Decision #76/16 - Type: Workers Compensation
Preamble
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that no responsibility should be accepted for further cortisone injections in relation to the effects of her compensable injury. A file review was held on April 20, 2016 to consider the worker's appeal.
Issue
Whether or not responsibility should be accepted for further cortisone injections.
Decision
That responsibility should not be accepted for further cortisone injections.
Decision: Unanimous
Background
The worker suffered injury to her left shoulder and neck on November 12, 1985 while employed as a grocery store cashier. Her claim for compensation was accepted and various types of benefits have been paid.
On August 25, 2014, the treating physician reported that the worker had been seen in the clinic on April 29, 2013 and May 27, 2014. He stated that the worker's right shoulder was pain free and that the left shoulder had a painful active range of motion, with pain in the deltoid area. Clinical examination showed a positive Hawkins maneuver and abduction was reduced to less than 75 degrees. On both occasions, injections into the left subacromial bursa was performed and on both occasions there was a good response. The physician stated: "I am unable to comment on a knee (sic) findings related to the shoulder injury sustained in 1985, as by the time I have seen her she already had surgery to the shoulder. Of the present time the diagnosis is residual cuff tendinitis. The plan is for her to return when her symptoms worsened, and I reinject the shoulder."
On September 21, 2014, a WCB medical advisor responded to questions posed by the case manager and stated:
"The compensable injury was a left rotator cuff tendonopathy. It is noted that the claimant had a left shoulder acromioplasty, distal clavicle excision and biceps tenotomy on October 12, 2010. It is noted that subjectively and functionally [the worker] had recovered as per the physiotherapy report of April 11, 2010 with no reported functional deficits and no restrictions outlined. It is noted that [the worker] was reportedly not performing any further activities ie. Work duties that would presumabley (sic) aggravate the condition. Given the above, it is more likely than not that [the worker] had recovered from the compensable injury and subsequent surgery. With the information submitted, any further symptoms or treatments would be directed at a condition not related to the compensable workplace injury.
The continuing cortisone injections would not be related to the compensable injury.
There is no evidence that the injections have improved function or provided sustained benefit."
On October 27, 2014, the WCB wrote the treating physician to advise that after a review of the current findings and treatment plan, the WCB would no longer cover the cost of the injections as they were not considered related to the worker's compensable injury.
On January 26, 2015, the WCB wrote the worker and stated: "We received information regarding cortisone injections and given you are having problems with both shoulders, we are unable to relate this condition to the impact of the injury." On August 12, 2015, the worker appealed the decision to Review Office.
Prior to considering the worker's appeal, Review Office sought medical advice from the WCB's healthcare branch as to whether a cortisone injection was an appropriate treatment for the worker's compensable condition, pre-existing condition, or the combined effect of both. A response to Review Office is on file dated September 18, 2015.
On September 24, 2015, Review Office determined that further cortisone injections were not warranted in relation to the effects of the workplace injury. In reaching its decision, Review Office referred to the September 18, 2015 WCB medical consultant's opinion which stated:
It is noted that on October 12, 2010, she had a left shoulder acromioplasty, distal clavicle excision and biceps tenotomy that would make continuing rotator cuff tendonopathy unlikely. The treating orthopaedic surgeon on November 3rd, 2011 does document "She does not really have any classic impingement signs." (sic) to suggest possible persistant (sic) rotator cuff tendonopathy. It was also documented that [the worker] "was doing well until a few months ago" suggesting functional and subjective recovery. This is further evidenced by the physiotherapist's report of April 11, 2010 that noted that subjectively and functionally, the patient had recovered.
…
A rotator cuff tendonopathy or tendonitis cannot be established given: i. inconsistent
impingement findings, ii. a noted acromioplasty and distal clavicle excisions that would not make impingement possible anatomically, and iii. no further work duties …that would lead to a possible rotator cuff impingement or tendonopathy.
…
A further anatomical diagnosis [to explain the worker's current symptoms] was not presented and can not be related to the original compensable injury or the subsequent surgery. The treating practitioners attempted to treat symptoms without a noted confirmed anatomical diagnosis.
…
Without an established diagnosis or continued evidence of impingement or rotator cuff
Tendonopathy, the writer is unable to comment on the appropriateness of a cortisone injection. The writer would not consider the injection an appropriate treatment for the noted recovered compensable injury.
On November 12, 2015, the worker appealed Review Office's decision to the Appeal Commission and a file review 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 and treatments, 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 prescribed medications and treatments (including cortisone injections) under this policy on condition that '"all treatments must satisfy the WCB that their use will aid in the recovery of an injured worker or minimize their symptoms."
Worker's Position
In her Appeal of Claims Decision form, the worker indicated that she needs cortisone injections "…as I get older the pain gets stronger and I feel it is from the injury."
In an earlier discussion with the worker, a WCB case management representative noted that:
[the worker] has injections about once per year for sx (symptoms) ... the shoulder is getting weaker all the time and lifting and bending effects it. Also repetitive bending. She is retired and doesn't do these types of activities.
The worker told WCB staff that her shoulder has always been the same.
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 for a cortisone injection. In order for the worker's appeal to succeed, the panel must be satisfied that the injection is necessary to cure and provide relief from the injury resulting from an accident. We are not able to make this finding. In the panel's opinion, the medical information is not sufficient, on a balance of probabilities, to establish that a cortisone injection will effectively provide relieve from the effects of the compensable injury.
The panel accepts that a cortisone injection is a common treatment for rotator cuff tendonopathy or impingement. In this case, the worker underwent an operation which would prevent any further impingement type symptoms and no impingement type symptoms have been noted by medical professionals. The panel therefore finds that the cortisone injection cannot be accounted for on a medical basis.
In reaching this decision, the panel accepts the September 17, 2015 opinion of the WCB Medical Advisor. The medical advisor noted that:
on October 12, 2010 the worker had a left shoulder acromioplasty, distal clavicle excision and biceps tenotomy that would make continuing rotator cuff tendonopathy unlikely.
on November 3, 2011, the treating orthopedic surgeon noted that the worker "does not really have any classic impingement signs" to suggest possible persistent rotator cuff tendinopathy.
a physiotherapist report of April 11, 2010 noted that subjectively and functionally, the patient had recovered
The medical advisor opined that it was likely the worker had objectively and functionally recovered from the compensable injury. He concluded he was not able to determine a current anatomical diagnosis to explain the current symptoms.
A rotator cuff tendonopathy or tendinitis can not be established given: i. inconsistent impingement findings, ii. A noted acromioplasty and distal clavicle excisions that would not make impingement possible anatomically, and iii. No further work duties that would lead to a possible rotator cuff impingement or tendonopathy.
While the panel notes that physicians have periodically provided cortisone injections for the worker's shoulder, the panel is not able to find a medical reason for such treatments or that it is necessary to cure and provide relief from the worker's injury.
The worker's 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 19th day of May, 2016