- There is a finding that the claimant is totally disabled;
- There is evidence from a treating medical source that there is prescribed medical treatment for the disabling condition;
- There is evidence that the claimant did not follow prescribed treatment.
One key factor in number 2 above is that the prescribed medical treatment must come from a treating medical provider. It cannot be a suggestion by a consultative examiner or hearing medical expert. Another important note is that medical treatment does NOT include lifestyle modifications such as dieting, exercise or smoking cessation. The focus is upon medication, surgery, therapy, use of medical equipment and use of assistive devices.
Once there is a determination of the failure to follow prescribed treatment, SSA will ask two more questions: Would treatment be expected to restore the ability to work? Was there good cause for the failure to not follow prescribed treatment?
‘Whether treatment would restore the ability to work’ is a medical question. However, the ruling allows the adjudicators and administrative law judges to make that determination on their own. They do NOT have to consult with a medical expert to make that decision.
It is not good cause to reject a surgical procedure because the Claimant feels success is not guaranteed or because the Claimant knows of others for whom the procedure did not work. This is very often the reason people reject surgery and it will not suffice as good cause.
“Good cause” for failing to follow prescribed treatment is strictly defined as the following:
- Religion – the individual must be able to prove membership and provide evidence that the prescribed treatment is prohibited;
- Cost – the individual must prove why health insurance is not available and that there is no free or subsidized provider available;
- Incapacity – this relates to mental inability to understand the consequences of refusing the prescribed treatment;
- Medical disagreement – if two treating sources disagree over a prescribed treatment an individual is allowed to choose which path to follow;
- “Intense fear of surgery” – this requires written statements from a treating medical source that the fear is so intense that it is a contraindication to surgery;
- Prior history – a prior major surgery for the same problem was unsuccessful;
- High risk of loss of life or limb such as open-heart surgery, organ transplants, amputation of an extremity;
- Risk of addiction if the prescribed treatment is opioid medication;
- Other – other reasons for failing to follow prescribed treatment will be decided on a case-by-case basis.
If “Good Cause” is found, the failure to follow prescribed treatment will not be a bar to benefits.
SSA Will use this in all applications, in fraud reviews and in Continuing Disability Reviews. Therefore, people working with clients receiving SSDI or SSI benefits must make certain that they are following prescribed treatment.