Statement of Principles concerning chronic venous insufficiency of the lower limb and varicose veins of the lower limb (Balance of Probabilities) (No. 8 of 2021) (Cth)

Statement of Principles concerning CHRONIC VENOUS INSUFFICIENCY OF THE LOWER LIMB AND VARICOSE VEINS OF THE LOWER LIMB (Balance of Probabilities) (No. 8 of 2021) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 24 December 2020

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:

Professor Nicholas Saunders AO Chairperson

Contents 1 Name 2 Commencement 3 Authority 4 Repeal 5 Application 6 Definitions 7 Kind of injury, disease or death to which this Statement of Principles relates 8 Basis for determining the factors 9 Factors that must exist 10 Relationship to service 11 Factors referring to an injury or disease covered by another Statement of Principles Schedule 1 - Dictionary 1 Definitions

1 Name This is the Statement of Principles concerning chronic venous insufficiency of the lower limb and varicose veins of the lower limb (Balance of Probabilities) (No. 8 of 2021). 2 Commencement This instrument commences on 25 January 2021. 3 Authority This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning chronic venous insufficiency of the lower limb No. 30 of 2012 (Federal Register of Legislation No. F2012L00461) and the Statement of Principles concerning varicose veins of the lower limb No. 121 of 2011 (Federal Register of Legislation No. F2011L02138) made under subsection 196B(3) of the VEA are repealed. 5 Application This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about chronic venous insufficiency of the lower limb and varicose veins of the lower limb and death from chronic venous insufficiency of the lower limb and varicose veins of the lower limb. Meaning of chronic venous insufficiency of the lower limb (2) For the purposes of this Statement of Principles, chronic venous insufficiency of the lower limb: (a) means chronic impairment of venous blood flow or venous return affecting one or both of the lower limbs; and (b) includes: (i) corona phlebectatica (dilated veins on the foot and ankle); (ii) lipodermatosclerosis; (iii) pigmentation or venous eczema; and (iv) venous ulcers; and (c) excludes varicose veins of the lower limb. Note: Symptoms and signs of chronic venous insufficiency of the lower limb include ache, pain, tightness, skin irritation, heaviness, muscle cramps and venous oedema. Meaning of varicose veins of the lower limb (3) For the purposes of this Statement of Principles, varicose veins of the lower limb: (a) means dilated, bulging, tortuous superficial veins of the lower limb; and (b) excludes spider veins (telangiectasias) and reticular veins. (4) While chronic venous insufficiency of the lower limb attracts ICD‑10‑AM code I87.0 or I87.2 and varicose veins of the lower limb attracts ICD‑10‑AM code I83 or O22.0, in applying this Statement of Principles the meaning of chronic venous insufficiency of the lower limb or varicose veins of the lower limb is that given in subsection (2) or (3), respectively. (5) For subsection (4), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4. Death from chronic venous insufficiency of the lower limb or varicose veins of the lower limb (6) For the purposes of this Statement of Principles, chronic venous insufficiency of the lower limb or varicose veins of the lower limb, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's chronic venous insufficiency of the lower limb or varicose veins of the lower limb. Note: terminal event is defined in the Schedule 1 - Dictionary. 8 Basis for determining the factors On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that chronic venous insufficiency of the lower limb or varicose veins of the lower limb and death from chronic venous insufficiency of the lower limb or varicose veins of the lower limb can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary. 9 Factors that must exist At least one of the following factors must exist before it can be said that, on the balance of probabilities, chronic venous insufficiency of the lower limb or varicose veins of the lower limb or death from chronic venous insufficiency of the lower limb or varicose veins of the lower limb is connected with the circumstances of a person's relevant service: (1) having deep vein thrombosis within a deep vein that drains the affected lower limb before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; Note: deep vein that drains the affected lower limb is defined in the Schedule 1 - Dictionary. (2) having chronic complete or partial obstruction of a vein that drains the affected lower limb before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (3) being pregnant at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (4) standing for at least four hours per day, on more days than not, for a continuous period of at least the five years before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; Note: Standing does not require complete immobility for four continuous hours, and may include intermittent periods of walking short distances. (5) having chronic dysfunction of the calf muscle pump in the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; Note: Causes of chronic dysfunction of the calf muscle pump include trauma and motor disorders (such as paraplegia, arthritis, chronic immobility, frozen ankle and severe sedentary state). (6) having an acquired arteriovenous fistula involving the blood vessels that supply the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (7) having trauma to a valve in a vein of the affected lower limb causing dysfunction or incompetence of that valve before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (8) having tricuspid valve regurgitation, in the presence of a pulsatile greater saphenous vein, at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (9) for chronic venous insufficiency of the lower limb only: (a) having varicose veins of the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb; (b) having heart failure at the time of the clinical onset of chronic venous insufficiency of the lower limb; (c) being obese at the time of the clinical onset of chronic venous insufficiency of the lower limb; Note: being obese is defined in the Schedule 1 - Dictionary. (10) for varicose veins of the thigh only, having a varicosity of an abdominal or pelvic vein, leading to reflux into the affected thigh vein via interconnecting or collateral veins, at the time of the clinical onset of varicose veins of the thigh; (11) having deep vein thrombosis within a deep vein that drains the affected lower limb before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; Note: deep vein that drains the affected lower limb is defined in the Schedule 1 - Dictionary. (12) having chronic complete or partial obstruction of a vein that drains the affected lower limb before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (13) being pregnant at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (14) standing for at least four hours per day, on more days than not, for a continuous period of at least the five years before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; Note: Standing does not require complete immobility for four continuous hours, and may include intermittent periods of walking short distances. (15) having chronic dysfunction of the calf muscle pump in the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; Note: Causes of chronic dysfunction of the calf muscle pump include trauma and motor disorders (such as paraplegia, arthritis, chronic immobility, frozen ankle and severe sedentary state). (16) having an acquired arteriovenous fistula involving the blood vessels that supply the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (17) having trauma to a valve in a vein of the affected lower limb causing dysfunction or incompetence of that valve before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (18) having tricuspid valve regurgitation, in the presence of a pulsatile greater saphenous vein, at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; (19) for chronic venous insufficiency of the lower limb only: (a) having varicose veins of the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb; (b) having heart failure at the time of the clinical worsening of chronic venous insufficiency of the lower limb; (c) being obese at the time of the clinical worsening of chronic venous insufficiency of the lower limb; Note: being obese is defined in the Schedule 1 - Dictionary. (20) for varicose veins of the thigh only, having a varicosity of an abdominal or pelvic vein, leading to reflux into the affected thigh vein via interconnecting or collateral veins, at the time of the clinical worsening of varicose veins of the thigh; (21) inability to obtain appropriate clinical management for chronic venous insufficiency of the lower limb or varicose veins of the lower limb. 10 Relationship to service (1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person. (2) The factors set out in subsections 9(11) to 9(21) apply only to material contribution to, or aggravation of, chronic venous insufficiency of the lower limb or varicose veins of the lower limb where the person's chronic venous insufficiency of the lower limb or varicose veins of the lower limb was suffered or contracted before or during (but did not arise out of) the person's relevant service. 11 Factors referring to an injury or disease covered by another Statement of Principles In this Statement of Principles: (1) if a factor referred to in section 9 applies in relation to a person; and (2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA; then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.