When the individual does not provide good cause for failing to comply with the DDSs request and the evidence is insufficient to support a continuance, the DDS will apply the Group II exception, as explained in DI 28075.005D in this section. The month disability ends is the first month in which the individual fails to comply with an appropriate initial request by a certain date, without good cause, and we provided them an explanation that their benefits may cease as an effect of not cooperating. The cessation date will be the date the requested action or information was due.
EXAMPLE
1: Adult individual does not cooperate with DDS. Special handling is not involved.
The DDS adjudicator reviews the CDR case and obtains the medical records from the individual’s medical source(s). The records are insufficient to make a determination. On 09/03/2024 the adjudicator calls the individual to ask additional questions about their condition. There is no answer, so the adjudicator leaves a voicemail with their contact information and the date they called asking the individual to call by 09/13/2024, 10 days from the date of the message. In addition to leaving a message, the adjudicator sends the individual a “call-in” letter dated 09/03/2024 with a due date of 09/18/2024 (10 days plus 5 days mail time) for the individual to call DDS. The letter also explains if the individual does not call by the due date (09/18/2024), DDS may make a determination based on the evidence in file. If we do so, we may determine the individual is no longer disabled and will no longer receive benefits. The individual does not call DDS by 09/18/2024. Therefore, the individual failed, without good cause, to do what DDS requested. The adjudicator documents on an SSA-5002 or on a Case Note in DCPS and “write to” the case development worksheet all the efforts they took to obtain the individual’s cooperation. The adjudicator prepares a cessation determination using 09/18/2024 as the cessation date.
EXAMPLE
2: Adult individual requests CE to be rescheduled; however, the individual does not keep the
rescheduled CE. Special handling is not involved.
On 09/09/2024 the DDS adjudicator sends a letter to the individual explaining we need a CE, and we have scheduled it for 10/07/2024.The letter also explains if the individual does not keep the appointment, we may make a determination based on the evidence in file. If we do so, we may determine that the individual is no longer disabled and will no longer receive benefits. The individual confirms the appointment. However, on the date of the CE the individual does not keep the appointment. The individual contacts DDS and explains they were ill and would like another appointment. The adjudicator determines that the illness is good cause for missing the CE and reschedules the appointment for 10/25/2024. The individual confirms they will attend the CE. However, the individual again does not attend the CE. The individual does not contact DDS to explain why they did not attend the rescheduled CE. The adjudicator documents all the efforts they took to ensure the individuals cooperation to keep the CE on an SSA-5002 or on a Case Note in DCPS and “write to” the case development worksheet. The adjudicator prepares a cessation determination using 10/25/2024 as the cessation date.
EXAMPLE
3: Adult individual with representative payee. Special handling is involved.
This individual alleges difficult walking because of a broken left leg that occurred in 201. The DDS adjudicator requests medical evidence form all the pertinent medical sources. The current medical evidence reveals that the claimant walks unassisted but with a limp. The file contains an x-ray that is about a year old. It shows that the left leg fracture is completely healed. There is no evidence of any other significant current physical problems. The adjudicator determines that the physical part of the case is complete and submits the case to the medical consultant for determination and signature. During review of the medical evidence, the adjudicator finds a note stating the claimant’s mother helps with general activities such as grocery shopping, keeping up with his appointments, etc., because the claimant has memory problems. The mother is the representative payee.
The adjudicator calls the mother on 09/30/2024 to determine if the individual has significant memory problems and can’t reach her, so they leave a voice mail to call by 10/10/2024 (10 days from the voice mail). On the same day, the adjudicator sends a “call-in” letter with a due date of 10/25/2024 (10 days plus 5 days mail time). The letter also states that if the mother doesn’t contact us by the due date, we may make a determination based on the evidence in file. If we do so, we may determine the claimant is no longer disabled and will no longer receive benefits. The mother does not call by the due date. The adjudicator calls the mother to follow up the letter, talks to her, and obtains ADLs. It is determined a mental CE is needed and the CE process is explained to her. The CE is scheduled for 12/03/2024 and the mother confirms they will attend. The claimant and the mother do not keep the appointment; nor do they contact DDS to explain the reason why. Therefore, the individual and his representative payee failed, without good cause, to do what DDS requested. The adjudicator documents on an SSA-5002, or on a Case Note in DCPS and “write to “the case development worksheet all the efforts they took to obtain the individual’s cooperation. The adjudicator prepares a cessation determination using 12/03/2024 as the cessation date.