The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

A non-oral file review was held on September 30, 2003, at the claimant's request.

Issue

Whether or not responsibility should be accepted for the reimbursement of costs for the claimant's medication beyond May 30, 2003.

Decision

That responsibility should be accepted for the reimbursement of costs for the claimant's medication for myofascial pain beyond May 30, 2003.

Decision: Unanimous

Background

During the course of her employment as a registered nurse on January 30, 2000, the claimant experienced left hip pain radiating down into her right leg after lifting a patient from the floor, to a wheelchair, to bed and then onto a stretcher. The diagnosis rendered by the first attending physician was a low back strain. A second physician diagnosed the claimant as having sustained an acute muscular and ligamentous sprain of the muscles and the muscle attachments. The Workers Compensation Board (WCB) accepted the claim and benefits were paid accordingly.

In a report to the WCB dated November 28, 2001, the attending physician stated that the claimant was taking the following antidepressant medications which were beneficial in treating people with myofascial pain syndrome: Levothyroxine 100 mcgm a day, Prozac 40 mg a day and Nortriptyline 50 mg at h.s.. The physician commented that the claimant was working full time and that it would be a mistake to discontinue the medications.

On December 11, 2001, primary adjudication asked a WCB medical advisor to review the file and to comment on whether or not the medications prescribed by the attending physician were related to the compensable injury. The medical advisor responded that the prescribed medications were due to pre-existing conditions that were unrelated to the compensable injury. Based on this opinion, a WCB case manager advised the claimant on December 17, 2001, that no responsibility would be accepted for the medications that she had requested reimbursement for beyond December 17, 2001. In September 2002, the claimant appealed this decision to Review Office.

Prior to considering the claimant's appeal, Review Office sought the medical advice of a WCB consultant in physical medicine and rehabilitation. His response to Review Office is dated October 16, 2002.

In a decision dated October 18, 2002, Review Office agreed with the opinion expressed by the WCB consultant in physical medicine and rehabilitation, namely, that the medications being taken by the claimant were often helpful in resolving problems associated with soft tissue injuries of a myofascial nature. Review Office agreed with the consultant that responsibility should be accepted for the worker's prescribed medications (Nortriptyline and Prozac) beyond December 17, 2001 and that these should be paid for a further three months from the publishing of the decision. After this time, the consultant felt that the claimant should either be off of these medications or that the WCB should not further fund them. Review Office also agreed with the consultant's recommendation that the claimant should be assessed by the WCB's Pain Management Unit.

On January 18, 2003, the claimant was interviewed by a medical advisor from the WCB's Pain Management Unit. He determined at this interview that the claimant had difficulty in pinpointing the factors that contributed to her pain.

On March 17, 2003, a treating physical medicine and rehabilitation specialist wrote to the attending physician regarding his assessment of the claimant along with details regarding the types of medications that the claimant was receiving. The specialist commented that the claimant had diffuse hypersensitivity of the soft tissues and that the diagnosis of fibromyalgia was appropriate.

On March 25, 2003, a WCB physical medicine and rehabilitation consultant reviewed the file information at the request of primary adjudication. The consultant commented that the current diagnosis of the claimant's condition was fibromyalgia syndrome. He felt this diagnosis and the claimant's current medication usage were not related to the compensable accident. In a letter dated May 30, 2003, the claimant was informed by her case manager that the WCB was unable to reimburse her for any of her current medications as they were considered to be unrelated to her compensable injury and were prescribed for the fibromyalgia syndrome. On July 11, 2003, the claimant appealed this decision to Review Office.

On August 1, 2003, Review Office determined that as of May 30, 2003, the claimant's subjective complaints of pain were not related to her injury of January 30, 2000 and thus the claimant's request for ongoing coverage of her medication was denied. Review Office made reference to certain comments made by the treating physical medicine and rehabilitation specialist in his report dated March 17, 2003 that the claimant's lumbar complaints were not as significant as her complaints regarding her multiple painful areas in her upper body. Review Office noted that this was never an upper body claim and thus it did not relate any of the complaints involving the neck, shoulders and upper back as having a relationship to the January 30, 2000 injury. With regard to the diagnosis of fibromyalgia, Review Office was aware that the dominant medical opinion regarding this diagnosis was that medical literature did not relate fibromyalgia to trauma, and its onset was generally felt to be idiopathic.

Review Office summated that it did not relate the claimant's multiple areas of subjective complaints of pain to her low back and hip injury of January 30, 2000 and that it agreed with the decision rendered by the case manager of May 30, 2003 that the WCB could not be responsible for reimbursement of any of her current medications. In August 2003, the claimant appealed Review Office's decision and an oral file review was arranged.

Following review of the case on September 30, 2003, the Appeal Panel requested additional information from the claimant's treating physiatrist prior to rendering its final decision. Correspondence from the specialist was later received and was forwarded to the claimant for comment.

On November 3, 2003, the Panel met further to discuss the case and it requested a computer print-out outlining the names of prescription medication that had been prescribed to the claimant and paid for by the WCB. This information was obtained from the WCB's medical aid branch and was again forwarded to the claimant for comment. On November 24, 2003, the Panel met to discuss the case further and to render its final decision.

Reasons

A recent medical report dated October 16^th, 2003 together with enclosures, which were submitted to the Appeal Commission by the claimant's treating physiatrist, suggest that the claimant's myofascial pain syndrome continues to be in play. We note that this medical condition has been accepted by the WCB as being work-related.

There is neither medical information nor an adjudicative decision on file stating that the claimant has recovered from her compensable myofascial pain syndrome. However, it should be pointed out that the claimant is not claiming a loss of earning capacity at this time, but rather she is claiming for medical aid costs. We find that the claimant should be entitled to ongoing medical aid in respect of her ongoing compensable myofascial pain syndrome condition.

Accordingly, we further find that the WCB should be responsible after May 30, 2003 for the costs of medications, but limited only to those associated with the treatment of her myofascial pain syndrome. The claimant's appeal is hereby allowed.

Panel Members

R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

R.W. MacNeil - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 25th day of November, 2003