BASIC (04-00)

DI 22510.047 Pediatric CE Report Content Guidelines - Neurological Disorders

A. Policy - General

Specific requirements exist in addition to all general pediatric guidelines in DI 22510.035.

B. Policy - Description for Seizures

If seizures are present, there should be a description of:

  • Type;

  • abnormal behavior prior to seizure;

  • Aura;

  • Frequency, timing, provocative factors;

  • Nature and duration of seizure activity;

  • Post-ictal state;

  • Duration of post-ictal state;

  • Medication with dosage (including any recent adjustments to medication);

  • Response to treatment; and

  • Side effects of medication;

  • Any signs of injury due to seizures;

  • Episodes of headache;

  • Pain;

  • Incontinence;

  • Speech and language abnormalities;

  • Weakness; and

  • Abnormal movements and coordination.

C. Policy - Physical Exam

The physical exam should include a description of the claimant's:

  • Mental status (e.g., orientation);

  • Reflexes, balance, strength;

  • Fine motor skills; and,

  • Gait (where age-appropriate) at rest and with activity.

  • Coordination and abnormal movements, if any.

  • Sensory examination;

NOTE: When formal muscle strength testing is not possible for younger children, record observations of sitting, pulling, rolling over, rising from supine position, etc.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422510047
DI 22510.047 - Pediatric CE Report Content Guidelines - Neurological Disorders - 10/06/2016
Batch run: 10/06/2016
Rev:10/06/2016