Identification Number:
DI 23010 TN 1
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Failure to Follow Prescribed Treatment
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 230 – Special Issues
Subchapter 10 – Failure to Follow Prescribed Treatment
Transmittal No. 1, 05/21/2020

Audience

PSC: CS, DE, DEC, DTE, IES;
OCO-OEIO: CR, ERE, FCR, FDE, RECONE;
DQB: DE, PA, PE, TL;
OCO-ODO: DE, DEC, DS, RECONE;
FO: CR TII, CR TXVI, CS, CSR, DRT, FR, OA, OS, RR;
ODD-DDS: ADJ, DHU;
RO: CDP;

Originating Component

ODP

Effective Date

05/21/2020

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

DI 23010.009 Necessary Conditions to Make a Failure to Follow Prescribed Treatment (FTFPT) Determination

In "Section D", The example in DI 23010.009D states, "A medical source’s treatment note includes a statement that the patient has not been compliant with a prescribed medication regiment". "Regiment" was replaced by "regimen".

DI 23010.009 Necessary Conditions to Make a Failure to Follow Prescribed Treatment (FTFPT) Determination

A. Three conditions necessary before making a FTFPT determination

Only make a FTFPT determination when all three of the following conditions are met:

  • The individual is found to be entitled to benefits based on disability or eligible for blindness benefits;

  • The individual's own medical source prescribed treatment for the impairment(s) upon which the disability finding was based; and

  • The individual did not follow the prescribed treatment.

B. Condition 1: Otherwise disabled or blind

The individual has been found entitled to disability or statutory blindness benefits under Titles II and XVI of the Act.

C. Condition 2: Own medical source prescribed treatment

The individual's own medical source prescribed treatment for the medically determinable impairment(s) upon which the disability finding is based. If the individual’s residual functional capacity includes a limiting effect from an impairment, then the impairment is one upon which the disability finding is based.

1. What is prescribed treatment

Prescribed treatment includes medication, surgery, therapy, durable medical equipment, or an assistive device. Prescribed treatment does not include lifestyle modifications, such as dieting, exercise, or smoking cessation.

EXAMPLE: A claimant with a Body Mass Index of 70 and severe degenerative arthritis of the knees is told by her medical source that if she reduced her weight, the arthritis in her knees would improve. We will not make a FTFPT determination for this treatment, even if there is evidence that the claimant refused to exercise or diet to reduce her weight.

2. Who prescribed treatment

Consider treatment prescribed by the individual’s own medical source(s). For a definition of medical source, see DI 22505.001A.4.

Do not make a FTFPT determination if the treatment was prescribed only by a consultative examiner (CE), medical consultant (MC), psychological consultant (PC), medical advisor (MA), medical expert (ME), or by any medical source during an evaluation conducted solely to determine eligibility for any State or Federal benefit, including workers compensation.

3. Evidence of prescribed treatment

Consider any evidence of prescribed treatment, including:

  • statements offered on prescription forms;

  • indications within a medical source’s records that he or she prescribed a specific treatment.; and

  • information provided by the individual or third parties that corroborates evidence on record.

4. When treatment was prescribed

The medical source may have prescribed treatment at any time, even in the distant past. However, you evaluate whether the individual failed to follow the prescribed treatment only during the relevant claim period from the earliest of the alleged onset date, potential onset date, or established onset date. If the prescribed treatment is not relevant to the adjudicative period in the claim, do not make a FTFPT determination. Do not consider whether the individual failed to follow prescribed treatment prior to the first possible date of entitlement.

EXAMPLE: On August 2, 2018, an individual files for disability benefits based on an impairment related to a lower-extremity amputation. The individual is no longer wearing prostheses that her medical source prescribed in 2016. You determine that the individual meets all of the other criteria for disability. Even though the individual’s own medical source prescribed the treatment in the past, and the individual may no longer see the medical source who prescribed the prosthesis, it meets condition 2.

D. Condition 3: Individual did not follow the prescribed treatment

This condition is met if you have any evidence that the individual did not follow the prescribed treatment during the time(s) which the individual may be entitled to disability or blindness benefits.

EXAMPLE: A medical source’s treatment note includes a statement that the patient has not been compliant with a prescribed medication regimen.


DI 23010 TN 1 - Failure to Follow Prescribed Treatment - 5/21/2020