the degree possible, and you should provide the names and addresses of available community resources.

e. No Treatment Necessary -- Condition(s) Not Amenable to Treatment or MC/PC Determines Treatment Not Necessary

There will be certain instances, such as with some palliative treatments in cases of terminal illness or some cases of profound mental retardation, for which it would be reasonable to conclude that there would be no or negligible improvement or restoration of function with treatment. In such cases, it is proper to conclude that no treatment is medically necessary for the child. In addition, even if treatment is prescribed by a TS for an impairment not amenable to treatment, this will be a situation in which it is proper to conclude that no treatment is necessary. If it can be determined, either on the basis of the diagnosis alone or by review of the evidence, that the condition is not amenable to treatment, enter the following remark in item 24 of the SSA-832-C2/U3:

“No treatment issue.” Also enter list code “283” in item 34.

Also, enter this remark if the TS does not prescribe treatment or if the child has no TS and the MC/PC determines that treatment is not necessary and available for any other reason. If the child's TS does not prescribe treatment, enter list code “282” in item 34. If the child has no TS and the MC/PC determines that treatment is not necessary and available for any other reason, enter list code “283” in item 34.

f. When “Show Treatment” Provisions Do Not Apply

A title XVI edit was added to the National Disability Determinations Services System (NDDSS) to prevent title XVI childhood CDR continuances from clearing the NDDSS if no list code is entered. However, there will be instances in which the case characteristics established for this edit will apply (i.e., the child has not attained age 18 as of the examiner signature date on the NDDSS) but the “show treatment” provisions will not apply. This will occur when a child under the age of 18 has no representative payee, or when the case is a disability redetermination (rather than a CDR.) A list code is still necessary to clear the edit condition. Enter list code “281” on the SSA-832-C2/U3 and on the NDDSS for any case in which the “show treatment” provision does not apply but the edit message appears.

g. List Codes

Every title XVI childhood CDR continuance must have a list code in item 34 on the SSA-832-C2/U3. The following edit message appears anytime a continuance is cleared on the NDDSS without entering a “show treatment” list code: “T16 CHILDHOOD CASE REQUIRES VALID LIST CODE.” To clear this edit, enter one of the following “show treatment” list codes on the NDDSS along with the appropriate remark according to the facts and findings shown in DI 28005.031C.

C. Continuance -- situation and actions