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Current RMA Instruments
|Reasonable Hypothesis SOP||75 of 2013|
|Balance of Probabilities SOP||76 of 2013|
Changes from previous Instruments
- ICD-9-CM Codes: 333.2,345.0,345.1,345.2,345.3,345.4,345.5,345.7,345.8,345.9
- ICD-10-AM Codes: G40
This is a neurological disease which manifests with chronic and recurring epileptic seizures. This excludes a single seizure event without any enduring propensity to suffer from future seizures. See further information, below.
Confirming the diagnosis
Diagnosis is normally based on specialist opinion and imaging of the brain is usually undertaken.
There is a separate SOP for epileptic seizure. The epilepsy SOP applies if there have been at least two seizures, more than 24 hours apart and not due to an acute (short term) precipitating cause, such as a low blood sugar level, high blood calcium level or acute brain hypoxia (decreased oxygen supply) at the time of the seizure.
The epileptic seizure SOP applies if:
- There has only ever been one seizure event (multiple seizures within a 24 hour period = 1 event), or
- There has been an acute precipitating cause for a seizure.
Both SOPs may apply in the one case:
- If a claimant has epilepsy (and that SOP applies or has been applied previously), but there is a new seizure event, due to an acute precipitating cause, then the epileptic seizure SOP will also apply.
- Two seizure events, not due to an acute precipitating cause, are required to establish a diagnosis of epilepsy. If there has been only one such seizure, the epileptic seizure SOP applies, if there is subsequently a second such seizure, the diagnosis of epilepsy can then be made and the epilepsy SOP would then apply. There may be months, years or even decades between such seizures.
The appropriate medical specialist is a neurologist.
Additional diagnoses covered by SOP
- reflex epilepsy
Conditions that may be covered by SOP (further information required)
- status epilepticus (if first and only fitting episode – use epileptic seizure SOP)
Conditions excluded from SOP
- convulsions associated with: syncope; vertigo; migraine; sleep or movement disorders; or G-force induced loss of consciousness#
- epileptic seizure occurring acutely in response to acute precipitating event* - epileptic seizure SOP
- hysterical or psychogenic seizure#
* another SOP applies
# non-SOP condition
Once the diagnosis has been confirmed (with at least two seizure events not due to an acute precipitating cause) the clinical onset can be backdated to the time of the inital such event.
The course of the disease is variable, as is the degree to which control can be achieved with appropriate therapy. Worsening may be evidenced by an increase in frequency or severity of seizures or the need for altered or additional treatment to control seizures.