{"id":"F2018L00556","name":"Statement of Principles concerning Cushing syndrome (Balance of Probabilities) (No. 44 of 2018)","slug":"statement-of-principles-concerning-cushing-syndrome-balance-of-probabilities-no-44-of-2018","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":439608,"registerId":"F2018L00556-fast-fetch-1775955568101","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Statement of Principles concerning Cushing syndrome (Balance of Probabilities) (No. 44 of 2018)","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\nmeta-generator: Aspose.Words for .NET 20.2\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n\n\n \n\nStatement of Principles\n\nconcerning\n\nCUSHING SYNDROME (Balance of Probabilities)\n\n(No. 44 of 2018)\n\nThe Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.\n\n \n\nDated 27 April 2018\n\n \n\n \n\n \n\n \n\n \n\n| The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:
|\n| --- |\n| 
Professor Nicholas Saunders AO
Chairperson
|\n\n\n \n\n \n\n\nContents\n\n1 Name\n\n2 Commencement\n\n3 Authority\n\n4 Revocation\n\n5 Application\n\n6 Definitions\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n8 Basis for determining the factors\n\n9 Factors that must exist\n\n10 Relationship to service\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nSchedule 1 - Dictionary\n\n1 Definitions\n\n \n\n\n\n\n1 Name\n\nThis is the Statement of Principles concerning Cushing syndrome (Balance of Probabilities) (No. 44 of 2018).\n\n2 Commencement\n\n This instrument commences on 28 May 2018.\n\n3 Authority\n\nThis instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.\n\n4 Revocation\n\nThe Statement of Principles concerning Cushing's syndrome No. 34 of 2009 made under subsection 196B(3) of the VEA is revoked.\n\n5 Application\n\nThis instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.\n\n6 Definitions\n\nThe terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n(1) This Statement of Principles is about Cushing syndrome and death from Cushing syndrome.\n\nMeaning of Cushing syndrome\n\n(2) For the purposes of this Statement of Principles, Cushing syndrome means an endocrine disorder resulting from an excess of endogenous or exogenous glucocorticoids.\n\nNote: Features of Cushing syndrome may include proximal muscle weakness, facial plethora, wasting of the extremities with increased fat in the abdomen (centripetal fat) and face (\"moon facies\"), wide (> 1 cm) purplish striae, bruising with no obvious trauma, supraclavicular fat pads and dorsocervical fat pad (\"buffalo hump\").\n\n(3) While Cushing syndrome attracts ICD‑10‑AM code E24.0, E24.2, E24.3, E24.8 or E24.9, in applying this Statement of Principles the meaning of Cushing syndrome is that given in subsection (2).\n\n(4) For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.\n\nDeath from Cushing syndrome\n\n(5) For the purposes of this Statement of Principles, Cushing syndrome, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's Cushing syndrome.\n\nNote: terminal event is defined in the Schedule 1 – Dictionary.\n\n8 Basis for determining the factors\n\nOn the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that Cushing syndrome and death from Cushing syndrome can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.\n\nNote: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.\n\n9 Factors that must exist\n\nAt least one of the following factors must exist before it can be said that, on the balance of probabilities, Cushing syndrome or death from Cushing syndrome is connected with the circumstances of a person's relevant service:\n\n(1) having a specified condition at the time of the clinical onset of Cushing syndrome;\n\nNote: specified condition is defined in the Schedule 1 - Dictionary. \n\n(2) having glucocorticoid therapy as specified before the clinical onset of Cushing syndrome, and where the glucocorticoid therapy as specified has ceased or decreased, the last dose of the therapy was received within the 30 days before the clinical onset of Cushing syndrome;\n\nNote: glucocorticoid therapy as specified is defined in the Schedule 1 - Dictionary.\n\n(3) being treated with medroxyprogesterone acetate or megestrol acetate for a malignant disease or human immunodeficiency virus infection:\n\n(a) for at least four weeks before the clinical onset of Cushing syndrome; and\n\n(b) where treatment has ceased, the clinical onset of Cushing syndrome has occurred within 30 days of cessation;\n\n(4) inability to obtain appropriate clinical management for Cushing syndrome.\n\n10 Relationship to service\n\n(1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.\n\n(2) The factor set out in subsection 9(4) applies only to material contribution to, or aggravation of, Cushing syndrome where the person's Cushing syndrome was suffered or contracted before or during (but did not arise out of) the person's relevant service.\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nIn this Statement of Principles:\n\n(1) if a factor referred to in section 9 applies in relation to a person; and\n\n(2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;\n\nthen the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.\n\n \n\n \n\nSchedule 1 - Dictionary \n\nNote: See Section 6\n\n1 Definitions\n\nIn this instrument:\n\n adrenal neoplasm means a primary neoplasm, either benign (adenoma) or malignant (carcinoma), arising from the adrenal gland.\n\n Cushing syndrome—see subsection 7(2).\n\n equivalent glucocorticoid therapy means a glucocorticoid in the following table, at the doses specified in the table, or a therapeutically equivalent dose of another glucocorticoid:\n\n| Glucocorticoid | Minimum cumulative
dose (milligram) | Minimum average
rate (milligram/day) |\n| --- | --- | --- |\n| betamethasone | 45 | 1.5 |\n| cortisone | 1 875 | 62.5 |\n| dexamethasone | 55 | 1.8 |\n| methylprednisolone | 300 | 10 |\n| paramethasone | 150 | 5 |\n| prednisolone | 375 | 12.5 |\n| prednisone | 375 | 12.5 |\n| triamcinolone | 300 | 10 |\n\n\n equivalent inhaled glucocorticoid means:\n\n(a) 2 000 micrograms of beclometasone;\n\n(b) 1 600 micrograms of ciclesonide;\n\n(c) 2 500 micrograms of fluticasone propionate;\n\n(d) 1 000 micrograms of fluticasone furoate;\n\n(e) 10 000 micrograms of triamcinolone; or\n\n(f) a therapeutically equivalent dose of another inhaled glucocorticoid.\n\n glucocorticoid therapy as specified means:\n\n(a) applying a high or very high potency topical glucocorticoid to at least 30% of total skin surface area, daily, for at least six months; or\n\n(b) inhaling at least 4 000 micrograms of budesonide, or equivalent inhaled glucocorticoid, daily, for at least six months; or\n\n(c) taking:\n\n(i) hydrocortisone, orally or by injection:\n\n(A) to a cumulative dose of at least 1 500 milligrams; and\n\n(B) at a minimum dose rate averaging 50 milligrams per day, or\n\n(ii) equivalent glucocorticoid therapy, orally or by injection; or\n\n(d) using a glucocorticoid concurrently with a drug, daily, for at least 4 weeks, where that drug can inhibit the activity of the metabolising enzyme cytochrome P450 3A4 by at least 30% (moderate to strong inhibition); or\n\n(e) using a glucocorticoid concurrently with a drug from the specified list of drugs, daily, for at least four weeks; or\n\n(f) using a clobetasol containing oral preparation, daily, for at least four weeks; or\n\n(g) using glucocorticoid containing enemas, daily, for at least six months.\n\nNote: equivalent glucocorticoid therapy, equivalent inhaled glucocorticoid, high or very high potency topical glucocorticoid and specified list of drugs are also defined in the Schedule 1 – Dictionary.\n\n high or very high potency topical glucocorticoid means:\n\n(a) betamethasone dipropionate 0.05%;\n\n(b) betamethasone valerate 0.1%;\n\n(c) clobetasol proprionate 0.05%;\n\n(d) diflucortolone valerate 0.1%;\n\n(e) fluocinolone acetonide 0.025%;\n\n(f) methylprednisolone 0.1%;\n\n(g) mometasone 0.1%;\n\n(h) triamcinolone acetonide 0.5%; or\n\n(i) another topical glucocorticoid of equivalent potency.\n\n MRCA means the Military Rehabilitation and Compensation Act 2004.\n\n neuroendocrine neoplasm means a non-pituitary neoplasm that secretes polypeptides functionally equivalent to adrenocorticotrophic hormone (ACTH) or corticotropin-releasing hormone (CRH), and includes oat cell or small cell lung carcinoma, carcinoid tumour, islet cell tumour, tumours of the thymus, medullary carcinoma of the thyroid, and phaeochromocytoma.\n\n relevant service means:\n\n(a) eligible war service (other than operational service) under the VEA;\n\n(b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; or\n\n(c) peacetime service under the MRCA.\n\nNote: MRCA and VEA are also defined in the Schedule 1 - Dictionary.\n\n specified condition means one of the following:\n\n(a) adrenal neoplasm;\n\n(b) adrenocorticotrophic hormone (ACTH) secreting neoplasm of the pituitary gland;\n\n(c) macronodular adrenal hyperplasia;\n\n(d) micronodular adrenal hyperplasia; or\n\n(e) neuroendocrine neoplasm.\n\nNote: adrenal neoplasm and neuroendocrine neoplasm are also defined in the Schedule 1 - Dictionary.\n\n specified list of drugs means:\n\n(a) amprenavir;\n\n(b) atazanavir;\n\n(c) boceprevir;\n\n(d) clarithromycin;\n\n(e) darunavir;\n\n(f) delavirdine;\n\n(g) erythromycin;\n\n(h) fosamprenavir;\n\n(i) indinavir;\n\n(j) isoniazid;\n\n(k) itraconazole;\n\n(l) ketoconazole;\n\n(m) lopinavir;\n\n(n) nelfinavir;\n\n(o) posaconazole;\n\n(p) ritonavir;\n\n(q) saquinavir;\n\n(r) telaprevir;\n\n(s) telithromycin;\n\n(t) tipranavir; or\n\n(u) voriconazole.\n\n terminal event means the proximate or ultimate cause of death and includes the following:\n\n(a) pneumonia;\n\n(b) respiratory failure;\n\n(c) cardiac arrest;\n\n(d) circulatory failure; or\n\n(e) cessation of brain function.\n\n VEA means the Veterans' Entitlements Act 1986.\n\n \n\n \n","sortOrder":0}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"kimi_summary":{"content_quality":"ok","complexity_score":6,"scope_assessment":{"changed":false,"description":"The legislation maintains its original purpose as a medical determination instrument for a specific condition under the veterans' compensation framework. It updates the 2009 version with revised medical criteria and new pharmaceutical references (reflecting updated clinical knowledge), but does not expand beyond its core function of establishing service connection factors for Cushing syndrome claims."},"complexity_factors":["Multiple nested definitions: 15 defined terms in Schedule 1, with some definitions referring to other defined terms (e.g., 'glucocorticoid therapy as specified' incorporates 'equivalent glucocorticoid therapy', 'equivalent inhaled glucocorticoid', 'high or very high potency topical glucocorticoid', and 'specified list of drugs')","Detailed quantitative thresholds: Extensive tables and specific numerical requirements for medication doses (e.g., '375 milligrams minimum cumulative dose' for prednisolone, '30% of total skin surface area', '4,000 micrograms of budesonide')","Temporal conditions: Multiple time-based requirements that must align (e.g., 'within 30 days before clinical onset', 'at least six months', 'at least four weeks', 'where treatment has ceased')","Cross-referencing structure: Section 11 creates a recursive relationship where factors can invoke other Statements of Principles, requiring readers to consult multiple instruments","Medical-legal hybrid language: Combines clinical terminology (ICD-10-AM codes, pharmacological names, anatomical terms) with legal concepts ('balance of probabilities', 'terminal event', 'material contribution')","Conditional logic in factor 9(2): Requires both cessation/decrease of therapy AND specific timing of last dose within 30 days — a compound condition with temporal limitation","Factor 9(4) limitation: Contains a specific restriction that the 'inability to obtain appropriate clinical management' factor only applies to aggravation cases, not initial onset — an exception to the general rule"],"plain_english_summary":"This instrument updates the medical rules for when current and former Australian Defence Force members (and their estates) can claim compensation for Cushing syndrome under the Veterans' Entitlements Act and the Military Rehabilitation and Compensation Act, replacing a 2009 version. It tells claimants and DVA decision‑makers which medical causes or exposures qualify and why it matters for service connection.\n\nKey to eligibility are specific pathways — underlying adrenal/pituitary disease, certain hormone therapies, inability to access treatment, or high‑dose glucocorticoid use — with strict dose, duration and timing thresholds forming a precise checklist."},"flash_summary":{"complexity_score":6,"scope_assessment":{"changed":true,"description":"Section 4 revokes the earlier Cushing syndrome Statement, and this instrument replaces it with updated, more detailed definitions and exposure thresholds (Schedule 1), explicit timing windows for onset and cessation, and an express application to VEA and MRCA claims (s 4; s 5). The practical scope therefore changes to require use of the newer criteria and evidentiary standards set out here."},"complexity_factors":["Detailed, medical‑technical exposure thresholds and equivalence tables for multiple glucocorticoids (Schedule 1: equivalent glucocorticoid therapy table) increase evidentiary complexity.","Multiple routes of exposure covered (topical, inhaled, oral, injection, enemas, concurrent drug interactions) require different record types and calculations (Schedule 1: 'glucocorticoid therapy as specified').","Timing rules and short windows (30 days for onset after cessation; minimum durations such as 4 weeks or 6 months) create narrow evidentiary cutoffs (ss 9(2)–(3); Schedule 1).","Requirement that an identified factor be related to the person's relevant service means causation must be linked to service history, adding legal-medical assessment (s 10(1)).","The 'inability to obtain appropriate clinical management' factor is inherently subjective and limited to pre‑existing conditions, requiring factual assessment of access to care (s 9(4); s 10(2)).","Cross-reference to other Statements of Principles when factors invoke other diseases introduces dependency and potential chain complexity (s 11).","Revocation of the prior Statement means practitioners must use updated criteria and may need to re-evaluate prior decisions (s 4).","Determination of 'clinical onset' and cumulative/average dose rates requires retrospective calculation from clinical records, increasing administrative burden.","A specified list of enzyme‑inhibiting drugs and named agents creates additional evidentiary checks for concurrent therapy (Schedule 1: specified list of drugs).","The instrument’s definitions override ICD codes for legal purposes, requiring familiarity with the Statement’s specific meanings rather than only standard diagnostic codes (s 7(3)–(4); Schedule 1)."],"plain_english_summary":"This Statement of Principles sets the medical tests and timing rules that must be met for Cushing syndrome (and deaths contributed to by it) to be accepted as connected with a veteran's or service member's relevant service for claims under the VEA and MRCA. It replaces the earlier Cushing syndrome Statement and specifies precise medical causes, drug‑exposure thresholds, timing windows and an \"inability to obtain appropriate clinical management\" ground.\n\nMeeting any one listed factor makes it more probable than not that the condition is service‑related, affecting entitlement decisions and requiring clinical records and dose calculations."}},"importantCases":[],"_links":{"self":"/api/acts/statement-of-principles-concerning-cushing-syndrome-balance-of-probabilities-no-44-of-2018","history":"/api/acts/statement-of-principles-concerning-cushing-syndrome-balance-of-probabilities-no-44-of-2018/history","analysis":"/api/acts/statement-of-principles-concerning-cushing-syndrome-balance-of-probabilities-no-44-of-2018/analysis","conflicts":"/api/acts/statement-of-principles-concerning-cushing-syndrome-balance-of-probabilities-no-44-of-2018/conflicts","importantCases":"/api/acts/statement-of-principles-concerning-cushing-syndrome-balance-of-probabilities-no-44-of-2018/important-cases","documents":"/api/acts/statement-of-principles-concerning-cushing-syndrome-balance-of-probabilities-no-44-of-2018/documents"}}