Decision #47/18 - Type: Workers Compensation
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that he is not entitled to coverage for the medication Pariet. A file review was held on January 17, 2018 to consider the worker's appeal.
Whether or not the worker is entitled to coverage for the medication Pariet.
The worker is not entitled to coverage for the medication Pariet.
The worker, a truck driver, reported injuring his right shoulder, neck and left knee on December 2, 2009, describing the incident as:
I fell off the side of the trailer, about 9 - 10 feet above the ground. I missed a step and fell all the way down, my left leg caught the one trap door. And I fell on my right shoulder…
On December 4, 2009, the worker attended at an emergency department and was diagnosed with a right shoulder and neck injury and recommended to be off work until December 14, 2009. The worker's entitlement to wage loss and medical aid benefits was ended on February 14, 2010 following a decision by Review Office. That decision was rescinded by Review Office on June 14, 2010 and the worker's claim for wage loss and medical aid benefits was accepted.
The worker underwent surgery to repair his right shoulder on June 22, 2010 and again on March 17, 2011. On August 26, 2011, the worker's orthopedic surgeon reported:
He is not doing well functionally, dysfunctional range of motion shoulder, a lot of guarding and lack of some motion. The only thing that seemed to help him was hot, pool and spa treatments out in [location]. He was prescribed [medication] once again. Best option is to keep the shoulder moving. For surgeries for a younger man of his size and demand would only be a resurfacing arthroplasty at this stage, which would not necessarily move him very far forward so continue general fitness, weight reduction but long term disability with respect to his shoulder an inability to do his previous truck driving job, which is likely more or less permanent.
On April 5, 2012, the WCB advised the worker's employer that the following restrictions were permanent for the worker:
Right upper limb
Avoid above shoulder activities
No single lifts waist to shoulder and above over 10 pounds
No repetitive lifts waist to shoulder and above over 5 pounds
No push/pull activities over 15 pounds
The worker advised the WCB on September 6, 2013 that he had returned to work. The WCB confirmed by letter to the worker on September 6, 2013 that he was no longer entitled to full long term wage loss benefits. The WCB further advised that they would continue to cover medications and medical treatment related to the worker's right shoulder.
On January 6, 2016, the worker met with the WCB. The worker advised that he had not been working since August 10, 2015 as he felt "…overwhelmed with the discomfort in his R (right) shoulder he felt he had no choice but to go off work for a period so he could get the symptoms under control." The WCB advised the worker that a review of his claim, including obtaining medical reports, would be conducted.
The WCB advised the worker on October 21, 2016 that after a review of his claim, including a report by a WCB medical advisor, it was the opinion of the WCB that the worker's current symptoms were not related to the original workplace injury. The WCB also advised the worker that they would continue to only accept financial responsibility for the Tylenol No. 3s being prescribed in relation to the original workplace injury.
The worker requested reconsideration of the WCB's decision to the Review Office on June 5, 2017. The worker's reasons for not agreeing with the WCB decision is noted as:
T3's were prescribe (sic) by doctor and laxatives and stomach meds for life. Then later [WCB medical advisor] from W.C.B. decided on T3s would stay, the other meds were meds that I needed cause T3 to (sic) hard on stomach.
A WCB sports medicine advisor provided an opinion on June 17, 2017 noting:
Pariet, a stomach protecting medication using prescribed in relation to NSAID (nonsteroidal anti-inflammatory drug) use. From the goods and services information on file, Pariet was previously dispensed with Arthrotec (an NSAID), however it does not appear that Arthotec is being used currently. Therefore it does not appear that Pariet is required in relation to the workplace injury at this point in time.
Review Office, on August 1, 2017, determined that the worker was entitled to medical aid for the medication, Restoralax but upheld the WCB's decision that the worker was not entitled to medical aid for the medication, Pariet.
Review Office noted that the worker was still not taking Arthrotec and relied on the WCB sports medicine advisor's opinion that Pariet would not be required in relation to his right shoulder injury or his current reported symptoms.
The worker filed an application with the Appeal Commission on August 10, 2017. A file review was scheduled for January 17, 2018.
Following the file review, the appeal panel requested additional medical information prior to discussing the case further. The requested information was later received and was forwarded to the interested parties for comment. On April 5, 2018, the appeal panel met further to discuss the case and render its final decision on the issues under appeal.
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.
Pursuant to 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.
Medical aid payments for expenses, including medication, are payable in accordance with Subsection 27(1) of the Act which authorizes the WCB to make payments for expenses where it determines that the medical aid is necessary to cure and provide relief from an injury resulting from an accident.
The WCB has also established WCB Board Policy 44.120.10, Medical Aid (the “Medical Aid Policy”) which is intended to assist with the interpretation and implementation of medical aid entitlements. The Medical Aid Policy provides, among other things, that the provision of medical aid is for the purpose of minimizing the impact of the worker’s injury and enhancing the injured worker’s recovery to the greatest extent possible. The Medical Aid Policy further provides that:
All such treatments must satisfy the WCB that their use will aid in the recovery of an injured worker or minimize the impact of the injury.
The worker was represented by a worker advisor who provided a written submission. The worker's representative noted, in part:
• the worker has a compensable right shoulder rotator cuff tear injury as a result of a 10-foot fall off the side of a truck trailer on December 2, 2009.
• the worker's physician prescribed Pariet (rabeprazole) because it significantly alleviates the stomach issues he has as a result of taking Tylenol #3 (T3s).
• the WCB continues to accept responsibility for T3s and has recently accepted responsibility for T4s, which have a higher content of codeine and acetaminophen.
• the worker reports that he has significant stomach symptoms and pain when he takes the prescribed T3s including upset stomach/pain, burning, gas, heartburn and an increase in acid reflux.
• the worker reports that when he does not take Pariet after takingT3s, the symptoms increase substantially.
• the worker also reports that when he takes Pariet with T3s, the symptoms are significantly alleviated.
• the worker's attending physician confirms that she prescribed Pariet to alleviate the side effects from the chronic use of T3s.
• literature indicates that medications containing codeine can increase or worsen acid reflux conditions.
• the WCB denied coverage for Pariet based on the opinion of a WCB medical adviser which indicated that there is no relationship between the need for Pariet and the compensable injury.
The worker's representative submitted that the worker's use of T3s justifies his need for Pariet.
The worker's representative made a further submission upon receipt of the opinion received by the panel from an Assistant Professor in the College of Pharmacy, University of Manitoba. She submitted, in part:
In support of our position, [assistant professor] responds to the question of "What are the known side effects of consuming Tylenol #3 over an extended period of time?" That the overall side effect profile is expansive and includes as one of the primary reactions is that of gastrointestinal (GI) effects. He (sic) supports that this to some extent is dependent on duration and body systems.
In review of [assistant professor's] further opinion, he (sic) responds to the panel's question of "specifically for what symptoms would Pariet be considered to be an appropriate treatment?" with information from Health Canada on rabeprazole (Pariet). This information supports that it is for the treatment of symptoms of heartburn and regurgitation and symptomatic gastroesophageal reflux disease, which in our opinion are stomach related issues.
It is [worker's] positon that Pariet helps him with his stomach or gastric issues as a result of using WCB approved Tylenol3 (T3s). He reports that there is a considerable difference when he does not take Pariet as his gastrointestinal symptoms (i.e. acid reflux, heartburn) significantly worsened and Pariet is the only medication found to help him to counter the effects of the T3s…
It is our position that with the physician's medically prescribed treatment being the need for Pariet is to offset WCB accepted use of T3s related to the compensable injury, then Pariet is also a WCB responsibility.
The issue in this case is whether the worker is entitled to coverage for the medication Pariet. For the appeal to succeed, the panel must be satisfied that the medication is necessary to cure and provide relief from an injury resulting from an accident.
The panel notes that the worker's physician prescribes the use of Pariet. In a letter dated June 20, 2017, the physician noted that the WCB covers the cost of the worker's T3 prescription and advised that:
…this medication causes some side effects and therefore, with long term use, is usually prescribed with other medications in order to combat the side effects. [worker] need to use….Pariet which reduces his stomach discomfort caused by Tylenol #3.
The panel notes that a WCB medical advisor reviewed the request for coverage of Pariet, and provided an opinion dated September 21, 2017, which indicated that:
To the extent that [worker] may experience stomach discomfort in some manner related to Tylenol #3 use, it is not likely that use of Pariet would be required or be effective for treatment of this condition,
The medical advisor noted that:
Pariet is a proton pump inhibitor (PPI) which reduces acid secretion in the stomach. It is typically used for treatment of gastroesophageal reflux, stomach ulcers, or other conditions related to increased acid secretion in the stomach…PPI is known to reduce NSAID associated GI side effects.
To the extent that [worker] may experience stomach discomfort in some manner related to tylenol #3 use, it is not likely that use of Pariet would be required or be effective for treatment of this condition.
To assist in its deliberations, the panel obtained an opinion from an Assistant Professor at the College of Pharmacy, University of Manitoba regarding known side effects of consuming T3s over an extended period of time and whether Pariet (rabeprazole) would be considered an appropriate medication to manage symptoms caused by T3s.
The Assistant Professor noted that:
• the overall side effect profile of codeine, the primary ingredient in T3s, is expansive including primarily reactions to the central nervous system and gastrointestinal (GI) effects.
• the approved applications for rabeprazol include:
o symptomatic relief and healing of erosive or ulcerative gastroesophageal reflux disease (GERD)
o long-term maintenance of healing of erosive or ulcerative GERD
o treatment of symptoms (i.e. heartburn and regurgitation) in symptomatic GERD
o symptomatic relief and healing of duodenal ulcers
o symptomatic relief and healing of gastric ulcers
o long-term treatment of pathological hypersecretory conditions
• none of the approved applications of rabeprazole are considered to be known side effects of codeine
• a review of various commonly used tertiary resources found that none of these lists PPIs as a treatment for any of the codeine side effects noted in this opinion.
The Assistant Professor opined, in part, that:
Codeine containing products are generally not associated with the symptoms/conditions listed for the approved uses for PPI's (rabeprazole). As well there is an absence of information in the medical literature regarding use of PPI's to treat potential GI effects of codeine, making it difficult to support a case even for off-label use.
The panel notes that the Assistant Professor and the WCB medical advisor are in agreement that the use of Pariet is not recognized as a treatment for the side effects caused by T3 use.
The panel places greater weight on the criteria and analysis provided by the Assistant Professor and the WCB medical advisor than on the opinion of the treating physician and finds, on a balance of probabilities, that the medication should not be covered by the WCB.
With respect to the Medical Aid Policy, the panel finds that the prescribed use of Pariet is not required by reason of the compensable injury.
The panel also notes that the worker was initially prescribed Pariet in conjunction with another medication well before he was prescribed T3s.
The worker's appeal on this issue is denied.
A. Scramstad, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner
Recording Secretary, J. Lee
A. Scramstad - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 20th day of April, 2018