Decision #103/20 - Type: Workers Compensation
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that she is not entitled to further additional coverage for the prescription Ralivia. A file review was held on October 1, 2020 to consider the worker's appeal.
Whether or not the worker is entitled to further additional coverage for the prescription Ralivia.
The worker is entitled to further additional coverage for the prescription Ralivia.
The worker has an accepted WCB claim for an injury to her right arm that occurred at work on August 14, 1995 when she sustained a right head of biceps rupture and right partial rotator cuff tear. The worker underwent a right shoulder arthroscopy on June 6, 1996. The worker was deemed unemployable due to her compensable injury and remained in receipt of long term wage loss and medical aid benefits.
In July 2011, the worker reported to her treating family physician increasing pain and disability in her right shoulder. The worker was sent for an MRI study of her right shoulder on September 25, 2011 which indicated "…quite severe AC (acromioclavicular) arthrosis with inferior spurring and less severe glenohumeral osteoarthritis. A large cuff tear is present…" A referral to an orthopedic surgeon was made. The worker was seen by the orthopedic surgeon on November 4, 2011 who noted the MRI study showed "…a large to massive cuff tear with almost complete atrophy and significant retraction." Recommendation was made for the worker to participate in active assisted range of motion activities as the surgeon noted the worker was "…barely moving her shoulder at all." At a follow-up appointment on February 1, 2012, the orthopedic surgeon noted the worker had made "minimal to no progress" since the previous appointment and surgery was not recommended.
On April 16, 2012, the worker's WCB case manager contacted her to discuss the status of her claim. In that discussion, the worker was advised that her treating family physician would be contacted on an annual basis for a review of the medications the worker was being prescribed. A WCB medical advisor reviewed the medications and on June 18, 2012 noted the "…opioid medications are appropriate at this time, however, no further increases in doses would be supported." As a file note, the file references to Ralivia, Tramadol, and Tramacet relate to the same opioid medication. The terms are interchanged throughout the file.
Medication reviews were conducted in 2013, 2014, 2016 and 2018. An Opioid Management Progress Report was received by the WCB on January 8, 2020. The worker's treating family physician reported examination findings of ongoing right shoulder pain, with marked limitation of range of motion and indicated the worker's diagnosis of a chronic rotator cuff tear, which had plateaued. The physician noted limited to poor ratings for the worker's functions of her activities of daily living with no side effects from the opioids indicated. The Report was reviewed by a WCB medical advisor on January 21, 2020. The advisor noted the worker's treating physician's reporting of a "…Pain Score of 7/10 and an Aggregate Functional Score of 2/40" and no reported side effects. The WCB medical advisor opined that the use of opioids were "…not associated with significant/sustained benefit to pain and function" for the worker. A follow-up review was completed on February 12, 2020, where the WCB medical advisor opined a review of the risk/benefit ratio for the worker's continued use of opioid medication was "…considered to be not favorable and the use of Opioids therefore does not qualify for medical support…" On February 26, 2020, the worker was advised coverage for the prescription Ralivia would not be approved as the medical information on file did not support the medication was having a sustained benefit to relieving her pain or improving her function.
The WCB received a letter from the worker's treating physician on March 7, 2020, advising the worker would be appealing the February 26, 2020 decision and providing support for the worker's continued use of Ralivia as other treatments had been trialed but were not successful. On March 10, 2020, the worker requested reconsideration of the WCB's decision to Review Office, noting her treating healthcare provider's support of the medication, which was noted to be the "most helpful" in relieving her chronic pain due to her workplace accident.
Review Office determined on May 4, 2020 the worker was entitled to limited additional coverage for the prescription Ralivia. Review Office relied and placed weight on the opinion of the WCB medical advisor but noted the worker had been on the same or similar opioid medication since the workplace accident approximately 25 years prior. No advance notice or warning of the possible change in her medication coverage was provided to the worker or her treating family physician nor was consideration given to a weaning period as the worker had been on a high dose of opioid medications for an extended period of time. The worker's file was returned to the WCB's Compensation Services to determine an appropriate weaning period. On May 7, 2020, the WCB medical advisor reviewed the worker's file and determined a 4 month time period would be appropriate "…for the implementation and completion of an Opioid weaning process."
On August 10, 2020, the worker's representative filed an appeal with the Appeal Commission. A file review was arranged.
Applicable Legislation and Policy
The Appeal Commission and its panels are bound by the provisions of The Workers Compensation Act (the "Act"), regulations under that Act and the policies established by the WCB's Board of Directors.
Section 1(1)(a) of the Act defines an accident as a chance event occasioned by a physical or natural cause, as a result of which a worker is injured. When it is established that a worker has been injured as a result of an accident at work, the worker is entitled to compensation under s 4(1) of the Act.
Section 27(1) of the Act provides the WCB with authority to provide the worker with medical aid as is "…necessary to cure and provide relief from an injury resulting from an accident."
Entitlement to wage loss benefits is addressed in s 4(2) of the Act which provides that wage loss benefits are payable for loss of earning capacity resulting from an accident.
WCB Policy 44.120.10, Medical Aid (the "Medical Aid Policy") sets out general principles regarding a worker's entitlement to medical aid, which is defined to include drugs. The Medical Aid Policy states that the WCB's objectives in funding medical aid are to promote a safe and early recovery and return to work, enable activities of daily living, and eliminate or minimize the impacts of a worker's injuries. The Policy further provides that the WCB will refuse or limit the funding of any medical aid it considers excessive, ineffective, inappropriate or harmful.
WCB Policy 44.120.20, Opioid Medication (the "Opioid Policy") recognizes that physicians are confronted with the challenge of prescribing opioids in a way that balances their ability to relieve pain and improve function while minimizing side effects and risks. The stated intent of the Opioid Policy is to provide parameters for the authorization and payment of opioids. The Opioid Policy provides that the WCB may suspend or discontinue authorization of payment for opioid medication in circumstances which include when the side effects or risks of opioid medication outweigh their benefit.
The worker provided medical reports and anecdotal evidence for a file review by the appeal commission. The worker, through her representative, indicated that she has been managing her pain with Tramadol since the workplace injury in 1995. The worker indicates that the dose is not high, and that risk of addiction or misuse is not an issue in this instance. Under the supervision of the worker’s regular physician, attempts to provide alternate medications were not successful due to ineffectiveness and other non-compensable health risk factors.
The reduction of the Tramadol dose has caused discomfort that has not been well managed. The worker requests continued funding of the Tramadol (Ralivia) prescription.
The employer did not participate in the appeal.
For the appeal on this issue to be successful, the panel must find, on a balance of probabilities, that opioid medications are reasonably necessary to cure and provide relief from the effects of the worker's workplace injury. The panel is able to make that finding.
Information on file indicates that the worker has been prescribed pain management medication since the 1995 workplace injury.
The panel notes that in her letter to file dated March 7, 2020, the worker’s physician indicates that Tramadol (Ralivia) provided relief to the worker. Alternate medications (NSAIDs) did not represent a viable option due to potential specific health risks including a heart condition.
The panel acknowledges and respects the opinion of the WCB medical advisor. The panel recognizes the concerns which were identified by the WCB with respect to potential risks or side effects vs the benefits from the use of opioid medications as outlined by the WCB medical advisor in his memorandum of February 12, 2020. The panel notes that such side effects do not appear to have manifested themselves as a result of the worker's use of the opioid medications for more than 25 years, up to this point in time. In the circumstances of this case, the panel is of the view that there is a sustained benefit overall to the worker from the use of the opioid medications in terms of both pain and function that outweigh the potential risks.
The panel acknowledges the challenge with prescribing opioids and fully accepts the Opioid Policy. Given the particular facts of this case, including the fact that the worker has been taking opioids for decades, her advanced age, the overall relatively static or sustained benefit from the use of opioids, and the absence of any significant side effects having manifested themselves in relation to the use of these medications, the panel is satisfied, on a balance of probabilities, that the opioid medications are reasonably necessary to cure and provide relief from the effects of the workplace injury. The panel is further satisfied that ongoing coverage of the opioid medications at this time is consistent with the Medical Aid and Opioid Policies.
The worker indicated that her family physician monitors her to regularly ensure that her consumption of medication is safe. The panel notes that the best practices listed under the Administrative Guidelines in the Opioid Policy do speak to monitoring the use of opioids and adherence to the opioid treatment plan. The panel agrees with the WCB medical advisor's opinion indicated on a medical review dated October 11, 2016 that the worker's "…use of Tramacet…should be reviewed on an annual basis with an accompanying narrative report from the treating physician as well as an Opioid Progress Management report."
Based on the foregoing, the panel finds, on a balance of probabilities, that the opioid medications are reasonably necessary at this time to cure and provide relief from the effects of the worker's workplace injury. The worker is therefore entitled to additional coverage for the prescription Ralivia.
The worker's appeal of this issue is allowed.
B. Hartley, Presiding Officer
J. Witiuk, Commissioner
M. Kernaghan, Commissioner
Recording Secretary, J. Lee
B. Hartley - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 27th day of October, 2020