The Social Security Administration (SSA) has issued a new ruling about the effect of failure to follow prescribed treatment. In general, an individual who is otherwise disabled is not entitled to Social Security Disability or Supplemental Security Income benefits if they do not follow prescribed treatment that would be expected to restore the ability to perform substantial gainful activity without good cause.
SSA determines whether an individual has failed to follow prescribed treatment when:
1) The individual would otherwise be eligible for benefits
2) There is evidence that the individual’s own medical source prescribed the treatment for the impairment upon which the disability finding is based. Prescribed treatment means medication, surgery, therapy, use of durable medical equipment or use of assistive device. Prescribed treatment does not include lifestyle modifications such as dieting, exercising or smoking cessation. SSA considers any evidence of prescribed treatment including prescription forms and medical records.
3) There is evidence that the individual did not follow the prescribed treatment.
If all these conditions exist, then SSA determines whether the prescribed treatment, if followed, would be expected to restore the individual’s ability to perform substantial gainful activity, and whether the individual has good cause for not following the prescribed treatment. Good cause includes religion, cost, incapacity that means the individual is unable to understand the consequences of failure to follow prescribed treatment, medical disagreement among individual’s own medical sources, intense fear of surgery, prior unsuccessful major surgery, high risk of loss of life or limb, or risk of addiction to opioid medication. Good cause does not include the individual’s allegation that they were unaware of the prescribed treatment unless the individual shows incapacity. If either of these criteria is met, then SSA will not find failure to follow treatment.
To develop failure to follow prescribed treatment, SSA can contact the medical source. SSA can purchase a consultative examination or obtain testimony from a medical expert but is not required to do so.
For listings, if SSA finds failure to follow prescribed treatment without good cause, SSA continues by evaluating residual functional capacity. For listings, SSA will not find failure to follow prescribed treatment if disability is based on a listing that requires only the presence of laboratory findings, or the listing requires consideration of whether the individual was following a specific treatment.
For residual functional capacity, SSA will find that the individual is disabled if they would be unable to perform substantial gainful activity even if they had followed prescribed treatment.
SSA can reopen a favorable determination or decision if it discovers that it did not apply failure to follow prescribed treatment correctly.
For continuing disability reviews, SSA will make a failure to follow prescribed treatment finding when the individual’s medical source prescribes a new treatment since the last favorable determination without good cause. SSA also will find failure to follow prescribed treatment for a new impairment alleged during the continuing disability process and there is evidence that the individual did not follow prescribed treatment without good cause.
For drug and alcohol cases where SSA finds that drugs and alcohol are not material to the disability determination, a failure to follow prescribed treatment, SSA does failure to follow prescribed treatment determination only for impairments other than drugs and alcohol. (SSR 18-03, October 29, 2018.)