3.6.3.02 Guidelines to the rules for applying the Impairment Tables - applying the Tables

Summary

This topic provides guidance on Part 2 of the Social Security (Tables for the Assessment of Work-related Impairment for Disability Support Pension) Determination 2023 (the Determination), which sets out rules that are to be complied with in applying the Impairment Tables. This topic has headings emphasising significant principles and concepts when applying the Impairment Tables to assess a person's functional impairment, which underpin provisions contained in that part of the Determination. It also provides guidance on the concepts and practical application of the DSP eligibility criteria contained in the SSAct.

This topic does not restate the definitions contained in Part 1 of the Determination. These definitions are to be accessed directly from the Determination.

Assessing functional capacity

The impairment of a person must be assessed on the basis of what the person can, OR could do, not on the basis of what the person chooses to do or what others do for the person (refer to 3.6.3.08 'Descriptors involving performing activities').

Note: A determination that a person cannot perform certain activities must be based on an objective assessment of a person's capability to do those things.

The Impairment Tables require that self-reported symptoms must be consistent with and supported by corroborating medical evidence of the functional impact of a person's condition.

Assessment tools appropriate for the assessment of First Nations, & culturally & linguistically diverse (CALD) claimants

The Impairment Tables allow for the use of culturally appropriate, standardised assessment tools (for example, in the assessment of intellectual and adaptive function under Table 9 – Intellectual Function).

Particular care should be given to an individual’s cultural background where it is relevant to the diagnosis and/or treatment of their condition. Further information on culturally appropriate considerations, can be found in the guidelines for information that must be taken into account in applying the Tables (see 3.6.3.03 'Culturally appropriate considerations').

Assessable conditions & impairments

The Impairment Tables can only be applied when a person has a condition which is diagnosed, reasonably treated and stabilised; and the condition and the resulting impairment is more likely than not, in light of available evidence, to persist for more than 2 years.

In deciding whether the Impairment Tables can be applied, the following must be considered:

• whether a person has a condition, with consideration to its diagnosis, treatment and stability
• whether this condition has an impact on a person's ability to function, that is, whether the condition causes an impairment, and
• how long the condition and resulting impairment are likely to last.

The information to enable these considerations can be obtained from corroborating evidence provided by a person (see 3.6.3.03 'Corroborating evidence').

The above criteria, in particular the criteria related to treatment and stability of conditions, are interrelated and are not to be considered in isolation from one another.

Note: An impairment must be more likely than not, in light of the available medical evidence, to persist for more than 2 years, to be assigned a rating under the Impairment Tables. Impairments unlikely to persist for more than 2 years are not to be assessed under the Impairment Tables and an impairment rating cannot be assigned.

It is possible for a condition to last for more than 2 years but for the resulting impairment to improve or even cease within 2 years through medical intervention or other treatment.

Note: Refer below for definition of reasonable treatment and compelling reasons for not undertaking reasonable treatment.

Diagnosis

In determining whether a condition can be assessed under the Impairment Tables, diagnosis and consideration of diagnostic information is required.

For DSP purposes diagnosis of a condition must usually be made by an appropriately qualified medical practitioner, however, for the purpose of Table 9 - Intellectual Function, an assessment of the condition must be made by an appropriately qualified psychologist.

Other relevant diagnostic information may be available in corroborating evidence.

Note: Appropriately qualified medical practitioner means a medical practitioner whose qualifications and practice are relevant to diagnosing a particular condition.

When applying some Tables, the diagnosis of conditions made by an appropriately qualified medical practitioner must be supported by evidence from another appropriately qualified health professional. This requirement is noted in the introduction to these particular Tables.

This is to ensure a person has received the necessary diagnostic input and associated treatment considerations. The information should be contained within the medical records provided by the claimant or, where necessary, in limited circumstances the assessor may obtain verbal confirmation of the diagnosis from the medical practitioner at follow up. This verbal confirmation must be clearly documented by the assessor and is only to be used where all avenues for obtaining written evidence have been exhausted.

The below table includes a summary of common types of medical evidence that may be used to confirm that a condition is diagnosed, for the purposes of applying Table 5 - Mental Health Function, Table 11- Hearing and other Functions of the Ear or Table 12 - Visual Function. These Tables have particular diagnosis requirements, in addition to the standard requirement for conditions to be diagnosed by an appropriately qualified medical practitioner.

Please note that the examples in the below table are not exhaustive.

The introduction to each Table also contains examples of the types of valid corroborating evidence and the types of health professionals who can provide it.

Treatment & stabilisation

If diagnosis of a condition has been established, treatment undertaken for the condition must be regarded. A condition must be reasonably treated for the Impairment Tables to be applied and a rating assigned.

The following factors are to be considered:

• the nature and effectiveness of past treatment
• the expected outcome of current treatment
• any plans for further treatment, and
• whether past, current or future treatment can be considered reasonable, giving consideration to the individual and overall medical status and circumstances of a person.

Based on the above considerations, it must be determined a person has received reasonable treatment or rehabilitation for their condition. Treatment includes medical treatment and other appropriate therapy (for example, physiotherapy) involving rehabilitation aimed at restoring or maintaining mental or physical function, but does not extend to rehabilitation involving specific vocational programs.

If it is determined that a person has not undertaken reasonable treatment, and there are no compelling reasons why they have not undertaken reasonable treatment, then they must not be assigned an impairment rating.

Note: For further information on determining whether a person has compelling reasons for not undertaking reasonable treatment, please refer to the ‘Reasonable treatment & compelling reasons for not undertaking reasonable treatment’ section below.

In some circumstances, a condition may be considered as reasonably treated even if the treatment is ongoing or is planned. This may apply where it is clear a person's functional capacity is unlikely to significantly improve within the next 2 years even if a person continues to receive appropriate reasonable treatment.

It should also be considered whether treatment is continuing or is planned in the next 2 years. This is because the stability of a condition may depend on whether reasonable treatment has been, is being, or is planned to be undertaken, and the likely effect of such treatment on functional improvement within the next 2 years.

The criteria for treatment is interrelated to the criteria for stability, required of conditions for the Impairment Tables to apply. For a condition to be considered stabilised, consideration must be given to whether a person has undertaken reasonable treatment for the condition, and the prospects for significant functional improvement in the next 2 years.

Note: In this context, significant improvement is improvement that will enable a person to undertake work in the next 2 years. 'Work' is taken to refer to any work that exists in Australia, even if not within the person’s locally accessible labour market and that is for at least 15 hours per week on wages that are at or above the relevant minimum wage (1.1.R.133).

In determining the prognosis for the significant functional improvement of a condition, the following factors are to be considered:

• the history of the condition
• response to treatment, and
• the expected rate of recovery.

The information necessary to establish prognosis and stability of conditions can be obtained from corroborating evidence provided by the claimant, or where relevant, directly from the treating health professional/s. Specific types of corroborating evidence stipulated as being required in the introduction to each Table must be provided.

If corroborating evidence indicates the condition is likely to persist for more than 2 years, but significant functional improvement within the next 2 years is likely, the condition is not to be considered stabilised.

Where the available medical evidence indicates the condition is likely to fluctuate, deteriorate or remain unchanged, it should be considered whether reasonable treatment has been undertaken before determining whether the condition is stabilised (3.6.3.08).

A condition may still be considered stabilised for DSP purposes when, even with incomplete or ongoing treatment if there is:

• no functional improvement expected at all
• no functional improvement is expected within the next 2 years
• treatment is no longer effective, is aimed at preventing further deterioration, treatment options have been exhausted or is palliative, and/or
• the level of impairment resulting from that condition is anticipated to worsen over the next 2 years.

Note: In some situations, functional improvement may appear theoretically possible, for example, where a change of treatment is proposed. However, it may not be reasonable to consider a condition as 'not stabilised' based solely on this fact. A thorough consideration of the clinical history of the condition, response to previous treatment and prognosis for improvement or otherwise with a new medication must be undertaken.

In other situations, even though significant improvement in functional ability with treatment is expected to occur over time, a condition may be considered stabilised if such improvement is unlikely to occur within the next 2 years. This may apply to conditions where corroborating evidence indicates slow, gradual improvement, or with very severe injuries where recovery is expected to be quite prolonged.

Note: If a person has a diagnosed condition caused or exacerbated by a diagnosed substance use disorder, the Impairment Tables cannot be applied and a rating assigned to the initial condition, until the substance use disorder has been reasonably treated and stabilised.

Where treatment of a diagnosed substance use disorder can lead to improvement of symptoms and functional impact from another diagnosed condition, the other condition cannot be considered stabilised, until the substance use disorder has been reasonably treated and stabilised.

However, where treatment of a substance use disorder is not expected to lead to any significant improvement of another condition, the other condition can be considered stabilised.

Reasonable treatment & compelling reasons for not undertaking reasonable treatment

It is assumed a person would generally wish to pursue any reasonable treatment that will improve or alleviate their condition. However, people cannot be expected to undergo treatment that is unreasonable.

There may be medical or other compelling and acceptable reasons for not proceeding with reasonable treatment, including where a person:

• has religious or recognised cultural beliefs prohibiting treatment (for example, blood transfusions)
• lacks insight or the ability to make appropriate judgements due to their condition and are unlikely to comply with treatment (for example, a person with a severe psychotic illness or dementia).

See also 3.6.3.03 ‘Culturally appropriate considerations’ and ‘Assessing co-morbid conditions’.

To be considered 'reasonable', treatments must be evidence-based and consistent with treatment guidelines issued by appropriate authorities.

Alternative or complementary treatments without such evidence are not considered reasonable treatment for DSP purposes. A referral to the HPAU (1.1.H.60) should be made if clarification is required.

For DSP purposes, reasonable treatment means treatment:

• that is available at a location reasonably accessible to the person at a reasonable cost

  • Explanation: It would not be reasonable to expect a person to undergo prohibitively expensive treatment, or travel long distances to seek treatment, in order to satisfy the qualification criteria.

• that is of a type regularly undertaken or performed

  • Explanation: Treatments that are experimental in nature or not yet widely accepted or performed by the general medical community would not be considered reasonable.

• that has a high success rate and where substantial improvement can be reliably expected

  • Explanation: It would not be reasonable to consider impairment as being temporary solely because a person has not undertaken a treatment that has a poor success rate or is likely to result in only marginal functional improvement.

• that is of a low risk nature.

  • Explanation: A person may decide against having electroconvulsive therapy (ECT) for severe depression, even though ECT is usually very successful in the treatment of depression, as ECT procedures have the risk of subsequent memory loss and entails having frequent general anaesthetics.

If a person has not received or is not able to receive treatment within reasonable timeframes due to issues such as extended waiting lists, evidence is to be obtained, for example, a document from the relevant hospital or other relevant authority, setting out waiting times for the treatment or the proposed date of treatment. In cases where long waiting lists mean that treatment is not expected to commence, or the effects of treatment will not be known, within 2 years, it may be appropriate to consider a condition as stabilised.

Where significant functional improvement is not expected or where there is a medical or other compelling reason for a person not to pursue further treatment, it may be reasonable to consider the condition stabilised. A person's views (the subjective test) and all available information on treatment options, risks etc. (the objective test) must be considered in such situations.

If a person has not undertaken reasonable treatment due to factors which are not considered to be compelling (for example, a lack of personal motivation which is not due to their condition), then their condition would not be considered diagnosed, reasonably treated and stabilised. Consequently, the Impairment Tables must not be applied and an impairment rating must not be assigned to any impairment arising from this condition. In such situations, the following needs to be evaluated and documented:

• what reasonable treatment is feasible and what the probable outcome of treatment is
• what the risks and side effects of the treatment are
• why the treatment is considered reasonable, and
• what the person's reasons for choosing not to undertake this treatment are.

Assessing functional impact of chronic pain

There is no specific Impairment Table to assess chronic pain.

Chronic pain may be a stand-alone diagnosis and/or a symptom of another condition. The nature of a person's chronic pain is to be determined from corroborating evidence.

There are chronic pain conditions, for example, chronic pain syndrome, where the condition has been diagnosed, reasonably treated and stabilised, and is more likely than not to persist for more than 2 years. Any impairment resulting from such a condition is to be assessed using the Impairment Table most relevant to the function affected.

Chronic pain can also be a symptom of a condition, for example, where a person experiences constant pain from rheumatoid arthritis. Where the condition causing the chronic pain is diagnosed, reasonably treated and stabilised, and is more likely than not to persist for more than 2 years, any resulting impairment from chronic pain symptoms is to be assessed using the Impairment Table most relevant to the function affected.

It should be noted people may have multiple conditions causing pain, for example, osteoarthritis and fibromyalgia. In such cases, where these conditions are diagnosed, reasonably treated and stabilised and will more likely than not persist for more than 2 years, any resulting functional impairment from these conditions should be assessed on the relevant Impairment Tables, taking care to avoid double counting.

Note: For further information on how chronic pain can be assessed across multiple tables, see 3.6.3.09.

To assign an impairment rating for chronic pain that is a stand-alone diagnosis, or the symptom of a condition, the first step is to consider the functional impact as outlined in the evidence. For example, whether the condition impacts spinal function, upper or lower limb function, concentration and memory or physical exertion and stamina.

The next step is to determine which Impairment Table/s apply to the functional impact while avoiding double counting of the impairment. When selecting Impairment Tables, the following should be taken into account:

• where chronic pain does not impact physical exertion and stamina, it would not be appropriate to select Impairment Table 1 - Functions requiring Physical Exertion and Stamina
• where chronic pain impacts physical exertion and stamina and is adequately assessed by another Impairment Table, there is no need to consider Impairment Table 1 - Functions requiring Physical Exertion and Stamina, and
• where chronic pain impacts physical exertion and stamina (for example, results in fatigue symptoms) and this is not adequately assessed by another Impairment Table, Impairment Table 1- Functions requiring Physical Exertion and Stamina should be considered, while ensuring the level of impairment is not overstated and all required criteria are met.

The SS Guide page for each Table includes examples of chronic pain conditions that may be assessed under such Table.

If a person experiences chronic pain as a result of a condition and this pain impacts a particular function, the most relevant Impairment Table is to be used to assess the impact of the condition. For example, Impairment Table 2 - Upper Limb Function is to be used if pain affects the functioning of their upper limbs.

If a person experiences chronic pain as a result of a condition and this pain impacts multiple functions, more than one Impairment Table may be used to assess the resulting impairments. For example, Table 2 - Upper Limb Function, Table 3 - Lower Limb Function and/or Table 4 - Spinal Function can be used if these functions are affected, as long as the overall level of impairment is not overstated or double counted.

Note 1: For systemic conditions (that is, affecting the whole body) that result in chronic pain, the impact on activities requiring physical exertion and stamina should be assessed under Table 1 - Functions requiring Physical Exertion and Stamina.

Note 2: Where a person's concentration and/or memory is also impacted by chronic pain and/or is associated with the side effects of treatment, consideration should be given to whether an additional rating under Table 7 - Brain Function is required.

Note 3: Where a person's chronic pain results in functional impairments which are adequately assessed by another Table, a rating should only be given on that Table, and no rating given on Table 1 - Functions requiring Physical Exertion and Stamina. For example, where Table 10 - Digestive and Reproductive Function adequately assesses the impacts from chronic pain, a rating should only be assigned on Table 10 - Digestive and Reproductive Function, without an additional rating being assigned on Table 1 - Functions requiring Physical Exertion and Stamina.

The following scenarios show how the Impairment Tables are to be applied when assessing chronic pain to ensure the Tables are appropriately used and to avoid double counting. It includes consideration of the impact of pain and fatigue on a person's ability to undertake activities within the descriptors.

These examples are not exhaustive and chronic pain may affect a number of different body functions. If a person experiences chronic pain that falls outside these scenarios and it is unclear how this is to be rated to avoid double counting, the case is to be referred to the HPAU.