Clinical investigations and diagnostic testing for compensation claims

In many cases, compensation claims can be assessed using information already obtained through routine clinical care, including:

• clinical history and examination findings
• existing imaging and pathology results
• specialist reports
• current medical records.

Most compensation claims can be assessed without additional testing. Clinical investigations should only be undertaken if they are clinically indicated or where they have been specifically requested or approved by DVA for claim assessment purposes. If a provider has concerns regarding the need for, or risks associated with, a requested investigation, they should contact the claim delegate before proceeding.

While a compensation assessment may be the first time a medical practitioner becomes aware of a problem that requires clinical investigation, this does not automatically mean that the investigations are essential for the claim, nor that DVA will pay for them. 

Any clinical investigation carries potential risks. Consistent with good clinical practice, investigations should be limited to those necessary to inform diagnosis or management, with consideration given to patient burden, exposure to biohazards such as ionising radiation, procedural discomfort, and the potential for incidental findings that may lead to further testing without clear clinical benefit.

Funding of investigations

DVA will meet the reasonable costs associated with:

• investigations specifically requested by DVA
• investigations approved by DVA in advance for claim assessment purposes.

DVA will generally not fund as part of the compensation assessment:

• routine investigations that would ordinarily be undertaken through standard healthcare pathways
• investigations undertaken without prior approval
• investigations performed for conditions which are not suspected based on thorough history and examination findings
• investigations outside the scope of the claim assessment request.

Veterans should not incur out-of-pocket costs for clinical investigations approved by DVA as part of a compensation assessment.

Clinical investigations undertaken as part of routine clinical care

It is anticipated that the veteran’s doctor will have some existing knowledge of a condition and may have already undertaken the relevant investigations before a veteran submits a claim with DVA. 

If the compensation claim process acts as a trigger for a medical practitioner to request imaging or other investigations, the doctor may choose to conduct these investigations as part of standard care. It would be appropriate for a treatment consultation to be undertaken separately from the compensation assessment and billed through standard Medicare arrangements.  

Additional clinical investigations considered necessary by the medical practitioner

If additional investigations are considered necessary by the provider to support an opinion for the condition under assessment, and these cannot be billed through normal MBS arrangements, the medical practitioner should contact the claim delegate before arranging the investigation.

Funding approval must be obtained before the testing is undertaken. DVA will only fund clinical investigations that are specifically required for assessment of the claim.

Clinical investigations requested by DVA

In some circumstances, DVA may identify that additional evidence is required to assess a claim and request specific diagnostic investigations. 

When a medical practitioner is arranging an investigation requested by DVA, consider the safety and appropriateness of this investigation for this individual. 

If there are any concerns, please discuss with DVA before proceeding. Providers are not obligated to arrange investigations they consider unsafe or unnecessary. DVA will meet the reasonable costs of investigations it has specifically requested for claim assessment purposes.      

Unnecessary clinical investigations

The compensation process is not intended to identify previously undiagnosed conditions in the absence of a reasonable clinical suspicion. Compensation assessments should not be used to undertake clinical investigations for conditions which are not suspected based on thorough history and examination findings.

Medical practitioners should avoid as part of the compensation process:

• imaging of asymptomatic body regions or other screening assessments
• multi-joint, whole-limb or whole-spine imaging solely on the basis of having a history of military service 
• investigation of conditions outside the scope of the request.