Effective Dates: 01/03/2019 - Present Previous | Next

Basic (01-19)

DI 23010.040 Adjudication and Notice Procedures for a Failure to Follow Prescribed Treatment (FTFPT) Determination

A. Claims for new Title II and/or Title XVI disability benefits

A claimant is not entitled to benefits for any month after the month in which he or she fails, without good cause, to follow prescribed treatment that would be expected to restore the claimant's ability to work or result in the claimant being no longer disabled.

1. If treatment is prescribed, FTFPT is established within 12 months of onset, and no good cause is established

Deny the claim on duration.

2. If treatment is prescribed, FTFPT is established more than 12 months after onset of disability, and no good cause established

Allow the claim for a closed period. Find that disability ended the month in which the claimant failed to follow the prescribed treatment without good cause.

B. Claims for new Title XVI blindness benefits

1. No duration requirement

Because Title XVI blindness claims do not have a duration requirement, a statutorily blind individual is entitled to benefits as of the established onset date (EOD). See DI 25501.380.

If you determine that the claimant failed to follow prescribed treatment without good cause prior to the EOD, deny the claim.

2. Closed period

If you determine that the claimant failed to follow prescribed treatment without good cause on or after the EOD and duration is met, find blindness ended the month in which the individual failed to follow prescribed treatment without good cause.

3. Need for further development

However, if further development is needed to make a FTFPT determination and the individual otherwise meets the criteria for Title XVI blindness, the individual is entitled to benefits while we conduct the additional development. Prepare a favorable determination pending resolution of the FTFPT issue. Develop the claims per DI 23010.013.

If you find the individual failed to follow prescribed treatment without good cause:

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    Find that blindness ended the month in which you established the individual failed to follow prescribed treatment without good cause; and

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    Notify the beneficiary using a Notice of Planned Action. Use the notice language in DI 23010.045.

C. Continuing Disability Review (CDR) claims - disability and blindness

1. Predetermination requirements

If, after CDR development, you make a FTFPT determination that a beneficiary has failed to follow prescribed treatment without good cause, you must send a predetermination notice to the beneficiary.

For the appropriate predetermination notice language, see DI 23010.045.

For Title II CDR cessations based on FTFPT, this notice requirement is based on GN 03001.005. For procedural simplicity, we extend this requirement to all Title II CDR cessations based on FTFPT, see DI 40515.020A. This notice is not based upon statutory benefit continuation (SBC) provisions because these cases do not involve medical cessations. See DI 12027.015 Cases Excluded from Statutory Benefit Continuation (SBC).

For Title XVI CDR cessations based on FTFPT, this notice requirement is based on Goldberg/Kelly procedures because they are non-medical group II deficiency cases, see DI 27540.030A. Send these notices to all relevant people listed in SI 02301.300E.2.

Give the individual 30 days to respond to the predetermination notice.

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    If the individual does not respond after 30 days, cease the claim.

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    If the individual responds and provides sufficient evidence of good cause, continue the benefits.

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    If the claimant responds but does not provide good cause for FTFPT, cease the claim.

The benefits cessation date for both situations is 30 days after you sent the predetermination notice.

D. Adverse reopenings

Individuals have a due process right to receive a notice to respond to the proposed adverse action.

For additional information on adverse reopenings, see DI 27525.001.

For the appropriate predetermination notice language, see DI 23010.045.

E. References

DI 12027.015 Cases Excluded from Statutory Benefit Continuation (SBC)

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

DI 23010.045 Predetermination Notice Language for Failure to Follow Prescribed Treatment (FTF) Cessations and Adverse

DI 25501.380 Establishing the Established Onset Date (EOD) of Statutory Blindness in Title II Disability Insurance Benefits (DIB) Claims

DI 27525.001 Due Process Notification for Adverse Reopenings

DI 27540.032 Concurrent Title II/Title XVI – Statutory Benefit Continuation Does Not Apply

DI 28001.020 Frequency of Continuing Disability Reviews (CDRs)

DI 40515.020 Due Process Notification in Title II and Title XVI Cases

GN 03001.005 Notice Requirements for Title II Due Process Actions

SI 02301.300 Due Process Protections - General

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DI 23010.040 - Adjudication and Notice Procedures for a Failure to Follow Prescribed Treatment (FTFPT) Determination - 01/03/2019
Batch run: 05/08/2019
Rev:01/03/2019