The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that he was not entitled to further coverage for the medication Nifedipine (Adalat). A file review was held on September 2, 2021 to consider the worker's appeal.

Issue

Whether or not the worker is entitled to further coverage for the medication Nifedipine (Adalat).

Decision

That the worker is entitled to further coverage for the medication Nifedipine (Adalat).

Background

This claim has been the subject of two previous appeals. Please see Appeal Commission Decision Nos. 102/05 dated June 21, 2005, and 62/17 dated May 18, 2017. The background will therefore not be repeated in its entirety.

Briefly, the worker sustained a crush injury to his left foot in a workplace accident on June 25, 1998, which resulted in multiple fractures and dislocations. The worker underwent several surgeries, which included amputation of two toes, partial amputation of the third toe, and surgery to correct the defects of the remaining toes. The claim was accepted by the WCB and payment of various benefits, including medical aid benefits for medications, commenced.

The WCB conducted medication reviews with the worker's treating family physicians over the course of the worker's claim. On April 20, 2016, a WCB medical advisor with the WCB's pain management unit opined that the worker's medications, including Nifedipine (Adalat), were appropriate and related to the worker's compensable injury, and noted that "Based on the information on file the claimant will likely require these medications on a long-term basis."

By letter dated May 15, 2017, the worker's treating family physician provided a report to the WCB indicating the only medication the worker was taking with respect to his compensable injury was a non-steroidal anti-inflammatory medication. On May 30, 2017, the WCB medical advisor reviewed the treating physician's letter, and recommended that coverage be provided for the anti-inflammatory medication and be reviewed again in one year.

On January 19, 2018, the WCB wrote to the treating family physician, as the pharmacy where the worker filled his prescriptions had requested approval for a pain medication and Nifedipine (Adalat). The WCB requested an update, noting that the physician had previously indicated the worker was only prescribed the anti-inflammatory medication. By letter dated March 8, 2018, the treating family physician responded and advised the WCB that "As mentioned earlier he is recovered well from his previous foot injury and does not take any medication for this. His current medications do not relate in any way to his foot injury of 1998." On March 9, 2018, the WCB's Compensation Services determined that Nifedipine was unrelated to the worker's claim and advised the worker they would only provide coverage for the anti-inflammatory medication that had been prescribed by his family physician.

On March 29, 2018, the WCB received a further letter from the worker's treating family physician, in which the physician indicated she had met with the worker and discussed his medication requirements. The treating physician opined that: "…it could be viewed that the use of nifedipine is not specifically related to a partial amputation of the foot however he states with certainty that he did not have problems with his blood pressure until he had the initial foot injury. Since hypertension is often something that gets worse with age, one could make a stretch that this is not necessarily related to the foot however, it is clear that he believes that his hypertension began at the time of the foot injury."

On May 23, 2018, the WCB medical advisor contacted the worker's treating family physician seeking clarification of the physician's March 8 and March 29, 2018 letters and discussed the medications prescribed to the worker, including Nifedipine. In a memorandum to file, the medical advisor indicated that "With regard to the use of Nifedipine this medication is being used to treat the claimant's Hypertension. As the Hypertension is not causally related to the compensable injury therefore the use of Nifedipine is not causally related to the compensable injury and as such its use is not eligible for WCB financial support." On May 24, 2018, Compensation Services advised the worker that they would not provide coverage for certain medications, including Nifedipine.

On August 8, 2018, the worker requested that Review Office reconsider Compensation Services' decision, noting these medications, including Nifedipine, had been prescribed by his treating healthcare providers and covered by the WCB for his compensable injury for 17 years. On November 15, 2018, Review Office spoke with the worker, who advised that "The Adalat (Nifedipine) is prescribed for both his foot (vaso-dilator) and high blood pressure. He said Adalat has always been prescribed for his foot since the injury because of poor circulation."

On November 16, 2018, Review Office spoke with the worker's treating family physician, who advised that the worker "…was already on Adalat (Nifedipine) for his left foot when he became her patient and noted it is also useful in the treatment of high-blood pressure. So one can say she prescribes it for both." On November 19, 2018, Review Office determined that the worker was entitled to funding for Nifedipine (Adalat), as well as certain other medications.

On July 9, 2019, the worker's new family physician provided a list of medications and an update of the worker's care. On September 17, 2019, the WCB medical advisor opined that:

The pertinent information on file including the letter from [name] dated July 9, 2019 has been reviewed. With regard to the use of Nifedipine it is noted that in the writer's discussion with the claimant's previous attending physician dated May 23, 2018 she did not mention that the Nifedipine was being used for circulatory problems in the injured foot. The use of Nifedipine in order to benefit circulation in the injured foot is appropriate and related to the compensable injury and as such is eligible for medical support in Healthcare.

On May 26, 2020, the WCB medical advisor reviewed a further letter from the worker's current family physician dated May 21, 2020, updating the worker's medication and care. The medical advisor noted that Nifedipine (Adalat) was listed as a medication the worker was taking, but was not mentioned in the body of the physician's letter as being related to the compensable injury, and sought clarification from the worker's physician. On June 2, 2020, the treating family physician advised that "This patient has been on nifedipine for blood pressure control. It is not used for his injury." On January 20, 2021, Compensation Services advised the worker that they were no longer able to continue funding for Nifedipine (Adalat).

On March 16, 2021, the worker requested that Review Office reconsider Compensation Services' decision. The worker submitted that his treating healthcare providers prescribed Nifedipine 20 years ago for a reason. He further submitted that his blood pressure had been high since the workplace accident, and as such, he should be entitled to coverage for this medication. On March 29, 2021, the worker's treating family physician provided Review Office with a letter in support of the worker's request.

On May 19, 2021, the WCB medical advisor reviewed the information on the worker's file and noted that the worker was prescribed nifedipine as a primary vasodilator to increase blood flow to the damaged foot at the time of injury and that this use would be off label. The medical advisor advised Review Office that "The WCB Healthcare Department does not support the use of nifedipine as a primary vasodilator medication." A copy of this opinion was provided to the worker on May 19, 2021.

On May 27, 2021, Review Office determined that the worker was not entitled to further coverage of the medication Nifedipine (Adalat). Review Office did not find evidence to support the worker developed hypertension related to the workplace accident, and determined that Nifedipine (Adalat) was not considered necessary as a result. Review Office also determined that given the length of time since the workplace accident and the surgical procedures, the use of Nifedipine (Adalat) as a vasodilator to increase blood flow to the foot would no longer be required.

On June 23, 2021, 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"), the regulations under the Act and policies of the WCB's Board of Directors.

Subsection 27(1) of the Act states that the WCB "…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."

Subsection 27(10) states, in part, that "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..."

WCB Policy 44.120.10, Medical Aid (the "Policy") sets out general principles regarding a worker's entitlement to medical aid, which is defined to include drugs. The Policy provides that the WCB determines the appropriateness and necessity of medical aid provided to injured workers in respect of the compensable injury. The Policy also provides 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, and that the WCB will refuse or limit funding of any medical aid it considers excessive, ineffective, inappropriate or harmful. Schedule A to the Policy further sets out general principles regarding the WCB's funding of prescription and non-prescription medications.

Worker's Position

The worker was self-represented in this review.

The worker's position, as outlined in his Appeal of Claims Decision form, was that he had been on Nifedipine (Adalat) since his accident. The worker referred to the November 16, 2018 telephone conversation between the Review Officer and the worker's family physician, as documented to file by the Review Officer, and the Review Office decision of November 19, 2018, where it was determined that he was entitled to funding for this medication as being related to his compensable injury.

The worker submitted that the prescription for Nifedipine (Adalat) was initiated for circulatory problems which were due to his compensable injury and subsequent surgeries; that it did not begin as a prescription for hypertension. He stated that his foot is still damaged and that he continues to have problems with it. The worker submitted that Nifedipine (Adalat) is therefore used for both his left foot circulatory problems and hypertension, and as such should be acceptable.

In conclusion, the worker asked why coverage for the medication Nifedipine (Adalat) would be taken away, given that he still has circulatory problems with his foot as a result of his compensable injury and Nifedipine (Adalat) works in addressing these problems.

Employer's Position

The employer did not participate in the appeal.

Analysis

The issue before the panel is whether or not the worker is entitled to further coverage for the medication Nifedipine (Adalat). For the worker's appeal on this issue to be allowed, the panel must find, on a balance of probabilities, that coverage for Nifedipine (Adalat) is required to cure or provide relief from the worker's injury resulting from the June 25, 1998 workplace accident. The panel is able to make that finding, for the reasons that follow.

The worker has indicated that he has been prescribed Nifedipine (Adalat) since shortly after his accident, or approximately 20 years. A March 24, 2003 report from an attending anesthesiologist at a pain clinic notes that she had discussed the potential benefits of a trial of nifedipine medication with the worker, and that "In particular, this vasodilator may be helpful in relieving his symptoms of a chronically cold foot." An April 3, 2003 report from the worker's then treating family physician indicated that the worker had been seen by the anesthesiologist at the pain clinic and was placed on Adalat for its vasodilator effects, and that the worker felt this was helping the pain in the foot.

Information on file shows that the WCB conducted regular reviews of the worker's medications over the course of the worker's claim arising out of his June 25, 1998 workplace accident. The WCB medical advisor with the WCB's pain management unit reviewed and approved the worker's prescriptions for Nifedipine (Adalat) for several years, as being related to the effects of the worker's left foot injury and surgeries. Reports on file relating to those reviews include:

• a November 30, 2012 report, where the medical advisor opined that the use of certain medications by the worker, including "Adalat (for vasodilation to aid in the claimant's foot related symptoms) is appropriate and related to the C.I. [compensable injury];"

• a June 14, 2013 report, where the medical advisor opined that in keeping with the previous opinions dated November 30, 2012 and for the reasons noted therein, the use of Adalat "…is appropriate and related to the C.I.;"

• the April 20, 2016 report, where the medical advisor opined that the worker's medications, including Nifedipine (Adalat), were appropriate and related to the worker's compensable injury. The medical advisor further opined that "Based on the information on file the claimant will likely require these medications on a long-term basis;"

• the September 17, 2019, report where the medical advisor again opined that "The use of Nifedipine in order to benefit circulation in the injured foot is appropriate and related to the compensable injury and as such is eligible for medical support in Healthcare."

On May 19, 2021, however, the same WCB medical advisor noted that the worker was prescribed Nifedipine as a primary vasodilator to increase blood flow to the damaged foot at the time of injury, that this use would be off label, and that "The WCB Healthcare Department does not support the use of nifedipine as a primary vasodilator medication."

Based on the evidence which is before us, the panel is unable to reconcile the WCB medical advisor's May 19, 2021 opinion that the use of Nifedipine (Adalat) as a primary vasodilator medication was not supported by the WCB Healthcare Department, with his previous opinions that the use of that medication for that purpose was eligible for medical support in Healthcare and would likely be required on a long-term basis.

The panel accepts the worker's evidence that he continues to have circulatory problems with his left foot and is satisfied that his circulatory problems have never gone away. The panel further finds that an explanation as to why the medication Nifedipine (Adalat) would no longer be required to address the previously described long-term effects of the worker's left foot injury and circulatory problems is lacking.

The panel acknowledges that the worker's more recent treating physician indicated in her June 2, 2020 letter that the worker "…has been on nifedipine for blood pressure control. It is not used for his injury." The panel notes that the physician had indicated in her July 9, 2019 report that she had recently taken over the worker's care from his previous family physician. The panel also notes that further clarification does not appear to be been sought from this physician, in spite of the historical acceptance of this medication.

The panel acknowledges that the medical evidence on file indicates the worker has hypertension and that Nifedipine (Adalat) has been prescribed to treat his hypertension. The panel finds, however, that there is insufficient evidence to establish, on a balance of probabilities, that Nifedipine (Adalat) was no longer necessary or being used to treat ongoing circulatory problems in his left foot.

Based on the foregoing, the panel finds, on a balance of probabilities, that coverage for Nifedipine (Adalat) is required to provide relief from the worker's injury resulting from the June 25, 1998 workplace accident. The panel therefore finds that the worker is entitled to further coverage for the medication Nifedipine (Adalat).

The worker's appeal is allowed.

Panel Members

M. L. Harrison, Presiding Officer
J. Peterson, Commissioner
W. Skomoroh, Commissioner

Recording Secretary, J. Lee

M. L. Harrison - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 1st day of November, 2021