The failure to follow prescribed treatment often arises in Social Security Disability (SSD) claims for a variety of reasons, such as not having insurance, religion, or in recovery from substance abuse. However, the Social Security Administration (SSA) does not treat all reasons equally. This can be problematic for SSD representatives when handling an SSD claim
Good Causes
Fortunately, there are ‘good causes’ for not following prescribed treatment that may help argue a case. Pursuant to Social Security Ruling 18-3p (which replaced SSR 82-59 in October 2018), ‘good cause’ for a claimant not following a treatment plan includes religion, cost, incapacity, medical disagreement, intense fear of surgery, prior history of unsuccessful treatment, high risk of loss of life or limb, risk of opioid addiction, and on a case-by-case basis. Let’s review these ‘good causes’ in detail.
Religion
Individual must provide evidence of membership in the religion and religion’s teachings that prohibit following the treatment plan.
Cost
Evidence must be submitted showing why the individual was not able to seek free community resources or free community resources were unavailable.
Incapacity
Individual was unable to understand the consequences of not following prescribed treatment.
Medical Disagreement
Treating physicians disagree on a treatment plan.
Intense Fear of Surgery
Treating physician provides written document confirming an individual’s intense fear of surgical procedure due to success not guaranteed or he/she knows of someone else for who treatment was not successful.
Prior History
Procedure has been unsuccessful for the individual in the past and prescribed again.
High Risk of Loss of Life or Limb
These procedures typically involve heart surgeries, amputation, or loss of vision.
Risk of Addiction to Opioids
Individual is prescribed opioids, typically pain medication, and there is risk of addiction. This typically applies to those in recovery for substance abuse and those fearful of opioid addiction due to the current epidemic in the U.S.
Other
The adjudicator can determine on a case-by-case basis if failure to follow prescribed treatment is reasonably justified. A common ‘other’ category would include medications that cause adverse reactions with other medications or affect an organ such as the liver.
Forewarnings: Cost of Treatment, History of Substance Abuse
Common reasons for failure to follow prescribed treatment may be due to the cost of treatment and/or history of substance abuse. If the failure to follow prescribed treatment was due to the cost of the treatment, an individual must show low-cost, free community resources, or sliding-scale resources were not available.
Someone in recovery from substance abuse cannot claim ‘good cause’ for failing to take Paxil for depression due to having a history of substance abuse; the medications applicable here are opioids. There is an opportunity to argue ‘good cause’ if psychotropics are unusually strong or significant fear of the drug due to past experiences or risk of relapse.
If an adjudicator finds DAA is not material, he/she will apply the ‘good cause’ evaluation to other impairments. The adjudicator will consider treatment options for other impairments such as liver disease, cervicalgia, and depression separate from history of substance abuse. If treatment options for other impairments would have an effect on DAA, the adjudicator does not reevaluate DAA materiality a second time. The DAA analysis is applied only once.
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