Statement of Principles concerning sleep apnoea (Reasonable Hypothesis) (No. 68 of 2022) (Cth)

Statement of Principles concerning SLEEP APNOEA (Reasonable Hypothesis) (No. 68 of 2022) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 24 June 2022

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

Professor Terence Campbell AM 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 sleep apnoea (Reasonable Hypothesis) (No. 68 of 2022). 2 Commencement This instrument commences on 25 July 2022. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning sleep apnoea No. 41 of 2013 (Federal Register of Legislation No. F2013L01129) made under subsection 196B(2) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004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 sleep apnoea and death from sleep apnoea. Meaning of sleep apnoea (2) For the purposes of this Statement of Principles, sleep apnoea: (a) means chronic sleep-related disordered breathing characterised by periods of cessation or reduction in airflow in the upper airway, leading to arousals from sleep and disrupted sleep architecture, which has been diagnosed by a specialist physician; and (b) includes: (i) central sleep apnoea; (ii) mixed sleep apnoea; and (iii) obstructive sleep apnoea. Note 1: Clinical consequences of sleep apnoea include excessive daytime sleepiness, impaired memory, difficulty concentrating, morning headache, pulmonary hypertension, right heart failure and respiratory failure. Note 2: central sleep apnoea, obstructive sleep apnoea and upper airway are defined in the Schedule 1 - Dictionary. (3) While sleep apnoea attracts ICD‑10‑AM code G47.30, G47.31, G47.32, G47.33 or G47.39, in applying this Statement of Principles the meaning of sleep apnoea is that given in subsection (2). (4) For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4. Death from sleep apnoea (5) For the purposes of this Statement of Principles, sleep apnoea, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's sleep apnoea. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that sleep apnoea and death from sleep apnoea can be related to relevant service rendered by veterans, members of Peacekeeping Forces, 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 as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting sleep apnoea or death from sleep apnoea with the circumstances of a person's relevant service: (1) having heart failure at the time of the clinical onset of sleep apnoea; (2) having a central nervous system lesion or disorder from the specified list of central nervous system lesions or disorders at the time of the clinical onset of sleep apnoea; Note: specified list of central nervous system lesions or disorders is defined in the Schedule 1 – Dictionary. (3) having autonomic neuropathy at the time of the clinical onset of sleep apnoea; Note: autonomic neuropathy is defined in the Schedule 1 – Dictionary. (4) having chronic renal failure at the time of the clinical onset of sleep apnoea; Note: chronic renal failure is defined in the Schedule 1 – Dictionary. (5) having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical onset of sleep apnoea; Note 1: Examples of a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles include myasthenia gravis, postpolio syndrome and motor neurone disease. Note 2: upper airway is defined in the Schedule 1 – Dictionary. (6) having acromegaly at the time of the clinical onset of sleep apnoea; Note: acromegaly is defined in the Schedule 1 – Dictionary. (7) taking an antipsychotic drug for at least the 2 months before the clinical onset of sleep apnoea; (8) for obstructive sleep apnoea only: (a) having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, at the time of the clinical onset of obstructive sleep apnoea; (b) having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical onset of obstructive sleep apnoea; Note: upper airway is defined in the Schedule 1 – Dictionary. (c) being obese at the time of the clinical onset of obstructive sleep apnoea; Note: being obese is defined in the Schedule 1 – Dictionary. (d) being in a supine position when sleeping for at least the 6 months before the clinical onset of obstructive sleep apnoea; or (e) taking protease inhibitors as antiretroviral drugs for human immunodeficiency virus infection before the clinical onset of obstructive sleep apnoea; Note: obstructive sleep apnoea is defined in the Schedule 1 - Dictionary. (9) for central sleep apnoea only, taking a long-acting opioid at an average daily morphine equivalent dose of at least 75 milligrams for at least the 2 months before the clinical onset of central sleep apnoea; Note: central sleep apnoea and long-acting opioid are defined in the Schedule 1 – Dictionary. (10) having heart failure at the time of the clinical worsening of sleep apnoea; (11) having a central nervous system lesion or disorder from the specified list of central nervous system lesions or disorders at the time of the clinical worsening of sleep apnoea; Note: specified list of central nervous system lesions or disorders is defined in the Schedule 1 – Dictionary. (12) having autonomic neuropathy at the time of the clinical worsening of sleep apnoea; Note: autonomic neuropathy is defined in the Schedule 1 – Dictionary. (13) having chronic renal failure at the time of the clinical worsening of sleep apnoea; Note: chronic renal failure is defined in the Schedule 1 – Dictionary. (14) having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical worsening of sleep apnoea; Note 1: Examples of a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles include myasthenia gravis, postpolio syndrome and motor neurone disease. Note 2: upper airway is defined in the Schedule 1 – Dictionary. (15) having acromegaly at the time of the clinical worsening of sleep apnoea; Note: acromegaly is defined in the Schedule 1 – Dictionary. (16) consuming an average of at least 30 grams of alcohol per day for at least the 6 months before the clinical worsening of sleep apnoea; Note: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink. (17) taking an antipsychotic drug for at least the 2 months before the clinical worsening of sleep apnoea; (18) for obstructive sleep apnoea only: (a) having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, at the time of the clinical worsening of obstructive sleep apnoea; (b) having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical worsening of obstructive sleep apnoea; Note: upper airway is defined in the Schedule 1 – Dictionary. (c) being obese at the time of the clinical worsening of obstructive sleep apnoea; Note: being obese is defined in the Schedule 1 – Dictionary. (d) being a supine position when sleeping for at least the 6 months before the clinical worsening of obstructive sleep apnoea; or (e) taking protease inhibitors as antiretroviral drugs for human immunodeficiency virus infection before the clinical worsening of obstructive sleep apnoea; Note: obstructive sleep apnoea is defined in the Schedule 1 - Dictionary. (19) for central sleep apnoea only, taking a long-acting opioid at an average daily morphine equivalent dose of at least 75 milligrams for at least the 2 months before the clinical worsening of central sleep apnoea; Note: central sleep apnoea and long-acting opioid are defined in the Schedule 1 – Dictionary. (20) inability to obtain appropriate clinical management for sleep apnoea. 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(10) to 9(20) apply only to material contribution to, or aggravation of, sleep apnoea where the person's sleep apnoea 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(2) 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.