TN 41 (02-22)

DI 28020.900 Group II Exceptions

A. Procedure for group II exceptions

These exceptions (described in the definitions and references in subsection B) do not require:

  • A finding that the individual is not currently disabled; i.e., do not require a finding of ability to engage in Substantial Gainful Activity (SGA) or,

  • For Title XVI child cases, a finding that the child's impairment(s) no longer causes marked and severe functional limitations.

Consider these issues whenever they arise, at any point in the Continuing Disability Review (CDR) evaluation process (DI 28005.015, DI 28005.030).

Related Procedure:

See DI 28005.205 concerning cessation month where a group II exception applies.

B. Definitions and references regarding group II exceptions

1. Fraud or similar fault (FSF)

For definitions of the terms “fraud” and “similar fault” refer to GN 04105.005B.

The Group II exception for FSF applies when a prior favorable determination or decision was obtained by FSF. If we find that any prior favorable or partially favorable decision was obtained by FSF, we may find that the beneficiary or recipient is not disabled. In addition, we may reopen the prior determination on the remaining evidence.

This exception does not apply when FSF is involved only in the pending CDR. In this situation; follow the FSF instructions in DI 23025.000. When FSF occurs in the pending CDR, disregard evidence obtained by FSF and make a determination on the remaining evidence. This may result in either a cessation or a continuance determination.

References:

  • DI 27505.015 Fraud or Similar Fault (FSF) - Reopenings

  • DI 28020.375 Error, Reopening, and the Medical Improvement Review Standard (MIRS)

2. Failure to cooperate

Failure to cooperate (FTC) means the beneficiary or recipient failed to comply with the request for evidence or action without good cause. Specifically,

  • the beneficiary or recipient did not state orally or in writing that he or she would not provide the needed evidence (e.g. description of past work) or perform the needed action (e.g. respond to a call in letter), or

  • the beneficiary or recipient states orally or in writing that he or she will not provide the needed evidence or perform the needed action, and the individual does not provide good cause why he or she will not cooperate with the request.

If the beneficiary or recipient provides good cause for not cooperating, give the individual another opportunity to provide the needed evidence or perform the needed action. FTC without good cause is a basis for the Disability Determinations Services (DDS) to find a cessation and terminate Title II and/or Title XVI benefits only when there is not enough evidence in file to justify a continuance. FTC does not apply if there is enough evidence to make a continuance determination. For good cause reasons for FTC, see DI 28075.005H.1.

Children are not ordinarily in a position to pursue their claims independently. Make special efforts in Title XVI child cases involving noncooperation to identify and contact another adult or agency responsible for the child's care.

The general approach to apply FTC and whereabouts unknown (WU) for CDRs is located in DI 28075.005. The references cited below provide a more detailed overview of the FTC and WU process that applies to CDRs as well as initial claims. Field office (FO) instructions can be found in DI 13015.001 through DI 13015.025.

References:

  • DI 23007.000 Failure to Cooperate - Table of Contents

  • DI 25205.020 Failure to Cooperate and Insufficient Evidence in Title XVI Disabled Child (DC) Cases

  • DI 28075.005 Failure to Cooperate (FTC) and Whereabouts Unknown (WU) During a Medical Continuing Disability Review (CDR)

3. Whereabouts unknown

WU status exists when there is a question that needs the be resolved about whether the beneficiary or recipient continues to be disabled and the individual cannot be located at the last known address. If the DDS identifies the WU exception applies, the disability examiner stops development and returns the case to the FO as a "No Determination."

References:

  • DI 13015.025B Field Office (FO) Assistance in Medical Continuing Disability Reviews (CDR) and Failure to Cooperate-Insufficient Evidence Decision (FTC) or Whereabouts Unknown (WU)

  • DI 28075.005 Failure to Cooperate (FTC) and Whereabouts Unknown (WU) During a Medical Continuing Disability Review (CDR)

4. Failure to follow prescribed treatment

An individual must follow his or her own medical source’s prescribed treatment to receive disability, SSI, or statutory blindness benefits if the treatment is expected to:

  • restore the ability to engage in SGA in adult claim,

  • reduce functional limitations so that they are no longer marked and severe in child claims, or

  • restore vision in blindness claims.

    However, we do not require the individual to follow the prescribed treatment if he or she shows good cause. See POMS DI 23010.011C for good cause reasons for failing to follow prescribed treatment.

References:

  • DI 23010.006 Failure to Follow Prescribed Treatment (FTFPT) - General

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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428020900
DI 28020.900 - Group II Exceptions - 02/14/2022
Batch run: 02/14/2022
Rev:02/14/2022