Basic (01-19)

DI 23010.011 How to Make a Failure to Follow Prescribed Treatment (FTFPT) Determination

A. General process

To make a failure to follow prescribed treatment determination (when all three conditions explained in DI 23010.009 are met) consider the following:

  • If you start your assessment by determining that the prescribed treatment, if followed, would be expected to restore the individual's ability to engage in substantial gainful activity (SGA), or sufficiently reduce severity in a Title XVI child disability claim or statutory blindness claim (as explained below), next assess whether the individual has good cause for not following the prescribed treatment.

  • If you start your assessment by determining that the prescribed treatment, if followed, would not be expected to restore the individual’s ability to engage in SGA, or sufficiently reduce severity in Title XVI child disability claim or statutory blindness claim (as explained below), allow the claim and do not make a good cause determination.

  • If you start your assessment by determining that the individual has good cause for not following the prescribed treatment, there is no need to assess the effect of the prescribed treatment.

B. Assessing whether we would expect the prescribed treatment, if followed, to restore the individual’s ability to engage in SGA

1. Overview

We will assess whether we would expect the prescribed treatment, if followed, to:

  • Restore the individual’s ability to engage in SGA – in adult disability claims;

  • Eliminate or improve a child’s impairment so that it no longer results in marked and severe functional limitations in Title XVI child disability claims; or

  • Restore vision to the extent that the individual will no longer be considered blind in statutory blindness claims.

2. Who makes the assessment

At the Disability Determination Services (DDS), the medical or psychological consultant (MC/PC) makes this medical assessment. In other adjudicative levels, the adjudicator makes this assessment.

3. Relevant evidence

  • Consider all medical evidence received, including a medical source’s prognosis about prescribed treatment. For instance, you can consider and use a medical source’s statement that an individual is currently unable to walk because the individual is not wearing a prosthetic, but she would be able to walk at least 2 hours in an 8-hour workday with use of a prosthetic. However, our administrative finding is not dependent upon receipt of, or determined by, a medical source’s prognosis.

  • Examples of evidence that might show that the prescribed treatment, if followed, would sufficiently improve the impairments includes evidence that:

    • The individual followed the prescribed treatment in the past and it was sufficiently effective at that time.

    • The treatment is generally known to be sufficiently effective for the individual’s impairment.

    • Although it may be helpful to have evidence from a CE or ME, we are not required to purchase a CE or obtain testimony from an ME to help us determine whether we expect a prescribed treatment, if followed, would restore the ability to engage in SGA.

C. Assessing whether the individual has good cause for not following the prescribed treatment

1. Who makes the assessment

At the DDS, the disability examiner makes this assessment. In other adjudicative levels, the adjudicator makes this assessment.

2. Burden to show good cause

In adult claims, the individual has the burden to provide evidence showing that he or she has good cause for failing to follow prescribed treatment. In child claims, the child’s parent or guardian has the burden to provide evidence showing that the child has good cause for failing to follow prescribed treatment.

Accept any reasonable good cause explanation that is sufficiently supported by evidence as explained below. If needed, develop for the individual’s alleged reasons for FTFPT.

If the individual's alleged reasons for FTFPT are inconsistent with the existing evidence, ask the individual for an explanation. If the explanation you obtain continues to be inconsistent with the existing evidence, consider whether a recontact with the claimant’s medical source or a contact with a third party could resolve the inconsistency.

IMPORTANT: An individual’s mere assertions or allegations about the possible ineffectiveness of the prescribed treatment are not good cause.

3. Examples of Good Cause

The following are examples of what may be good cause for not following prescribed treatment:

a. Religion

The established teaching and tenets of the individual’s religion prohibit him or her from following the prescribed treatment. To support this assertion, the individual must identify the religion, provide evidence of the individual’s membership or affiliation to the religion, and provide evidence that the religion’s teachings do not permit the individual to follow the prescribed treatment.

b. Cost of treatment

The individual is willing to follow the prescribed treatment but is unable to afford the prescribed treatment and affordable or free community resources are unavailable. Because some individuals can obtain free or subsidized health insurance plans or healthcare from a clinic or other provider, to support this assertion, the individual must explain why he or she does not have health insurance that pays for the prescribed treatment or why he or she failed to obtain treatment with a free or subsidized healthcare provider.

  • Document the individual's financial resources and whether he or she has health insurance.

  • Determine whether the individual's health insurance pays for the prescribed treatment. Consider whether the insurance provides coverage of the prescribed treatment at a level the individual can afford.

  • Follow your local business process to identify potential local community resources (i.e., clinics, charitable organizations, public assistance agencies). In most states, this means you must consult with the DDS public relations officer (PRO), and the PRO will consult directly with the individual regarding any potential assistance. Several DDSs have their own lists or links to websites that they encourage staff to use. Other DDSs use a SharePoint that contains the state’s resource information. Always document the results of the PRO consultation or other efforts made.

c. Incapacity

The individual is unable to understand the consequences of failing to follow the prescribed treatment due to incapacity. Do not consider as good cause an individual’s allegation that he or she was unaware that his or her own medical source prescribed the treatment, unless the claimant demonstrates incapacity. Where the evidence in file does not address mental capacity:

  • Contact the individual's medical source(s) to understand whether the individual has signs of a mental impairment and whether the individual is able to understand the consequences of failure to pursue prescribed treatment.

  • Consider ordering a psychiatric or psychological consultative examination if the medical source(s) is unable to assess the individual's ability to understand and pursue treatment.

d. Disagreement among medical sources about treatment

When the individual’s own medical sources disagree about whether the claimant should follow a prescribed treatment, he or she has good cause to not follow the prescribed treatment. Similarly, when an individual chooses to follow one kind of treatment prescribed by one medical source to the simultaneous exclusion of an alternate treatment prescribed by another medical source, the individual has good cause for not following the alternate treatment.

If existing evidence from these medical sources does not corroborate this disagreement, DDS must recontact the relevant medical sources to determine whether they do in fact disagree about whether the individual should follow the prescribed treatment.

e. Intense fear of surgery

The individual’s fear of surgery is so intense that it is a contraindication for the surgery. We require a written statement from the individual’s medical source affirming that the individual’s intense fear of surgery is in fact a contraindication for surgery. Consider whether to order a psychiatric or psychological consultative examination if you are unable to obtain a signed statement from the individual’s medical source.

An individual does not have good cause for failing to follow a prescribed treatment of surgery if the failure to comply is based on the individual’s assertion that an effective result is not guaranteed, or that the individual knows of someone else for whom the treatment was not effective.

f. Prior history

If the individual previously had major surgery for the same impairment with unsuccessful results and the same or similar additional major surgery is now prescribed, the claimant has good cause for FTFPT if he or she decides not to pursue the same or similar surgery again.

g. High risk of loss of life, limb, or vision

If the prescribed treatment involves a high risk for loss of life, limb, or vision, the individual has good cause for FTFPT. This includes a prescribed:

  • surgery with a risk of death, such as open-heart surgery or organ transplant.

  • amputation of an extremity or a major part of an extremity.

  • cataract surgery in one eye with a documented, unusually high-risk of serious surgical complications when the individual also has a severe visual impairment of the other eye that cannot be improved through treatment.

h. Opioid medication

The prescribed treatment is opioid medication.

i. Other

If the individual offers another reason for failing to follow prescribed treatment, determine whether it is reasonably justified on a case-by-case basis.

4. Special good cause procedures for Title XVI child claims

If the child’s parent or guardian does not provide evidence showing good cause for FTFPT, follow established procedures specific to child cases before denying the claim or ceasing benefits. If the parent, guardian, or child asserts that the child would have followed prescribed treatment but for the actions of the child’s representative payee, return the claim to the field office (FO) as a “no determination” and ask the FO to pursue a new payee for the child. For more information about “no determination” claims, see DI 81020.127 (electronic processing) or DI 32005.020 (paper case only).

The FO will defer adjudication on the claim. After establishing a new representative payee, the FO will provide six additional months to allow the child time to follow the prescribed treatment. After 6 months, the FO will return the claim to DDS for adjudication.

For more information about determining if a payee sought medically necessary and available treatment, see DI 28005.031.

Refer child claims to the appropriate Vocational Rehabilitation (VR) agency or to the appropriate State agency administering the State program under Title V of the Act when medical evidence from a CE, MC, PC, or ME (but not from one of the child’s own medical sources) indicates a specific treatment if followed would result in the child no longer having marked or extreme limitations.

IMPORTANT: In States participating in the Ticket to Work program, you are prohibited from referring any adult to a VR agency. See DI 26520.010 and DI 55001.500.

D. Examples of situations that may require development for good cause resolution

1. Insurance issues

A recent hospitalization admissions sheet lists the claimant’s insurance company, but the claimant indicates he or she does not have money for medications prescribed by the claimant’s medical source, and you have determined that the medications would restore the claimant's ability to perform SGA. The adjudicator should ask the claimant why the insurance listed on the recent hospitalization cover sheet does not cover the costs of his medication. If the claimant indicates his copay for the medication is an amount that he reasonably does not have the money to pay for (such as $65 a week in a Title XVI disability claim), the adjudicator should generally find good cause.

2. Transportation issues

The claimant’s medical source indicates that he has prescribed a course of physical therapy after the claimant has had a knee replacement. You determine that the prescribed course of physical therapy would be expected to restore the claimant’s ability to perform SGA. The claimant alleges that he has no transportation to attend physical therapy although his insurance would cover the cost. The adjudicator should contact a third party who may be familiar with the claimant’s transportation issues. If the third party confirms that the claimant lives in an area with no public transportation and has no way to obtain transportation to the physical therapy, the adjudicator should generally find good cause.

3. Prosthesis use

The claimant is prescribed a lower limb prosthesis for a well-healed amputation. He has the prosthesis but does not wear it. He indicates he does not have any problem using the prosthesis, but believes he is more mobile using crutches and prefers them to using the prosthesis. You determine that the claimant’s use of the prosthesis would result in his ability to perform SGA. The adjudicator generally would not find good cause.

E. References

DI 23010.007 When to Apply Failure to Follow Prescribed Treatment (FTFPT) Policy

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

DI 23010.035 Required Written Analysis for a Failure to Follow Prescribed Treatment (FTFPT) Determination

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

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

DI 26520.010 Initial Referrals and Re-referrals to the Vocational Rehabilitation (VR) Agency and Initial Referrals to Other Agencies

DI 28005.031 CDR Evaluation Process -- Title XVI DC Under Age 18 --Determining If Payee Sought Medically Necessary and Available Treatment for the Child

DI 32005.020 Disability Determination Services “No Determination” Routing – Paper Case Only

DI 55001.500 Repeal of Referral Authority for Rehabilitation Services In States Where the Ticket to Work Program Is Implemented

DI 81020.127 Processing “No Determination” (ND) Claims


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DI 23010.011 - How to Make a Failure to Follow Prescribed Treatment (FTFPT) Determination - 01/03/2019
Batch run: 01/14/2019
Rev:01/03/2019