Statement of Principles concerning Osteomyelitis (Balance of Probabilities) (No. 24 of 2024)

The instrument builds on several legal and medical concepts. Central is the definition of osteomyelitis itself. Subsection 7(2) provides that osteomyelitis “means inflammation of bone caused by infection” and excludes chondritis, septic arthritis and discitis. This exclusion is significant because those conditions can involve bone inflammation or infectious processes but are treated as separate injuries or diseases for compensation purposes. The accompanying notes confirm that osteomyelitis can affect all bones including the jaw, bones of the inner ear and vertebrae, and can be caused by bacteria, fungi, and specific parasites (Echinococcus, Trichinella, Schistosoma). The reference to ICD‑10‑AM codes is illustrative only; the legal definition prevails, so a condition that fits a code but not the subsection (2) definition would not qualify.

The instrument operates on two temporal concepts: “clinical onset” and “clinical worsening”. Clinical onset refers to the first manifestation of osteomyelitis sufficient to warrant a diagnosis. Clinical worsening refers to a material increase in severity after the disease has already manifested. Several factors require the existence of a condition or event before the clinical onset (e.g., wound within one year before onset), while others (diabetes, chronic conditions, immunosuppression, chronic ischaemia) apply to both onset and worsening. Factor 11 (inability to obtain appropriate clinical management) applies only to clinical worsening, not onset.

The standard of proof is “balance of probabilities”, which is the standard applied under subsection 196B(3) of the VEA for non‑operational service. This means the decision‑maker must be reasonably satisfied that the connection exists. It is a lower threshold than “beyond reasonable doubt” but higher than “reasonable hypothesis”. The instrument itself does not define this standard but is grounded in the Authority’s view that it is “more probable than not” that the disease can be related to service (section 8).

Relevant service is defined in the dictionary. Under the VEA, it means eligible war service (other than operational service) and defence service (other than hazardous service and British nuclear test defence service). Under the MRCA, it means peacetime service. This means the instrument does not apply to operational service under the VEA or hazardous service - those are covered by the reasonable hypothesis SoP (No. 23 of 2024, presumably, though the source only gives this balance of probabilities version). The effect is that veterans with operational service (generally combat service) have a different, more claimant‑favourable standard, while those with peacetime or non‑operational service must prove causation on balance of probabilities using these factors.

The dictionary contains several technical definitions that are critical to applying the factors. “Chronic renal failure” has three alternative limbs: a glomerular filtration rate of less than 15 mL/min/1.73 m² for at least three months; a need for renal replacement therapy (dialysis or transplantation); or undergoing chronic dialysis. This is a strict medical threshold. “Immunosuppressive drug” includes corticosteroids (other than inhaled or topical), transplant rejection drugs, tumour necrosis factor‑α inhibitors, and chemotherapeutic agents. The exclusion of inhaled or topical corticosteroids means common treatments for asthma or eczema do not count. “Severe malnutrition” is defined as protein‑calorie malnutrition associated with a Body Mass Index (BMI) less than or equal to 18.5 kg/m². BMI is itself defined by the formula weight/height².

A notable concept is the note to factor 4, which gives examples of foreign bodies: internal fixation devices, joint replacements, vascular grafts, shrapnel and bullets. This indicates that surgical hardware left in place can be a factor linking osteomyelitis to service if the hardware was placed during service or as a result of service. The factor requires that the foreign body be at the site or adjacent to the site of osteomyelitis at the time of clinical onset.

The instrument also introduces a cross‑reference mechanism in section 11. If a factor refers to an injury or disease for which its own SoP has been made under subsection 196B(3) (balance of probabilities), then the factors in that other SoP apply. For example, factor 5 requires diabetes mellitus at the time of onset or worsening. Diabetes mellitus has its own SoP. To prove that diabetes mellitus is related to service, one must satisfy the factors in that SoP. This can create a chain of causation that may be complex for claimants.

The instrument directly affects veterans and members of the Australian Defence Force who have rendered “relevant service” and who suffer from osteomyelitis or die from it. Relevant service under the VEA includes eligible war service (non‑operational) and defence service (non‑hazardous, non‑British nuclear test). Under the MRCA, it includes peacetime service. This excludes veterans with operational service (who are covered by a separate SoP on the reasonable hypothesis standard) and those with hazardous service or British nuclear test defence service (also covered by other standards). Practically, the instrument applies to veterans who served in non‑combat roles, reservists on peacetime service, and defence members who served during peacetime or non‑hazardous periods.

The instrument also affects the dependents of such veterans or members who claim dependency benefits following death from osteomyelitis. The definition of death from osteomyelitis includes death contributed to by a terminal event, so the estate or family may claim if osteomyelitis was a contributing factor.

The primary decision‑makers bound by the instrument are the Repatriation Commission (under the VEA) and the Military Rehabilitation and Compensation Commission (under the MRCA). They must apply the SoP when determining whether osteomyelitis is related to service. They cannot simply decide causation on general medical evidence; they must check whether at least one of the 11 factors exists and is service‑related. This restricts their discretion but also provides a clear framework for decision‑making.

The instrument also affects healthcare providers who give evidence in claims. They need to understand the specific definitions (e.g., chronic renal failure, immunosuppressive drug, severe malnutrition) to provide relevant medical reports. For example, a doctor may need to specify GFR readings or dialysis status for chronic renal failure, or distinguish inhaled corticosteroids from oral ones for immunosuppressive drug.

Legal practitioners and advocates advising veterans must navigate the factor list carefully. They need to gather evidence matching the timing windows (e.g., wound within one year before clinical onset) and the diagnostic criteria. The cross‑reference to other SoPs (section 11) means they may need to establish that a precondition disease like diabetes mellitus is itself service‑related, which can multiply the complexity of a claim.

The Australian taxpayer is ultimately affected through the cost of compensation. The instrument determines eligibility, so it influences the Commonwealth’s liability. If the factors are too broad, more claims are allowed, increasing expenditure; if too narrow, some deserving claims are denied, potentially leading to review and litigation costs. The replacement of the 2014 SoP with the 2024 version could shift the balance, though the source does not list the differences.

The instrument does not affect the general public or private healthcare providers outside the veterans’ compensation system. It is specific to the VEA and MRCA statutory regimes.

The instrument creates no new duties or rights directly; rather, it specifies the conditions under which existing rights to compensation for osteomyelitis are triggered. Under the VEA and MRCA, a veteran has the right to compensation for an injury or disease if it is related to service. The SoP is a tool for determining that relationship. The key right it confers is a pathway to proving causation: if the veteran can show that one of the 11 factors exists and is related to their relevant service, the decision‑maker must (subject to other requirements) accept that the osteomyelitis is connected to service.

The duty of the claimant is to produce evidence that satisfies the factor. For example, for factor 1, the claimant must show they had a wound, laceration, or other injury disrupting the skin or mucosa at or adjacent to the site of osteomyelitis within one year before clinical onset. The claimant must also prove that the wound or injury was related to their service (section 10). That may require showing the injury occurred during service or was worsened by service. The claimant does not need to prove that the osteomyelitis was directly caused by service; it is enough that the factor exists and is service‑related.

The decision‑maker (the Repatriation Commission or MRCC) has a duty to apply the SoP correctly. This means they must consider each factor raised by the claimant, interpret the definitions strictly as given in the dictionary, and ensure that the timing and other requirements are met. If the claimant does not raise a factor that is evident from the material, the decision‑maker may still be obliged to consider it if it would affect the outcome. The SoP is binding; a decision‑maker cannot refuse to apply a factor that is satisfied. However, the decision‑maker must also ensure that the factor is related to service under section 10. That involves a separate causation step: even if diabetes mellitus exists at the time of osteomyelitis onset, the diabetes itself must be related to service (via its own SoP, per section 11).

The Authority’s duty under subsection 196B(3) is to determine factors based on sound medical‑scientific evidence. The instrument’s preamble states that the Authority is satisfied on that basis. While claimants cannot challenge the SoP itself easily (as it is a legislative instrument), they can challenge its application in individual cases.

The instrument also recognises a right to claim for clinical worsening. If a veteran had osteomyelitis before service (or contracted it during service but it did not arise out of service), and service‑related factors worsen it, they may be entitled to compensation for the worsening. Factor 11 (inability to obtain appropriate clinical management) specifically addresses worsening, and the note to section 10(2) clarifies that the clinical worsening aspects apply only to material contribution or aggravation where the disease was suffered or contracted before or during service but did not arise out of it. This prevents double recovery for a disease already caused by service.

The cross‑reference in section 11 creates a duty on decision‑makers to consider the terms of other SoPs as they stand from time to time. This means that if the diabetes SoP is amended, the standard for proving diabetes related to service changes for the purpose of factor 5 without amending this osteomyelitis SoP.

This instrument does not itself impose penalties. It is a statement of principles that guides decision‑making; enforcement mechanisms arise from the underlying Acts and general law. The most directly relevant penalty is for false or misleading statements in support of a compensation claim. Under section 137.1 of the Criminal Code (Cth), a person who provides false or misleading information to a Commonwealth entity (including the Department of Veterans’ Affairs) faces imprisonment for up to 12 months. Section 134.1 (obtaining property by deception) and section 135.1 (general dishonesty) could also apply if a claimant knowingly fabricates evidence to match a factor.

Under the VEA, section 212 provides for recovery of overpaid compensation if a person has made a false statement or representation. The MRCA has similar provisions in Part 10. These allow the Commonwealth to recover amounts paid as a result of fraud or error. The instrument itself does not create any civil penalty provisions.

The Repatriation Medical Authority has no enforcement function. Its role ends once the SoP is made and published. Enforcement is left to the administering departments and, ultimately, the courts. A decision‑maker who incorrectly applies the SoP (e.g., by accepting a claim that does not meet the factors, or rejecting one that does) can be reviewed. The veteran can seek merits review in the Veterans’ Review Board (VRB) under the VEA, or in the MRCC review panel under the MRCA. Further appeal to the Administrative Appeals Tribunal (AAT) and then to the Federal Court on questions of law is available.

If the SoP itself is challenged, a person can apply for judicial review under the Administrative Decisions (Judicial Review) Act 1977 or seek a declaration that the SoP is invalid (e.g., on grounds that it was not based on sound medical‑scientific evidence, although the Authority has broad discretion). The instrument is a legislative instrument subject to disallowance by Parliament under the Legislation Act 2003, but that is a political check, not a legal penalty.

For claimants, the practical penalty for not meeting the factors is denial of the claim. There is no penalty for making a claim that fails, unless it is frivolous or vexatious. The instrument may indirectly penalise claimants who develop osteomyelitis from service but cannot fit the factor list; they have no remedy unless they can argue the SoP is unreasonable or that another factor not listed should apply (which the Authority has precluded by making the list exhaustive).

The costs of compliance for the administration are not penal but operational. If the Department overpays because of a misinterpretation of factors, it can seek recovery but bears the administrative cost of doing so. The existence of the SoP reduces discretion, which should lower the risk of inconsistent decisions but may also create a rigid framework that misses genuine cases.

The instrument is made under the VEA and directly references the MRCA. It is a creature of the veterans’ compensation framework. Its primary statutory interaction is with section 120B of the VEA and section 339 of the MRCA, which require the Repatriation Medical Authority to determine SoPs for injuries and diseases, and require decision‑makers to apply them. The instrument sits alongside other SoPs for other conditions. Section 11 of this instrument specifically provides that if a factor refers to an injury or disease covered by another SoP under subsection 196B(3), the factors in that other SoP apply. This creates a network of interdependent instruments. For example, factor 5 requires diabetes mellitus. The decision‑maker must consult the SoP for diabetes mellitus (balance of probabilities version) to determine if that diabetes is related to service. Similarly, factor 6 requires chronic renal failure, cirrhosis, Crohn disease, or sickle cell disorder; each likely has its own SoP, and section 11 would incorporate them by reference. This cross‑referencing is as at the time of decision (the SoP “as in force from time to time”).

The instrument also interacts with the ICD‑10‑AM classification system. While the definition of osteomyelitis prevails over the ICD codes, the codes are used for administrative recording and may be referenced in medical reports. If a medical certificate uses a code that falls outside the subsection (2) definition, the decision‑maker must still apply the legal definition. This could lead to inconsistency if a condition is coded as osteomyelitis but does not meet the definition (e.g., discitis coded under M46.2 falls outside the exclusion).

The instrument interacts with the Legislation Act 2003. It is a legislative instrument registered on the Federal Register of Legislation. It is subject to disallowance by either House of Parliament within 15 sitting days of tabling. If disallowed, it would have no effect, and the 2014 SoP would be revived? Not exactly: the repeal provision in section 4 would be voided, so the old SoP would continue. However, the instrument as a whole is subject to Parliamentary scrutiny.

The instrument also interacts with the common law of causation. The factors are a statutory code for the balance of probabilities standard. A decision‑maker cannot rely on a causal theory not listed in section 9 unless it fits one of the factors. This overrides general tort‑style causation analysis. The note to factor 1 says “Examples of injuries that disrupt the skin include penetrative injuries, compound fractures, burns or pressure ulcers. Examples of diseases that disrupt the skin include chronic ischaemia or diabetes mellitus.” These examples are not exhaustive but guide interpretation. There is also interaction with the Safety, Rehabilitation and Compensation Act 1988 (SRCA) for certain employees, but the instrument does not apply to SRCA claims because it is specifically under VEA and MRCA.

The definition of “terminal event” in the dictionary is likely derived from common usage in veterans’ law. It lists specific causes of death that can be considered contributed to by osteomyelitis. This interacts with the coronial and death registration systems, but no direct legislative interaction is stated.

This instrument is new and was made on 22 February 2024, to commence on 26 March 2024. It repeals the previous Statement of Principles concerning osteomyelitis No. 91 of 2014 (made under subsections 196B(3) and (8) of the VEA). The 2014 instrument was the prior version applying the balance of probabilities standard. No other amendments have been made to this 2024 instrument as of the date of this analysis. The instrument itself has not been amended. The repeal clause (section 4) is explicit. The Authority has determined that the 2024 version reflects current sound medical‑scientific evidence, which is the basis for replacing the earlier version.

The source does not provide a transition provision for claims pending at commencement. However, section 5 states the instrument applies to a claim to which section 120B VEA or section 339 MRCA applies. Generally, the operative provision is the SoP in force at the time of the decision, not at the time of the claim or the onset of disease. So a claim made before 26 March 2024 but decided after that date would be determined under the 2024 SoP. This could affect entitlements if the factors changed.

Because the 2014 SoP is not reproduced, we cannot compare the factor lists. However, the new instrument now has 11 factors (previously 10? Not known). The definitions of chronic renal failure, immunosuppressive drug, and severe malnutrition may have been refined. The exclusion of chondritis, septic arthritis and discitis might be new or clarified. Without the old text, practitioners should compare if they have it on file.

The instrument is a legislative instrument and may be amended in the future by the Repatriation Medical Authority under subsection 196B(3) as medical evidence evolves. The Authority regularly reviews SoPs. The amendment history of this particular instrument is currently just the original making and repeal of the predecessor.

No litigation is mentioned in the source. The instrument is too recent (commenced 26 March 2024) to have generated reported decisions. However, one can anticipate how litigation might arise. Under the VEA and MRCA, decisions applying SoPs are frequently reviewed by the Veterans’ Review Board and the Administrative Appeals Tribunal. The AAT may consider whether the decision‑maker correctly interpreted the factors, whether the medical evidence supports the existence of a factor, and whether the factor is related to service. The Federal Court may consider questions of law, such as whether the Authority complied with subsection 196B(3) in determining the factors based on sound medical‑scientific evidence.

Previous litigation under the 2014 SoP for osteomyelitis may provide guidance, but we cannot cite cases not in the source. Generally, courts have given the Authority broad latitude in determining factors, but have intervened if a factor is irrational or not grounded in evidence. The instrument’s definition of osteomyelitis is narrow, likely to reduce disputes about whether a condition falls within the disease. The exclusion of septic arthritis and discitis may lead to borderline cases where a claimant has bone infection adjacent to a joint - the decision‑maker will need to determine if it is osteomyelitis or septic arthritis.

Factor 11, “inability to obtain appropriate clinical management,” is a potential source of litigation. It does not define “appropriate” - whether that means clinically indicated guidelines, or what a reasonable veteran would have done. In the veterans’ context, “inability” may be due to service‑related factors (e.g., being at sea, in a remote area, or due to financial constraints). The AAT may need to interpret this.

Section 10(2) adds a layer: the clinical worsening aspects apply only to material contribution or aggravation where the disease was suffered or contracted before or during service but did not arise out of it. This could lead to disputes about whether the original osteomyelitis arose out of service (in which case the worsening factor is not needed) or not. If it arose out of service, the claim would be for the original disease, not worsening.

The cross‑reference to other SoPs may produce litigation chains: a veteran may need to prove diabetes is service‑related to then use factor 5. If the diabetes SoP is challenged or interpreted strictly, it could block the osteomyelitis claim.

Overall, given the age of the instrument, there is no litigation history yet. Future litigation will likely focus on the boundaries of the definitions and the interpretation of the timing requirements.

Several provisions could trip up claimants and decision‑makers. First, the definition of osteomyelitis excludes chondritis, septic arthritis and discitis. A veteran with infection in a vertebral disc or joint space may be misdiagnosed as having osteomyelitis, or the conditions may co‑exist. The decision‑maker must ensure the primary diagnosis is inflammation of bone caused by infection. If the medical report only mentions “discitis” or “septic arthritis,” the condition may not meet the SoP even if there is some bone involvement.

Second, factor 1 requires the wound or injury within one year before clinical onset. The one‑year period is strict. If the wound occurred 13 months before onset, the factor does not apply, even if there is a plausible causal link. Claimants should get precise dates. The wound must also be “at the site or adjacent to the site of osteomyelitis.” For osteomyelitis of the spine, a wound on the back may be “adjacent”, but a wound on the foot would not be for spinal osteomyelitis.

Third, factor 3 (septicaemia, bacteraemia, systemic fungal or parasitic infection) requires the infection within one year before clinical onset. “Septicaemia” is not defined in the instrument. It must be diagnosed clinically. A claimant who had a transient bacteraemia without symptoms may struggle to prove it.

Fourth, factor 4 requires a foreign body at the site or adjacent to the site “at the time of the clinical onset of osteomyelitis.” If the foreign body was removed before onset, it does not satisfy the factor, even if it caused the infection. The timing is not within a window; it must be present at the exact time of onset. This could be difficult to prove if the onset is insidious.

Fifth, factor 5 (diabetes mellitus) does not have a timeframe; it must exist at the time of onset or worsening. But diabetes mellitus must be related to service per section 10. That means proving diabetes is a service‑related disease, which may be challenging for veterans who developed diabetes later in life from lifestyle factors. The cross‑reference to the diabetes SoP (section 11) means the veteran must satisfy the factors in that SoP. If they cannot, the diabetes factor does not help, even if the diabetes is clearly present.

Sixth, factor 6 lists chronic medical conditions, including chronic renal failure, cirrhosis, Crohn disease, and sickle cell disorder. The definition of chronic renal failure is strict: GFR less than 15 for three months, or need for dialysis. A veteran with stage 4 chronic kidney disease (GFR 15‑29) does not satisfy the definition. Similarly, cirrhosis must be diagnosed; non‑alcoholic fatty liver disease without cirrhosis is not enough.

Seventh, factor 8 on immunosuppression: it requires a “substantially compromised immune system” due to one of six causes. The cause itself must exist at the time of onset or worsening. For “taking an immunosuppressive drug,” the dictionary excludes inhaled or topical corticosteroids. A veteran on oral prednisolone for asthma would count, but one on inhaled steroids only would not. The list is exhaustive; other causes of immunosuppression (e.g., HIV with high CD4 count not counted as infection? Actually HIV is listed, but only if the infection with HIV is present; the immune compromise must be due to the infection, not just the presence of HIV without low CD4). The dictionary’s “immunosuppressive drug” definition includes chemotherapeutic agents used for cancer treatment, but not biologic agents for rheumatoid arthritis unless they are TNF‑α inhibitors (which are included). So a veteran on rituximab for lymphoma would be covered, but if on another biologic for psoriasis not listed, it might not count.

Eighth, factor 11: “inability to obtain appropriate clinical management for osteomyelitis before the clinical worsening.” This factor applies only to clinical worsening, not onset. It does not require fault; it just requires that the veteran could not obtain appropriate management. But what is “appropriate”? If the treating doctor provided substandard care but the veteran could have sought a second opinion, is that an inability? The instrument does not define. The onus is on the claimant to show they tried but could not obtain it, possibly due to service‑related location or financial barriers.

Ninth, section 10(2): the clinical worsening aspects of the factors apply only if the osteomyelitis was suffered or contracted before or during service but did not arise out of it. This is an important limitation. If the osteomyelitis arose out of service (e.g., from a combat wound), the worsening factors cannot be used - the claim would be for the original disease. This may confuse claimants who have a pre‑existing condition that gets worse during service.

Tenth, the instrument uses the term “adjacent to the site.” This is vague. A wound on the ankle may be adjacent to the tibia, but is it adjacent to a vertebral focus? Decision‑makers will need medical opinion on anatomical adjacency.

Compliance depends on the role: claimant, representative, or decision‑maker. For a claimant with osteomyelitis seeking compensation, the first step is to obtain a definitive medical diagnosis that fits the definition in subsection 7(2): inflammation of bone caused by infection, not merely chondritis, septic arthritis, or discitis. Imaging and microbiology reports are essential.

Next, identify which of the 11 factors might apply. The claimant should gather evidence of any wound, injury, or medical procedure at or near the affected bone within one year before the osteomyelitis was first diagnosed. Military service records, medical records, and incident reports can show this. If the osteomyelitis is related to a compound fracture from a training accident, that would satisfy factor 1. The wound must disrupt skin or mucosa; a simple bruise would not.

If a dental procedure is involved, check if it involved tooth extraction or other breach of mucosa (e.g., dental implant). The procedure must be within one year before clinical onset. Get the dentist’s records.

If the claimant had septicaemia or a systemic infection, ensure blood cultures or clinical notes confirm the infection and its timing. Similarly, note the foreign body factor: if osteomyelitis developed around an internal fixation device from a previous service‑related fracture, get the surgical records confirming the device was in place at the time of osteomyelitis diagnosis.

For chronic conditions like diabetes, chronic renal failure, cirrhosis, or Crohn disease, obtain specialist confirmation and dates. For diabetes, also gather evidence that the diabetes itself is service‑related, as per the diabetes SoP. That might require showing diabetes factors such as obesity from service‑related inactivity, or exposure to certain chemicals.

For immunosuppression, document the cause (e.g., HIV positive, organ transplant, chemotherapy) and ensure it meets the dictionary definitions. For severe malnutrition, calculate BMI and get a dietitian report confirming protein‑calorie malnutrition.

For osteonecrosis (factor 10), get imaging evidence of osteonecrosis preceding osteomyelitis, and link it to service.

For clinical worsening claims (factor 11), the claimant must show that after the osteomyelitis developed, they were unable to obtain appropriate clinical management, and that the inability was related to service. For example, a veteran posted to a remote base without access to an orthopaedic surgeon for six months. The worsening must be material; a small progression may not suffice. The decision‑maker will require medical evidence comparing the condition before and after the period of inability.

The claimant must also satisfy section 10: the factor must be related to relevant service. For most factors, this means the injury, procedure, infection, or condition must have occurred or arisen during service. For example, a wound from a sporting accident outside service would not count, even if it caused osteomyelitis. For conditions like diabetes or chronic renal failure that develop after service, the link must be through service‑related causes.

For decision‑makers (the Repatriation Commission or MRCC delegates), compliance means creating a checklist for each claim. First, confirm the diagnosis of osteomyelitis under the SoP definition. Second, list each factor that might be raised by the evidence. Third, check the timing: does the factor require the event within one year before clinical onset? Does it require the condition at the time of onset or worsening? Fourth, verify that the factor is related to service - e.g., was the wound sustained during service? Fifth, for factors that reference another disease, apply the relevant SoP for that disease (section 11). Sixth, for clinical worsening, confirm that the osteomyelitis did not arise out of service, and that the worsening factor materially contributed.

The decision‑maker should also be aware that the factors are cumulative: at least one must exist. But multiple factors can be used. The instrument does not require that the factor directly caused the osteomyelitis; only that the factor exists and is related to service. However, the medical‑scientific basis for the SoP should mean that the factor is a recognised causal pathway.

Documentation is critical. The decision‑maker should cite the specific factor(s) satisfied and the evidence for each. If a claim is rejected, the reasons must explain why no factor is met, or why the factor is not related to service.

For legal practitioners, the key is to thoroughly explore all 11 factors early. Obtain full medical history, including any records of wounds, procedures, infections, and chronic conditions. Consider whether diabetes or other conditions can be linked to service via their own SoPs. If the claimant has multiple conditions, check each SoP for cross‑references.

Administrative compliance for the department involves updating internal guidelines and training staff on the new definitions (e.g., the exclusion of discitis, the strict definition of chronic renal failure). The start date of 26 March 2024 means all claims decided after that date must use this instrument, even if the claim was lodged earlier. The department should also maintain a register of all current SoPs to manage cross‑references.

Given the potential for review, both claimants and decision‑makers should be precise about dates and diagnostic criteria. If there is any dispute about whether a condition meets the definition of osteomyelitis, obtain an independent specialist opinion. The AAT will likely require evidence addressing each element.