What medical documentation is required to confirm a stroke‑induced permanent hemiplegia for a disability claim?

Medical Documentation for Stroke-Induced Permanent Hemiplegia in Disability Applications

For a disability claim based on stroke-induced permanent hemiplegia, you must provide neuroimaging confirmation of CNS infarction (CT or MRI showing the stroke location), documentation of persistent neurological deficits using standardized scales (NIHSS and modified Rankin Scale), and functional disability assessment demonstrating mRS ≥2 at 90 days post-stroke with an increase of ≥1 from baseline. 1

Core Documentation Requirements

1. Neuroimaging Evidence

• Brain CT or MRI showing focal CNS infarction with pathological confirmation of brain tissue death attributable to ischemia 1
• The imaging must demonstrate the stroke location that corresponds to the clinical hemiplegia pattern 2
• For middle cerebral artery strokes (most common cause of hemiplegia), imaging should show infarction in the frontal-parietal-temporal region or insular cortex 3

2. Acute Stroke Severity Documentation

• National Institutes of Health Stroke Scale (NIHSS) score documented at time of stroke diagnosis 1, 4
  • Mild dysfunction: NIHSS 0-5
  • Moderate dysfunction: NIHSS 6-14
  • Severe dysfunction: NIHSS ≥15 1, 4
• The NIHSS must document specific motor deficits in affected limbs, with scores of 3-4 indicating no antigravity movement or complete paralysis 1

3. Disability Assessment at 90 Days

This is the most critical component for disability determination. 1

• Modified Rankin Scale (mRS) assessment performed between 30-90 days post-stroke, with 90 days being optimal 1
• Stroke with disability is defined as: mRS score ≥2 at 90 days AND an increase of ≥1 from pre-stroke baseline 1
• The mRS scale ranges from:
  • 0 = No symptoms
  • 1 = Able to carry out all usual duties and activities
  • 2 = Slight disability (unable to carry out all previous activities but able to look after own affairs without assistance)
  • 3-5 = Moderate to severe disability requiring assistance 1

4. Functional Status Documentation

• Barthel Index assessment documenting inability to perform activities of daily living independently 1
• Document specific functional limitations in:
  • Feeding, bathing, grooming, dressing 1
  • Transfers (bed to chair) 1
  • Mobility on level surfaces 1
  • Toilet use 1
• A Barthel Index ≤60 indicates disabling stroke in many clinical trials 1

5. Neurological Examination Findings

Document persistent deficits including: 1

• Motor paresis: Severity of weakness in affected limbs (complete paralysis or severe weakness without antigravity movement) 1, 5
• Sensory deficits: Deep sensitivity impairment carries significant prognostic weight 5
• Trunk control: Instability of trunk balance 5
• Associated deficits: Aphasia, hemianopsia, cognitive impairment if present 1

6. Permanence Documentation

• Follow-up assessments demonstrating no significant improvement beyond 90 days post-stroke 1
• Most neurological recovery occurs within the first 3 months, with stabilization by 6 months 5
• Document that the patient has reached maximum medical improvement with persistent functional limitations 6

Clinical Pitfalls to Avoid

Timing of Assessment: Do not assess disability too early. The 90-day timepoint is critical because earlier assessments may overestimate disability, while patients may show some recovery in the first 3 months. 1, 5

Incomplete Functional Assessment: Simply documenting hemiplegia is insufficient. You must demonstrate how the hemiplegia impacts activities of daily living and instrumental activities of daily living using standardized scales. 6

Missing Baseline Comparison: The mRS requires documentation of pre-stroke functional status to demonstrate an increase of ≥1 point from baseline. 1

Inadequate Imaging: Clinical diagnosis alone without neuroimaging confirmation is insufficient for disability claims, as imaging is required to differentiate ischemic stroke from hemorrhage and exclude stroke mimics. 1, 2

Additional Supporting Documentation

• Rehabilitation records showing participation in therapy and response to treatment 1, 3
• Caregiver needs assessment if patient requires assistance with daily activities 6
• Discharge planning documentation confirming need for ongoing support services 6
• Complications documentation: Shoulder pain, spasticity, falls, pressure injuries that further impact function 1