Licence Appeal Tribunal File Number: 22-013647/AABS
In the matter of an application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8, in relation to statutory accident benefits.
Between:
Anna Shvartsmann
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
ADJUDICATOR:
Nadia Mauro
APPEARANCES:
For the Applicant:
Alexander Makaronets, Counsel
For the Respondent:
Athina Ionita, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Anna Shavrtsmann, the applicant, was involved in an automobile accident on December 9, 2020, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Allstate Insurance Company of Canada, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
Is the applicant entitled to $3,857.36 for physiotherapy services, proposed by Newmarket Health and Wellness Centre in a treatment plan (“OCF-18”) dated July 30, 2022?
Is the applicant entitled to $2,269.26 (3,909.59 less 1,640.33) for physical therapy services, proposed by Newmarket Health and Wellness Centre in an OCF-18 dated May 10, 2023?
Is the applicant entitled to $5,380.00 for a PRP Injection, proposed by All Health Medical Centre in an OCF-18 dated May 25, 2023?
Is the applicant entitled to $5,440.00 for Botox Injections, proposed by All Health Medical Centre in an OCF-18 dated May 25, 2023?
Is the applicant entitled to $10,657.67 for a chronic pain program, proposed by All Health Medical Centre in an OCF-18 dated May 25, 2023?
Is the applicant entitled to $3,702.61 for physical therapy, proposed by Newmarket Health and Wellness Centre in an OCF-18 dated July 22, 2023?
Is the applicant entitled to $2,160.00 for a Social Work Assessment, proposed by All Health Medical Centre in an OCF-18 dated December 2, 2022?
Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3The applicant is partially entitled to the physical therapy treatments, a chronic pain program, and a social work assessment plus interest.
4The applicant is not entitled to the PRP and Botox injections.
ANALYSIS
5To receive payment for a treatment and assessment plan under s. 15 and 16 of the Schedule, the applicant bears the burden of demonstrating on a balance of probabilities that the benefit is reasonable and necessary as a result of the accident. To do so, the applicant should identify the goals of treatment, how the goals would be met to a reasonable degree and that the overall costs of achieving them are reasonable.
The OCF-18 for physiotherapy services dated July 30, 2022
6I find that the applicant has proven, on a balance of probabilities, that the treatment plan for physiotherapy services is partially reasonable and necessary.
7The OCF-18 for the proposed physiotherapy services completed by physiotherapist, Mr. Hanan Ibrahim, dated July 30, 2022, seeks the following:
| Line Number | Description | Proposed Amount | Amount approved | Balance |
|---|---|---|---|---|
| 1 | Exercise, multiple body sites (8 sessions) | $1,503.60 | $0.00 | $1,503.60 |
| 2 | Assessment – Reassessment | $200.00 | $0.00 | $200.00 |
| 3 | Exercise equipment – 10lb med ball | $89.20 | $0.00 | $89.20 |
| 4 | Exercise equipment – Fitness Acupoint Foam Roller | $86.50 | $0.00 | $86.50 |
| 5 | Exercise equipment – speed rope | $32.10 | $0.00 | $32.10 |
| 6 | Neck/shoulder massager | $175.00 | $0.00 | $175.00 |
| 7 | Documentation, support activity – completion of OCF-18 | $200.00 | $0.00 | $200.00 |
| 8 | Orthotic devices – orthotic pillow | $98.65 | $0.00 | $98.65 |
| 9 | Therapy, multiple body sites – multidisciplinary rehabilitation (6 sessions) | $720.00 | $0.00 | $720.00 |
| 10 | Therapy, multiple body sites – massage therapy (6 sessions) | $230.46 | $0.00 | $230.46 |
| 11 | Acupuncture (6 sessions) | $230.46 | $0.00 | $230.46 |
| 12 | Omega 3 (120) Softgels | $101.39 | $0.00 | $101.39 |
| 13 | Documentation support activity - Progress report | $190.00 | $0.00 | $190.00 |
8The OCF-18 identifies goals of pain reduction, increase in strength, and to return to activities of daily living.
9The applicant submits that she sought to be referred for additional physiotherapy services at or around the time that the treatment plan was submitted. The applicant further argues that her symptoms returned as soon as she ceased treatment.
10The respondent submits that s. 44 physiatry assessor, Dr. Farooq Ismail, found that the treatment plan was not reasonable and necessary because this assessor could not identify any ongoing musculoskeletal or neurological impairment as a result of the accident. Moreover, the respondent argues that there is no compelling support for the need of the exercise sessions, suggested equipment, acupuncture, Omega soft gels, and documentation fees.
a) Physical therapy treatment
11With respect to Line 1: exercise, multiple body sites, and Line 10: massage therapy, I find that the contemporaneous medical reporting indicates that the applicant’s treating and assessing practitioners have recommended physical therapy. Specifically, I find that the clinical notes and records (“CNRs”) of the applicant’s family practitioner, Dr. Arthur Staroselsky, support that the applicant has continued to make complaints of accident-related impairments since the accident. On July 5, 2022, the applicant asked Dr. Staroselsky for a referral to “physio” as she “felt better after physio, but sx are back as soon as she stopped it.” By referral of Dr. Staroselsky, the applicant also began treatment at The Pain Clinic Toronto (“TPC”), on October 7, 2022, with respect to accident-related complaints of headaches, neck pain radiating to both shoulders, left hand and fingers. Dr. Pezhman Mehrabian, of TPC recommended physiotherapy with an emphasis on core muscle strengthening techniques. Moreover, physiatrist Dr. Ammar Al Khudairy, in an assessment dated January 22, 2023, recommended the applicant continue with an active rehabilitation program to build strength, endurance, and range of motion.
12I am less persuaded by the report of s. 44 physiatry assessor, Dr. Farooq Ismail, dated October 5, 2022, despite his finding that the treatment plan was not reasonable and necessary. When weighing the evidence of Dr. Ismail against that of Dr. Staroselsky, Dr. Pezhman, and Dr. Al Khudairy, I prefer the latter. These treating practitioners have recommended, in some way, physical therapy. The only departing opinion is that of s.44 assessor, Dr. Ismail. As such, I find it more probable than not that the applicant’s evidence is supportive of the need for the proposed physical therapy.
13Given the above, I find that, on a balance of probabilities, the proposed Line 1 and Line 10 treatments to be reasonable and necessary.
b) Goods and Services
14At the same time, I find that the applicant has not demonstrated that the proposed goods and services as listed within the OCF-18 as Line 12: Omega 3 (120 Softgels), Lines 3, 4, and 5: Exercise Equipment, Line 6: Neck/Shoulder Massager, Line 8: Orthotic Devices, and Line 11: Acupuncture, are reasonable and necessary.
15Line 12 of the OCF-18 identifies a proposed good as Omega 3 (120 softgels), however, the applicant did not make any submissions, or reply submissions, with respect to its cost. I agree with the respondent and find that $101.39 for Omega 3 Softgels, without explanation for same, is not reasonable and necessary. Moreover, given that the applicant did not make any submissions with respect to these Softgels, it is unclear what purpose they serve in meeting the overall goals for the proposed treatment plan.
16The applicant also did not make any submissions with respect to the exercise equipment as identified on the proposed OCF-18 as Line 3: 10lb med ball, Line 4: Fitness Acupoint Foam Roller, and Line 5: Speed Rope. I am also not pointed to contemporaneous evidence that would support the need for the proposed exercise equipment. Similarly, the applicant has not made submissions with respect to the reasonableness and necessity for the proposed Line 6: Neck/Shoulder Massager, Line 8: Orthopaedic Pillow, or Line 11: Acupuncture. As such, given that the applicant has not met her onus with respect to line items 3, 4, 5, 6, 8, 11, and 12, in the OCF-18, I find that these proposed goods and services are not reasonable and necessary.
c) Documentation Fees
17I find that the applicant has demonstrated that the documentation fees are reasonable and necessary, in part.
18While the respondent argues that the documentation fees are listed twice on the OCF-18, and are therefore duplicative, I find that the OCF-18 clarifies that the two line items for ‘document fees’ as “Line 7: Completion of OCF-18” and “Line 13: Progress Report”. The respondent also argues that the line item for the assessment, Line 1: Assessment (examination), total body, is vague and not supported.
19While I find that Line 7: Completion of OCF-18 to be reasonable and necessary as it complies with the fees prescribed by the Guidelines, I find that the treatment plan does not comment on or explain the purpose of the Line 1: Assessment, or Line 13: Progress Report, and how they relate to the overall goals of the proposed treatment plan. Additionally, the applicant did not make submissions as to the reasonableness or necessity of these line items. Therefore, I find that the applicant has not met her onus with respect to line item 1 and 13 of the OCF-18.
20Given the foregoing, I find that on a balance of probabilities, that the applicant is entitled to the following:
i. Line 1: Exercise, multiple body sites, total body;
ii. Line 7: Documentation, support activity for claim form;
iii. Line 9: Therapy, multiple body sites; and
iv. Line 10: Therapy, multiple body sites, are reasonable and necessary.
The OCF-18 for physical therapy services dated May 10, 2023
21I find that the applicant has proven, on a balance of probabilities, that the proposed physical therapy services are partially reasonable and necessary.
22The respondent partially approved the OCF-18 for the proposed physical therapy services completed by chiropractor, Dr. Craig Brennan, dated May 10, 2023. The applicant seeks the “Balance” as set below:
| Line Number | Description | Proposed Amount | Amount approved | Balance |
|---|---|---|---|---|
| 1 | Assessment (examination), total body – Reassessment | $200.00 | $200.00 | $0.00 |
| 2 | Documentation, support activity – completion of OCF-18 | $200.00 | $200.00 | $0.00 |
| 3 | Therapy, multiple boy sites – Shockwave machine therapy | $1,500.00 | $0.00 | $1,500.00 |
| 4 | Therapy, multiple boy sites – massage therapy | $307.28 | $0.00 | $307.28 |
| 5 | Acupuncture | $307.28 | $307.28 | $0.00 |
| 6 | Therapy, multiple boy sites – multidisciplinary rehabilitation | $676.66 | $676.66 | $0.00 |
| 7 | Education, promoting health and preventing disease | $0.00 | ||
| 8 | Exercise, multiple body sites – Exercise | $0.00 | ||
| 9 | Hyperthermy, multiple body sites | $0.00 | ||
| 10 | Stimulation, muscles of the back | $0.00 | ||
| 11 | Manipulation, multiple body sites | $0.00 | ||
| 12 | Mobilization, multiple body sites | $0.00 | ||
| 13 | Exercise, multiple body sites – Strengthening exercise | $0.00 | ||
| 14 | Exercise, multiple body sites – stretching exercises | $0.00 | ||
| 15 | Therapy, multiple body sites | $0.00 | ||
| 16 | Massager, personal | $159.59 | $159.59 | $0.00 |
| 17 | Multivitamin Mineral Complex | $48.63 | $0.00 | $48.63 |
| 18 | Hot/Cold gel pack | $99.60 | $99.60 | $0.00 |
| 19 | Paraffin Wax Treatment | $223.35 | $0.00 | $223.35 |
| 20 | Documentation, support activity | $190.00 | $0.00 | $190.00 |
| Total = | $2,269.26 |
23The OCF-18 identifies goals of pain reduction, increased range of motion, increase in strength, to return to activities of normal living, and return to pre-accident work activities.
24The applicant submits that she has maintained her commitment to rehabilitation by visiting specialists, trying new pharmacological regimes and treatment modalities. The applicant further argues that the proposed OCF-18 indicated a slight improvement in her condition due to the previous therapy sessions, however, without the necessary treatment she goes backwards in her progress.
25The respondent submits that the plan was partially approved for $1,640.33, and the denied portions include items listed at Line 3: shockwave machine therapy, Line 4: massage therapy, Line 17: multivitamins, Line 19: paraffin wax treatment and Line 20: documentation support.
a) Physical Treatment
26I find the massage therapy to be reasonable and necessary. Despite the respondent arguing that the applicant was approved for a personal massager, I do not agree that this substantiates that the massage therapy is somehow not needed. As indicated above, Dr. Ammar Al Khudairy in his physiatry report, dated January 22, 2023, recommended to continue with an active rehabilitation program to build strength, endurance, and range of motion. Additionally, chronic pain specialist, Dr. Igor Wilderman, in a chronic pain report, dated April 24, 2023, recommended various treatment modalities including active exercise, chiropractic treatment, and physiotherapy. While these assessors do not specifically opine on massage therapy, they do recommend various forms of physical therapy. I find that, on a balance of probabilities, massage therapy to be within the ambit of physical therapy, and as such, is reasonable and necessary.
b) Goods and Services
27I agree with the respondent in that it is not clear what shockwave machine therapy, paraffin wax, and multivitamins intend to achieve with respect to the applicant’s accident-related impairments, and I am not pointed to any recommendation for same from any of the applicant’s treating physicians. The applicant also did not make any submissions, with respect to these line items and it is unclear what purpose they serve in meeting the goals for the proposed treatment plan. As such, I find that line items, Line 3: Shockwave Machine Therapy, Line 17: Multivitamin Mineral Complex, and Line 19: Paraffin Wax treatment, are not reasonable and necessary.
c) Documentation Fees
28Lastly, I agree with the respondent and find that the Line 20: documentation support, is not reasonable and necessary. The applicant did not make submissions as to the reasonableness or necessity of this line item, nor does the OCF-18 indicate the purpose of this line item with respect to the overall goals of the proposed treatment plan. As such, I find that the applicant has not met her onus with respect to Line 20 of the proposed OCF-18.
29In sum, I find that on a balance of probabilities, the applicant is entitled to the proposed items within the OCF-18, dated May 10, 2023, except for the following:
i. Line 3: Therapy, multiple body sites;
ii. Line 17: Multivitamin Mineral Complex;
iii. Line 19: Paraffin Wax Treatment; and
iv. Line 20: Documentation, support activity.
The OCF-18 for the proposed physical therapy dated July 22, 2023
30I find that the applicant has proven, on a balance of probabilities, that the proposed treatment plan is partially reasonable and necessary.
31The OCF-18 for the proposed physical therapy services completed by physiotherapist, Mr. Hanan Ibrahim, dated July 22, 2023, seeks funding for:
| Line Number | Description | Proposed Amount | Amount approved | Balance |
|---|---|---|---|---|
| 1 | Assessment - Reassessment | $200.00 | $0.00 | $200.00 |
| 2 | Documentation, support activity – Completion of OCF-18 | $200.00 | $0.00 | $200.00 |
| 3 | Therapy, multiple body sites – Multidisciplinary Rehabilitation | $1200.00 | $0.00 | $1200.00 |
| 4 | Education, promoting health and preventing disease | $0.00 | $0.00 | $0.00 |
| 5 | Exercise, multiple body sites | $0.00 | $0.00 | $0.00 |
| 6 | Hyperthermy, multiple body sites | $0.00 | $0.00 | $0.00 |
| 7 | Stimulation, muscles of the back – IFC, TENS, Electrotherapy | $0.00 | $0.00 | $0.00 |
| 8 | Manipulation, multiple body sites | $0.00 | $0.00 | $0.00 |
| 9 | Mobilization, multiple body sites | $0.00 | $0.00 | $0.00 |
| 10 | Exercise, multiple body sites – Strengthening exercise | $0.00 | $0.00 | $0.00 |
| 11 | Exercise, multiple body sites – stretching exercises | $0.00 | $0.00 | $0.00 |
| 12 | Therapy, multiple body sites - Ultrasound | $0.00 | $0.00 | $0.00 |
| 13 | Acupuncture | $384.10 | $0.00 | $384.10 |
| 14 | Therapy, multiple body sites – Massage therapy | $384.10 | $0.00 | $384.10 |
| 15 | Preparation, service | $112.82 | $0.00 | $112.82 |
| 16 | Massager, personal | $156.59 | $0.00 | $156.59 |
| 17 | Calcium Vitamins | $25.40 | $0.00 | $25.40 |
| 18 | Orthotic Devices | $500.00 | $0.00 | $500.00 |
| 19 | Paraffin Wax | $250.00 | $0.00 | $250.00 |
| 20 | Hot/cold gel pack | $99.60 | $0.00 | $99.60 |
| 21 | Documentation, support activity | $190.00 | $0.00 | $190.00 |
32The applicant submits that she has tried various treatment modalities and continued to seek referrals for physiotherapy, massage therapy, acupuncture, and chiropractic services due to pain in her left shoulder, hand, and neck. The applicant further submits that despite her adherence to a comprehensive therapy regimen, she continues to endure significant pain that adversely affects her quality of life.
33The respondent submits that the OCF-18 for physical therapy dated July 22, 2023 is a duplication of previously submitted treatment plans. The respondent argues that the applicant has not demonstrated that the documentation, vitamins, paraffin wax, foot orthotics, personal massager, hot/cold pack, and acupuncture are reasonable and necessary.
a) Physical Treatment
34While I agree with the respondent that some of the listed items on the proposed treatment plan are “duplications” of the treatment plans dated July 30, 2022 and May 10, 2023, I find that this does not negate the need for some of these services. Both Dr. Ammar Al Khudairy in his physiatry report, dated January 22, 2023, and Dr. Igor Wilderman, in a chronic pain report, dated April 24, 2023, recommended various treatment modalities including physical therapy. Moreover, CNRs of the TPC dated August 4, 2023, report ongoing pain in the neck radiating to both shoulders, mainly the left arm, left hand and fingers. Dr. Pezhman Mehrabian subsequently recommended physiotherapy. As such, I find that on a balance of probabilities, the proposed line items, Line 2: Completion of OCF-18, Line 3: Multidisciplinary Rehabilitation, Line 4: Education, Line 5: Exercises, Line 6: Hyperthermy, Line 8: Manipulation of Spine, Line 9: Mobilization of Extremities, Line 10: Strengthening Exercises, Line 11: Stretching Exercises, Line 12: Ultrasound, and Line 14, Massage Therapy, to be reasonable and necessary. Dr. Wilderman also specifically recommended acupuncture and microcurrent electrical therapy or a TENS machine. As such, I also find Line 7: IFC, TENS, Electrotherapy, and Line 13: Acupuncture to be reasonable and necessary.
b) Goods and Services
35I agree with the respondent that the applicant has not demonstrated that the documentation, vitamins, paraffin wax, hot/cold gel pack, and foot orthotics are reasonable and necessary. As I found in my reasonings for the OCF-18s dated July 30, 2022, and May 10, 2023, it is not clear what paraffin wax, vitamins, and foot orthotics intend to achieve with respect to the applicant’s accident-related impairments, and I am not pointed to any recommendation for same from any of the applicant’s treating physicians. The applicant also did not make any submissions, with respect to these line items and it is unclear what purpose they serve in meeting the goals for the proposed treatment plan. As such, I find that the good and services listed on Line 17, 18, and 19, are not reasonable and necessary. Lastly, I agree with the respondent in that the goods listed as Line 16: Percussion Massager with Heat, and Line 20: Hot/Cold Gel Pack, are not reasonable and necessary as a personal massager and a hot/cold gel pack were already approved in the treatment plan dated May 10, 2023.
c) Documentation Fees
36While I find that Line 2: Completion of OCF-18 to be reasonable and necessary as it complies with the fees prescribed by the Guidelines, I find that there is a duplication of this service on Line 15. The service listed on Line 15 is for a file and medical documentation review, however, the applicant’s submissions and the OCF-18 are silent with respect to how this differentiates from Line 2, the completion of the OCF-18. Moreover, the OCF-18 does not comment on or explain the purpose of the Line 1: Assessment, or Line 21: Progress Report, and how they relate to the overall goals of the proposed treatment plan. Additionally, the applicant did not make submissions as to the reasonableness or necessity of these line items.
37In sum, I find that on a balance of probabilities, the applicant is entitled to the proposed items within the OCF-18, dated July 22, 2023, except for the following:
i. Line 1 – Assessment;
ii. Line 16 – Massager, personal;
iii. Line 17 – Calcium Vitamins;
iv. Line 18 – Orthotic Devices;
v. Line 19 – Paraffin wax treatment;
vi. Line 20 – Hot/cold gel packs; and
vii. Line 21 – Documentation, support activity.
The applicant is not entitled to the PRP and Botox injections
38I find that the applicant has not proven, on a balance of probabilities that the treatment plans for PRP and Botox injections are reasonable and necessary.
39The OCF-18 for the proposed PRP injections, completed by Dr. Igor Wilderman, dated May 25, 2023, and the OCF-18 for the proposed Botox injections, completed by Dr. Igor Wilderman, dated May 25, 2023, identify goals of pain reduction, increased range of motion, increase in strength, and to assist pain management.
40With respect to the PRP injections, the applicant refers to the Tribunal decision Martincic v TD Insurance Meloche Monnex, 2020 CanLII 94771 (ONLAT) in which it was found that the applicant failed to advise how the PRP injections would work or reduce the applicant’s pain. The applicant argues that unlike in Martincic, in the present case, Dr. Wilderman explains the function of the PRP injections. The applicant submits that the proposed Botox injections have the potential to significantly reduce the severity of the applicant’s symptoms, thereby improving her ability to function daily and enhance her overall quality of life.
41The respondent submits that the PRP injections are experimental and thus not payable pursuant to s. 15(2)(a) of the Schedule, referencing the Tribunal decision in Bajor v Aviva Insurance Company of Canada, 2024 CanLII 896 (ON LAT). Moreover, the respondent relies on s. 44 assessor, Dr. Ismail, who determined that the proposed treatment plan was not reasonable and necessary.
42While the applicant does not make submissions with respect to whether the PRP treatment is experimental in nature, I find that there is insufficient information provided by the respondent that would substantiate whether PRP injections are experimental. It is well established that submissions are not evidence, and the respondent has not provided any medical opinion or documentation that speaks to the viability of the PRP injections. With that said, I am not satisfied that this treatment is reasonable and necessary, considering Dr. Wilderman’s own statement within his report, dated April 24, 2023, that “if standard therapeutic modalities fail, PRP (Platelet-Rich Plasma) injections on her cervical facet joints would probably be of benefit (Filardo et al., 2013). Targeting the patient’s myofascial pain of the rhomboids with botulinum toxin injections should be beneficial (American Society of Anesthesiologists, 2010).” My emphasis added. Dr. Wilderman, in his report, makes a number of recommendations, such as a chronic pain program, chiropractic treatment, physiotherapy, an aqua-fit program, dry needling, and acupuncture. I find that Dr. Wilderman’s wording of “if standard therapeutic modalities fail” suggests that the applicant has yet to exhaust the recommended treatment. I am also not pointed to any additional compelling medical evidence or expert opinion that would substantiate the need for the proposed treatment plans.
43Given the above, I find that the applicant has not proven, on a balance of probabilities that the PRP and Botox injections are reasonable and necessary.
The applicant is entitled to the chronic pain program, in part
44I find that the applicant has proven, on a balance of probabilities that the treatment plan for the chronic pain program is reasonable and necessary, in part.
45The OCF-18 for the proposed chronic pain program, completed by chiropractor, Dr. Mikhail Shteynberg, dated May 25, 2023, list treatment modalities such as:
i. Line 1: exercise, multiple body sites – guided exercise program;
ii. Line 2: therapy – interpersonal relationships – SW-therapy, interpersonal relationships
iii. Line 3: therapy – mental health and addictions
iv. Line 4: assessment, documentation support – MD Visit
v. Line 5: Documentation support activity – OCF-18 Completion
vi. Line 6: Documentation, support activity – Progress Report-Mental Health
vii. Line 7: TENs unit
viii. Line 8: transdermal compounding cream, and
ix. Line 9: Delivery
46The treatment plan identifies goals of pain reduction, increased range of motion, and to return to activities of normal living.
47The applicant submitted that the proposed chronic pain program is reasonable in light of the applicant’s diagnosed chronic pain and profound impact on the applicant’s life. The applicant also submits that s. 44 assessor, Dr. Ismail, in a paper review dated July 7, 2023, did not reference the CNRs of TPC or the assessment of Dr. Wilderman, dated April 24, 2023, and alternatively advises that the applicant had sustained uncomplicated soft tissue injuries to her cervical spine.
48The respondent submitted that the applicant has not demonstrated how she meets the American Medical Associate Guides to Evaluation of Permanent Impairment (“AMA Guides”), as she has returned to work as a nurse which indicates that her pain is not limiting her function.
49I find that the evidence supports the reasonableness and necessity of the proposed chronic pain program, in part.
50I am persuaded by the report of Dr. Wilderman, dated April 24, 2023, as this assessor found the applicant scored positive for 5/6 characteristics of chronic pain syndrome according to the AMA Guides. More specifically, the applicant scored positive on:
i. Excessive dependence on health care providers, spouse, or family;
ii. Secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity;
iii. Withdrawal from social milieu, including work, recreation, or other social contacts;
iv. Failure to restore injury function after period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs; and,
v. Development of psychosocial sequelae after the initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviours.
51Dr. Wilderman subsequently diagnosed chronic pain syndrome, post-concussion syndrome, chronic whiplash associated disorder (WAD II) type II, post-traumatic chronic headaches, bilateral myofascial pain syndrome of rhomboid region, dizziness, depression, anxiety, and PTSD. The CNRs of TPC further endorse the applicant’s chronic pain symptomology as Dr. Pezhman Mehrabian has diagnosed chronic neck pain, chronic cervicogenic headaches, and chronic left shoulder pain.
52I give little weight to the paper review report of Dr. Ismail, as I find that this assessor’s opinion to be limited by his expertise. This assessor reviewed the report of Dr. Wilderman, and the CNRs of TPC, he found that from a physiatric perspective, the OCF-18 was not reasonable and necessary. However, Dr. Ismail notes that “any comment with respect to [the applicant’s] ongoing headaches was deferred to the appropriate specialist.” It is clear from Dr. Wilderman’s report that the applicants chronic pain complaints are predominantly due to her ongoing headaches. Moreover, Dr. Ismail does not comment on Line Items 2, 3, and 6 of the proposed OCF-18 as he deferred comment to a mental health professional.
53In addition to Dr. Wilderman’s opinion with respect to the applicant’s functional limitations, I am also satisfied that the evidence supports the applicant’s functional ability has been impaired. Psychologist, Dr. Leon Steiner, in his report dated February 16, 2022, reported that the applicant had difficulties performing her work-related duties secondary to post-accident physical restrictions, impaired cognitive function, and mood difficulties. The applicant also reported that she had to decline a contract with George Brown College as a sessional instructor as a result of accident-related impairments. Similarly, Al Khudairy, in his report dated January 22, 2023, reported that the applicant initially went on work-related modified duties post-accident, however, is now working three shifts per week and switched to the night shift as it is easier work and less stress. The applicant also reported that she had to “cancel her contract with George Brown College” due to functional limitations.
54However, I do not find the goods and services listed as Line 4: MD Visit, Line 8: Transdermal compounding cream, and Line 9: Delivery, to be reasonable and necessary. I find that it is unclear from the OCF-18 and the applicant’s submissions what the line items for MD Visit and Delivery are for or how they are related to the overall goals of the proposed treatment plan. I also find that, from a cost perspective, $55.99 for transdermal compounding cream, without explanation for same, to not be reasonable and necessary.
55I find that the applicant has proven, on a balance of probabilities that the chronic pain program is reasonable and necessary, with the exception of the following goods/services:
i. Line 4: Assessment, documentation support – MD Visit;
ii. Line 8: Transdermal compounding cream; and
iii. Line 9: Delivery.
The applicant is entitled to the social work assessment
56I find that the applicant has proven, on a balance of probabilities that the treatment plan for a social work assessment is reasonable and necessary.
57The OCF-18 for the social work assessment, completed by occupational therapist, Ms. Elizabeth Silenzi, dated December 2, 2022, identifies goals of improving cognition, adjustment to emotional sequalae, improving motivation and initiation, to reduce depressive effect, and to achieve a return to activities of normal living. The OCF-18 also indicates that the assessment is recommended to help the applicant to deal with any emotional, social, financial concerns, options for future lifestyle/living, community integration and opportunities for meaningful daily activities, education on impact of disabilities, information and connection to community resources, as well as assisting with filling out any disability forms.
58The applicant submits that the social work assessment is designed to offer a multidimensional support system that is essential for addressing the multifaceted impacts of her post-accident condition.
59The respondent submitted that the applicant is being treated by a psychologist, and as such, this treatment plan would overlap with treatment already provided and is therefore duplicative.
60Submissions are not evidence, and while the respondent argues that this service would be duplicative, I am not pointed to evidence of overlapping treatment that the respondent relied on in its submissions.
61I find that the evidence that is before me supports that the proposed treatment plan is reasonable and necessary. The applicant has seen a number of psychological practitioners as a result of her accident-related psychological impairments. Each assessor has commented on the applicant’s social-emotional functioning. For example, s. 25 psychological assessor, Dr. Leon Steiner, in his report dated February 16, 2022, noted a 60-percent decrease in her social life due to loss of interest and motivation. Similarly, s. 44 psychological assessor, Dr. Mehdi Lotfalizadeh, in his report dated February 1, 2022, the applicant reported changes to her weight and appearance, effect on her relationship, and does not have anymore hobbies. Psychiatrist, Dr. Zhila Fazeli, on consultation dated October 27, 2022, and June 20, 2023, noted the applicant spends too much time on her work and feels exhausted afterward, subsequently diagnosing shift work sleep difficulty and burnout syndrome, among others. I also note that chronic pain specialist, Dr. Wilderman, in his report dated April 24, 2023, recommended a social-emotional assessment for further detailed evaluation of the applicant’s social, financial, and family difficulties. I find that the evidence is therefore supportive of the need for a social work assessment that seeks to help the applicant to deal with her emotional, social, and financial concerns.
62As such, I find that the applicant has proven, on a balance of probabilities, that the social work assessment is reasonable and necessary.
Interest
63The applicant is entitled to interest on overdue benefits pursuant to s. 51 of the Schedule.
ORDER
64I find that:
i. The applicant is partially entitled to the proposed treatment plan for physiotherapy services, dated July 30, 2022, plus interest in accordance with s. 51 of the Schedule;
ii. The applicant is partially entitled to the proposed treatment plan for physical therapy services, dated May 10, 2023, plus interest in accordance with s. 51 of the Schedule;
iii. The applicant is not entitled to the proposed treatment plan for PRP injections, dated May 25, 2023;
iv. The applicant is not entitled to the proposed treatment plan for Botox injections, dated May 25, 2023;
v. The applicant is partially entitled to the proposed treatment plan for a chronic pain program, dated May 25, 2023, plus interest in accordance with s. 51 of the Schedule;
vi.
vii. The applicant is partially entitled to the proposed treatment plan for physical therapy services, dated July 22, 2023, plus interest in accordance with s. 51 of the Schedule;
viii. The applicant is entitled to the proposed treatment plan for a social work assessment, dated December 2, 2022, plus interest in accordance with s. 51 of the Schedule.
Released: December 11, 2024
Nadia Mauro
Adjudicator