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9.8.7 Chapter 7 - Ear, Nose & Throat Conditions
The below outlines a general policy for assessing permanent impairment (PI) compensation and Disability Compensation Payment (DCP) for tinnitus. The purpose of the policy is to align permanent impairment assessment with clinical best practise and ensure claims are evaluated consistently and accurately.
This policy applies to all cases regardless of whether the person is a serving member or a former member. Unlike the incapacity provisions of the MRCA, the PI provisions do not make a distinction between serving and former members. The VEA DCP provisions also apply equally to former and serving members.
Where tinnitus is very severe it is a debilitating condition causing extreme discomfort with significant effect to an individual’s lifestyle.
Where milder, the condition may be tolerable for much of the time, with a minor effect to lifestyle.
General Policy for majority of Tinnitus cases
Determination of a PI or DCP claim for tinnitus should NOT rely on self-assessment alone with regard to severe to very severe tinnitus (tinnitus warranting a GARP rating of 10 to 15). However, provided the delegate is comfortable with the assessment (i.e. there is no contrary evidence), milder tinnitus (tinnitus warranting a GARP rating of 0 to 5) can be determined without further investigation.
Where the evidence indicates a severe or very severe impairment, a client must be referred to an audiologist before the delegate determines the appropriate GARP impairment rating.
An audiologist is qualified to assess and determine tinnitus severity using a set of scientifically validated questions known as the Tinnitus Functional Index (TFI). There are available alternative assessment methodologies but, among other advantages, the TFI was developed and validated with a veteran population and exhibits sensitivity to mental health issues.
Delegates should explicitly request the TFI be used (See Hearing Condition - Medical Assessment.pdf). The audiologist will provide a TFI score out of 100 in their clinical report. This score is sufficient to determine the impairment rating under GARP in the vast majority of cases.
The delegate should make use of Table A to translate the TFI score into an impairment rating.
|impairment rating||criteria||tfi score|
|NIL||No tinnitus or occasional tinnitus.||0 - 17|
|TWO||Very mild tinnitus: not present every day.||18 - 31|
|FIVE||Tinnitus every day, but tolerable for much of the time.||32 - 53|
|TEN||Severe tinnitus, e.g. of similar severity to that requiring a masking device, present every day.||54 - 72|
|FIFTEEN||Very severe tinnitus, present every day, causing distraction, loss of concentration and extreme discomfort, and regularly interfering with sleep.||73 - 100|
If the audiologist is unable to accurately assess a person, or if the audiologist suspects there may be other medical issues that require attention, the audiologist can refer the person for an assessment by a specialist (e.g. an ENT or neurologist). The delegate should make the referral processes clear to the audiologist. The delegate should not refer the person to an ENT unless this is recommended by the audiologist, GP or another specialist.
Policy for 'special' cases
Person already has an audiology report
In the event that the person already has an audiologist report, this should be used – provided that it is no more than three years old. Ideally the report would have some score or evaluation relating to tinnitus. If there is not sufficient evidence in the report on hand, the assessing audiologist should be contacted by the delegate in order to clarify their view of the tinnitus severity.
Audiologist does not make use of the TFI
Although the TFI is most suitable for the veteran population, this does not discount other questionnaires as invalid for the assessment of tinnitus. Some audiologists may decline to use the TFI and make use of an alternative assessment methodology. In the event this occurs, the delegate should utilise this alternative assessment method (such as the Tinnitus Handicap Questionnaire or the Tinnitus Reaction Questionnaire) in determining impairment. The audiologist should not be asked to reassess on the basis that they have substituted the TFI for an alternative method, nor should the client be sent for another assessment. However, it would be permissible for the client to be reassessed if the audiologist report makes no reference to an assessment methodology and provides no helpful description of the symptoms at all - for example, there is a single statement along the lines of “experiences severe tinnitus” – or makes no reference to tinnitus at all (i.e. is just a hearing assessment).
Tables for the conversion from these alternative assessment scores into impairment ratings under GARP can be found in HP content manager at record number 20167512E
Some points as to why the TFI is the preferred assessment tool:
- The Tinnitus Functional Index is scientifically validated and has been tested on a veteran population.
- The Tinnitus Functional Index is useful to identify specific areas of life which can be affected by tinnitus (these are intrusiveness of tinnitus, the sense of control over tinnitus the person has, cognitive interference [i.e. thought processes/concentration], sleep disturbance, auditory issues [i.e. perceived interference with hearing], relaxation issues, quality of life, and emotional distress).
- Questions in the Tinnitus Functional Index are sensitive to the mental health of people completing the questionnaire.
TFI score is on the boundary of an impairment rating
The advancement of research in tinnitus has resulted in a mismatch between the broad categories of the GARP impairment ratings and the detailed information provided by the TFI. As such, there are going to be cases in which a client will receive a TFI score which is on the boundary of the impairment rating under GARP. For example, a client may have a TFI score of 72, which is on the upper boundary for a GARP impairment rating of ten. Only a single TFI point would have placed such a person in the higher GARP impairment rating of 15. Or a person may have a TFI score of 54, which is the lower boundary of the impairment rating of ten.
In such a situation, the delegate should determine the person in the higher or lower rating only if there is sufficient reason to do so. Simply being on the boundary is not a sufficient reason to place them in the alternative rating.
What would constitute sufficient reason for placing the client in a lower or higher impairment rating? Delegates should consider other information that helps determine the functional impact of tinnitus, such as the presence or absence of mental health conditions, reported information about its impact on work performance, sleep or close relationships.
If the delegate has information that shows a discrepancy between the impairment rating and a boundary TFI score, the delegate may make a decision to determine a higher or lower impairment rating. Table B may help in this regard.
|impairment rating||criteria||tfi score||impact guide||presentation guide|
|NIL||No tinnitus or occasional tinnitus||0 - 17||Not a problem||Non.|
|TWO||Very mild tinnitus: not present ever day.||18 - 31||Small problem||May be noticed occasionally, no impact on daily life.|
|FIVE||Tinnitus ever day, but tolderable for much of the time.||32 - 53||Moderate problem||Frequently noticed, may interfere with sleep, occasional impact on performing everyday tasks.|
|TEN||Severe tinnitus, e.g. of similar severity to that requiring a masking device, present every day.||54 - 72||Big problem||Always noticed, frequently distracts and impairs everyday tasks, frequently interferes with sleep, evidence of anxiety, depression, anger, irritability.|
|FIFTEEN||Very severe tinnitus, present every day, causing distraction, loss of concentration and extreme discomfort, and regularly interfering with sleep.||73 - 100||Very big problem||Advanced trouble performing everyday activities, insomnia, psychological consultation, failure of human relations, suicial ideation.|
The fourth and fifth columns provide descriptions based on validation of the TFI in the latest research. These may be used by the delegate to override the boundary TFI score and place the person in a higher or lower impairment rating (note that these two columns are for internal use only). For example, if a person has a TFI score of 72, and yet information on hand shows they match the description in the 6th row of the fifth column (the Presentation Guide), then it would be appropriate to determine an impairment rating of fifteen. Likewise, if a person’s TFI score was 53, and they did not report impact on performing daily tasks or significant sleep interference, then a rating of five would be appropriate. Benefits and Payments Policy section can be contacted if the delegate requires guidance in this regard.
Permanence and Stability
The delegate is entitled to assume that an impairment rating is permanent and stable. Given the nature of the condition, a person with tinnitus is highly likely to satisfy the legislative requirements for permanency and stability. With regard to tinnitus:
- it is likely to continue indefinitely;
- there is a low probability of the condition resolving; and
- in nearly all cases, no medical or pharmaceutical treatment is available that is likely to improve the condition.
Although there are available therapeutic treatments, such as Tinnitus Retraining Therapy, for managing tinnitus, these are not designed to resolve the underlying condition. Rather, they are designed to help manage a person’s response to tinnitus. A person’s response to tinnitus is highly subjective and variable, and depends on many factors that may be unique to a given person. As such, there is no guarantee that such treatment regimens would improve a person’s ability to manage their tinnitus.
Also to be considered is that a refusal by the person to participate in such treatment programs would be compatible with the policy on reasonable refusal of treatment.
Clients already at 15 impairment points
Where a person, before the introduction of the policy requiring the use of objective testing (i.e. the TFI or similar), already attained a rating of 15 points for tinnitus (being the maximum points available under GARP), the Department’s approach is that no further testing or investigation is necessary.
Where a person’s tinnitus is yet to be rated at 15 points, and the veteran is requesting an increase to their DCP, or reassessment for MRCA PI purposes, then the condition is subject to a reassessment, and the Department should use the current testing guidelines to examine whether a change to the tinnitus rating is appropriate.
Assessing hearing loss when the veteran has a cochlear implant device
The below outlines a general policy for assessing PI compensation and DCP for the assessment of hearing loss where the veteran has undergone surgery to fit a cochlear implant device. A known side-effect of implanting the device is that the veteran’s remaining natural hearing loss is destroyed, however, with the device switched on, the veteran’s level of hearing is significantly improved.
The GARP provides clear instructions regarding the assessment of hearing loss in situations where the veteran has a hearing aid. In that situation, a veteran’s hearing loss must be measured without the benefit of any hearing aid. For consistency and to align this principle with all hearing loss claims, the assessment of hearing loss should be performed with the cochlear device switched off.
When considering PI under the MRCA, the delegate should also consider whether the impairment has reached a stable and static level following the medical procedure to implant the device, as the stabilisation of hearing following this process can take some months.
The VEA DCP provisions however do not require the delegate makes any consideration regarding permanence or stability.