Statement of Principles concerning osteoporosis (Reasonable Hypothesis) (No. 66 of 2024)

This SoP revolves around a small set of legal‑medical concepts defined in the text and the attached Schedule 1 dictionary. The key concepts are: the legal meaning of osteoporosis for claims, the “reasonable hypothesis” test, “relevant service”, temporal qualification of factors (onset versus clinical worsening), and a catalogue of discrete, measurable factors that will, if evidenced, support a link to service.

Osteoporosis , the instrument adopts a specific, measurable definition. Osteoporosis is a systemic bone disease characterised by low bone density resulting in greater susceptibility to fragility fracture. Low bone mineral density is defined as a T score 2.5 standard deviations or more below the mean for young adult sex‑matched controls, or radiologically confirmed fragility fracture or loss of ≥20% vertebral height due to fragility fractures; alternately, anyone over 70 years with low BMD, or people with low bone density taking glucocorticoids for at least 3 months qualify (s7(2)(a); Schedule 1). The SoP also lists exclusions, explicitly removing a number of other bone disorders from the meaning of osteoporosis in this instrument (s7(2)(b)).

Reasonable hypothesis and basis , the RMA states that it is of the view there is sound medical‑scientific evidence indicating osteoporosis may be related to relevant service (s8). The SoP operationalises that view by setting out the factors (s9) that must minimally exist to raise a reasonable hypothesis connecting the condition or death to service. The instrument therefore does not assert causation as a fact but furnishes a threshold for administrative determination.

Relevant service , defined in Schedule 1, relevant service covers the VEA and MRCA categories: operational, peacekeeping, hazardous, British nuclear test defence service, warlike and non‑warlike service (Schedule 1 definition of relevant service). The SoP links medical factors to that service, so timing and proof of service are material (s5, s10).

Onset versus clinical worsening , many factors in s9 are qualified by time before clinical onset or clinical worsening, typically requiring the factor to have existed for a specified period prior to the event (for example 1 year, 3 months, continuous periods within a 10 year window). Section 10(2) constrains the clinical worsening rule so it applies only where the osteoporosis was suffered or contracted before or during (but did not arise out of) relevant service; that is, worsening claims require a pre‑existing disease to have been present before or during service and not caused by service.

Discrete, evidentiary factors , s9 provides a closed list of factors. They are concrete and measurable: prisoner of war status; specified autoimmune diseases; HIV infection; multiple sclerosis or Parkinson disease; chronic renal impairment with GFR <45 ml/min/1.73 m2 for specified time; haematological malignancies and systemic mastocytosis; solid organ/stem cell/bone marrow transplant; specified endocrine, gastrointestinal, surgical and nutritional conditions; defined exposures such as cadmium with quantified urinary thresholds; quantified smoking and alcohol history; BMI and weight loss thresholds; quantified vitamin A, vitamin C and vitamin D levels; glucocorticoid cumulative dose thresholds with explicit drug equivalence multipliers in Schedule 1; and a specified list of medications with dose and duration thresholds included in the Schedule (s9; Schedule 1).

Cross‑reference mechanism , s11 requires that where a listed factor is itself an injury or disease for which the RMA has an SoP, that other SoP applies according to its own terms. This creates an explicit mechanism to incorporate the findings of other SoPs into assessments under this instrument.

Units and standards , the instrument references established measurement standards and classification systems: ICD‑10‑AM codes (s7(3)-(4)), DSM‑5‑TR (Schedule 1) for the definition of anorexia nervosa, and specific laboratory thresholds (for example serum 25(OH)D <50 nmol/L, serum ascorbic acid <2.5 mg/L, urinary cadmium ≥0.5 μg/g creatinine) in the main text and Schedule 1. Those anchors make several components of the SoP strictly evidentiary rather than evaluative.

Primary subjects of the instrument are claimants to the VEA and MRCA who assert that osteoporosis or death from osteoporosis is connected to their relevant service (s5, Schedule 1 relevant service). This group includes veterans, members of Peacekeeping Forces and members of the Forces within the statutory definitions in the VEA and MRCA (Schedule 1). Because the SoP applies when a claim is made under s120A VEA or s338 MRCA (s5), it directly affects persons pursuing administrative entitlements, and indirectly affects practitioners who prepare medical evidence , treating clinicians, specialists, medico‑legal experts and advocates.

Administrators and adjudicators , Departmental decision makers, case officers and medical assessors who adjudicate claims under the VEA and MRCA will apply this SoP as a template for whether the statutory reasonable hypothesis is raised; the instrument therefore materially affects their evidence requests and file review procedures. The RMA itself, as the author of the SoP, will rely on the definitions and factors it contains when giving medical advice to the Minister and to the department (s3, s8 implied).

Healthcare providers , clinicians will be affected in the sense that the SoP prescribes which clinical findings, test results and historical data will be probative for claims. Examples include the need to document BMD T scores, radiographic evidence of fragility fractures, GFR measurements, serum 25(OH)D levels, serum ascorbic acid levels, urinary cadmium levels, insulin or endocrine tests, and precise medication histories (s7(2), s9, Schedule 1). Treating clinicians may be asked to quantify cumulative glucocorticoid exposure, confirm dates of onset or worsening, and document weight and BMI histories. The Schedule specifies routes, doses and minimum durations for a long list of medications that can be relevant (Schedule 1, “taking a medication from the specified list”).

Record keepers and employers , to the extent that service records, pharmacy dispensing histories, or occupational exposure records (for example cadmium exposure causing renal damage) are needed to establish a factor in s9(23), those who hold such records will be called upon to provide them. Defence records documenting type and timing of relevant service are, by implication, necessary to satisfy the s10 requirement that factors be related to the person’s relevant service.

Family and estate trustees , because the SoP includes death from osteoporosis where death was contributed to by osteoporosis (s7(5)), those making decedent claims or actuarial assessments for estates may need to assemble relevant medical evidence according to the thresholds set out in the SoP.

Administrative law practitioners and tribunals , solicitors and counsel advising claimants will need to assess whether the facts support at least one factor in s9, whether that factor is causally related to service under s10, and whether any overlapping SoP under s11 supplies additional or substitutive criteria.

The SoP does not create direct obligations on private third parties unless they are furnishing evidence. It does not purport to alter private contracts, insurance entitlements, workers’ compensation or general tort law. Its territorial and legal effect is administrative: it prescribes the medical criteria used by the RMA and decision makers in VEA/MRCA claims (s3, s5).

The SoP itself does not impose duties or grant rights in the manner of criminal statutes. Instead it defines thresholds and evidentiary requirements that administrative decision makers must use when considering whether a reasonable hypothesis has been raised linking osteoporosis, or death from osteoporosis, to relevant service (s3, s8, s9). The practical legal effects are:

• Duty of decision makers to consider the SoP factors when applying the reasonable hypothesis test for claims that fall under s120A VEA or s338 MRCA, because the instrument is an SoP made under subsection 196B(2) of the VEA (s3, s5). While the SoP states the RMA’s view as to medical‑scientific evidence (s8), it is used as the medical standard in administrative decisions.
• Claimant’s right to have their claim assessed using the SoP’s criteria. If an applicant can evidence at least one of the factors in s9, properly related to relevant service per s10, then a “reasonable hypothesis” is said to be raised under the terms of the instrument.
• Evidence requirements arising from the SoP: claimants and their advisers must produce clinical, laboratory and service documentation that correspond to the explicit thresholds in the SoP and Schedule 1. Examples include BMD T scores, radiology for fragility fractures, cumulative glucocorticoid dosing (calculated using dose equivalence multipliers in Schedule 1), prescribed medication dose and duration records for agents on the specified list, GFR records, vitamin assay results and recorded smoking/alcohol histories quantified to the specified metrics (s7(2), s9, Schedule 1).
• Rights of cross‑application: where a factor in s9 refers to a disease or injury covered by another SoP, the claimant may rely on that other SoP’s factors as well, in accordance with s11. This gives claimants an avenue to incorporate the RMA’s determinations for related conditions.
• Temporal obligations: the SoP delineates precise time windows that must be demonstrated. For instance, numerous factors require the condition or exposure to have existed for defined minimum periods before clinical onset or clinical worsening (for example, 1 year for certain autoimmune diseases, 3 months for chronic renal impairment with GFR <45 ml/min/1.73 m2, or specified durations in the medication table in the Schedule) (s9; Schedule 1). Claimants therefore have the practical duty to establish these temporal elements.

The SoP does not confer a private right of action nor specify appeal mechanisms. Those procedural rights and duties are contained within the VEA and MRCA legislative frameworks and the administrative law rights of review and appeal that apply to decisions under those statutes. The SoP governs the medical threshold for the reasonable hypothesis element in those statutory decision processes; it changes what evidence is necessary to satisfy the statutory test (s5, s8, s9).

The instrument does not itself create criminal offences, pecuniary penalties or compliance sanctions. It is an evidentiary and standard‑setting instrument used in the administrative adjudication of claims under the VEA and MRCA (s3, s5, s8). Consequently, enforcement is administrative rather than penal: the SoP changes how entitlement decisions are made by providing specified medical criteria.

Administrative consequences , if a claimant fails to establish at least one of the factors set out in s9, or cannot show that any factor is related to relevant service under s10, a decision maker may determine that the statutory threshold of a reasonable hypothesis has not been raised and deny the claim. Conversely, demonstration of one or more factors meeting the SoP thresholds and temporality requirements may be sufficient to require the decision maker to accept that a reasonable hypothesis has been raised, triggering further entitlement processes under the VEA or MRCA. The SoP functions as a gatekeeper for the reasonable hypothesis stage of claims; its role is procedural and evidentiary.

Evidence standards and proof burden , the SoP sets thresholds (for example numeric laboratory values, cumulative drug doses, duration requirements, and diagnostic criteria such as DSM‑5‑TR for anorexia nervosa) which become the touchstones by which medical advisors and decision makers assess proof. This shifts the enforcement question into meticulous forensic assembly of medical and service records rather than the imposition of sanctions.

No express enforcement role for external regulators , the text does not confer enforcement authority on bodies outside the VEA/MRCA claim infrastructure. There is no mention of reportable offences to third party regulators or private penalties for non‑compliance with the SoP because it is an administrative statement by the RMA (s3).

Appeal and review pathways , while the SoP itself is silent on appeal processes, decisions reached using it will be subject to the statutory review and appeal mechanisms that apply under the VEA and MRCA, administered by the department, tribunals and courts. The instrument thereby influences the content and direction of administrative review litigation, but does not itself stipulate enforcement processes.

Risk of administrative discretion , because the SoP specifies factors and thresholds, much of enforcement depends on how vigorously departmental decision makers and medical officers request and weigh evidence. The SoP reduces some discretionary judgement by providing measurable criteria, but many provisions still require evaluative inferences about temporality, the relative contribution of one factor over another, or the sufficiency of “inability to obtain appropriate clinical management” where that is alleged (s9(28)). These areas are loci for disputes that will be resolved through the statutory administrative review mechanisms.

The instrument is made under VEA subsection 196B(2) and applies to claims under particular sections of the VEA and the MRCA (s3, s5). It therefore operates inside a broader legislative ecosystem: the VEA and MRCA provide the statutory entitlement, administrative procedures and review mechanisms. The SoP provides the RMA’s medical criteria for the reasonable hypothesis element that decision makers must apply when assessing those claims.

Cross‑SoP interaction , section 11 expressly provides that if a factor in s9 refers to an injury or disease already covered by another SoP made under subsection 196B(2) of the VEA, then the factors in that other SoP apply according to its terms as they are in force from time to time. This creates a legal and procedural link between SoPs. Practically, an adjudicator evaluating a factor that is identified as another listed disease should consult that disease’s current SoP and apply those factors in assessing causation and temporality. That mechanism ensures consistency across RMA products but also introduces complexity where multiple SoPs must be read together.

Interaction with diagnostic classifications and clinical standards , the SoP ties its medical definitions to external classification systems and manuals. Section 7(3)-(4) anchors osteoporosis to ICD‑10‑AM codes M80, M81 or M82 but disclaims that those codes exhaust the meaning of osteoporosis for the SoP; the legal meaning is that given in s7(2). The Schedule references DSM‑5‑TR for anorexia nervosa and various laboratory cutoffs and measurement units for vitamin assays, urinary cadmium and GFR. These references import clinical standards into law by reference and mean that claims‑related proof will typically rely on tests and diagnostic criteria developed for clinical practice, now having legal significance.

Overlap with other Commonwealth and state statutes , while the SoP is an instrument under the VEA, its evidentiary standards may intersect with other laws in practice. For example, evidence used to satisfy the SoP (medical records, lab results, workplace exposure records) may be the same evidence considered for workers’ compensation, life insurance or private civil claims. The SoP does not displace those regimes, but the RMA’s standards may be persuasive in other contexts because they are a statutory medical opinion used by a federal authority. The text itself does not purport to modify or preclude rights or obligations under other statutes.

Administrative law limits , decisions made using the SoP remain subject to administrative law doctrines such as reasonableness, procedural fairness and the requirements of the VEA and MRCA. The SoP reduces some medical uncertainty by providing explicit thresholds, but it cannot override procedural protections in those Acts. It is a material but not exclusive input into adjudication.

Regulatory and clinical practice effects , by defining specific laboratory and dosage thresholds and requiring particular durations for medications and exposures, the SoP may shape what evidence clinicians assemble for patients who are veterans or serving members. Clinicians’ documentation practices may adapt to ensure that records contain the measurement units, dates and quantifications that the SoP requires. Again, those practice effects are incidental; the instrument does not directly regulate clinical practice.

International or external standards , the instrument references the Australian ICD‑10‑AM edition effective 1 July 2017 and the DSM‑5‑TR (Schedule 1), binding those editions into the interpretive matrix. Any later clinical or classification changes will be relevant to interpretation only to the extent RMA updates its SoPs or decision makers adopt newer editions; the SoP itself specifies the edition it relies on (s7(4); Schedule 1).

This SoP, dated 20 August 2024 and signed by the RMA Chairperson, Professor Terence Campbell AM, commences on 24 September 2024 (front matter; s2). Section 4 expressly repeals the prior Statement of Principles concerning osteoporosis No. 98 of 2014 (Federal Register of Legislation No. F2014L01388) made under subsection 196B(2) of the VEA. Beyond that, the instrument contains no internal amendment history because it is a fresh instrument replacing the 2014 SoP.

The document does, by operation, sit in a framework where the RMA routinely issues and updates SoPs under subsection 196B(2) of the VEA. The instrument’s cross‑reference rules in s11 indicate that future amendments to other SoPs will be applicable where s11 directs that a listed factor is covered by another SoP “as in force from time to time”. That language preserves the applicability of future SoP amendments without needing to remade this instrument when linked SoPs change.

Practical implications of the repeal , the repeal of the 2014 SoP means that decision makers and claimants should use this 2024 instrument for all relevant claims from its commencement date (s2, s4). The change may alter evidentiary thresholds, the list of qualifying factors, the duration or dosing thresholds for medications, and the exclusions. The repeal was effected without an amendment schedule showing a clause‑by‑clause comparison to the 2014 instrument in this text; therefore practitioners must compare the prior SoP to the new one to identify substantive shifts. The instrument itself does not summarise differences.

Reference to external standards , s7(4) fixes the ICD‑10‑AM edition cited (Tenth Edition, effective 1 July 2017). The Schedule references DSM‑5‑TR (2022) and other measurement units. Any future updates to these external materials will not automatically amend the SoP, although decision makers may take account of more recent standards when interpreting medical evidence; the SoP only references the specific editions and definitions it cites.

No transitional provisions are included , the instrument contains no explicit transitional rules dealing with claims begun before the commencement date, or specifying whether evidence obtained under the prior SoP remains valid. Practitioners should therefore treat the 2024 SoP as the operative instrument for claims to which s120A VEA or s338 MRCA applies from its commencement. Administrative guidance or departmental practice directions may further clarify the effect of the repeal, but those are not part of the text provided here.

The provided instrument contains no case citations, judicial decisions or an account of litigation relating to the prior SoP or to osteoporosis claims generally. It does not narrate any challenge to the RMA’s determinations or specify judicial interpretations of SoPs. Therefore, based on the text alone, there is no litigation history recorded within the instrument itself.

What the text does indicate is that these SoPs are intended to be authoritative inputs into administrative decisions under the VEA and MRCA (s3, s5, s8). As administrative standards they are likely to be invoked in departmental decisions that may subsequently be the subject of internal review, tribunal hearings or judicial review. The instrument does not supply those outcomes here, so counsel and researchers will need to consult tribunal and court records for litigation concerning the 2014 SoP or the RMA’s approach to osteoporosis generally.

Useful research steps that the instrument indicates claimants and advisers will need to take outside the SoP itself include:

• searching decisions of the Veterans’ Review Board, Administrative Appeals Tribunal and federal courts for cases citing the RMA’s osteoporosis SoP or engaging with the reasonable hypothesis threshold as applied to osteoporosis;
• comparing how decision makers applied the now‑repealed 2014 SoP to understand possible areas of contest under the 2024 SoP, particularly in relation to newly defined factors or changed dose/duration thresholds; and
• examining any departmental policy or practice notes issued after 24 September 2024 that explain how the department will operationalise the 2024 SoP in file processing, evidence gathering and referral to medical advisers.

Because the instrument expressly cross‑references other SoPs (s11), litigation involving diseases or exposures listed at s9 that have their own SoPs may be relevant. Any judicial interpretation of those other SoPs will therefore be informative in litigation implicating the current SoP.

Finally, the absence of litigation history in the instrument does not mean none exists. The RMA’s SoPs are frequently central to administrative decisions that are litigated. Practitioners should treat the instrument as an evidentiary standard to be tested in adjudicative forums where medical interpretation, the sufficiency of evidence, and questions of temporality and causation are litigated.

The SoP contains numerous technical thresholds and cross‑references that create pitfalls for claimants, advocates and clinicians. Key areas where mistakes or misunderstandings are likely include:

1. Measurement thresholds are strict and numeric. Low bone mineral density is defined as a T score ≤ −2.5 (Schedule 1). The SoP accepts radiologically confirmed fragility fractures or loss of ≥20% vertebral height as alternatives (s7(2)(a)). Failure to provide a precise T score or radiological measurement may mean the criterion is not met.

2. Exclusions are explicit. The SoP excludes “localised osteoporosis”, Paget disease of bone, osteomalacia, osteonecrosis, osteomyelitis, bone neoplasms and osteogenesis imperfecta from its meaning of osteoporosis (s7(2)(b)). If a claimant’s bone pathology is actually one of the excluded conditions, the SoP will not assist unless another factor applies.

3. Timing matters. Many factors require the condition or exposure to exist for a specified duration before the clinical onset or clinical worsening of osteoporosis (for example autoimmune diseases for at least 1 year prior to onset for s9(2), GFR <45 for at least 3 months for s9(5), or continuous vitamin D deficiency for at least 1 year within the 10 years before onset for s9(21)). Establishing precise dates is therefore crucial.

4. Distinction between onset and clinical worsening. Section 10(2) limits the clinical worsening aspect to situations where the osteoporosis was suffered or contracted before or during but did not arise out of relevant service. That is an unusual legal constraint: a claimant seeking to rely on clinical worsening must show the disease pre‑existed or arose during service but was not caused by service. Mischaracterising a claim as “worsening” where onset was actually during service, or where the disease arose out of service, may render s9(2)‑style factors inapplicable.

5. Glucocorticoid dosing complexity. s9(13) lists cumulative dose thresholds for specific glucocorticoids and provides a catch‑all referencing dose equivalence to prednisolone. The Schedule contains multipliers to convert different glucocorticoids to prednisolone equivalents. Errors in conversion or failure to account for combination dosing risks under‑ or over‑estimating cumulative exposure. Clinical records must show route, dates and quantities dispensed or administered.

6. The medication list is precise. The Schedule’s table sets dose, route and minimum durations for a list of medications; for example, inhaled glucocorticoids qualify only if ≥640 μg/day on average for 24 months, or ≥3 grams any duration. Tamoxifen is listed for premenopausal women only and requires 60 months of treatment. Failure to demonstrate the specific dose, route and duration will disqualify the medication factor.

7. Quantifying lifestyle exposures uses non‑intuitive units. Alcohol consumption is measured in kilograms over a 10 year period (s9(16)-(17)) using the Australian standard of 10 g alcohol per standard drink. Translating clinical histories or self‑reports into kilograms requires careful conversion. Smoking is quantified in pack‑years with specific equivalences in the Schedule that include weight‑based measures for tobacco. Casual or imprecise statements like “heavy drinker” or “smoker for many years” will be insufficient.

8. Laboratory cut‑offs are specific. Vitamin D deficiency is defined as serum 25(OH)D <50 nmol/L for a continuous year within the 10 years before onset (s9(21)); severe vitamin C deficiency is serum ascorbic acid <2.5 mg/L (Schedule 1). A single borderline result or a result outside the required time window may be inadequate.

9. “Inability to obtain appropriate clinical management” is open to interpretation. s9(28) is potentially subjective and requires evidentiary support such as appointment records, referrals, wait times, or evidence of refusal of care. The SoP provides no prescriptive standard for what constitutes inability to obtain appropriate care; claimants relying on this factor should produce contemporaneous documentation.

10. Prisoner of war status as a factor. s9(1) lists “being a prisoner of war before clinical onset or clinical worsening” as a standalone factor. Proof of POW status will rely on service records and is an evidentiary threshold that is separate from medical proof.

11. Cross‑SoP implications. If a s9 factor is itself covered by another SoP, practitioners must consult that other SoP because s11 requires the factors in the other SoP to be applied. Failing to identify and deploy a relevant companion SoP may omit crucial criteria.

12. Death from osteoporosis is included but only where osteoporosis contributed to death via a terminal event or condition; terminal events are listed in Schedule 1 and examples include pneumonia and respiratory failure (s7(5); Schedule 1). Claims for death therefore must link osteoporosis to a listed proximate terminal event.

13. No transitional detail for claims straddling the repeal. Because the instrument repeals the 2014 SoP and contains no transitional provisions (s4), claims with evidence compiled under the prior SoP will need re‑assessment under the new criteria from the commencement date.

All of these points emphasise that successful claims require precise, contemporaneously recorded, quantifiable evidence that aligns with the numerical and temporal thresholds set out in the SoP and its Schedule.

For practitioners preparing or advising on claims that will be assessed against this SoP, the practical compliance task is documentary assembly and expert analysis mapped to the SoP’s explicit criteria. Below is a focused compliance checklist and recommended evidentiary approach tied to the instrument’s requirements.

1. Establish the diagnosis as the SoP defines it (s7(2), Schedule 1).

   • Obtain the most recent and historical DEXA scan reports showing T scores; ensure the T score is recorded and, if applicable, sex‑matched young adult controls are identified.
   • If relying on radiographic evidence of fragility fracture, secure radiology reports confirming fragility fracture or loss of ≥20% vertebral height with dates.
   • Exclude conditions enumerated in s7(2)(b) by obtaining relevant diagnostic records and pathology where necessary.

2. Establish timing relative to relevant service (s5, s10).

   • Obtain service records proving the type and dates of relevant service as defined in Schedule 1.
   • Document the clinical onset date of osteoporosis and any dates of clinical worsening. Use treating clinicians’ notes, imaging dates and specialist reports to substantiate onset and worsening.

3. Prove at least one s9 factor, with precise temporal and quantitative proof.

   • For autoimmune, neurological or endocrine diagnoses, obtain specialist letters or hospital records confirming diagnosis and the date of diagnosis, and demonstrate continuous duration where required (for example 1 year).
   • For chronic renal impairment, document GFR measurements over time showing <45 ml/min/1.73 m2 for at least 3 months before onset/worsening.
   • For transplant history, obtain operative and discharge summaries with dates.
   • For malignancies (myeloma, lymphomas) provide pathology and oncology treatment records.
   • For nutritional deficiencies, extract lab records: serum 25(OH)D values, serum ascorbic acid, iron studies, and dietary histories where relevant; demonstrate continuous duration where required.

4. Document medication exposures carefully.

   • For glucocorticoids, assemble prescribing and dispensing records, hospital administration charts and outpatient infusion records. Convert all glucocorticoid agents to prednisolone equivalents using the Schedule 1 multipliers and calculate cumulative doses over the specified windows (s9(13); Schedule 1 “dose equivalence to prednisolone”).
   • For medications in the specified list, obtain exact dose, route and duration records to match the table in Schedule 1. For example, inhaled glucocorticoids require documentation of ≥640 μg/day on average for 24 months or ≥3 grams any duration to qualify.

5. Quantify lifestyle exposures accurately.

   • For smoking, calculate pack‑years and, if using the Schedule’s alternate weight metrics for tobacco, convert quantities accordingly. Document dates of cessation to show clinical onset/worsening occurred within 20 years if smoking ceased (s9(15); Schedule 1).
   • For alcohol, convert reported consumption into kilograms of alcohol over rolling 10 year periods using the Australian standard of 10 g per standard drink as the conversion anchor, and document the relevant 10 year period(s) within 20 years before onset (s9(16)-(17)).

6. Provide objective measures for exposures and work‑related factors.

   • For cadmium exposure, obtain occupational exposure records, industrial hygiene reports, urinary cadmium levels and evidence of renal damage where applicable; show urinary cadmium ≥0.5 μg/g creatinine for at least 5 years if relying on that threshold (s9(23)).
   • For loss of physical activity or immobility, document rehabilitation, hospitalization and mobility assessments showing gross diminution or near‑complete absence of movement for at least 3 months within the 2 years before onset (s9(24)) or inability to undertake activity >3 METs for 5 years (s9(25)).

7. Demonstrate BMI and weight change where relevant.

   • Provide serial weight and height records to calculate BMI over time and show continuous BMI <20 for at least 1 year within the 10 years before onset (s9(26)); document weight loss of 10%+ within consecutive 3 year periods in the specified age group when applicable (s9(27)).

8. If relying on “inability to obtain appropriate clinical management” (s9(28)), gather contemporaneous evidence.

   • This may include referral letters, waiting list records, attempts to access care, correspondence indicating refusal or lack of local services, and expert opinion on what constitutes appropriate care and whether it was reasonably accessible.

9. For death claims, link osteoporosis to a listed terminal event.

   • Obtain the death certificate, clinical course notes, and any pathology or coronial documentation showing that a terminal event or condition listed in Schedule 1 (for example pneumonia or respiratory failure) was contributed to by osteoporosis (s7(5), Schedule 1).

10. Prepare expert medical reports that map facts to the SoP.

    • Experts should state whether one or more s9 factors exist, specify the supporting evidence, explain the temporal relation to clinical onset/worsening and to relevant service (s10), and, where needed, engage with the dose equivalence conversions and measurement thresholds in the Schedule.
    • For cross‑referenced conditions covered by other SoPs, experts should reference and apply those SoPs per s11.

11. Anticipate cross‑SoP dependencies.

    • If a listed factor is itself governed by another SoP, obtain and apply the other SoP’s criteria and evidence thresholds as well (s11).

12. Archive and present records in a way that matches the SoP’s structure.

    • Organise the claim file so that each s9 factor is addressed with clear documentary proof, temporal mapping to onset/worsening, service linkage, and any conversion tables used for drug equivalence or exposure quantification. This makes decision makers’ job easier and reduces the likelihood of evidence being overlooked.

13. Monitor departmental guidance and practice notes post‑commencement.

    • Because the SoP repealed the 2014 instrument (s4) and contains no transitional rules, check for department or RMA guidance clarifying how claims in progress will be handled and any evidentiary preferences that may smooth decision making.

Following this compliance plan will align claim preparation to the instrument’s numeric and temporal thresholds and reduce the risk that a claim is dismissed simply for lack of evidence matching the SoP’s strict criteria.