Maddern and Secretary, Department of Social Services (Social services second review)

[2018] AATA 4613

Maddern and Secretary, Department of Social Services (Social services second review) [2018] AATA 4613 (17 December 2018)

Division:GENERAL DIVISION

File Number:2018/0780           

Re:Barbara Maddern  

APPLICANT

AndSecretary, Department of Social Services

RESPONDENT

DECISION

Tribunal:Dr I Alexander, Member

Date:17 December 2018

Place:Sydney

The decision under review is affirmed.

..................[sgd]..............................

Dr I Alexander, Member

CATCHWORDS

SOCIAL SECURITY – disability support pension – whether applicant’s impairments are fully diagnosed, treated and stabilised –  continuing inability to work – Applicant had not actively participated in a program of support – whether Applicant has a severe impairment – application of Impairment Tables  –  decision affirmed

LEGISLATION

Social Security Act 1991 (Cth), s 94

Social Security (Administration Act) 1999 (Cth), sch 2, subcl 4

SECONDARY MATERIALS

Social Security (Tables for the Assessment of Work-related Impairment for Disability Support Pension) Determination 2011

Social Security (Active Participation for Disability Support Pension) Determination 2014

REASONS FOR DECISION

Dr I Alexander, Member

17 December 2018

1. On 12 December 2016 Ms Maddern, who is now 53 years old, lodged a claim for Disability Support Pension (DSP) under the Social Security Act 1991 (the Act).

2. The claim was rejected by Centrelink both initially[1] and on internal review,[2] on the basis that she did not satisfy the requirements of s 94 of the Act. In particular, she did not satisfy s 94(1)(b) of the Act as she did not have an impairment rating of 20 points or more under the Impairment Tables.

   [1] 20 January 2017

   [2] 10 April 2017

3. In a decision dated 30 January 2018, the Social Services & Child Support Division of the Administrative Appeals Tribunal (AAT1) considered several medical conditions and assigned a total rating of 10 points under the Social Security (Tables for the Assessment of Work-related Impairment for Disability Support Pension) Determination 2011 (the Impairment Determination) and found that Ms Maddern did not qualify for DSP.

4. In particular, AAT1 found that, at the date of application for DSP, Ms Maddern suffered a medical condition diagnosed as “sarcoidosis” which was permanent for the purposes of the Impairment Determination and assigned 10 points under Impairment Table 1 for “her persistent tiredness and easy fatigability, consistent with a diagnosis of sarcoidosis.”

5. Ms Maddern, who was self-represented, attended the hearing by telephone and seeks review of the AAT1 decision.

   ISSUES

6. In order to qualify for DSP Ms Maddern must satisfy the requirements of s 94 of the Act as at the date of the claim or within 13 weeks of lodging the claim, in accordance with subclause 4(1) of Schedule 2 to the Social Security (Administration) Act 1999, that is, between 12 December 2016 and 13 March 2017 (the qualification period).

7. Section 94(1) of the Act provides that a person is qualified for DSP if:

   (a)the person has a physical, intellectual or psychiatric impairment; and

   (b)the person’s impairment is of 20 points or more under the Impairment Tables; and

   (c)the person has a continuing inability to work as defined by the Act.

8. The Impairment Determination requires that an impairment rating can only be assigned to an impairment if the condition causing that impairment is “permanent” (para 6(3)(a)).

9. For the purposes of para 6(3)(a) of the Impairment Determination, a condition is permanent if it is:

   ·fully diagnosed by an appropriately qualified medical practitioner (para 6(4)(a)); and

   ·fully treated (para 6(4)(b)); and

   ·fully stabilised (para 6(4)(c)); and

   ·the condition is more likely than not, in light of available evidence, to persist for more than 2 years (para 6(4)(d)).

10. The Introduction to each relevant Table requires that self-report of symptoms alone is insufficient and there must be corroborating evidence of the person’s impairment.

11. It is agreed that, during the claim period, Ms Maddern suffered medical conditions that may cause impairment and, therefore, satisfied s 94(1)(a) of the Act.

12. For present purposes the relevant medical conditions include sarcoidosis, left knee osteoarthritis and depression.[3]

    [3] DSP claim dated 11.12.2018

13. The Respondent contends that, in the qualification period, all the medical conditions, except the left knee osteoarthritis were not fully treated and stabilised and, therefore, a rating under the Impairment Tables cannot be assigned.

14. In respect of the condition sarcoidosis the Respondent submits that, if the Tribunal finds that the condition was permanent for the purposes of the Impairment Determination, no more than 10 points can be assigned under Impairment Table 1.

15. Ms Maddern contends that, in the qualification period, the condition of sarcoidosis was fully treated and fully stabilised and submits that because of her persisting symptoms which include shortness of breath, decreased mobility and chronic pain, she suffers a severe functional impact on activities requiring physical exertion or stamina and, therefore a rating of 20 points under Impairment Table 1 should be assigned.

16. It is agreed that, in the qualification period, the condition of left knee osteoarthritis was permanent for the purposes of Impairment Determination.

17. The respondent submits that a rating of 0 points Impairment Table 3 should be assigned.

18. At the hearing Ms Maddern conceded that, following her successful recovery from a total left knee replacement in June 2016, the left knee osteoarthritis no longer has any impact on activities requiring the use of the lower limbs and, therefore a rating of 0 points under Impairment Table 3 can be assigned.

19. It is agreed that Ms Maddern has been treated for depression; however, as this condition has not been confirmed by a clinical psychologist or psychiatrist a rating under the Impairment Tables cannot be assigned.

20. Therefore, the definitive issue in this matter is whether, in the qualification period Ms Maddern’s condition of sarcoidosis was fully treated and fully diagnosed and, if so, whether she has a rating of 20 points or more under Impairment Table 1.

    EVIDENCE

    Ms Maddern

21. In an attachment to her claim for DSP Ms Maddern stated, inter alia, that she suffers “chronic fatigue where there are days getting out of bed is an issue. Showering takes all my energy on my bad days so my husband needs to be with me …..when I am in an acute phase of my disease mobility is hard and walking is an effort. I suffer severe breathlessness and pain in my chest. Each day I start the day with severe nausea and vomiting and need medication to help with this.”

22. In a letter dated 8 March 2017 Ms Maddern stated, inter alia, the following:

    “On the 3^rd March 2017 I had an appointment with a Respiratory Specialist and her team her name is Dr Amy McLean, she is concerned with my chest pain, shortness of breath and level of pain I am suffering. Dr McLean is organising nuclear scans which will be performed on the 21^st March 2017. Dr McLean is organising for me to see a Cardiologist who is quite aware of the condition of Sarcoidosis and who will organise Specialised MRI’s of my heart as there is a chance my heart is now affected by Sarcoidosis. I have a follow up appointment with Dr McLean on the 31^st March.

    Over the past 2 months[4] I have a deterioration in my health I am suffering badly with Chest pain, Shoulder tip pain, pain with swelling under my ribcage and thoracic area. Fatigue has made it very hard for me to do menial tasks and am relying more on my husband for assistance and most days it is difficult getting out of bed …….” [emphasis added]

    [4] I note that this apparent clinical deterioration occurred in the qualification period.

23. At the hearing Ms Maddern told the tribunal that her condition is generally stable but that there are intermittent acute episodes where she suffers an exacerbation of symptoms which include “fever, pain, chills and vomiting”.

24. Ms Maddern also stated that she suffers severe and persistent shortness of breath, generalised musculoskeletal pain and fatigue. She spends most of her days resting and apart from frequent medical appointments rarely leaves the houseboat in which she lives with her husband. She claims that she suffers significant limitations in her mobility but is able to walk short distances with the assistance of a walking aid.[5]

    [5] It was not clear from Ms Maddern’s evidence whether the description of her symptoms was related to the qualification period or her current situation.

    Medical Evidence

25. A CT scan of the chest performed on 6 February 2015 is reported as showing “significant mediastinal and bilateral hilar lymphadenopathy.”

26. In a letter dated 24 February 2015 Dr Peng w Seah, cardiothoracic surgeon, stated that Ms Maddern was recovering from cervical mediastinoscopy but continued to suffer “musculoskeletal pain” and increasing “shortness of breath” which had been present prior to the operation. Histopathology is recorded as confirming a diagnosis of sarcoidosis.

27. A Gallium scan performed on 27 February 2015 confirmed sarcoidosis which was “confined to the lungs” with “marked lymphadenopathy in the hilar and subcarinal regions” as well as “mild diffuse inflammatory changes” in both lung fields.

28. In a Centrelink Medical Report dated 4 June 2015 Dr Peck, GP, stated that the medical condition with most functional impact was “multisystem sarcoidosis.”

29. Dr Peck notes current treatment as “high dose prednisolone” which commenced on 10 March 2015 and “methotrexate Bactrim OS” which commenced on 21 March 2015.

30. Current symptoms are reported as “shortness of breath, back pain, weight gain (steroid induced)” and impact on ability to function as “endurance very decreased, mood instability (steroid induced), easy fatiguing (medication and illness induced).” 

31. In a letter dated 19 August 2015 Dr Tyler, respiratory and general physician stated, inter alia, the following:

    “In late January of this year she developed fevers, aches and pains, chest tightness, breathless and coughing …….sarcoidosis was diagnosed. Because of severe       symptoms of chest tightness, discomfort and breathlessness she was treated initially with      steroids ……methotrexate was added and her steroids have been slowly weaned.

    Pulmonary function tests in March and again in June were normal. I suspect the chest     tightness and malaise was related to the mediastinal lymphadenopathy. She has had significant weight gain since being on the steroids….. As far as I am aware she has had no other organ involvement as far as I am      similar changes. A repeat CT scan of the chest on 11/3/2015 shows similar changes. The last CT scan of the chest performed on 1/8/15 suggests resolution of the mediastinal and hilar lymphadenopathy and no new changes in the lung fields [emphasis added]

    Examination: She weighed 127 Kg…..respiratory examination was unremarkable without crackle or wheeze. Cardiac examination revealed normal heart sounds and I could not detect any evidence of heart failure …she now has significant steroid side effects…she has confirmed sarcoidosis without significant lung involvement ….She is now feeling relatively well. I have suggested that my approach at this time would be to wean her steroids by 1mg per month until she is off them and then subsequently consider withdrawing the Methotrexate. I have stressed that she needs to look at reducing her weight significantly. Her ongoing breathlessness I think is due to her weight rather than her sarcoid. Her initial symptoms I suspect were due to acute inflammation within the mediastinal and hilar nodes.”

32. The report of High Resolution CT scan of the chest performed 13 August 2015 is reported as showing “significant reduction in the size of mediastinal and hilar nodes” as well as “improvement” in the changes in the lung.

33. A Gallium scan performed on 20/11/2015 is reported as showing “no evidence of active sarcoidosis” and “comparison to the previous scan of 27/02/2015 shows a good response to treatment."

34. In a letter dated 8 April 2016 Dr Spencer, rheumatic diseases stated, inter alia, the following:

    “…..Barbara who is 51 and has a fairly complex history dating back to February of last year. She had a respiratory illness with flu-like symptoms. Investigations had shown marked hilar and mediastinal lymphadenopathy and a biopsy revealed sarcoidosis.

    She was treated with high dose steroids which were eventually weened off in January of this year. Methotrexate had been added 15 mg weekly. The only problem with which has been a degree of stomatitis. I have added folic acid which should correct this …….she has a number of problems currently aside from a recurrence of respiratory symptoms, some shortness of breath and a tight sensation in the chest. She has had left knee swelling since September last year and has recently been reviewed where it has been suggested she have a total knee replacement.

    …..There is a story of ocular involvement by sarcoid with papilledema. I am uncertain whether an MRI demonstrated any cerebral involvement. The papilledema was noticed in 2009[6] ……

    Examination showed her weight was 114 kilograms which I gather is a loss of fourteen kilograms since her peak weight on steroids and this has occurred since she has come off steroids ……there were occasional rhonchi in the chest …..echocardiogram was normal.”

    [6] I note that there is no other evidence in the documents before the Tribunal that confirm this claimed history of ocular involvement by sarcoid

35. The report of High Resolution CT scan of the chest performed on 18 April 2016 an “Excellent response to treatment with almost complete resolution of the previously noted mediastinal and bilateral hilar lymphadenopathy”. Also the “lungs are clear… apart from minor subsegmental atelectasis in the middle lobe and lingula …..no other features of interstitial lung disease.” 

36. The Discharge Summary from Dudley Hospital states that Ms Maddern was admitted on 4 May 2016 and discharged on 16 May 2016. A left total knee replacement was performed on the 4 May 2016.

37. Progress was noted as follows:

    “Transferred to Rehab day 5. Complex ongoing medical situation which chronic pain issues [sic]. Required increased pain management and modified rehab program with most sessions held in am, but made good progress.  Mobilising on Canadian crutches at discharge with knee bend 5-85 degrees. Will need to wean breakthru’ opiates over next 7-10 days and continue with home exercises and PT……[sic][7]

    Medication on discharge ……Targin 30/15mg bd weaning after breakthrough pain ceased in one week. Endone 5-10 mg q4hr reducing to max 20 mg daily at and weaning. Mersyndol forte 2 QID prn weaning. Gabapentin 200 mg tds.”

    [7] I note that there is no mention of “shortness of breath” being a problem during Ms Maddern’s recovery from major surgery and the first time that “chronic pain” has been identified as a significant clinical issue

38. In a brief letter dated 16 June 2016 Dr Ashton orthopaedic surgeon noted that the surgery was uneventful and that Ms Maddern “had been making a steady recovery.” In note that Dr Ashton did not indicate that Ms Maddern had significant difficulty with her mobility.

39. Medical certificates provided by Dr Goyal, GP, dated 13/4/2016, 17/7/2016 and 8/9/2016 list sarcoidosis as a medical condition that had an impact on Ms Maddern’s capacity for work. The conditions was considered to be “temporary” and “ likely to show considerable improvement with in 2 years” . Symptoms were described as “SOB” with no other details.

40. In a letter dated 6 July 2016 Dr Chu, gastroenterologist, stated, inter alia as follows:

    “Thanks for referring this 51 year old lady with complex medical history ….. a long standing history of gastro-oesophageal reflex with heartburn …… she gained significant weight on Prednisone last year (up to 127 kg) but since the medication was ceased at the beginning of this year has managed to lose 10kg…a long standing history of irritable bowel syndrome  … her background medical history includes…. sarcoidosis, chronic back pain, recent total knee replacement and depression…I understand that initially when she commenced Methotrexate there were significant mouth ulcers but this has since settled    …. ….I understand that initially when she commenced Methotrexate there was significant mouth ulcers but this has since settled. …..At physical examination ……sitting BP 120/80 and morbidly obese at 115kg with BMI 43kg/m2……normal cardiac auscultation…”[8]

    [8] In this letter Dr Chu has focused on Ms Maddern’s gastrointestinal conditions and there is no mention of problems with shortness of breath, generalized musculoskeletal pain or limitations with mobility.

41. A medical certificate provided by Dr Soliman, GP, dated 12/12/2016[9] listed sarcoidosis as a medical which had an impact on Ms Maddern’s capacity for work. The condition was now considered to be permanent within an “uncertain” prognosis; symptoms were described as “SOB, tiredness, chronic pain” with no other details.   

    [9] The same date as Ms Maddern’s application for DSP

42. In a report of a conversation with a JOB Capacity assessor dated 18 January 2017 the assessor noted that, with respect to the condition of sarcoidosis Dr Soliman confirmed that Ms Maddern had “difficulty climbing stairs and unable to stand for more than 10 minutes, was “unable to walk far outside the home and needs to drive to local shops, had “difficulty performing activities of daily living including changing linen on the bed and “Often comes into his office out of breath.”

43. In a letter dated 28 February 2017 Dr Soliman stated that Ms Maddern “suffers ongoing shortness of breath, fatigue, dizziness and unsteadiness on feet” and also “suffers nausea and vomiting each morning, with difficulty getting out of bed some days.”

44. Dr Soliman goes on to state that Ms Maddern “requires daily assistance by her carer and husband …for daily routines including showering, cooking and cleaning, she is unable to perform outdoor tasks….has difficulty walking more than 100 metres without assistance. Whilst a wheelchair is not needed, a walker is used when required for mobility at shopping centres, or a trolley is used in supermarkets for short period.”

45. In a letter dated 30 January 2018 Dr Tjeuw, rheumatologist[10] lists rheumatological issues as “Sarcoidosis of lung with sarcoidosis of lymph nodes (2015), Sweet’s syndrome (febrile neutrophilic dermatosis), Dyspnoea (24 December 2016), Fatigue Generalized aches and pain, Depression” but did not provide any meaningful assessment of any of these conditions with no reference as to the impact of these conditions on Ms Maddern’s functional capacity.  

    [10] According to Medicare records Ms Maddern’s first consultation with Dr Tjeuw was on 24 April 2017 on referral by Dr McLean. This was about 5 weeks after the end of the claim period.

46. Dr Tjeuw stated, inter alia, the following:

    “Barbara looked very good today having lost 12 kg in weight through diet since last review. However she had quite a rough month starting with a colonoscopy on 22 Dec 2017 ….she tells me it was a difficult procedure due to adhesions….since then Barbara has had quite severe upper quadrant pain with local tenderness ……she picked up the flu a few weeks ago and then an umbilical abscess…..the flu also manifested with shortness of breath, but art least this has responded to puffers

    Barbara otherwise continues to respond to subcutaneous methotrexate with only mild nausea for one or two days post injection, but overall she is far better compared to oral methotrexate…..I have suggested suspension of methotrexate when she is ill, but it otherwise seems to be a reasonable steroid sparing agent.” 

47. In a letter dated 1 May 2018 Dr McLean, respiratory and sleep physician” stated, inter alia, the following:

    “When I first saw Barbara 3^rd march 2017 she was incredibly unwell. She mobilised with a great difficulty from the waiting room to my office……At that stage Barbara was troubled with multiple symptoms. She has widespread pain, extreme breathlessness, mobility that was impaired and requiring to walk with a stick. She was also experiencing fevers and sweats and chills…..she was able to provide us with the details of her background and the known diagnosis of systemic sarcoidosis.

    The treatment at that stage she was receiving was prednisolone in varying doses. Reduction of the dose of prednisone without any other disease modifying agent had resulted in a flare of her sarcoidosis.”[11]

    [11] I note that in a letter dated 23/11/2016 Dr Soliman indicated that Ms Maddern’s medication list includes Methotrexate 15 mg per week orally. Prednisolone was not listed.

    In a letter dated 24 April 2018 Dr Soliman confirms that Ms Maddern has been on Methotrexate since March 2015.

    Review of PBS records show that only 15 methotrexate tablets (10mg) were supplied to Ms Maddern in December 2016 and there is no evidence of use until 5 methotrexate vials for subcutaneous injection were dispensed in August and November 2017 and in January 2018.

1. The Tribunal was provided with a report from department of Human service Health Professional Advisory Unit.

2. The author of the report dated 16 July 2018 was Dr Minogue, occupational physician and Medical Adviser and was based on documents alone.

3. Most of the evidence raised in the report has already been addressed above, however, additional evidence as a result of telephone contact with treating doctors was provided as follows:

   Dr Tjeuw (27/07/18) – He advised of a “lot of confounding factors” in her clinical presentation and that her ongoing symptoms are not necessarily all related to sarcoidosis. The possibility of fibromyalgia has been considered. I understand that repeat chest imaging findings do not indicate a recurrence of sarcoidosis. She is still obese which could contribute to dyspnoeic symptoms. Dr Tjeuw agrees that the clinical is confusing and believes the sarcoidosis to be “relatively inactive” His patient is tolerating self-administered subcutaneous injections of methotrexate “quite well” and this treatment is to continue …..She has been referred to a specialist pain clinic …

   Dr McLean (31/07/18) - Dr McLean confirmed that repeat imaging for chest sarcoidosis is now good and she was unsure about prior diagnoses of bronchiectasis or asthma; she sees the former condition as more of a recurrent bronchitis, and if present bronchiectasis is not clinically significant The patient has had some 3 or 4 chest infections since March 2017. Asthma if it exists is well controlled …..No airways pathology was identified on repeat spirometry, although the diffusing capacity of the lungs was quite low at 73% of predicted. Pulmonary hypertension was excluded. There is no evidence of alveolitis on CT imaging and her patients ‘s lings are now “OK”. Dr Mclean believes the breathlessness to be multifactorial ……however that the sarcoidosis has “left its legacy” …….the chronic pain condition is a mixed bag”…..she agreed that that the sarcoidosis was not fully treated and stabilised during the DSP application.

   CONSIDERATION

4. Ms Maddern submits that, at the date of application for DSP and in the qualification period, her medical condition of sarcoidosis was fully treated and fully stabilised. She claims that as a result of this condition she suffered significant shortness of breath, chronic pain and impaired mobility, such that had a severe functional impact on her activities requiring physical exertion or stamina and, therefore, a rating of 20 points under Impairment Table 1 should be assigned.

5. The difficulty for Ms Maddern is that, in my view, the evidence before the Tribunal does not provide sufficient support for her claim.

6. The available evidence, particularly with reference to the qualification period can best be described as incomplete, inconsistent and somewhat confused.

7. Sarcoidosis is a “systemic granulomatous disease of unknown aetiology, primarily affecting the lungs and lymphatic systems, although any organ may be involved.”[12]

   [12] Sarcoidosis: a state of the art review from the Thoracic Society of Society of Australia and New Zealand MJA 18 June 2018 Vol 208 No11 499-504

8. The presentation may be an incidental finding on chest radiology or due to symptoms, “most commonly cough or breathlessness, or relating to the other organs.”[13] 

   [13] ibid

9. There is no dispute that in March 2015 when Ms Maddern was diagnosed as suffering from sarcoidosis she suffered significant respiratory and other symptoms.

10. What is not clear, however, from the available evidence, is whether the severity of symptoms she claims to have suffered during the qualification period are related to the condition of sarcoidosis or some other medical condition not yet diagnosed.

11. The medical evidence clearly indicates that the initial pathology was confined to the lungs and intrathoracic lymph nodes and that that there was a good response to treatment with steroids and methotrexate.

12. The report of the CT scan of the chest performed on 18 April 2016 noted an “excellent response to treatment with almost complete resolution of the previously noted mediastinal and bilateral hilar lymphadenopathy”.

13. In May 2016 when Ms Maddern underwent major surgery, which would have included general anaesthesia, there were no reports of any respiratory difficulties during the operation or during recovery and rehabilitation periods.

14. Between May 2016 and the 12 December 2016 there is no evidence before the Tribunal to indicate that there was any recurrence of pathology associated with sarcoidosis. Also, there is no meaningful evidence which could explain the claimed severity of Ms Madden’s symptoms.

15. Dr Soliman’s medical certificate of 12 December 2016 is of little value as it provides no meaningful information about Ms Maddern’s sarcoidosis and no detailed assessment of significant functional impairment caused by this condition.

16. Dr Soliman’s letter of 28 February 2017, provided about 10 weeks after the date of claim, is, in my view, is also of limited value. Dr Soliman provides no meaningful assessment of Ms Maddern’s medical conditions and simply provides a list of her self-reported symptoms with no explanation as to how these symptoms can be attributed to the sarcoidosis.

17. Furthermore, Dr Soliman makes no reference to the fact that during the claim period, Ms Maddern had a suffered a deterioration of her health, as she had reported in her letter of 8 March 2017, and that she had been referred to Dr McLean for further assessment and treatment.

18. Also, in her letter Ms Maddern clearly appears to believe that the “deterioration” of her health was due to her sarcoidosis which suggests that the condition was not fully stabilised.

19. Ms Maddern relies on the report of Dr McLean dated 1 May 2018 in which she describes Ms Maddern’s acute presentation on the 3 March 2017. Dr McLean appears to be confused about Ms Maddern’s preceding and current treatment but concludes that she had suffered “a flare of her sarcoidosis”. Dr McLean does not provide any details with respect to any investigation or changes in treatment.

20. In her conversation with Dr Minogue, Dr McLean confirmed that “repeat chest imaging for chest sarcoidosis is now good” but was unable to provide a clear explanation for Ms Maddern’s symptoms and “believes the breathlessness to be multifactorial” and the chronic pain condition to be a “mixed bag”. She apparently agreed with the proposition “that the sarcoidosis was not fully stabilised during the DSP application period.”

21. Although the evidence before the Tribunal tends to suggest that at the date of claim Ms Maddern’s sarcoidosis was fully treated and fully diagnosed, there is no convincing medical evidence to explain the claimed severity of Ms Maddern’s symptoms either because of the sarcoidosis or any other medical condition.

22. The evidence suggests that during the claim period Ms Maddern suffered a deterioration with a significant increase in symptoms. However, there is no convincing explanation as to the cause of this deterioration and no information as to the any changes in her treatment or the subsequent outcome.

23. In April 2017 Dr McLean referred Ms Maddern to Dr Tjeuw for assessment and continuing treatment[14]. In August 2017 Dr Tjeuw changed her oral methotrexate to subcutaneous injections.

    [14] Medicare records indicate first consultation with Dr Tjeuw on 24 April 2014

24. In my view, the correspondence from Dr McLean and Dr Tjeuw does not provide a satisfactory explanation for Ms Maddern’s deterioration of symptoms or the continuing claimed severity of these symptoms.

25. In his conversation with Dr Minogue, Dr Tjeuw expressed some uncertainty about Ms Maddern’s clinical presentation and suggested that her ongoing symptoms were “not necessarily al related to sarcoidosis”.

26. On consideration of the available evidence I am not satisfied that, in the qualification period, the cause of Ms Maddern’s symptoms and the persisting claimed severity of these symptoms had been fully diagnosed, fully treated and fully stabilised.

27. The contribution of the condition of sarcoidosis to Ms Maddern’s symptoms and functional impairment in the qualification period is, in my view, poorly explained and uncertain.

28. Therefore, I cannot be satisfied that, in the qualification period, the condition of sarcoidosis was permanent for the purposes of the Impairment Determination and, therefore, a rating under the Impairment Table 1 cannot be assigned.

    DECISION

29. For reasons set out above, the Tribunal is satisfied that, in the qualification period, Ms Maddern did not have a rating of 20 points or more under the Impairment Tables and, therefore, did not satisfy section 94(1)(b) of the Act and did not qualify for DSP.

30. The decision under review is affirmed.

I certify that the preceding 77 (seventy-seven) paragraphs are a true copy of the reasons for the decision herein of Dr I Alexander, Member

.................................[SGD].......................................

Associate

Dated: 17 December 2018

Date of hearing:	29 November 2018
Applicant:	In person
Solicitors for the Respondent:	Mr L Dennis, Department of Human Services