When conducting a Title XVI child CDR in which the child has a representative payee
(payee), we must determine whether the child is and has been receiving treatment to
the extent considered medically necessary and available for the condition(s) that
was the basis for providing benefits at the comparison point decision (CPD), unless
requiring such evidence would be inappropriate or unnecessary considering the nature
of the child's impairment(s). See DI 28010.001, DI 28010.015, and DI 28010.020 for the policy on the CPD and which impairments to consider. We will refer to this
requirement as the "show treatment" requirement throughout this section.
The requirement to determine if the child has been receiving treatment that is medically
necessary and available only applies to child CDR cases where disability continues.
This requirement does not apply to cessations. Although we do not consider this in
cessations, if evidence suggests a different payee may be necessary, the adjudicator
should follow the same procedures in DI 28005.031B.4.b. for payee development.
In some instances, the payee may not be the legal guardian. The legal guardian may
care for the child, but there may be a different payee. For the purposes of assessing
the medically necessary and available treatment provision, we will determine if additional
action is necessary to consider another payee. For the definition of a payee, see
The payee has a statutory obligation to present this evidence. Consistent with 20 CFR 416.994a(i), the payee must present evidence to demonstrate the child has been receiving the
medically necessary and available treatment.
If the payee refuses without good cause to comply with this requirement, we may determine
whether a change is necessary to pay benefits to another payee or whether it would
be in the best interest of the child to receive benefits directly. Generally, we presume
children under age 18 to be incapable. If it is in the child's best interest, we may
pay benefits to a child who is age 15 or older, or to a child under age 15 who is
legally emancipated, see GN 00502.070A. For an additional discussion of good cause, see DI 28005.031B4.