Basic (01-19)

DI 23010.013 Development Procedures for a Failure to Follow Prescribed Treatment (FTFPT) Determination

A. Overview

If evidence already in a claim is insufficient to make a FTFPT determination, you must develop the evidence until it is sufficient to complete the FTFPT determination. You may contact the individual, the individual’s medical source(s), and third parties using the procedures in this section.

Always document the content of your contact in the claim communication section of eCAT. For paper cases, use an SSA-5002.

B. From whom to develop

1. The individual

When you contact the individual, ask him or her to explain why he or she did not follow the prescribed treatment. Avoid making statements to influence the individual’s decision whether to follow the prescribed treatment. State that you are not attempting to interfere with the relationship the individual has with his or her medical source.

NOTE: In a Title XVI child claim, contact the parent, guardian, or payee.

2. A medical source(s)

In claims at the initial or reconsideration levels of the adjudication process, a medical consultant (MC) or psychological consultant (PC), may be most effective at developing FTFPT evidence from medical source(s).

3. Third party

You may contact a third party source who might be able to provide evidence or information relevant to a FTFPT determination.

For more information about disclosing information to third parties, see GN 03305.001 and GN 03316.065.

C. Conflict

If there is inconsistency or conflict within information gathered during development conflict, attempt to resolve the inconsistency or conflict. For example, if an individual states that he or she is following the prescribed treatment but his or her medical source(s) contradicts the individual’s statements, attempt to resolve the discrepancy. We may also rely on expert medical judgment. If appropriate, evaluate the claim using the procedures for fraud or similar fault.

IMPORTANT: Do not purchase a consultative examination to obtain a prognosis or to resolve a conflict about whether good cause exists.

D. When to develop

You may develop evidence for a potential FTFPT determination anytime during normal case development procedures. However, if FTFPT is an issue in the case, you must make every reasonable effort to complete this development in order to make a FTFPT determination prior to issuing an allowance or continuance determination. If the case is a denial or cessation for any other reason, you may stop development for the FTFPT and issue the denial or cessation. However, include all FTFPT development in the folder to help subsequent reviewers on appeal. For the definition of every reasonable effort, see DI 22505.001 Medical and Nonmedical Evidence.

E. References

  • DI 23007.005 Failure to Cooperate With Requests to the Claimant for Evidence or Action

  • DI 23010.030 Exhibit - Predetermination Notice

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DI 23010.013 - Development Procedures for a Failure to Follow Prescribed Treatment (FTFPT) Determination - 01/03/2019
Batch run: 05/08/2019