Decision #44/14 - Type: Workers Compensation
Preamble
The worker is appealing the decision made by the Workers Compensation Board ("WCB") to deny financial responsibility for his Nabilone medication. A hearing was held on April 9, 2014 to consider the matter.Issue
Whether or not responsibility should be accepted for the medication Nabilone.Decision
That responsibility should not be accepted for the medication Nabilone.Decision: Unanimous
Background
On June 17, 2008, the worker felt a pull in his left groin area when assisting three co-workers lift a heavy wall. His claim for compensation was accepted by the Appeal Commission and benefits were paid to the worker which included wage loss, medical aid and vocational rehabilitation benefits and services. The compensable diagnosis was a left inguinal hernia.
On October 23, 2013, a WCB medical advisor with the Pain Management Unit ("PMU") reviewed the worker's file to determine whether the WCB should pay for the medications taken by the worker. Regarding Nabilone, the medical advisor stated that upon a review of literature there is not sufficient evidence from quality studies to support the use of this medication in this case.
Based on the WCB medical opinion of October 23, 2013, the worker was advised that the WCB would not provide financial responsibility for Nabilone. The worker disagreed with the decision and an appeal was filed with Review Office.
On January 21, 2014, Review Office was unable to find that the use of Nabilone was necessary in relation to the worker's compensable injury. Review Office indicated that it understood the medical advisor's concerns for the use of Nabilone to be the risk/benefit ratio and not solely the side effects. It accepted the medical advisor's opinion that upon review of the medical literature there was insufficient evidence from quality studies to support the use of Nabilone in this case. It found the evidence on file did not support a favorable risk/benefit ratio. On February 4, 2014, the worker appealed Review Office's decision to the Appeal Commission and a hearing was arranged.
Reasons
Applicable Legislation and Policy
The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the Board of Directors.
When a worker suffers personal injury by accident arising out of and in the course of employment, compensation is payable to the worker pursuant to subsection 4(1) of the Act.
Medical aid payments for expenses, such as medication, are payable in accordance with subsection 27(1) of the Act. This section authorizes the WCB to makes these payments where it determines that the medical aid is necessary to cure and provide relief from an injury resulting from an accident.
The WCB has established WCB Board Policy, 44.120.10, Medical Aid, which notes that "the provision of medical aid attempts to minimize the impact of the worker's injury and to enhance an injured worker's recovery to the greatest extent possible." The WCB pays for prescription medications under this policy. "All treatments must satisfy the WCB that their use will aid in the recovery of an injured worker or minimize the impact of the injury."
Worker's Position
The worker attended the hearing with his father and fiancée. The worker explained his reasons for appealing the WCB decision.
The worker explained that he was taking Nabilone for relief of pain caused by his workplace injury. He acknowledged that it is helpful for pain caused by activity and for stress.
He initially said that his pain increased when he started attending school full-time. He had to walk long distances which caused him to increase the amount of the dose he used. He thought he started using the medication around September 2013.
It was noted that the worker had previously provided pharmacy records which indicated that he was prescribed the medication in April 2013. He agreed the receipts are accurate. He also agreed with the information on file from his family physician and psychologist that he was experiencing stress. He said he used the medication for this purpose.
The worker was asked about the WCB medical advisor's position that the medication is approved for treating nausea and vomiting in cases of chemotherapy and whether he discussed this with the treating physician. He said his treating physician acknowledged the WCB medical advisor's position but said that as the medication worked for him he should continue to use it.
The worker said his own physician is in a better position to diagnose medication than a WCB medical advisor.
He said that he began educational upgrading for entry to a college in the summer of 2013 before the Appeal Commission decision. He started full-time studies in October 2013. He attends college from 8:00AM to 4:00 PM and on most days also attends tutoring from 4:30 PM to 6:00 PM.
The worker's father advised that information on the internet indicates that while the medication is used for treating nausea in cancer patients, the information also indicates that the medication is used for neuropathic pain. The father also said that he has noticed that his son is throwing up less frequently since he has been using the medication. The worker added that the medication is used in cases of fibromyalgia.
The worker listed the medications that he uses on a daily basis. He said that he assesses his medication use on a weekly basis.
The worker advised that he has not discussed alternatives to the medication with his treating physician.
The worker said that his physician is willing to discuss his case with the panel.
The worker confirmed that he continues to use the medication at his own expense.
Employer's Position
The employer did not participate in the hearing.
Analysis
The issue before the panel is whether or not the worker is entitled to coverage of the medication Nabilone. In order for the worker's appeal to succeed, the panel must be satisfied that the medication is necessary to cure and provide relief from the injury resulting from an accident. We are not able to make this finding at the current time.
In the panel's opinion, the medical information is not sufficient, on a balance of probabilities, to establish the use of Nabilone medication to relieve from the effects of the compensable injury. In reaching this decision, the panel accepts the opinion of the WCB Medical Advisor - Pain Management Unit set out in his memo of October 22, 2013, as follows:
"With regard to Nabilone this medication is approved by Health Canada for use in treating nausea and vomiting secondary to chemotherapy. As such its use in this case would be considered to be "off label." In order to consider whether or not the use of "off label" medication (ie. Nabilone) would meet criteria for eligibility for WCB financial support a risk/benefit ratio is required. This requires review of the medical literature to see if there is sufficient support (evidence) for its use in this case. Review of the medical literature does not reveal the presence of sufficient evidence from quality studies involving test subjects that would form a cohort of the claimant yielding robust results that would result in high grade recommendations supporting the use of Nabilone in a case such as this. Therefore, based on the above the risk/benefit ratio for the use of this medication in this case is not favorable and as such the use of Nabilone does not meet criteria for WCB financial support as such use would not be evidence informed."
The panel understands there is some support for the use of this medication for relief of nerve and other pain. However, the panel notes, there is not sufficient evidence, at this time, to support its use in the worker's case. The available evidence does not demonstrate, on a balance of probabilities, that the use of Nabilone will aid in the recovery of the worker or minimize the impact of the injury.
The appeal is dismissed.
Panel Members
A. Scramstad, Presiding OfficerA. Finkel, Commissioner
P. Walker, Commissioner
Recording Secretary, B. Kosc
A. Scramstad - Presiding Officer
Signed at Winnipeg this 15th day of April, 2014