Multiple Sclerosis

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 8 April 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 8 April 2025;
An inpatient record and serology by the medical officer, Base health facility, dated 21 March 2005;
A pathology report (serum 25-hydroxyvitamin D, deployed health facility) by the middle east, dated 15 January 2011;
An occupational health review by the medical officer, RAAF base health centre, dated 14 November 2011;
An endocrinology consultation by the endocrinologist, dated 18 June 2014;
A rheumatology consultation by the rheumatologist, dated 8 March 2016;
A histopathology report and surgical oncology letter by the surgical oncologist, dated 17 October 2017;
An MRI brain report by the radiologist, dated 5 March 2018;
An MRI brain and cervical spine report and CSF analysis by the radiologist and pathologist, dated 17 April 2018;
A neurology consultation by the neurologist, dated 21 May 2018;
A radiotherapy treatment summary by the radiation oncologist, dated 15 June 2018;
An MRI brain report and neurology review by the neurologist, dated 22 August 2018;
A fertility treatment summary by the fertility specialist, dated 8 September 2021;
A mental health assessment by the mental health officer, Role 3 hospital, Iraq, dated 4 November 2021;
An aeromedical evacuation record by the senior medical officer, Iraq, dated 18 November 2021;
An MRI brain and spine report and neurology admission by the neurologist, dated 30 November 2021.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

10 January 2005 and 14 July 2023

Multiple Sclerosis

You have stated that your condition was caused by:

having acute infectious mononucleosis before the clinical onset of multiple sclerosis
smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of multiple sclerosis, and where smoking has ceased, the clinical onset of multiple sclerosis has occurred within five years of cessation
being exposed to second-hand smoke for at least 10 000 hours before the clinical onset of multiple sclerosis
having vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 50 nanomoles per litre for a continuous period of at least one year before the clinical onset of multiple sclerosis, and where this vitamin D deficiency occurred more than two years before the clinical onset of multiple sclerosis
being obese for at least five years when aged less than 30 years before the clinical onset of multiple sclerosis, and where this five year period occurred within the 15 years before the clinical onset of multiple sclerosis

Diagnosis: Multiple Sclerosis

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 8 April 2025, and is supported by a neurology consultation by the neurologist, dated 21 May 2018.

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Multiple Sclerosis (Balance of Probabilities) (No. 12 of 2020)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having acute infectious mononucleosis before the clinical onset of multiple sclerosis
smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of multiple sclerosis, and where smoking has ceased, the clinical onset of multiple sclerosis has occurred within five years of cessation
being exposed to second-hand smoke for at least 10 000 hours before the clinical onset of multiple sclerosis
having vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 50 nanomoles per litre for a continuous period of at least one year before the clinical onset of multiple sclerosis, and where this vitamin D deficiency occurred more than two years before the clinical onset of multiple sclerosis
being obese for at least five years when aged less than 30 years before the clinical onset of multiple sclerosis, and where this five year period occurred within the 15 years before the clinical onset of multiple sclerosis

I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with ascending numbness and tingling of both legs to the waist, Lhermitte phenomenon and urinary urgency on 17 April 2018.

The diagnosis was confirmed by a neurologist on 21 May 2018 on the clinical attack of April 2018 together with MRI of 17 April 2018, which showed T2 lesions in periventricular, juxtacortical, infratentorial and spinal cord locations (dissemination in space) with simultaneous enhancing and non-enhancing lesions (dissemination in time), and CSF-specific oligoclonal bands. This satisfies the 2017 McDonald criteria and the Statement of Principles definition of a chronic relapsing-remitting disorder with multiple focal regions of demyelination occurring on multiple occasions.

This has then led to further investigations and the diagnosis of your condition of Multiple Sclerosis. I have accepted your condition of Multiple Sclerosis.

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your peacetime service.

I have therefore accepted that this condition is related to your service with effect from 10 April 2018.

Multiple Sclerosis (Worsening)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 8 April 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 8 April 2025;
An inpatient record and serology by the medical officer, Base health facility, dated 21 March 2005;
A pathology report (serum 25-hydroxyvitamin D, deployed health facility) by the middle east, dated 15 January 2011;
An occupational health review by the medical officer, RAAF base health centre, dated 14 November 2011;
An endocrinology consultation by the endocrinologist, dated 18 June 2014;
A rheumatology consultation by the rheumatologist, dated 8 March 2016;
A histopathology report and surgical oncology letter by the surgical oncologist, dated 17 October 2017;
An MRI brain report by the radiologist, dated 5 March 2018;
An MRI brain and cervical spine report and CSF analysis by the radiologist and pathologist, dated 17 April 2018;
A neurology consultation by the neurologist, dated 21 May 2018;
A radiotherapy treatment summary by the radiation oncologist, dated 15 June 2018;
An MRI brain report and neurology review by the neurologist, dated 22 August 2018;
A fertility treatment summary by the fertility specialist, dated 8 September 2021;
A mental health assessment by the mental health officer, Role 3 hospital, Iraq, dated 4 November 2021;
An aeromedical evacuation record by the senior medical officer, Iraq, dated 18 November 2021;
An MRI brain and spine report and neurology admission by the neurologist, dated 30 November 2021.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

10 January 2005 and 14 July 2023

Multiple Sclerosis (Worsening)

You have stated that the worsening of your condition was caused by:

having onset of a viral or bacterial infection within the five weeks before, or the two weeks after, the clinical worsening of multiple sclerosis
smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of multiple sclerosis, and where smoking has ceased, the clinical worsening of multiple sclerosis has occurred within five years of cessation
being exposed to second-hand smoke for at least 10 000 hours before the clinical worsening of multiple sclerosis
undergoing a course of treatment with a tumour necrosis factor alpha antagonist within the one year before the clinical worsening of multiple sclerosis
undergoing a course of treatment with granulocyte colony-stimulating factor or interferon within the six months before the clinical worsening of multiple sclerosis
undergoing a course of treatment with an immune checkpoint inhibitor within the four months before the clinical worsening of multiple sclerosis
experiencing the death of a significant other within the three months before the clinical worsening of multiple sclerosis
experiencing a category 1A stressor within the three months before the clinical worsening of multiple sclerosis
experiencing a category 1B stressor within the three months before the clinical worsening of multiple sclerosis
experiencing a category 2 stressor within the three months before the clinical worsening of multiple sclerosis
having a medical illness or injury, other than multiple sclerosis, which is life-threatening or which results in serious physical or cognitive disability, within the three months before the clinical worsening of multiple sclerosis
for women only, using hormonal assisted reproductive therapy within the three months before the clinical worsening of multiple sclerosis
undergoing a course of therapeutic radiation for cancer, where the affected site was in the field of radiation, before the clinical worsening of multiple sclerosis
inability to obtain appropriate clinical management for multiple sclerosis

Diagnosis: Multiple Sclerosis (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Multiple Sclerosis (Balance of Probabilities) (No. 12 of 2020)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having onset of a viral or bacterial infection within the five weeks before, or the two weeks after, the clinical worsening of multiple sclerosis
smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of multiple sclerosis, and where smoking has ceased, the clinical worsening of multiple sclerosis has occurred within five years of cessation
being exposed to second-hand smoke for at least 10 000 hours before the clinical worsening of multiple sclerosis
undergoing a course of treatment with a tumour necrosis factor alpha antagonist within the one year before the clinical worsening of multiple sclerosis
undergoing a course of treatment with granulocyte colony-stimulating factor or interferon within the six months before the clinical worsening of multiple sclerosis
undergoing a course of treatment with an immune checkpoint inhibitor within the four months before the clinical worsening of multiple sclerosis
experiencing the death of a significant other within the three months before the clinical worsening of multiple sclerosis
experiencing a category 1A stressor within the three months before the clinical worsening of multiple sclerosis
experiencing a category 1B stressor within the three months before the clinical worsening of multiple sclerosis
experiencing a category 2 stressor within the three months before the clinical worsening of multiple sclerosis
having a medical illness or injury, other than multiple sclerosis, which is life-threatening or which results in serious physical or cognitive disability, within the three months before the clinical worsening of multiple sclerosis
for women only, using hormonal assisted reproductive therapy within the three months before the clinical worsening of multiple sclerosis
undergoing a course of therapeutic radiation for cancer, where the affected site was in the field of radiation, before the clinical worsening of multiple sclerosis
inability to obtain appropriate clinical management for multiple sclerosis

After the condition arose, it was worsened during your service. COVID-19 pneumonia began on 25 October 2021 while you were serving in Iraq, confirmed by PCR, 24 days before the severe relapse of 18 November 2021. You had smoked about 16 pack-years by the first worsening on 20 August 2018, while still smoking, and about 18 pack-years when you stopped on 15 January 2020. You had accumulated more than 14 000 hours of enclosed second-hand smoke exposure in crew rooms, vehicles and accommodation by the worsenings of 20 August 2018 and 18 November 2021. You took adalimumab 40 mg fortnightly from 8 March 2016 to 10 December 2017 for reactive spondyloarthritis. Interferon beta-1a 44 micrograms three times weekly was commenced on 2 July 2018, within the six months before the worsening of 20 August 2018, and continued to the worsening of 18 November 2021, apart from five missed weeks on deployment. Pembrolizumab 200 mg three-weekly was given from 15 January 2018 to 30 April 2018 for stage IIIB melanoma. Your section commander, a close friend of nine years who was important in your life, was killed in a rocket attack on the air base in Iraq on 12 October 2021, 37 days before the worsening of 18 November 2021. On 12 October 2021 you were caught in the open during a rocket attack on the air base, with an impact about 30 metres away. In the same attack on 12 October 2021 you were an eyewitness to your section commander being killed and gave first aid to two critically injured colleagues, 37 days before the worsening. From late September 2021 you were the only woman in your maintenance section on deployment, socially isolated, and in ongoing conflict with a supervisor who questioned your fitness because of your multiple sclerosis, with stressful workloads after the attack. COVID-19 pneumonia from 25 October 2021 caused hypoxia with an oxygen saturation of 84 per cent on air, requiring high-flow oxygen at the role 3 hospital. You underwent an IVF cycle with follicle stimulating hormone, a gonadotrophin-releasing hormone antagonist and a chorionic gonadotrophin trigger from 20 August to 6 September 2021, timed to your pre-deployment leave so that embryos could be stored before you deployed. Whole-brain radiotherapy, 30 Gy in 10 fractions, was given from 04 June to 15 June 2018 for the melanoma brain metastasis. On deployment in Iraq your interferon beta-1a supply was spoiled by a refrigeration failure and could not be replaced for five weeks, and when the relapse began on 18 November 2021 there was no neurologist, MRI or intravenous methylprednisolone available.

This has then led to further investigations and the diagnosis of your condition of Multiple Sclerosis (Worsening). I have accepted your condition of Multiple Sclerosis (Worsening).

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 18 November 2021.

Multiple Sclerosis — example determination letter

See the letter exactly as it is delivered

Reference Determination Content

Multiple Sclerosis

Evidence

Your service

Multiple Sclerosis

Multiple Sclerosis (Worsening)

Evidence

Your service

Multiple Sclerosis (Worsening)