Decision #163/16 - Type: Workers Compensation
Preamble
The worker is appealing a decision made by Review Office of the Workers Compensation Board ("WCB") dealing with chiropractic treatment related to her workplace injury of January 29, 2015.
A file review was held on Thursday, July 21, 2016, to consider the matter. At that time, it was determined that further medical information was required. A chiropractic report dated August 16, 2016 was received from the worker’s chiropractor and a further file review was held on Monday, September 12, 2016.
Issue
Whether there is coverage for chiropractic treatment beyond July 31, 2015.
Decision
There is coverage for chiropractic treatment up to October 1, 2015.
Background
The worker suffered various injuries on January 29, 2015 when she fell in a parking lot at work. The claim was accepted. It was noted the worker was pregnant at the time she fell.
The worker was seen by her doctor, chiropractor and physiotherapist. The worker’s chiropractor, in his initial report dated February 2, 2015, started to treat the worker with adjustment/active treatments. On March 2, 2015, the physiotherapist contacted the WCB to advise that due to the worker’s pregnancy, he would not treat her until she was post pregnancy.
On March 6, 2015, the adjudicator sent a letter to the worker approving coverage for chiropractic treatment until March 31, 2015.
On April 23, 2015, the adjudicator accepted responsibility for the lower back and right knee injuries but denied responsibility for the reported pelvis/pubic injury. The adjudicator felt this was related to the worker’s pregnancy and that there was no medical information substantiating the fall had caused further issues. The worker then requested the Review Office reconsider the adjudicator’s decision pertaining to the duration of coverage for chiropractic treatment. The file was returned to the adjudicator to conduct a further review. File information indicated the worker attended the chiropractor on 10 occasions, with the last visit occurring on July 31, 2015.
On September 3, 2015, the adjudicator wrote to the worker and stated in part:
It is the opinion of Compensation Services that your current back/pelvic difficulties are not the result of falling at work on January 29, 2015. Given you could not receive a full chiropractic treatment plan due to your pregnancy WCB has approved chiropractic treatment to July 31, 2015.
The worker forwarded a request for reconsideration to the Review Office stating that she continued to have problems with pain and function and the chiropractic treatments continued to help her. Upon consideration of her file, Review Office held that the need for further chiropractic treatments beyond July 31, 2015 was not related to the compensable sprain injury as there was no additional evidence to support any ongoing relationship.
The worker appealed the decision to the Appeal Commission and a file review was held.
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 WCB's Board of Directors.
Under subsection 4(1) of the Act, where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid to the worker by the WCB.
Subsection 27(1) provides that medical aid will be paid by the WCB for so long as is necessary to cure and provide relief from the injury. Medical aid payments for expenses such as chiropractic and physiotherapy treatments are payable in accordance with this subsection which states the following:
Provision of Medical Aid
27(1) The Board may provide a worker with such medical aid as the Board considers necessary to cure and provide relief from an injury resulting from an accident.
The WCB makes these payments where it determines that the medical aid is necessary to cure and provide relief from an injury resulting from an accident. In making such a determination, the nature of the injury, the treatment provided and the worker's response to treatment may be considered.
In addition, subsection 27(10) states the following:
Medical Aid to be Under Supervision of Board
27(10) Medical aid furnished or provided under any of the preceding subsections of this section shall, at all times, be subject to the supervision and control of the Board; and the Board may contract with health care providers, hospitals or other health care facilities for any medical aid required, and agree on a scale of fees or remuneration for any such medical aid.”
In this particular matter, WCB Policy 44.120.10, Medical Aid, is applicable and states as follows:
“The Medical Aid Policy presents a comprehensive and coordinated approach to delivery of medical-aid services to injured workers. 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.”
In addition, the WCB Chiropractic Management Guideline provides that with respect to treatment duration, the WCB generally does not approve a course of manipulation in the presence of complicating factors beyond ten weeks. Where active rehabilitation is employed, the WCB generally does not approve the total duration of chiropractic care beyond fourteen weeks. The WCB expects that the duration of ancillary therapies (where employed) should not exceed the maximum duration specified for manipulation.
In exceptional circumstances (including the presence of complicating factors not specified in the guidelines), the WCB may approve treatment duration exceeding those guidelines. Under such circumstances, practitioners must request preauthorization no later than two weeks prior to the maximum treatment duration specified in the guidelines.
Worker's Position
The worker disagreed with the Review Office determination. She felt that further treatments were necessary and related to her original injury.
Employer's Position
The employer was in agreement with the Review Office decision.
Analysis
The issue before the panel is whether or not the worker is entitled to chiropractic treatment beyond July 31, 2015.
Chiropractic Report, August 16, 2016
The panel received further medical information on August 16, 2016 from the worker’s treating chiropractor (“Report”). The Report stated that the worker:
[…] attended this office on February 3, 2015. She complained of marked lower back pain subsequent to the slip and fall. She indicated that she experience pain of her upper back, lower back, her hips, her pubic region, as well as bruising and discomfort of her right knee. She was quite concerned that she felt pain extending down her left leg thigh and calve region. […] she had difficulty walking, pain with sitting, and an inability to lift her young child or perform exertional house work.
The initial diagnosis of the worker’s condition was:
[…] thoracic lumbar sprain / subluxation involving the segmental connective tissue. Subsequent diagnosis was extended to include sprain / subluxation of the pelvic joints, both sacroiliac joints as well as pubis symphysis. The latter pelvic joint injury was due in part to the patient’s pregnant condition at the time of injury, and the hormonal influence of being…pregnant.”
The Report further stated that for the worker’s initial treatment she:
[…] was administered chiropractic spinal manipulative therapy to the affected vertebral and sacroiliac articulations. She was treated with soft tissue therapy, including passive/resisted stretch and trigger point-pressure point therapy. The right knee was subsequently treated with ultrasound therapy for the related tendon insertion injury around the patella.
The worker was treated on the following dates: February 3, 6, 11, 12, 18, 26, 2015; March 25, 2015; June 4, 9, 11, 2015; and, July 3, 6, 9, 13, 14, 20, 31, 2015.
The Report further noted that as of July 31, 2015 the worker complained of residual lower back pain with intermittent referral to the thighs. In addition, she complained of intermittent discomfort and restriction of both sacroiliac joints. The intermittent sacroiliac discomfort was most notable during walking, or with long periods of sitting. She also experienced intermittent discomfort and restriction of the mid back accentuated with deep inhalation. The worker also indicated that she still experienced residual discomfort of the pubis symphysis.
It was further noted in the Report that the worker received the following treatment:
Chiropractic manipulative therapy was continued and applied as previously indicated. Spinal manipulative adjustment was used to correct segmental alignment and to restore vertebral and sacroiliac joint mobility. Ultrasound therapy was used to reduce inflammatory adhesions, and to enhance vascular circulation to the healing connective tissues. Soft tissue massage and pressure point therapy were used to reduce muscle hypertonicity.
The worker was subsequently treated on the following dates: September 15, 18, 22, 24, 28, 2015; October 1, 2015; November 25, 26, 2015; January 4, 7, 2016; March 9, 2016; May 11, 16, 2016; June 10, 17, 2016; and, July 26, 29, 2016.
Finally, the Report noted that with the completion of her pregnancy, the worker’s response to treatment has been satisfactory and more progressive. It was also noted that as of the July 2016 treatment dates both the frequency and intensity of signs and symptoms had greatly diminished. It was then noted that it was anticipated that the worker will attend treatment for residual intermittent segmental and sacroiliac discomfort and restriction on a twice a month frequency over the next six months.
In view of this new evidence, the panel finds that until October 1, 2015 the chiropractic treatments were related to the compensable injury of thoracic and lumbar sprain/subluxation involving connective tissue. However, thereafter, the treatments are what can be categorized as “maintenance” which is not covered by the Guidelines.
We therefore find that responsibility for chiropractic treatment up to October 1, 2015 is warranted in the circumstances.
Panel Members
C. Monnin, Presiding OfficerA. Finkel, Commissioner
P. Walker, Commissioner
Recording Secretary, B. Kosc
C. Monnin - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 7th day of November, 2016