TN 13 (11-22)

DI 28005.031 Determining If a Representative Payee Sought Medically Necessary and Available Treatment for the Child When Conducting a Continuing Disability Review (CDR) for a Title XVI Disabled Child (DC)

Citations

20 CFR 416.635, 20 CFR 416.994a(i), and 1614(a)(3)(H) of the Social Security Act

A. Policy overview on medically necessary and available treatment

1. Representative payee's responsibilities for showing that the child is receiving treatment

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 28010.010B and DI 28010.105 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 GN 00502.001B.

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.

2. What we mean by treatment that is medically necessary

a. Definition of medically necessary treatment

Medically necessary treatment is treatment that is expected to improve or restore a child's functioning that is prescribed by a medical source as defined in DI 22505.001A4.The treatment may include (but is not limited to):

  • physical or psychological medical management (such as examinations and follow ups for medication management);

  • psychiatric, psychological or psychosocial counseling, including treatment from a school psychologist;

  • speech, physical, or occupational therapy; and

  • home therapy, such as administering oxygen or giving injections.

Some examples of medically necessary treatment can include routine or recommended examinations and evaluations. However, medically necessary treatment does not include treatment that is experimental (for example, in a clinical trial) or treatment that is not generally available. If the child's condition(s) is not amenable to treatment, the medically necessary treatment provisions of the law outlined in this POMS do not apply, see DI 28005.031A4.

NOTE: The law does not specify the degree of improvement necessary to satisfy the "show treatment" requirement. The law also does not specify a timeframe for the improvement or restoration of functioning to occur. The improvement or restoration of functioning does not have to be to the point that the child no longer has marked and severe functional limitations.

If the treatment can be expected to improve the child's functioning at all and at any time in the future, the requirement is met. The adjudicator must carefully review the evidence and assess this requirement.

b. When we consider if the child received medically necessary treatment

For every Title XVI child CDR continuance, the adjudicator must consider if the child has received medically necessary treatment at the time of the CDR. The different treatment scenarios that apply are listed below in DI 28005.031C.

c. Developing evidence

Follow the procedures in DI 28030.020 for developing evidence from medical and other sources. The evidence of record will often contain sufficient evidence to determine whether the child is receiving treatment. Examples of evidence showing that the child is receiving (or has receive) treatment may include, but are not limited to: reports from medical sources and reports from the school or other third parties.

3. How to determine whether medically necessary treatment is available

When the adjudicator decides whether medically necessary treatment is available, the adjudicator will consider such things as (but not limited to):

  • The location of an institution or facility or place where treatment, services, or resources could be provided to the child in relationship to where the child resides;

  • The availability and cost of transportation for the child and the payee (or legal guardian) to the place of treatment;

  • The child's general health, including the child's ability to travel for treatment;

  • The capacity of an institution or facility to accept the child for appropriate treatment;

  • The cost of any necessary medications or treatments that are not paid for by Medicaid or another insurer or source; and

  • The availability of local community resources (e.g., clinics, charitable organizations, public assistance agencies) that would provide free treatment or funds to cover treatment.

The adjudicator should follow local business procedures to assess these factors. For additional information, see DI 23010.011C.

4. When evidence of medically necessary and available treatment is not required

We will not require a payee to show treatment if:

  • The child is no longer disabled, i.e., the determination is a cessation; or

  • We determine that the condition(s) that was the basis for providing benefits is not amenable to treatment, or

  • The child does not have a payee (i.e., we pay the child directly), or

  • The child attains age 18 before we make a determination on the CDR.

Although the "show treatment" requirement does not apply in these situations, the provisions for failure to follow prescribed treatment (FTFPT) do apply. See DI 23010.007 for the policies on following prescribed treatment, and DI 28020.900B4 for additional information on the FTFPT Group II exception.

B. How to determine if the child is receiving medically necessary treatment

1. Role of the medical consultant (MC) or psychological consultant (PC) and the adjudicator

a. Role of the MC/PC

The MC/PC must first assess if the child's impairment(s) is not amenable to treatment.

  • If the child's impairment(s) is not amenable to treatment, additional development of medically necessary treatment is not necessary.

  • If the child's impairment(s) is amenable to treatment, additional considerations are outlined below.

If the impairment(s) is amenable to treatment, the MC/PC must then consider whether the child:

  • Has a medical source or is in treatment,

  • Does not have a medical source or is not in treatment, or

  • Has a medical source but the child has not seen the medical source within the last 12 months preceding the date of the SSA-454.

NOTE: The 12-month period is based on our evidence request guidance for CDRs discussed in DI 28030.020D. If the evidence is outside the 12-month period, use judgment to determine if the evidence would support an ongoing treatment relationship.

The MC/PC will determine if there is treatment that is medically necessary that could have been prescribed by a medical source that would improve or restore the child's functioning. For example, the MC/PC believes the child should be receiving routine examinations or evaluations to improve or restore function.

b. Role of the adjudicator

If it is unclear if the child is receiving medically necessary treatment, the adjudicator may need to contact the child’s medical sources or third parties for clarification, as needed.

If the MC/PC determines that there is medically necessary treatment based on information from the longitudinal record and CPD and the child is not receiving treatment, the adjudicator (or, based on local practices, another member of the disability determination services (DDS) staff) must determine whether the treatment is available in the local community. For documentation instructions, see DI 28005.031B.4.b. The adjudicator will determine if good cause for not following prescribed treatment applies, see DI 23010.011C.

If good cause is not established, the adjudicator will need to initiate action to determine whether a change of payee is necessary (provided the treatment is available in the local community and the payee does not, otherwise, have good cause for failing to follow the treatment). See DI 28005.031B.4.a for additional discussion.

2. How to determine if treatment is prescribed

Determine whether the treatment was prescribed by the child's medical source. We define prescribed treatment as medication, surgery, therapy, durable medical equipment or an assistive device that is prescribed by an individual’s own medical source. For additional information on definitions relating to prescribed treatment and medical sources, see DI 23010.009C and DI 22505.001A.4, respectively.

  • Assume that any treatment prescribed by a medical source is medically necessary unless the condition is not amenable to treatment.

  • If the child's medical source is a medical facility (e.g., a hospital, clinic, or health maintenance organization) and the child does not have an ongoing treatment relationship with a particular physician, accept the medical facility's treatment plan as medically necessary, unless there is reason to question the facility's treatment plan. The MC/PC will determine if there is a reason to question the facility’s treatment plan. The MC/PC cannot substitute judgment of the child’s treatment plan.

  • If the condition is not amenable to treatment (meaning treatment is not expected to improve the child's impairment(s)) based on the diagnosis alone or a review of the evidence, assume that any treatment that the child is receiving is not medically necessary.

  • Do not consider experimental treatment modalities or treatment that is not generally available as medically necessary treatment.

3. The difference between a determination based on failure to follow prescribed treatment (FTFPT) and addressing if the child has received medically necessary treatment

The FTFPT may be the basis for a determination. In a CDR, the FTFPT is a Group II exception to medical improvement and does not require a finding that the child’s impairment(s) no longer causes marked and severe functional limitations. For specific CDR FTFPT instructions, see DI 23010.007D.

Additional FTFPT references:

The requirement for treatment that is medically necessary and available in Title XVI child CDRs considers similar factors as FTFPT, such as acceptable reasons to establish good cause, but a payee's failure to comply with the show treatment requirement does not result in a cessation of benefits.

If the payee refuses without good cause to comply with this requirement and it is in the best interest of the child, the adjudicator may request that the field office (FO) develop and select a more suitable payee and pay benefits to another payee or to the child directly. The DDS will alert the FO to any additional action that is required, such as determining the need for a different payee, when necessary and appropriate. See DI 28005.031B.4.b for additional instructions on referring the case to the FO for new payee development.

4. Determining if the payee established good cause and procedures for development of an alternate payee

a. Determining if good cause is established

We must consider if good cause is established when the child is prescribed treatment that is medically necessary and available but not obtained.

The adjudicator must consider factors such as the acceptable reasons for FTFPT in DI 23010.011C and other factors similar to those describing good cause for late filing in GN 03101.020B.

If FTFPT applies, the adjudicator will need to assess if good cause applies. There are two possible findings:

  • Good Cause Found – The payee has not sought or obtained treatment for the child, but good cause applies (no further development, annotate SSA-832 as appropriate in DI 28005.031C.3.a.).

  • Good Cause Not Found – The payee has not sought or obtained the treatment and there is no good cause for the failure, see DI 28005.031C.3.b.

For examples of good cause, see DI 23010.011C.3. For content relating to documentation and closure coding, please see DI 28005.031C.3. and DI 28005.031D below.

b. When to develop for a new payee

The adjudicator refers the case to the FO for payee development if:

  • Medically necessary treatment prescribed by a medical source is available that could improve or restore the child's functioning and without good cause, the child either did not receive it or did not receive it as prescribed, or

  • If there is no medical source, medically necessary treatment is available that could improve or restore the child's functioning.

If it is appropriate to refer the case to the FO based on the above information, the adjudicator will do all of the following:

  • Provide information to the FO on an SSA-883-U3 (Request for Assistance (Disability Case)), see DI 81020.100C for instructions on initiating an electronic assistance request.

  • Explain what treatment was prescribed that is expected to improve or restore the child’s functioning, and whether the treatment would need to be ongoing or necessary for a limited time. The statements should be written clearly using plain language with simple terms (to the degree possible) explaining how the payee did not demonstrate good cause for failing to obtain treatment for the child.

  • Follow local business procedures to identify local community resources that may be able to assist with medically necessary treatment for the child. Enter the names, addresses, and phone numbers of known local community resources in the child’s vicinity (e.g., clinics, charitable organizations, and public assistance agencies) that would provide free treatment or funds to cover treatment, in case the cost of treatment is a barrier. For additional information about locating affordable or free community resources, see DI 23010.011C.3.

  • Document the results of the search or briefly describe the efforts made in the SSA-883-U3. If the search efforts did not yield results, the document this information in the SSA-883-U3.

  • Forward the assistance request to the field office once the above documentation is complete. Ensure a copy of the SSA-883-U3 is imaged to the electronic folder.

The FO will contact the payee and advise him/her of the information described by the DDS in the SSA-883-U3. The FO will advise the payee to provide necessary information as described in DI 13005.080B3.

C. Detailed discussion of treatment scenarios

If the evidence shows that a medical source prescribed treatment, but it was not obtained for the child, the rules on FTFPT in DI 23010.006 apply in determining whether to recommend to the FO that it develop a more suitable payee. Follow the rules in DI 23010.011C4, which discusses special Title XVI issues for individuals under age 18 and determine whether a change of payee may be necessary.

The following sub-sections provide an overview of the difference scenarios and entries on the SSA-832-C2-U3 and the National Disability Determination Services System (NDDSS).

1. In treatment or show treatment provision does not apply

a. Child received medically necessary treatment

For those cases in which the evidence shows that the child is and has been receiving treatment prescribed by a medical source for the disabling condition(s), consider the treatment to be medically necessary and available.

Provided the payee is and has been making a good-faith effort to follow the requirements of the treatment, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark "In treatment."

  • Item 34, enter list code "281."

b. Child is under 18 years of age and does not have a payee

If a child under the age of 18 has no payee and we find that the show treatment provision does not apply, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark "Show treatment provision does not apply."

  • Item 34, enter list code "281."

We may still decide if FTFPT without good cause applies, see DI 23010.007D.

c. Child obtains age 18 and case is an age-18 redetermination

If a child attains age 18 and the case is an age-18 disability redetermination (rather than a Title XVI child CDR), and we find that the "show treatment" provision does not apply, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark- "Show treatment provision does not apply."

  • Item 34, enter list code "281."

2. No treatment issue

a. Child's medical source does not prescribe treatment and treatment is not necessary

  • If the child's medical source has not prescribed any treatment, assume that the impairment is not amenable to treatment or additional treatment is not necessary, or

  • If the child's medical source does not prescribe treatment and the MC/PC determines that treatment is not necessary and not available for any other reason, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark "No treatment issue."

  • Item 34, enter list code "282"

b. Child does not have a medical source and treatment is not necessary

If the child has no medical source and the MC/PC determines treatment is not necessary and available for any other reason, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark "No treatment issue."

  • Item 34, enter list code "283"

c. Condition(s) not amenable to treatment or treatment not medically necessary

There will be certain instances, such as with some palliative treatments in cases of terminal illness or some cases of profound intellectual disability, for which it would be reasonable to conclude that there would be no or negligible improvement or restoration of function with treatment. In such cases, even if treatment is prescribed by a medical source, it is proper to conclude that no treatment is medically necessary for the child. In the event that the MC/PC cannot make these judgments from the evidence in file and the child does not have a medical source, a telephone call by the adjudicator to another source (e.g., educational personnel, public and private social welfare agency personnel, or other non-medical sources), should be sufficient to obtain this information. Do not purchase additional evidence for the sole purpose of making this determination.

In instances where an impairment(s) is deemed not amenable to treatment or treatment is not medically necessary as deemed by the MC/PC, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark "No treatment issue."

  • Item 34, enter list code "283."

3. Medically necessary treatment prescribed but not obtained

a. Treatment unavailable or other good cause (e.g., treatment prescribed but not obtained - good cause demonstrated)

This scenario applies when the evidence shows that the payee attempted to get the treatment that was prescribed by a medical source for the child or independently sought treatment from a medical source but was not able to obtain the prescribed treatment for good cause (see DI 28005.031A.3.).

This scenario also applies to experimental treatment modalities or treatment that is not generally available as medically necessary treatment. Do not consider experimental treatment modalities or treatment that is not generally available as medically necessary treatment. If the payee chooses not to have the child undergo such treatment, even if recommended by a medical source, the above scenario applies and no further development is necessary.

If, due to good cause as discussed in DI 23010.011C., the payee has not sought or obtained the treatment for the child, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark "Treatment unavailable or other good cause."

  • Item 34, enter list code "284."

b. Treatment prescribed and medically necessary- good cause NOT found

If the payee has not sought or obtained the medically necessary treatment and there is no good cause for the failure, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark "Treatment medically necessary – Good cause not found."

  • Item 34, enter list code "285."

Follow instructions for payee development, see DI 28005.031B.4.b.

4. Treatment medically necessary and available - no medical source and condition requires medically necessary treatment

If the payee did not take the child for medically necessary treatment and the child does not have a medical source, the MC/PC will make a medical judgment to determine whether any generally accepted medical treatment would improve or restore the child's functioning, as discussed in DI 28005.031A.2.a. above. Whenever it is determined that treatment is medically necessary and available but not obtained, then:

Enter the following on the SSA-832-C2/U3:

  • Item 24, enter remark " Treatment medically necessary and available."

  • Item 34, enter list code "286."

Follow payee development guidelines and documentation requirements discussed in DI 28005.031B.4.b.

D. Completion of the SSA-832 for continuances

1. Remarks and list codes for the SSA-832

Based on the facts in a continuance, enter the appropriate remark and list code from the following table in items 24 and 34 of the SSA-832 respectively. Every Title XVI childhood CDR continuance must have a list code in item 34 on the SSA-832-C2/U3.

NOTE: The National Disability Determination Services System (NDDSS) requires a list code for all continuance determinations for DC CDRs. The DDS will receive an edit message "T16 CHILDHOOD CASE REQUIRES LIST CODE" if a list code (281 - 287) is not entered in the LA - LF fields. To clear this edit, enter the appropriate list code and remark from the table above. See SM 06001.920E.

Completion of Item 24 and 34 of the SSA-832-U3

In treatment?

Facts

Finding

Remarks - Item 24

List Code - Item 34

Yes

Has:

  • Medical source, or

  • Other source and treatment prescribed or child in treatment, or

  • Treatment provision does not apply, (e.g., the child does not have a payee, see DI 28005.031C1.)

Treatment is medically necessary

"In treatment"

281

No

  • Has a medical source but treatment is not prescribed, or

  • Does not have a medical source and MC/PC determines that treatment is not necessary

Not Applicable

"No treatment issue"

282

No

Has:

  • Medical source, or

  • Other source, or

  • No medical source (or has other source) because condition is not amenable to treatment

Condition is not amenable to treatment (e.g. no treatment necessary due to conditions, as there would be no improvement or negligible improvement expected due to the nature of the condition (see DI 28005.031B.2.c.))

"No treatment issue"

283

No

Has:

  • Medical source, or

  • Other source, or

  • Does not have medical source or other source

Treatment is prescribed or deemed medically necessary, but unavailable or other good cause

"Treatment unavailable or other good cause"

284

No

Has:

  • Medical source, but not in treatment and treatment is medically necessary without good cause

(Explain on SSA-883)

Treatment is prescribed and medically necessary and available, no good cause. (Explain on SSA-833-U3)

Treatment medically necessary. Good cause not found.

285

No

Has:

  • Other source, or

  • No medical source or other source

Treatment not prescribed, but determined medically necessary and available. (Explain on SSA-833-U3)

Treatment medically necessary and available.

286

2. Routing Instructions

Follow the routing instructions in DI 32010.020 for paper folders and DI 81020.250B1 for electronic folders.

Additional Considerations:

  • If list code 285 or 286 applies, follow instructions for payee development in DI 28005.031B.4.b. Ensure a SSA-833-U3 is completed and imaged to the electronic folder.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428005031
DI 28005.031 - Determining If a Representative Payee Sought Medically Necessary and Available Treatment for the Child When Conducting a Continuing Disability Review (CDR) for a Title XVI Disabled Child (DC) <EndLine/> <EndLine/> - 11/15/2022
Batch run: 11/15/2022
Rev:11/15/2022