SSR 18-3p: Titles II and XVI: Failure to Follow Prescribed Treatment

Effective Date: October 29, 2018 Federal Register,

vol. 83, No, 191, page 49616.

Policy Interpretation Ruling

This Social Security Ruling (SSR) rescinds and replaces SSR 82-59 :

“Titles II and XVI: Failure to Follow Prescribed Treatment.”

Purpose: To provide guidance on how we apply our

failure to follow prescribed treatment policy in disability

and blindness claims under titles II and XVI of the Social

Security Act (Act).

Citations (Authority): Sections 216(i) , 223(d)

and (f) , and 1614(a) of the Act,

as amended; 20

CFR 404.1530 and 416.930 .

Dates: We will apply this notice on October 29,

2018. [1]

Overview

- Background

- When we decide whether the failure to

follow prescribed treatment policy may apply in an initial claim Condition 1: The individual is otherwise entitled to

disability or statutory blindness benefits under titles II

or XVI of the Act Condition 2: There is evidence that an

individual’s own medical source(s) prescribed

treatment for the medically determinable impairment(s) upon

which the disability finding is based Condition 3: There is evidence that the individual did

not follow the prescribed treatment

- How we will make a failure to follow

prescribed treatment determination Assessment 1: We assess whether the prescribed

treatment, if followed, would be expected to restore the

individual’s ability to engage in substantial gainful

activity (SGA) Assessment 2: We assess whether the individual has good

cause for not following the prescribed treatment

- Development procedures

- Required written statement of failure

to follow prescribed treatment determination

- When we make a failure to

follow prescribed treatment determination within the sequential evaluation

process Adult claims that meet or equal a listing at step 3 Title XVI child claims that meet, medically equal, or

functionally equal the listings at step 3 Adult claims finding disability at step 5

- Reopening a determination or

decision

- Continuing Disability Reviews (CDR)

ermination

- When we make a failure to

follow prescribed treatment determination within the sequential evaluation

process Adult claims that meet or equal a listing at step 3 Title XVI child claims that meet, medically equal, or

functionally equal the listings at step 3 Adult claims finding disability at step 5

- Reopening a determination or

decision

- Continuing Disability Reviews (CDR)

- Duration in disability and Title II

blindness claims

- Duration in Title XVI blindness

claims

- Claims involving both drug addiction and alcoholism

(DAA) and failure to follow prescribed treatment

Background

When we decide whether the failure to

follow prescribed treatment policy may apply in an initial claim

Condition 1: The individual is otherwise entitled to

disability or statutory blindness benefits under titles II

or XVI of the Act

Condition 2: There is evidence that an

individual’s own medical source(s) prescribed

treatment for the medically determinable impairment(s) upon

which the disability finding is based

Condition 3: There is evidence that the individual did

not follow the prescribed treatment

How we will make a failure to follow

prescribed treatment determination

Assessment 1: We assess whether the prescribed

treatment, if followed, would be expected to restore the

individual’s ability to engage in substantial gainful

activity (SGA)

Assessment 2: We assess whether the individual has good

cause for not following the prescribed treatment

Development procedures

Required written statement of failure

to follow prescribed treatment determination

When we make a failure to

follow prescribed treatment determination within the sequential evaluation

process

Adult claims that meet or equal a listing at step 3

Title XVI child claims that meet, medically equal, or

functionally equal the listings at step 3

Adult claims finding disability at step 5

Reopening a determination or

decision

Continuing Disability Reviews (CDR)

determination

When we make a failure to

follow prescribed treatment determination within the sequential evaluation

process

Adult claims that meet or equal a listing at step 3

Title XVI child claims that meet, medically equal, or

functionally equal the listings at step 3

Adult claims finding disability at step 5

Reopening a determination or

decision

Continuing Disability Reviews (CDR)

Duration in disability and Title II

blindness claims

Duration in Title XVI blindness

claims

Claims involving both drug addiction and alcoholism

(DAA) and failure to follow prescribed treatment

A. Background

Under the Act, an individual who meets the

requirements to receive disability or blindness benefits

will not be entitled to these benefits if the individual

fails, without good cause, to follow prescribed treatment

that we expect would restore his or her ability to engage

in substantial gainful activity (SGA). [1]

We apply the failure to follow prescribed treatment

policy at all levels of our administrative review process

when we decide an initial claim for benefits based on

disability or blindness. We also apply the policy when we

reopen a prior determination or decision involving a claim

for benefits based on disability or blindness, when we

conduct an age-18 redetermination, and when we conduct a

continuing disability review (CDR) under titles II or XVI

of the Act.

This SSR explains the policy and procedures we

follow when we decide whether an individual has failed to

follow prescribed treatment as required by the Act and our

regulations. [2]

B. When we decide whether the failure to follow

prescribed treatment policy may apply in an initial

claim

We will determine whether an individual has

failed to follow prescribed treatment only if all three of

the following conditions exist:

1.The individual would otherwise be entitled to benefits

based on disability or eligible for blindness benefits

under titles II or XVI of the Act;

. When we decide whether the failure to follow

prescribed treatment policy may apply in an initial

claim

We will determine whether an individual has

failed to follow prescribed treatment only if all three of

the following conditions exist:

1.The individual would otherwise be entitled to benefits

based on disability or eligible for blindness benefits

under titles II or XVI of the Act;

2.We have evidence that an individual’s own medical

source(s) prescribed [3] treatment for the medically determinable

impairment(s) upon which the disability finding is based;

and

3.We have evidence that the individual did not follow the

prescribed treatment.

If all three conditions exist, we will determine whether

the individual failed to follow prescribed treatment, as

explained below. [4]

Condition 1: The individual is otherwise entitled to

disability or statutory blindness benefits under Titles II

or XVI of the Act

We only perform the failure to follow

prescribed treatment analysis discussed in this SSR after

we find that an individual is entitled to disability or

eligible for statutory blindness benefits under titles II

or XVI of the Act, regardless of whether the individual

followed the prescribed treatment. We will not determine

whether an individual failed to follow prescribed treatment

if we find the individual is not disabled, not blind, or

otherwise not entitled to or eligible for benefits under

titles II or XVI of the Act.

Condition 2: There is evidence that an

individual’s own medical source(s) prescribed

treatment for the medically determinable impairment(s) upon

which the disability finding is based

whether an individual failed to follow prescribed treatment

if we find the individual is not disabled, not blind, or

otherwise not entitled to or eligible for benefits under

titles II or XVI of the Act.

Condition 2: There is evidence that an

individual’s own medical source(s) prescribed

treatment for the medically determinable impairment(s) upon

which the disability finding is based

If we find that the individual is otherwise

entitled to disability or eligible for statutory blindness

benefits under titles II or XVI of the Act, we will only

determine if the individual has failed to follow prescribed

treatment for the medically determinable impairment(s) upon

which the disability finding is based if the

individual’s own medical source(s) prescribed the

treatment. [5] We will not

determine whether the individual failed to follow

prescribed treatment if the treatment was prescribed only

by a consultative examiner (CE), medical consultant (MC),

psychological consultant (PC), medical expert (ME), or by a

medical source during an evaluation conducted solely to

determine eligibility to any State or Federal benefit.

Prescribed treatment means any medication, surgery,

therapy, use of durable medical equipment, or use of

assistive devices. Prescribed treatment does not include

lifestyle modifications, such as dieting, exercise, or

smoking cessation. We will consider any evidence of

prescribed treatment, whether it appears on prescription

forms or is otherwise indicated within a medical

source’s records.

ibed treatment means any medication, surgery,

therapy, use of durable medical equipment, or use of

assistive devices. Prescribed treatment does not include

lifestyle modifications, such as dieting, exercise, or

smoking cessation. We will consider any evidence of

prescribed treatment, whether it appears on prescription

forms or is otherwise indicated within a medical

source’s records.

We will consider treatment a medical source

prescribed in the past if that treatment is still relevant

to the individual’s medically determinable

impairments that are present during the potential period of

entitlement or eligibility and upon which the disability

finding was based. We will evaluate whether the individual

failed to follow the prescribed treatment, and whether

there is good cause for this failure, only for the

period(s) during which the individual may be entitled to

benefits under the Act.

For example: On January 2, 2017, an individual

filed for disability benefits based on an impairment

related to a lower-extremity amputation. The individual is

no longer wearing a prosthesis that her medical source

prescribed in 2015. We determine that the individual meets

all of the other criteria for disability. In this scenario,

we will evaluate whether the individual is failing to

follow the prescribed treatment to wear the prosthesis

during the potential entitlement period and whether the

individual has good cause for not following the prescribed

treatment during this period. However, we will not consider

whether the individual failed to follow prescribed

treatment prior to the first possible date of

entitlement.

Condition 3: There is evidence that the individual did

not follow the prescribed treatment

If we have any evidence that the individual is

not following the prescribed treatment, this condition is

satisfied. For example, a medical source may include in a

treatment note that the patient has not been compliant with

a prescribed medication regimen.

the first possible date of

entitlement.

Condition 3: There is evidence that the individual did

not follow the prescribed treatment

If we have any evidence that the individual is

not following the prescribed treatment, this condition is

satisfied. For example, a medical source may include in a

treatment note that the patient has not been compliant with

a prescribed medication regimen.

C. How we will make a failure to follow prescribed

treatment determination

If all three conditions exist, we will

determine whether the individual has failed to follow

prescribed treatment in the claim. To make a failure to

follow prescribed treatment determination, we will:

- Assess whether the prescribed treatment, if followed,

would be expected to restore the individual’s ability

to engage in SGA.

- Assess whether the individual has good cause for not

following the prescribed treatment.

Assess whether the prescribed treatment, if followed,

would be expected to restore the individual’s ability

to engage in SGA.

Assess whether the individual has good cause for not

following the prescribed treatment.

We may make either assessment first. If we first

assess that the prescribed treatment, if followed, would

not be expected to restore the individual’s ability

to engage in SGA, then it is unnecessary for us to assess

whether the individual had good cause. Similarly, if we

first assess that an individual has good cause for not

following the prescribed treatment, then it is unnecessary

for us to assess whether the prescribed treatment, if

followed, would be expected to restore the

individual’s ability to engage in SGA.

Assessment 1: We assess whether the prescribed

treatment, if followed, would be expected to restore the

individual’s ability to engage in SGA

t assess that an individual has good cause for not

following the prescribed treatment, then it is unnecessary

for us to assess whether the prescribed treatment, if

followed, would be expected to restore the

individual’s ability to engage in SGA.

Assessment 1: We assess whether the prescribed

treatment, if followed, would be expected to restore the

individual’s ability to engage in SGA

This assessment focuses on the prescribed

treatment. We will determine whether we would expect the

prescribed treatment, if followed, to restore the

individual’s ability to engage in SGA. We are

responsible for making this assessment, and we will

consider all the relevant evidence in the record. At the

initial and reconsideration levels of the administrative

review process, an MC or PC will make this assessment. At

the hearings and Appeals Council (AC) levels, the

adjudicator(s) will make this assessment. Although the

conclusion of this assessment ultimately rests with us, we

will consider the prescribing medical source’s

prognosis.

If we first determine that following the prescribed

treatment would not be expected to restore the

individual’s ability to engage in SGA, then it is

unnecessary for us to assess whether the individual had

good cause for failing to follow the prescribed treatment.

If we determine that following the prescribed treatment

would restore the individual’s ability to engage in

SGA, we will then assess whether the individual has good

cause for not following the prescribed treatment.

Assessment 2: We assess whether the individual has

good cause for not following the prescribed treatment

This assessment focuses on whether the

individual has good cause for not following the prescribed

treatment.

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.

he prescribed treatment.

Assessment 2: We assess whether the individual has

good cause for not following the prescribed treatment

This assessment focuses on whether the

individual has good cause for not following the prescribed

treatment.

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 parent or guardian has the

burden to provide evidence showing that the child has good

cause for failing to follow prescribed treatment. If the

child has a representative payee and the parent, guardian,

or child asserts that the child would have followed

prescribed treatment but for the actions of the

representative payee, we will determine whether to obtain a

new representative payee. If we decide to obtain a new

representative payee, we will provide additional time for

the child to follow the prescribed treatment before we

continue considering the claim.

To assess good cause in both adult and child

claims, we will develop the claim according to the

instructions in the Development procedures section

below. The following are examples of acceptable good cause

reasons for not following prescribed treatment:

- Religion : The established teaching and tenets of

the individual’s religion prohibit him or her from

following the prescribed treatment. The individual must

identify the religion, provide evidence of the

individual’s membership in or affiliation to his or

her religion, and provide evidence that the

religion’s teachings do not permit the individual to

follow the prescribed treatment. Cost : The individual is unable to afford

prescribed treatment, which he or she is willing to follow,

but for which affordable or free community resources are

unavailable. Some individuals can obtain free or subsidized

health insurance plans or healthcare from a clinic or other

provider

nce that the

religion’s teachings do not permit the individual to

follow the prescribed treatment. Cost : The individual is unable to afford

prescribed treatment, which he or she is willing to follow,

but for which affordable or free community resources are

unavailable. Some individuals can obtain free or subsidized

health insurance plans or healthcare from a clinic or other

provider. In these instances, the individual must

demonstrate why he or she does not have health insurance

that pays for the prescribed treatment or why he or she

failed to obtain treatment at the free or subsidized

healthcare provider. Incapacity : The individual is unable to

understand the consequences of failing to follow prescribed

treatment. Medical disagreement : When the individual’s

own medical sources disagree about whether the individual

should follow a prescribed treatment, the individual 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

not to follow the alternate treatment. Intense fear of surgery : The individual’s

fear of surgery is so intense that it is a contraindication

to having the surgery. We require a written statement from

an individual’s own medical source affirming that the

individual’s intense fear of surgery is in fact a

contraindication to having the surgery. We will not

consider an individual’s refusal of surgery as good

cause for failing to follow prescribed treatment if it is

based on the individual’s assertion that success is

not guaranteed or that the individual knows of someone else

for whom the treatment was not successful. Prior history : The individual previously had

major surgery for the same impairment with unsuccessful

results and the same or similar additional major surgery is

now prescribed

ause for failing to follow prescribed treatment if it is

based on the individual’s assertion that success is

not guaranteed or that the individual knows of someone else

for whom the treatment was not successful. Prior history : The individual previously had

major surgery for the same impairment with unsuccessful

results and the same or similar additional major surgery is

now prescribed. High risk of loss of life or limb : The treatment

involves a high risk for loss of life or limb. Treatments

in this category include: Surgeries with a risk of death, such as open-heart

surgery or organ transplant. 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. Amputation of an extremity or a major part of an

extremity. Risk of addiction to opioid medication : The

prescribed treatment is for opioid medication. Other : If the individual offers another reason

for failing to follow prescribed treatment, we will

determine whether it is reasonably justified on a case-by-

case basis.

Religion : The established teaching and tenets of

the individual’s religion prohibit him or her from

following the prescribed treatment. The individual must

identify the religion, provide evidence of the

individual’s membership in or affiliation to his or

her religion, and provide evidence that the

religion’s teachings do not permit the individual to

follow the prescribed treatment.

Religion : The established teaching and tenets of

the individual’s religion prohibit him or her from

following the prescribed treatment. The individual must

identify the religion, provide evidence of the

individual’s membership in or affiliation to his or

her religion, and provide evidence that the

religion’s teachings do not permit the individual to

follow the prescribed treatment.

Cost : The individual is unable to afford

prescribed treatment, which he or she is willing to follow,

but for which affordable or free community resources are

unavailable. Some individuals can obtain free or subsidized

health insurance plans or healthcare from a clinic or other

provider. In these instances, the individual must

demonstrate why he or she does not have health insurance

that pays for the prescribed treatment or why he or she

failed to obtain treatment at the free or subsidized

healthcare provider.

Incapacity : The individual is unable to

understand the consequences of failing to follow prescribed

treatment.

Medical disagreement : When the individual’s

own medical sources disagree about whether the individual

should follow a prescribed treatment, the individual 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

not to follow the alternate treatment.

e individual

should follow a prescribed treatment, the individual 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

not to follow the alternate treatment.

Intense fear of surgery : The individual’s

fear of surgery is so intense that it is a contraindication

to having the surgery. We require a written statement from

an individual’s own medical source affirming that the

individual’s intense fear of surgery is in fact a

contraindication to having the surgery. We will not

consider an individual’s refusal of surgery as good

cause for failing to follow prescribed treatment if it is

based on the individual’s assertion that success is

not guaranteed or that the individual knows of someone else

for whom the treatment was not successful.

Prior history : The individual previously had

major surgery for the same impairment with unsuccessful

results and the same or similar additional major surgery is

now prescribed.

High risk of loss of life or limb : The treatment

involves a high risk for loss of life or limb. Treatments

in this category include:

- Surgeries with a risk of death, such as open-heart

surgery or organ transplant.

- 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.

- Amputation of an extremity or a major part of an

extremity.

Surgeries with a risk of death, such as open-heart

surgery or organ transplant.

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.

improved through treatment.

- Amputation of an extremity or a major part of an

extremity.

Surgeries with a risk of death, such as open-heart

surgery or organ transplant.

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.

Amputation of an extremity or a major part of an

extremity.

Risk of addiction to opioid medication : The

prescribed treatment is for opioid medication.

Other : If the individual offers another reason

for failing to follow prescribed treatment, we will

determine whether it is reasonably justified on a case-by-

case basis.

We will 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 individual shows incapacity as

described above. Similarly, mere assertions or allegations

about the effectiveness of the treatment are insufficient

to meet the individual’s burden to show good cause

for not following the prescribed treatment.

D. Development procedures

If evidence we already have in a claim is

insufficient to make the required assessment(s) in the

failure to follow prescribed treatment determination, we

may develop the evidence, as appropriate. This development

could include contacting the individual’s medical

source(s) or the individual to ask why he or she did not

follow the prescribed treatment. 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. We

are responsible for resolving any conflicts in the

evidence, including inconsistencies between statements made

by the individual and information received from his or her

medical source(s)

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. We

are responsible for resolving any conflicts in the

evidence, including inconsistencies between statements made

by the individual and information received from his or her

medical source(s). We may also evaluate the claim using the

procedures for fraud or similar fault, if appropriate.

E. Required written statement of failure to follow

prescribed treatment determination

When we make a failure to follow prescribed

treatment determination, we will explain the basis for our

findings in our determination or decision.

F. When we make a failure to follow prescribed treatment

determination within the sequential evaluation process for

initial claims

Adult claims that meet or equal a listing at

step 3

Generally, if we find that an

individual’s impairment(s) meets or medically equals

a listing at step 3 of the sequential evaluation process,

and there is evidence of all three conditions listed in

Section B above, we will determine whether the individual

failed to follow prescribed treatment. We will determine

whether an individual would still meet or medically equal a

listing had he or she followed the prescribed treatment. If

we determine the individual would no longer meet or

medically equal the listing had he or she followed

prescribed treatment, we will assess whether there is good

cause for not following the prescribed treatment. We will

determine that the individual is disabled if we find that

he or she has good cause for not following the prescribed

treatment. If we do not find good cause, we will continue

to evaluate the claim using the sequential evaluation

process by determining the individual’s residual

functional capacity (RFC). [6]

hether there is good

cause for not following the prescribed treatment. We will

determine that the individual is disabled if we find that

he or she has good cause for not following the prescribed

treatment. If we do not find good cause, we will continue

to evaluate the claim using the sequential evaluation

process by determining the individual’s residual

functional capacity (RFC). [6]

There are two instances when we will not make a

failure to follow prescribed treatment determination at

step 3 of the sequential evaluation process, even if there

is evidence that an individual did not follow prescribed

treatment. First, we will not make a failure to follow

prescribed treatment determination when we find the

individual disabled based on a listing that requires only

the presence of laboratory findings. In these claims,

treatment would have no effect on the disability

determination or decision. Second, we will not make a

failure to follow prescribed treatment determination when

we find the individual is disabled based on a listed

impairment(s) which requires us to consider whether the

individual was following that specific treatment as part of

the required listing analysis. If either of these

exceptions apply, we will find the individual is disabled

without making a failure to follow prescribed treatment

determination.

Title XVI child claims that meet, medically equal, or

functionally equal the listings at step 3

airment(s) which requires us to consider whether the

individual was following that specific treatment as part of

the required listing analysis. If either of these

exceptions apply, we will find the individual is disabled

without making a failure to follow prescribed treatment

determination.

Title XVI child claims that meet, medically equal, or

functionally equal the listings at step 3

Generally, if we find that a child’s

impairment(s) meets, medically equals, or functionally

equals the listings at step 3 of the sequential evaluation

process, and there is evidence of all three conditions

listed in Section B above, we will determine whether there

has been a failure to follow prescribed treatment. We will

determine whether the child’s impairment(s) would

still meet, medically equal, or functionally equal the

listings had he or she followed the prescribed treatment.

If we determine the child’s impairment(s) would no

longer meet, medically equal, or functionally equal the

listings had he or she followed prescribed treatment, we

will assess whether there is good cause for not following

the prescribed treatment. We will find the child is

disabled if we determine that he or she has good cause for

not following the prescribed treatment. If we determine

that there is not good cause for failing to following the

prescribed treatment, we will find the child is not

disabled.

or she followed prescribed treatment, we

will assess whether there is good cause for not following

the prescribed treatment. We will find the child is

disabled if we determine that he or she has good cause for

not following the prescribed treatment. If we determine

that there is not good cause for failing to following the

prescribed treatment, we will find the child is not

disabled.

There are two instances when we will not make a

failure to follow prescribed treatment determination at

step 3 of sequential evaluation process even if there is

evidence that a child did not follow prescribed treatment.

First, we will not make a failure to follow prescribed

treatment determination when we find the child is disabled

based on a listing that requires only the presence of

laboratory findings. In these claims, treatment would have

no impact on the disability determination or decision.

Second, we will not make a failure to follow prescribed

treatment determination when we find the child is disabled

based on a listed impairment(s) which requires us to

consider whether the child was following that specific

treatment as part of the required listing analysis. If

either of these exceptions apply, we will find the child is

disabled without making a failure to follow prescribed

treatment determination.

Adult claims finding disability at step 5

If we find that an individual is disabled at

step 5 of the sequential evaluation process and there is

evidence the individual is not following treatment

prescribed by his or her own medical source(s), before we

find the individual is disabled, we will assess whether the

individual would still be disabled if he or she were

following the prescribed treatment.

inding disability at step 5

If we find that an individual is disabled at

step 5 of the sequential evaluation process and there is

evidence the individual is not following treatment

prescribed by his or her own medical source(s), before we

find the individual is disabled, we will assess whether the

individual would still be disabled if he or she were

following the prescribed treatment.

We will determine what the individual’s

residual functional capacity (RFC) would be had he or she

followed the prescribed treatment. We will then use that

RFC to reevaluate steps 4 and 5 of the sequential

evaluation process to determine whether the individual

could perform his or her past relevant work at step 4 or

adjust to other work at step 5. We will find the individual

is disabled if we determine that the individual would

remain unable to engage in SGA, even if the individual had

followed the prescribed treatment. We will also find the

individual is disabled if we find the individual had good

cause for not following the prescribed treatment. However,

we will find the individual is not disabled if the

individual does not have good cause for not following the

prescribed treatment and we determine that, had the

individual followed the prescribed treatment, he or she

could perform past relevant work or engage in other

SGA.

G. Reopening a determination or decision

As permitted by our regulations, we may reopen

a favorable determination or decision if we discover we did

not apply the failure to follow prescribed treatment policy

correctly. [7] We may base our

reopening on the evidence we had in the folder at the time

we made our determination or decision or based on new

evidence we receive

n other

SGA.

G. Reopening a determination or decision

As permitted by our regulations, we may reopen

a favorable determination or decision if we discover we did

not apply the failure to follow prescribed treatment policy

correctly. [7] We may base our

reopening on the evidence we had in the folder at the time

we made our determination or decision or based on new

evidence we receive. When we reopen a disability or

blindness determination or decision and find that an

individual does not have good cause for failing to follow

prescribed treatment, we will issue a predetermination

notice and offer the individual an opportunity to respond

before we terminate benefits.

H. Continuing Disability Reviews (CDR)

When we conduct a CDR, we will make a failure

to follow prescribed treatment determination when the

individual’s own medical source(s) prescribed a new

treatment for the disabling impairment(s) since the last

favorable determination or decision and the individual did

not follow the prescribed treatment.

We will also make a failure to follow prescribed

treatment determination during a CDR if we find that an

individual would continue to be entitled to disability or

blindness benefits based upon an impairment first alleged

during the CDR and there is evidence that the individual

has not followed his or her own medical source’s

prescribed treatment for that impairment.

scribed treatment.

We will also make a failure to follow prescribed

treatment determination during a CDR if we find that an

individual would continue to be entitled to disability or

blindness benefits based upon an impairment first alleged

during the CDR and there is evidence that the individual

has not followed his or her own medical source’s

prescribed treatment for that impairment.

If we determine an individual does not have good

cause for failing to follow the prescribed treatment that

we have determined would restore the individual’s

ability engage in SGA, we will issue a predetermination

notice and, because benefits may be terminated, offer the

individual an opportunity to respond before terminating

benefits. Individuals are entitled to benefits while we

develop evidence to determine whether they failed to follow

prescribed treatment. If we determine that an individual

failed to follow prescribed treatment without good cause in

either situation, we will cease benefits two months after

the month of the determination or decision that the

individual is no longer disabled or statutorily blind.

I. Duration in disability and Title II blindness

claims

If an individual failed to follow the

prescribed treatment without good cause within 12 months of

onset of disability or blindness, we will find the

individual is not disabled because the duration requirement

is not met. [8] However, if an

individual failed to follow prescribed treatment without

good cause more than 12 months after onset of disability or

blindness and is otherwise disabled, we will find the

individual is disabled with a closed period that ends when

the individual failed to follow the prescribed treatment.

In this situation, we will continue to pay benefits as

usual through the second month after the month disability

or blindness ends.

J. Duration in Title XVI blindness claims

han 12 months after onset of disability or

blindness and is otherwise disabled, we will find the

individual is disabled with a closed period that ends when

the individual failed to follow the prescribed treatment.

In this situation, we will continue to pay benefits as

usual through the second month after the month disability

or blindness ends.

J. Duration in Title XVI blindness claims

Because title XVI blindness entitlement does

not have a duration requirement, an individual meeting the

title XVI blindness requirements may be entitled to

benefits beginning the month after he or she applies for

benefits. [9] If we determine

an individual failed to follow prescribed treatment without

good cause any time before the first day of the month after

filing, we will find the individual is not disabled.

However, if we determine the individual failed to follow

prescribed treatment without good cause any time after the

first day of the month after filing, we will find the

individual is disabled with a closed period from the date

of entitlement until the date we determined the individual

failed to follow the prescribed treatment without good

cause. In this situation, we will continue to pay benefits

as usual through the second month after the month blindness

ends.

If we need further development to determine whether a

title XVI blind individual failed to follow prescribed

treatment without good cause, the individual is entitled to

benefits while we conduct the additional development. At

the hearing and Appeals Council levels, we will refer the

claim to the effectuating component to develop the evidence

necessary to make a failure to follow prescribed treatment

determination.

K. Claims involving both drug addiction and alcoholism

(DAA) and failure to follow prescribed treatment

use, the individual is entitled to

benefits while we conduct the additional development. At

the hearing and Appeals Council levels, we will refer the

claim to the effectuating component to develop the evidence

necessary to make a failure to follow prescribed treatment

determination.

K. Claims involving both drug addiction and alcoholism

(DAA) and failure to follow prescribed treatment

In a claim that may involve both DAA and

failure to follow a prescribed treatment for an impairment

other than DAA, we will first make the DAA

determination. [10] If we find

that the individual is disabled considering all impairments

including the DAA and that DAA is material to our

determination of disability, we will deny the claim and not

make a failure to follow prescribed treatment

determination. If we find that the individual is disabled

considering all impairments including the DAA, but the DAA

is not material to our determination of disability, we will

then make the failure to follow prescribed treatment

determination for the impairment(s) other than DAA. Even if

the prescribed treatment for the other impairment(s) may

also have beneficial effect on the DAA, we do not

reevaluate for DAA materiality a second time.

For example, we cannot find that an individual has

failed to follow prescribed treatment for liver disease

based on a failure to follow treatment prescribed for

alcohol dependence. If the cessation of drinking alcohol

would be expected to improve the individual’s

functioning so that he or she is not disabled, we would

find that DAA is material to the determination of

disability and deny the claim for that reason.

at an individual has

failed to follow prescribed treatment for liver disease

based on a failure to follow treatment prescribed for

alcohol dependence. If the cessation of drinking alcohol

would be expected to improve the individual’s

functioning so that he or she is not disabled, we would

find that DAA is material to the determination of

disability and deny the claim for that reason.

[1] Our adjudicators will apply this ruling when we make determinations

and decisions on or after October 29, 2018. When a Federal court reviews

our final decision in a claim, we expect the court will review the final

decision using the rules that were in effect at the time we issued the

decision under review. If a court finds reversible error and remands

a case for further administrative proceedings on or after October 29,

2018, the applicable date of this ruling, we will apply this ruling to

the entire period at issue in the decision we make after the court's

remand. Our regulations on failure to follow prescribed treatment are

unchanged.

[2] Sections 223(f) and 1614(a) of the Act. The ability to engage in SGA

is the standard in adult disability claims. However, when this policy is

applied in title XVI child disability claims, the standard is “the

prescribed treatment is expected to eliminate or improve the child's

impairment so that it no longer results in marked and severe functional

limitations.” Similarly, for claims based on statutory blindness,

the standard is the prescribed treatment would be expected to “restore

vision to the extent that the individual will no longer be blind.”

[3] See 20 CFR 404.1530 and 416.930 .

d is “the

prescribed treatment is expected to eliminate or improve the child's

impairment so that it no longer results in marked and severe functional

limitations.” Similarly, for claims based on statutory blindness,

the standard is the prescribed treatment would be expected to “restore

vision to the extent that the individual will no longer be blind.”

[3] See 20 CFR 404.1530 and 416.930 .

[4] There are two exceptions at step 3 of the sequential evaluation

process, explained in section F (below), when we will not make a

failure to follow prescribed treatment determination even if these three [5] See 20 CFR 404.1502 and 416.902 for the definition of “medical source.” [6] See 20 CFR 404.1545 and 416.945 . [7] See 20 CFR 404.988 , 404.989 , 416.1488 ,

and 416.1489 . [8] See 20 CFR 404.1509 and 416.909 . [9] Section 216(i)(1)(B) of the Act. [10] See SSR 13-2p :

Titles II and XVI: Evaluating Cases Involving Drug

Addiction and Alcoholism (DAA), 78 FR 11939 (Mar. 22, 2013).

[5] See 20 CFR 404.1502 and 416.902 for the definition of “medical source.”

[6] See 20 CFR 404.1545 and 416.945 .

[7] See 20 CFR 404.988 , 404.989 , 416.1488 ,

and 416.1489 .

[8] See 20 CFR 404.1509 and 416.909 .

[9] Section 216(i)(1)(B) of the Act.

[10] See SSR 13-2p :

Titles II and XVI: Evaluating Cases Involving Drug

Addiction and Alcoholism (DAA), 78 FR 11939 (Mar. 22, 2013).

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