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Skipping Treatment or an Exam Can Deny a Michigan SSDI Claim
Two Michigan Social Security Disability denials have nothing to do with whether the claimant is disabled. One follows a missed consultative examination. The other follows a prescribed treatment the claimant did not pursue, and both are written into the regulations as grounds on which an otherwise qualifying claim is refused.
Under 20 C.F.R. § 404.1518, a claimant who fails or refuses without good reason to take part in a consultative examination the agency arranges may be found not disabled. Under 20 C.F.R. § 404.1530, a claimant who does not follow treatment prescribed by their own medical source, where that treatment is expected to restore the ability to work, will not be found disabled unless there is a good reason.
The first rule is discretionary and the second is not, and both can be answered with a phone call or a documented explanation made at the right time. Neumann Law Group sees both denials in Michigan Social Security Disability files from Lansing to Detroit, and in nearly every one the reason existed and was never put in writing. Both rules say what a good reason is.
The Consultative Examination and the Reasons for Missing One
A consultative examination is an examination or test the agency arranges and pays for when the evidence from a claimant’s own sources is insufficient or inconsistent, and in Michigan it is scheduled through the state’s Disability Determination Services during the initial and reconsideration reviews, the stage our how to apply for SSDI page describes. Section 404.1518(a) states the consequence of not attending and, in the same paragraph, the cure. A claimant with any reason they cannot attend should tell the agency as soon as possible before the examination date, and where the reason is good, another examination is scheduled.
The regulation lists what it considers good reasons: illness on the date of the examination, not receiving timely notice or any notice at all, being given incorrect or incomplete information about the physician or the time or place, and a death or serious illness in the immediate family. The agency also considers the claimant’s physical, mental, educational, and linguistic limitations in deciding whether a reason is good. Section 404.1518(c) adds a route people rarely use. Where a claimant’s own medical source says the claimant should not take the examination or test, the claimant should tell the agency at once, and the source may agree to a different examination for the same purpose.
The Treatment Rule Applies Only After a Finding of Disability
Social Security Ruling 18-3p, published at 83 FR 49616 and applied to decisions on or after October 29, 2018, sets the order of operations. The agency decides whether a claimant failed to follow prescribed treatment only if three conditions exist: the claimant would otherwise be entitled to benefits, the claimant’s own medical source prescribed treatment for the impairment on which the disability finding rests, and there is evidence the claimant did not follow it. A treatment recommended only by a consultative examiner, a state agency medical consultant, or a medical expert at hearing does not count.
The ruling also defines the term. Prescribed treatment means medication, surgery, therapy, durable medical equipment, or assistive devices. It does not include lifestyle modifications, and the ruling names dieting, exercise, and smoking cessation as the examples. A denial built on a claimant’s failure to lose weight or quit smoking has applied a rule the ruling says does not reach those things.
Where the three conditions are met, two assessments follow, in either order. The agency asks whether the treatment, if followed, would be expected to restore the ability to engage in substantial gainful activity, a judgment it makes itself while considering the prescribing source’s prognosis. And it asks whether the claimant had good cause for not following it. A negative answer on either assessment ends the inquiry in the claimant’s favor.
A declined surgery or an unfilled prescription usually has a reason behind it that the chart never records. Getting that reason into the file before the agency asks is a short piece of work, and it is one we do with new clients. One call is usually enough for us to tell you where things stand. Call us at (800) 525-6386.
What Counts as Good Cause
The regulation gives five examples and the ruling expands them. The burden of showing good cause is on the adult claimant, and the ruling states what each reason has to be supported by.
- Religion. The established teaching of the claimant’s religion prohibits the treatment, shown by evidence of membership and of the teaching.
- Cost. The claimant cannot afford treatment they are willing to follow and no affordable or free community resource is available, with a showing of why no insurance or free clinic covered it.
- Incapacity. The claimant is unable to understand the consequences of not following the treatment.
- Medical disagreement. The claimant’s own sources disagree about the treatment, or the claimant followed one source’s treatment to the exclusion of another’s.
- Intense fear of surgery. Supported by a written statement from the claimant’s own source that the fear is a contraindication to the surgery.
- Prior history. The same or similar major surgery for the same impairment was performed before with unsuccessful results.
- High risk of loss of life or limb. Open-heart surgery, organ transplant, one-eye cataract surgery with a severe impairment of the other eye, or amputation.
- Risk of opioid addiction. The prescribed treatment is opioid medication.
Any other reason is judged case by case. Two things are excluded in terms. A claim that the claimant did not know the source had prescribed the treatment is not good cause unless incapacity is shown, and a refusal of surgery because the surgery might not succeed, or because someone the claimant knows had a bad result, is not either. The ruling calls those mere assertions about the treatment’s effectiveness.
Documenting the Reason Before the Agency Asks
Each good-cause reason has a specific proof attached to it, and the proof is easier to gather at the time than at a hearing. A cost reason needs the insurance denial or the clinic’s response. A fear-of-surgery reason needs the treating source’s written statement, and a medical-disagreement reason needs both sources’ notes in the file. Where the claimant’s reason is that the treatment was tried and failed, the earlier operative report is the evidence.
Where a denial has already issued on either ground, the reconsideration stage described on our reconsideration page is where the explanation and its proof go, and a missed examination can be rescheduled at that stage rather than argued about. The reason travels with the file to every later level.
If a Treatment Was Refused or an Exam Was Missed
Both rules turn on reasons the claimant usually had and rarely wrote down, and both are far easier to answer while the file is open than after a decision. At Neumann Law Group, we handle Social Security Disability claims throughout Michigan, and we read a denial notice against both rules before recommending anything. We are glad to talk through any of these questions. Call (800) 525-6386 or send us a message and we will get back to you.