Effective Dates: 04/24/2024 - Present Previous | Next

TN 5 (04-24)

DI 23010.007 When to Apply Failure to Follow Prescribed Treatment Policy

A. In which claim types we apply the failure to follow prescribed treatment (FTFPT) policy

We apply the FTFPT policy in:

  • •

    Claims for new benefits in all Title II and Title XVI claims (see paragraph B, below);

  • •

    Age-18 redeterminations (see paragraph B, below);

  • •

    Adverse reopenings (see paragraph C, below); and

  • •

    Continuing disability reviews (CDRs) (see paragraph D, below)

B. When to apply the FTFPT policy in the sequential evaluation process

1. Step 3 of the sequential evaluation process

If you determine a claimant meets, medically equals, or functionally equals the Listings at step 3, and there is evidence of all three conditions listed in DI 23010.009 Necessary Conditions to Make a Failure to Follow Prescribed Treatment Determination, make an FTFPT determination (unless one of the below exceptions apply). Generally:

Step 3

Claim Type

Assessment

Action

An adult or child claim

Either:

  • •

    We would not expect the prescribed treatment, if followed to reduce the severity of the individual's impairment (s) to the extent that the impairment(s) would no longer meet, equal, or functionally equal the Listings; or

  • •

    A good cause exception applies.

Allow the claim.

An adult claim

Both:

  • •

    We would expect the prescribed treatment, if followed to reduce the severity of the individual's impairment(s) to the extent that the impairment(s) would no longer meet, equal, or functionally equal the Listings; and

  • •

    No good cause exception applies.

Proceed to the next step in the sequential evaluation process by determining the individual's residual functional capacity (RFC).

A child claim

Both:

  • •

    We would expect the prescribed treatment, if followed to reduce the severity of the individual's impairment(s) to the extent that the impairment(s) would no longer meet, equal, or functionally equal the Listings; and

  • •

    No good cause exception applies.

Deny the claim.

Exception 1: Allowance based solely on laboratory findings

If you determine a claimant meets, medically equals, or functionally equals a Listing at step 3 based on a listing that requires only the presence of laboratory findings, do not make an FTFPT determination. Allow the claim.

Current examples of Listings that can be met based solely on laboratory findings include:

Exception 2: Adherence to prescribed treatment has been considered

We will not make an FTFPT determination when we find the individual is disabled based on a listed impairment which requires us to consider whether the individual was following that specific treatment as part of the required listing analysis. If you already considered and determined that the individual was following the prescribed treatment required by a listing during your step 3 analysis, do not make an FTFPT determination about that same treatment. Allow the claim.

Current examples of Listings that include consideration of prescribed treatment during the step 3 analysis include:

  • •

    104.2 /104.02 - chronic heart failure

  • •

    4.10 - aneurysm of aorta or major branches

  • •

    6.06 - nephrotic syndrome

  • •

    11.02/111.02 - epilepsy

2. Step 5 of the sequential evaluation process

If you determine a claimant is unable to perform substantial gainful activity (SGA) at step 5, and there is evidence of all three conditions listed in DI 23010.009 Necessary Conditions to Make a Failure to Follow Prescribed Treatment Determination , make an FTFPT determination considering all established impairments.

Determine what the individual’s RFC would be if they had followed the prescribed treatment. Use that RFC to reevaluate steps 4 and 5 of the sequential evaluation process to determine whether the individual could perform their past relevant work at step 4 or adjust to other work at step 5.

Step 5

Assessment

Action

Either:

  • •

    We would not expect the prescribed treatment, if followed, to allow the individual to be able to perform their past relevant work (PRW) or engage in other SGA; or

  • •

    A good cause exception applies.

Allow the claim.

Both:

  • •

    We would expect the prescribed treatment, if followed, to allow the individual to be able to perform their PRW or engage in other SGA; and

  • •

    No good cause exception applies.

Deny the claim.

NOTE: You must make a new FTFPT determination at step 5, even in the rare situation in which you already have made an FTFPT determination at step 3, because the criteria for an allowance at steps 3 and 5 differ. However, you may use the evidence from the first FTFPT determination to help make the second FTFPT determination.

C. Adverse reopenings

When conditions for reopening a final determination or decision exist, reopen a claim with a previous favorable determination to develop for FTFPT if:

  • •

    The previous determination did not include an FTFPT determination when the evidence already in the folder required one; or

  • •

    New evidence requires us to make a new FTFPT determination.

IMPORTANT: If you determine the claimant does not have a good cause for FTFPT and the claimant would not be disabled or blind if they followed the prescribed treatment, you must issue a predetermination notice as described in DI 23010.040 Adjudication and Notice Procedures for a Failure to Follow Prescribed Treatment Determination.

For more information about adverse reopenings, see DI 27505.001 Conditions for Reopening a Final Determination or Decision.

D. CDR

During the CDR evaluation process, although you may develop evidence for FTFPT during normal development procedures, you only determine whether an individual failed to follow prescribed treatment without good cause once you determine that the individual otherwise remains under a disability or remains blind and either:

  • •

    The individual’s own medical source(s) prescribed a new treatment for the disabling impairment(s) since the last favorable determination or decision and the individual did not follow that prescribed treatment; or

  • •

    We find that the individual would continue to be entitled to disability or blindness benefits based upon an impairment first alleged during the CDR, and there is evidence that the individual has not followed their own medical source’s prescribed treatment for that new impairment.

For all cases in which FTFPT may be applicable, follow the development procedures in DI 23010.013 Development Procedures for a Failure to Follow Prescribed Treatment Determination.

If you determine an individual does not have good cause for failing to follow prescribed treatment from their own medical source and that the individual would not be disabled or blind if they followed the prescribed treatment, you must issue a predetermination notice before ceasing benefits, as described in DI 23010.040 Adjudication and Notice Procedures for a Failure to Follow Prescribed Treatment Determination.

NOTE: In claims that may involve both drug addiction and alcoholism (DAA) and FTFPT, make the DAA determination first. If DAA is material, do not allow the claim and do not make an FTFPT determination. If DAA is not material, then make an FTFPT determination. See DI 90070.000 Drug Addiction and Alcoholism Case Processing Under Public Law 104-121.

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DI 23010.007 - When to Apply Failure to Follow Prescribed Treatment Policy - 04/24/2024
Batch run: 04/24/2024
Rev:04/24/2024