Statement of Principles concerning polymyalgia rheumatica (Balance of Probabilities) (No. 6 of 2025)

The instrument centres on a small set of interlocking legal and medical concepts. The first is the statutory purpose: to identify, for claims assessment, when PMR or death from PMR can be connected to “relevant service” (s8, Schedule 1). “Relevant service” is defined in the Schedule and comprises eligible war service other than operational service, defence service other than hazardous service and British nuclear test defence service, and peacetime service under the MRCA (Schedule 1).

The second concept is the statutory meaning of polymyalgia rheumatica as a diagnostic construct for claims. The instrument supplies a specific clinical formulation (s7(2)(1)(a)-(c)). That formulation requires: bilateral aching and stiffness in defined proximal regions (shoulder/proximal arms; hip/proximal thighs; neck or lower back); elevated acute phase reactants (erythrocyte sedimentation rate and/or C reactive protein) or systemic symptoms such as malaise, fatigue and low-grade fever; and occurrence in the absence of other diseases capable of causing the musculoskeletal system symptoms (s7(2)). The Statement also notes that while PMR attracts ICD‑10‑AM code M35.3, the statutory meaning for the instrument is the definition in subsection 7(2) (s7(3)). The instrument further excludes PMR coexistent with giant cell arteritis (s7(2)(2)).

The third concept is causation factors. The instrument adopts a “factor‑based” approach: at least one enumerated factor must exist before a finding of service connection can be made on the balance of probabilities (s9). The two listed factors are (a) treatment with immune checkpoint inhibitors within the year before clinical onset or clinical worsening, and (b) inability to obtain appropriate clinical management for PMR before clinical worsening (s9(1)-(2)). The immunotherapy factor is exemplified by a non-exhaustive list of immune checkpoint inhibitors (e.g., atezolizumab, pembrolizumab) in a factual note (s9 note).

The fourth concept is temporal and relational scope. Section 10 requires that any factor in s9 be related to the person’s relevant service; and it circumscribes the “clinical worsening” application of the factors to those situations where the person’s PMR was suffered or contracted before or during, but did not arise out of, relevant service (s10(1)-(2)). Thus the Statement distinguishes between onset/contracting during service, onset arising out of service, and pre-existing disease that worsens in relation to service.

The fifth concept is cross‑reference to other Statements: where a s9 factor refers to an injury or disease covered by another Statement made under subsection 196B(3) of the VEA, the factors in that other Statement apply in accordance with that Statement as in force from time to time (s11). This creates a system of interlocking Statements for causation, whereby references to other conditions pull in their current factors.

Finally, definitions in Schedule 1 narrow scope on “terminal event” for death cases (Schedule 1 lists pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function) and confirm the statutory acronyms MRCA and VEA (Schedule 1). The Statement thus operates as a focused evidentiary tool for causation determinations under specified VEA and MRCA claim provisions.

The primary population affected by this Statement are persons making claims under section 120B of the VEA or section 339 of the MRCA, and decision‑makers who assess those claims (s5). Those claimants will principally be veterans or members of the Forces who meet the instrument’s definition of “relevant service” in the Schedule: eligible war service other than operational service, defence service other than hazardous service and British nuclear test defence service, and peacetime service under the MRCA (Schedule 1). The Statement explicitly states it applies to PMR and to death from PMR (s7(1), s7(4)).

Who determines entitlement is not set out in the Statement itself, but the instrument’s function is to guide the medical causation assessment that underpins determinations under the VEA and MRCA. The Repatriation Medical Authority made the Statement (s3) and expresses the medical‑scientific view that connection to service is more probable than not (s8). Administrative decision‑makers and medical assessors who apply the VEA and MRCA (for example, delegates or tribunals named in those Acts) will use this Statement when a claim is made under the specified claim provisions (s5). The Statement therefore affects those institutional actors responsible for benefit eligibility assessments and the medical experts they commission.

Practitioners likely to be affected include treating clinicians and medico‑legal experts who prepare reports: the Statement requires clinicians’ records to address the specific diagnostic features set out in s7(2) (clinical distribution of pain/stiffness, acute phase reactants or systemic symptoms, exclusion of other diseases) and the causation factors in s9 (treatment with immune checkpoint inhibitors within one year; inability to obtain appropriate clinical management). For death cases, coronial or pathology practitioners involved in cause‑of‑death documentation will be affected because the Statement treats death from terminal events as within scope if contributed to by PMR (s7(4) and Schedule 1 definitions of terminal event).

Finally, the Statement affects other Statements of Principles and their application because s11 provides that where a s9 factor refers to an injury or disease already covered by another Statement, the other Statement’s factors apply as in force from time to time. That means an affected claimant or decision‑maker may need to consider multiple Statements in a single claim where comorbidity or linked factors are alleged.

This Statement imposes no criminal or civil duties on its face; rather it prescribes the medical criteria and factors decision‑makers must have regard to when assessing causation for claims under specified VEA and MRCA sections (s5-s11). The operative legal effect is evidentiary: it sets the factors that, if established and related to relevant service, permit a finding of service connection on the balance of probabilities (s9, s10).

Rights implicated are rights to have a claim assessed against these medical criteria when a claimant falls within the Statement’s scope (s5). Claimants submit evidence to prove that one or more of the factors in s9 existed and that the factor(s) were related to their relevant service (s9, s10). The Statement furnishes the framework that supports a claimant’s right to assert a medical causal link between PMR (or death from PMR) and relevant service. It also clarifies exclusionary material that affects diagnostic rights: for example, if PMR coexists with giant cell arteritis the instrument excludes that presentation from its definition (s7(2)(2)).

Duties, for practical purposes, fall on evidence‑producers and decision‑makers. Medical practitioners preparing diagnostic or causation reports should address the particular elements in s7(2) and the causation factors in s9, and must provide temporally precise evidence tying the factor to relevant service as required by s10(1). Decision‑makers who determine claims to which s120B VEA or s339 MRCA apply must treat this Statement as the applicable Statement of Principles from its commencement, and give effect to its factors when weighing whether the balance of probabilities is met (s2, s3, s5, s8). Section 11 creates a duty on decision‑makers to consult other Statements where a s9 factor refers to another injury/disease and to apply those Statements’ factors as in force.

There is a substantive evidential gate: at least one of the s9 factors must exist before a finding that PMR or death from PMR is connected with the circumstances of relevant service on the balance of probabilities (s9). For “clinical worsening” aspects of the s9 factors, an additional temporal constraint applies: these aspects relate only to material contribution or aggravation where PMR was suffered or contracted before or during, but did not arise out of, the person’s relevant service (s10(2)). That creates an evidential duty to establish (a) the timing of onset relative to service and (b) whether the disease “arose out of” service, for the clinical worsening pathway to be available.

The instrument does not itself create entitlement to payments, compensation or treatment; instead it supplies the medical causation yardstick used under the referenced statutory claim provisions (s5). Rights to benefits remain governed by the VEA and MRCA, but whether those rights are triggered will often depend on demonstration of the factors set out in this Statement.

This instrument contains no penalty provisions, offence provisions, administrative fines or enforcement powers. Its operative effect is evidentiary and normative for claim assessment under the VEA and MRCA: it describes medical criteria and causation factors that decision‑makers must use in assessing whether PMR or death from PMR can be connected with relevant service (s5, s7-s11). There are therefore no enforcement mechanisms embedded in the Statement itself; enforcement and redress mechanisms, including review or appeal rights, would be those provided by the VEA, MRCA and tribunal processes, but those are not set out in this instrument.

Compliance with the Statement takes the form of procedural and evidential adherence by claimants, medical practitioners and decision‑makers. Decision‑makers assessing claims under s120B VEA or s339 MRCA must apply the Statement in their causation reasoning; failure to apply the relevant Statement of Principles could be material to administrative review or appeal, but the instrument does not specify remedies or sanctions for such failures. The Statement is made under the Repatriation Medical Authority’s statutory power (s3), and its repeal of the 2016 PMR Statement (s4) means that from the commencement date (s2) the 2016 text no longer governs causation assessments for PMR.

Because the Statement is descriptive rather than punitive, enforcement in practice will occur through adherence by decision‑makers to statutory decision‑making standards and by challenge in administrative review or merits review bodies if a claimant alleges incorrect application. The Statement itself, however, provides no enforcement timeline, compliance reporting requirements, or penalty matrix.

The Statement is expressly made under subsection 196B(3) of the Veterans' Entitlements Act 1986 (s3) and applies to claims to which s120B of the VEA or s339 of the MRCA applies (s5). It therefore functions within the statutory architecture of the VEA and MRCA as the Repatriation Medical Authority’s clinical‑scientific input for causation assessments. It does not amend the VEA or MRCA; rather it supplies a specialist evidentiary threshold that decision‑makers under those Acts will use when determining whether PMR or death from PMR is connected to relevant service.

The instrument cross‑references the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‑10‑AM) by noting that while PMR attracts ICD‑10‑AM code M35.3, the legal meaning for this Statement is the definition in subsection 7(2) (s7(3)) and that references to ICD‑10‑AM are to the Tenth Edition (effective date 1 July 2017) (s7(4) note). This preserves a distinction between coding conventions used in clinical records and the statutory diagnostic elements required for claims assessment.

Section 11 creates an explicit inter‑document interaction with other Statements of Principles made under subsection 196B(3) of the VEA. If a factor in s9 refers to an injury or disease covered by another Statement, then the factors in that other Statement apply “in accordance with the terms of that Statement of Principles as in force from time to time” (s11). Practically, that requires decision‑makers and practitioners to consult and apply the current terms of multiple Statements where factors bring in other conditions. The effect is dynamic: the relevant other Statement may change over time and the s11 cross‑application imports the other Statement as it stands at the relevant time.

The Statement defines “relevant service” in Schedule 1 and thereby narrows the population whose service is captured by the VEA/MRCA causation framework in respect of PMR (Schedule 1). The Schedule excludes certain types of service (for example, operational service is not listed under eligible war service, hazardous service and British nuclear test defence service are excluded from defence service), which will affect the application of this Statement to particular claimants because the underlying claim provisions cited in s5 operate only where “relevant service” is established under the VEA/MRCA framework.

The instrument is not a standalone entitlement law. It must be read and applied in conjunction with the substantive and procedural provisions of the VEA and MRCA that govern eligibility, causation standards, benefit types, decision‑making processes and rights of review. The Statement does not alter those statutory provisions; it supplies the medical causation criteria to be used within them.

This instrument is self‑contained and records a single explicit amendment action: the repeal of the earlier Statement of Principles concerning polymyalgia rheumatica (No. 20 of 2016) (Federal Register of Legislation No. F2016L00259) (s4). The instrument is dated 17 December 2024 and commences on 28 January 2025 (s2). It is designated as Statement of Principles concerning polymyalgia rheumatica (Balance of Probabilities) (No. 6 of 2025) (s1).

No other amendments, transitional provisions or savings clauses are contained in the text provided. The instrument does not set out retrospective application or transitional arrangements for claims in progress; it simply states that it applies to claims to which s120B VEA or s339 MRCA applies (s5) and commences on the specified date (s2). The repealing of the 2016 Statement (s4) indicates that, from the commencement date, the 2016 text no longer governs PMR causation assessments; however, this instrument does not itself state whether decisions made under the 2016 Statement remain unaffected or whether ongoing matters are to be reassessed. The absence of transitional detail means administrators and claimants must look to the VEA and MRCA or administrative practice for any transitional handling.

The Schedule supplies definitions, which effectively update and restate the terms used in the instrument (Schedule 1). There are no explicit amendment powers or triggers set out in the instrument itself; changes to this Statement in future would require the Repatriation Medical Authority to determine and publish a new Statement under the enabling provision (subsection 196B(3) of the VEA) and may involve repeal or amendment of the current text.

The text of this Statement contains no references to litigation or judicial decisions. It neither records prior case law nor cites any tribunal or court determinations. The instrument is an administrative medical statement rather than a judgment or central provision in litigation.

Because the Statement is a policy instrument used in administrative decision‑making, its application may later become the subject of administrative review or litigation in cases where claimants or representatives contest how decision‑makers applied the Statement’s factors when assessing causation under the VEA or MRCA. However, no such cases are recorded or referenced in the instrument itself. Likewise, the text does not provide any guidance about precedent value or how tribunals should treat the Statement beyond its role as the Repatriation Medical Authority’s view on medical causation for PMR and death from PMR (s8).

Practitioners seeking litigation history or precedent that interprets this or the prior 2016 Statement must therefore consult the administrative review and courts’ databases and decisions outside the instrument. The Statement itself does not supply that material.

Several features of the Statement can generate points of complexity or evidential difficulty in claims.

1. Definition takes priority over ICD code. The Statement notes that although PMR has ICD‑10‑AM code M35.3, for application of the Statement the meaning is the statutory definition in subsection 7(2) (s7(3)). In practice, a clinical coding entry on a record will not by itself meet the statutory diagnostic requirement; the examiner must document the specific clinical features set out in s7(2). Treating clinicians and medico‑legal reports must therefore map records to the statutory elements (bilateral distribution, laboratory or systemic symptoms, absence of alternative diagnoses), not merely state an ICD code.

2. Exclusion of coexistent giant cell arteritis. The Statement explicitly excludes PMR coexistent with giant cell arteritis (s7(2)(2)). Where both are present, claimants and clinicians need to determine which Statement of Principles governs causation of each condition, as the PMR Statement will not cover the coexistent presentation under this instrument.

3. Narrow list of factors and the “at least one” gate. The instrument mandates that at least one factor in s9 must exist before a connection to service can be made on the balance of probabilities (s9). Only two factors are listed: (a) immune checkpoint inhibitor treatment within one year before clinical onset/worsening; and (b) inability to obtain appropriate clinical management before clinical worsening. This limited enumeration can be a tactical constraint for claimants who cannot show either factor; absence of any listed factor bars connection under this Statement, even if other plausible mechanisms are asserted, unless those mechanisms are covered via s11 by other Statements.

4. Ambiguity of “inability to obtain appropriate clinical management”. The second factor in s9 , inability to obtain appropriate clinical management , is inherently fact‑specific and potentially open to evidential dispute. The Statement offers no statutory definition of what qualifies as “appropriate clinical management” or what evidence suffices to show inability to obtain it. Claimants will need to assemble documentary evidence of attempts to access care, contemporaneous clinical notes showing deterioration attributed to lack of management, wait‑list or access records, correspondences, or system‑level impediments. Decision‑makers will need to evaluate these against the standard implied by the Statement, but the Statement supplies no procedural guidance on necessary proof.

5. Timing and the one‑year window for immune checkpoint inhibitors. The immune‑checkpoint factor requires treatment within the one year before clinical onset or clinical worsening (s9(1)). Establishing precise timing of treatment and the clinical onset/worsening is therefore critical. Records must show dates of immunotherapy administration and clinical notes documenting onset or measurable worsening of PMR. The Statement’s one‑year temporal limit is strict in text; practitioners must be able to tie the immunotherapy use within that timeframe.

6. Application of “clinical worsening” restricted by service nexus. Section 10(2) limits the application of the clinical worsening aspects of s9 to situations where the person’s PMR was suffered or contracted before or during, but did not arise out of, relevant service. That means if PMR arose out of service, the clinical worsening pathway in s9 may not be the correct evidentiary route. Parties must establish correctly whether PMR “arose out of” service or pre‑existed service and was merely worsened by service, because the Statement’s pathways differ by that classification.

7. Cross‑reference to other Statements. Where a s9 factor refers to an injury or disease covered by another Statement, the other Statement’s factors apply as in force from time to time (s11). Practically, this creates a moving target: an older or newer Statement elsewhere may alter the causal analysis when a s9 factor invokes it. This can complicate case management and evidence assembly because claimants must identify and apply the current text of other Statements at the time of decision.

8. Death cases hinge on “contributed to by” and listed terminal events. The Statement includes death from PMR that was contributed to by PMR via a terminal event or condition (s7(4)). The Schedule defines “terminal event” to include several proximate causes (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). For death cases, establishing causal contribution requires clinical and death documentation that links PMR to the terminal event; mere concurrence of PMR and a terminal event will not suffice unless contribution is demonstrated.

9. No penalties, no procedural guidance. The Statement provides the medical yardstick but supplies no guidance on standards of proof beyond “balance of probabilities”, no evidential checklists, and no transitional rules following repeal of the 2016 Statement (s4). This absence can leave procedural discretion and evidential expectations to decision‑makers and administrators, increasing the importance of careful medical documentation.

10. Narrow definition of “relevant service”. Schedule 1 narrows the kinds of service that qualify (for example, defence service excludes hazardous service and British nuclear test defence service). Claimants whose service falls into excluded categories may find the Statement inapplicable and must consider whether other legislative avenues exist, but those alternatives are outside this instrument.

These are practical points where claim assembly, proof of timing, definition mapping, and interaction with other Statements will be decisive.

For claimants, treating clinicians and decision‑makers, compliance with this Statement means assembling and presenting evidence tailored to the statutory elements it prescribes.

1. Diagnose in statutory terms. Ensure clinical records address each element of the statutory PMR definition in s7(2): bilateral aching and stiffness in the specified anatomical regions; laboratory support by ESR and/or CRP or contemporaneous documentation of systemic symptoms (malaise, fatigue, low‑grade fever); and clinical exclusion of other conditions capable of producing the musculoskeletal symptoms. Do not rely solely on an ICD‑10‑AM code M35.3; explicitly map clinical findings to s7(2) (s7(3)). If giant cell arteritis coexists, note that this Statement excludes that coexistent presentation (s7(2)(2)) and obtain advice on which Statement covers giant cell arteritis.

2. For immune checkpoint inhibitor factor (s9(1)). Obtain and provide records of oncological or other specialist therapy showing dates and names of immune checkpoint inhibitors administered. The Statement includes examples (e.g., pembrolizumab, nivolumab) in its note; match the medication and date to establishment of onset or documented clinical worsening of PMR that occurred within one year after the treatment. Provide contemporaneous clinical notes that document either new onset of PMR symptoms after immunotherapy or objective worsening of pre‑existing PMR. Lab data (ESR/CRP) before and after immunotherapy may strengthen temporal causation narratives.

3. For inability to obtain appropriate clinical management factor (s9(2)). Assemble records evidencing attempts to obtain care, such as referral letters, specialist appointment bookings and cancellations, wait‑list communications, correspondence showing denial or delay in treatment, or contemporaneous clinical notes documenting deterioration due to lack of access to appropriate management. Also obtain contemporaneous medical opinions linking the clinical worsening to the absence of appropriate management. Because the Statement does not define “appropriate clinical management”, provide detailed factual evidence of the steps taken to obtain standard care, the nature of care considered appropriate, and how its absence materially contributed to worsening.

4. Establish timing and service nexus (s10). For either factor to operate in the service connection analysis, the relevant factor must be related to the person’s relevant service. Produce service records and medical timelines that align onset and factor exposure with periods of relevant service as defined in the Schedule (eligible war service other than operational service; defence service excluding hazardous and British nuclear test defence service; or peacetime service under the MRCA). Where the claim invokes clinical worsening, ensure documentation shows PMR was suffered or contracted before or during (but did not arise out of) service if relying on the worsening pathway (s10(2)). If PMR arguably “arose out of” service, treat the clinical worsening route as inapplicable and prepare an alternative causation pathway consistent with the VEA/MRCA framework.

5. Death claims. Where death is alleged to be from PMR contribution (s7(4)), collect death certificates, pathology or coronial reports, treating notes that link PMR to the terminal event, and evidence that the terminal event (as defined in Schedule 1) was contributed to by PMR. Show the causal chain from PMR to the terminal cause listed (pneumonia, respiratory failure, etc.) and obtain expert opinion where necessary.

6. Cross‑referenced conditions (s11). If a factor in s9 refers to another injury or disease covered by a different Statement, identify that Statement and assemble evidence required by it. The other Statement applies “as in force from time to time” (s11), so confirm you are relying on the current version.

7. Reports and expert evidence. Where medical opinion is needed, ask experts to address the statutory formulation directly: to opine whether the person’s condition satisfies s7(2), whether a s9 factor existed and its timing, how that factor related to relevant service, and if death cases, whether PMR contributed to the terminal event. Experts should explain how findings map to the wording of the Statement rather than only to general medical literature.

8. Administrative process considerations. Submit medical records, service records and expert reports in a manner that makes the statutory mapping explicit: label material under headings corresponding to s7(2) diagnostic criteria, s9 factors, s10 service relation, and Schedule definitions. For decision‑makers, document the reasoning that links evidence to the specific elements of the Statement.

9. Monitor versioning. Because s11 imports other Statements as in force from time to time, practitioners should check for subsequent Statements that might affect linked conditions. Also, the repeal of the 2016 Statement means assessors should apply this Statement from its commencement date (s2-s4).

10. Administrative appeals. If an adverse decision follows from application of this Statement, the available VEA/MRCA review and appeal mechanisms (not contained in this instrument) are the procedural routes to challenge application. Grounds focusing on misapplication or failure to consider the Statement’s factors should be supported by evidence showing how the statutory elements were unmet or misinterpreted.

In sum, compliance is evidence‑driven and requires close alignment of clinical documentation, treatment and service timelines, and focused expert opinion with the specific statutory language of the Statement (s7-s11; Schedule 1).