DSP medical evidence rules for health professionals

To be eligible for Disability Support Pension (DSP), your patient’s medical evidence must show the condition is diagnosed, reasonably treated and stabilised, or meets the manifest medical rules.

A medical certificate may not be enough evidence for us to assess your patient’s condition. We need detailed evidence or a report to support a DSP claim.

We’ll look at your patient’s medical evidence to assess if they meet either manifest or general medical rules.

Types of medical evidence we accept include:

• medical history records or reports
• specialist medical reports
• psychologist reports, including IQ testing
• medical imaging reports – not x-rays
• physical examination reports
• hospital or outpatient records including details of operations.

You can also give us:

• compensation and rehabilitation reports
• special school reports
• other evidence such as physiotherapy or audiology reports.

For some conditions we require specific medical evidence.

The DSP Medical Evidence Checklist for treating health professionals form (SA478) can guide you through what’s required from you to support your patient’s DSP claim.

You can read about how to help patients claiming DSP.

Your patient can read about the medical evidence they need to provide.

Diagnosed, reasonably treated and stabilised

A patient’s condition must be diagnosed, reasonably treated and stabilised to meet the Disability Support Pension (DSP) general medical rules.

Diagnosed

For most conditions, a general practitioner can make the diagnosis. For some conditions, a specialist must have made the diagnosis.

Reasonably treated

Your patient must have received reasonable treatment for their condition. The following factors are considered:

• Nature and effectiveness of past treatment.
• Expected outcome of current treatment.
• Any plans for further treatment.
• Whether past, current or future treatment can be considered reasonable, giving consideration to the individual and overall medical status and circumstances of your patient.

Reasonable treatments are low risk and expected to lead to substantial improvement. They are also available and accessible to your patient at a reasonable cost.

There may be medical or other compelling reasons for not getting reasonable treatment. For example, where a person:

• has religious or recognised cultural beliefs prohibiting treatment (for example, blood transfusions)
• lacks insight or the ability to make appropriate judgements due to their condition and are unlikely to comply with treatment (for example, a person with a severe psychotic illness or dementia).

Medical evidence should show outcomes of past treatment, current treatment and any plans for further treatment.

Stabilised

For a condition to be considered stabilised:

• your patient must have undertaken reasonable treatment for the condition
• any further reasonable treatment is unlikely to result in significant functional improvement in the next 2 years.

In this context, ‘significant improvement’ is improvement that will enable your patient to undertake work for 15 hours or more per week in open, unsupported employment in the next 2 years.

Medical evidence should show the condition is unlikely to result in a significant functional improvement, even if there’s ongoing treatment.

Specific medical evidence

The specialist evidence we need depends on your patient’s disability or medical condition. For some conditions or situations, we need specific information.

This evidence helps us assess if your patient meets medical rules for DSP. This may include any of the following medical evidence relevant to their condition from a treating specialist such as:

• an ophthalmologist
• an ophthalmic surgeon
• an audiologist
• an ear, nose and throat specialist
• a registered or clinical psychologist
• a psychiatrist.

This specialist evidence helps us assess your patient’s condition using the Impairment Tables.

If you have a terminally ill patient, we’ll need more information about their condition. This includes details from the treating doctor regarding the stage of the condition, treatment details, and prognosis. You can complete the Verification of Terminal Illness form (SA495).

Your patient can read about the medical evidence we need to assess their condition.

Medical evidence to support functional capacity assessment

We assess your patient’s functional capacity based on the medical evidence they give us.

If your patient claims DSP, they need to give us medical evidence from their treating health professionals. This evidence must detail any limitations your patient has which impacts their daily functioning as a direct result of their medical condition or conditions.

Functional impact is a loss of functional capacity affecting your patient’s ability to work that results from the person’s medical condition.

Medical evidence may include details about your patient’s functional capacity to perform daily tasks such as:

• self-care (showering, dressing, grooming tasks)
• household tasks (cleaning, cooking, vacuuming, mowing lawns)
• decision making or concentration abilities (watching a movie, reading a book, managing finances, cooking tasks with multiple steps, shopping)
• management of bowel/bladder
• using their senses (visual disturbances or limitations, depth perception, reading small text, hearing warning signals, ability to undertake conversations in loud rooms or on a phone)
• ability to engage in social activities (attend social functions, maintain friendships, leave the home to attend regular appointments without support, use public transport)
• mobility (use of aids, walking/standing tolerances, range of movement or whether assistance is needed from another person to manage mobility tasks)
• impacts to their physical functioning such as endurance limitations or ability to do a task on a repetitive basis.

Services Australia allied health professionals use this medical evidence to assess your patient’s medical conditions against the Impairment Tables.

The Impairment Tables focus on functional ability, concentrating on what your patient is able to do rather than what they can’t do. The tables are consistent with contemporary medical and rehabilitation practice.

They help assess if there’ll be any significant functional improvement, with or without reasonable treatment, within the next two years.

When assessing if your patient can perform an activity, we consider whether they can complete or sustain that activity. The allied health professional will assess how your patient would cope with the activity. They’ll consider when your patient would be expected to do so, and not only once or rarely.

The Impairment Table rating system uses a points system. It’s standardised across the tables.

Example of Impairment Table points system: