Decision #79/23 - Type: Workers Compensation
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that she is not entitled to coverage for the medication Concerta. A file review was held on May 9, 2023 to consider the worker's appeal.
Whether or not the worker is entitled to coverage for the medication Concerta.
Whether or not the worker is entitled to coverage for the medication Concerta.
The worker has an accepted claim with the WCB for a psychological injury resulting from incidents that occurred on September 25, 2019. Various benefits have been provided on the claim, including wage loss and medical aid benefits and vocational rehabilitation services.
On June 30, 2021, the worker's file was reviewed by a WCB psychological consultant, who stated that the worker's current diagnosis was Other Specified Trauma and Stressor-Related Disorder with lesser post-traumatic symptoms, and noted that this occurred in the context of the worker having a long history of depression and anxiety.
On November 17, 2021, the worker's medications were reviewed by a WCB psychiatric consultant as part of the ongoing management of the worker's claim. The psychiatric consultant advised that two of the medications which were prescribed to the worker by her treating family physician were appropriate for coverage by the WCB as they related to treatment for the worker's compensable injury, while use of the other medications was not related to the compensable diagnosis and would not be supported by the WCB.
By letter dated June 16, 2022, the worker's family physician advised that the worker was now taking the medication Concerta, and that the worker felt her focus and concentration had improved significantly and the medication was helping her with returning to work.
On July 5, 2022, the worker's file was again reviewed by the WCB psychiatric consultant, who opined that the medication Concerta was "…not indicated for treatment of a trauma related disorder…" and its use was not supported by the WCB Healthcare Department for the worker's accepted diagnosis. On the same date, the WCB advised the worker that she was not entitled to coverage for the medication Concerta.
On July 22, 2022, the worker requested that Review Office reconsider the WCB's decision. The worker submitted that her treating physician prescribed Concerta to her as it has "…other therapeutic uses and off label treatments" and further noted the medication had been helping her.
On September 22, 2022, Review Office determined that the worker was not entitled to coverage for the medication Concerta. Review Office found that Concerta was primarily prescribed for ADHD (attention deficit hyperactivity disorder) and the evidence did not support the medication being prescribed for use related to trauma-type disorders. Review Office therefore found the use of Concerta would not be related to the worker's compensable injury and there was no entitlement to coverage for that medication.
On February 21, 2023, the worker appealed Review Office's decision to the Appeal Commission and a file review was arranged.
Applicable Legislation and Policy
The Appeal Commission and its panels are bound by The Workers Compensation Act (the "Act"), regulations made under the Act and policies established by 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"), defines key terms and sets out general principles regarding a worker's entitlement to medical aid, which is defined in the Act to include drugs. The general principles governing the WCB's funding of medical aid, as outlined in the Policy, include the following:
• The Board determines the appropriateness and necessity of medical aid provided to injured workers in respect of the compensable injury.
• The Board'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 Board will refuse or limit the funding of any medical aid it considers excessive, ineffective, inappropriate or harmful.
Schedule A to the Policy provides additional details concerning the WCB's funding of prescription and non-prescription medications.
The worker was self-represented on the appeal.
The worker's position, as outlined in her Appeal of Claims Decision form and attachment, was that Concerta is required to provide relief from her September 25, 2019 workplace accident and she is entitled to coverage for that medication.
The worker submitted that her licensed physician prescribed Concerta to treat her workplace injury when other medications did not work. She stated that Concerta alleviated symptoms which were related to her accident, and she had been able to secure employment and remain employed since taking that medication.
The worker argued that like so many other prescription drugs, Concerta has off-label therapeutic uses other than for ADHD. The worker submitted that Concerta was prescribed by a medical professional for the sole purpose of treating the trauma which resulted from her accident. The worker noted the WCB had approved another medication, but it did not help her, so her physician prescribed Concerta. The worker stated she had been told Concerta mimics that other medication, so the WCB's refusal to cover Concerta made no sense.
The worker stated she does not have, and has never been diagnosed with, ADHD. She noted she had accomplished many things prior to her accident, including obtaining two university degrees, and submitted that this would not be consistent with someone who had ADHD. She noted she had also had many years of stable employment prior to her accident. The worker stated she did not need to take Concerta prior to her accident and would not be taking it now if it were not for the accident. She submitted that Concerta helps her manage her life now.
In conclusion, the worker submitted that the WCB's decision was in violation of subsection 27(1) of the Act, in not providing her with medical aid which is necessary to provide relief from the injury which resulted from the workplace accident, and her appeal should be accepted.
The employer did not participate in the appeal.
The issue before the panel is whether or not the worker is entitled to coverage for the medication Concerta. For the worker's appeal to be allowed, the panel must find, on a balance of probabilities, that Concerta is required to cure and provide relief from the worker's injury resulting from the September 25, 2019 workplace accident. The panel is unable to make that finding, for the reasons that follow.
Based on our review of all of the information and submissions on file, the panel is unable to relate the worker's prescription for Concerta to her September 25, 2019 workplace accident or compensable injury.
The panel notes that the list of the worker's medications which her treating family physician provided in late October 2021, and were reviewed by the WCB psychiatric consultant on November 17, 2021, did not include Concerta.
Subsequently, in a Progress Report dated January 7, 2022, the worker's treating family physician noted the worker was complaining of a lack of focus and concentration and queried where this could be due to symptoms of ADD (attention-deficit disorder). The physician further noted in that report that she was wondering whether a diagnosis and treatment for ADD could help with the worker's return to work.
Several months later, in a Progress Report dated June 3, 2022 and referring to a May 19, 2022 appointment, the treating family physician indicated that the worker had started taking Concerta and had said it was working. In a June 16, 2022 letter addressed "To whom it may concern", the family physician also stated that the worker "…is now on Concerta…She feels her focus and concentration has improved significantly and it (sic) helping with returning to work."
In reviewing the evidence on file, the panel is satisfied that it shows a direct line between the treating family physician's query with respect to ADHD as a possible diagnosis and Concerta being prescribed for the worker.
It is the panel's understanding that Concerta is indicated for and used to treat ADD or ADHD. The panel notes that our understanding is consistent with the advice from the WCB psychiatric consultant who stated on July 5, 2022 that the medication "Concerta is a stimulant used for treatment of ADHD."
The WCB psychiatric consultant went on to opine on July 5, 2022, that "Concerta is not indicated for treatment of a trauma related disorder, and hence its use is not accounted for by the workplace incident or the diagnosis of Other Specified trauma and Stressor Related Disorder" and that the WCB Healthcare Department did not support use of this medication in relation to the workplace accident.
The panel notes that the worker's argument appears to be that Concerta was prescribed for an off-label use, as a substitute for another medication, to address symptoms of PTSD (post-traumatic stress disorder). The panel is unable to find that the evidence supports that argument. Rather, the panel finds that the medical evidence shows that Concerta was only prescribed after the treating family physician started querying ADHD, and that the medical evidence does not support that Concerta was prescribed for or intended to treat anything other than ADHD.
Based on the foregoing, the panel in unable to find that the worker's prescription for and use of Concerta is related to her workplace accident or compensable injury. The panel therefore finds, on a balance of probabilities, that the medication Concerta is not required to cure or provide relief from the worker's injury resulting from the September 25, 2019 workplace accident, and the worker is not entitled to coverage for that medication.
The worker's appeal is dismissed.
M. L. Harrison, Presiding Officer
J. Peterson, Commissioner
M. Kernaghan, Commissioner
Recording Secretary, J. Lee
M. L. Harrison - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 7th day of July, 2023