WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
Decision Number: 20150103
Decision Date: November 23, 2015
Objecting Party: Worker
Represented by: Worker Representative
Respondent: Employer (not participating)
Hearing: Hearing in Writing
Heard by: B. Craddock, Appeals Resolution Officer
ISSUE(S)
The Worker objects to the June 1, 2015 decision of the Nurse Consultant, which denied ongoing entitlement for Durolane injections.
BACKGROUND
This claim was established for this now 52-year-old automotive technician. Entitlement was accepted for a right knee injury caused by prolonged kneeling on November 3, 2010. The Worker underwent arthroscopic surgery on June 23, 2011 with a pre- and post-operative diagnosis of internal derangement. The Operative Report indicates a posterior horn meniscus tear that was repaired. The medical reporting also indicated pre-existing chondromalacia. The Worker was able to return to his regular job duties by March 2012. According to the information on file, has remained at work performing regular duties.
The Operating Area concluded the Worker had fully recovered from the right knee injury. The Worker appealed this decision, and as per the Workplace Safety and Insurance Appeals Tribunal (WSIAT) decision of December 23, 2014, entitlement was accepted for a permanent impairment of the right knee. The Worker was granted a 7% Non-Economic Loss (NEL) award.
Subsequent to the surgery, the worker received a trial of Durolane injections to treat the ongoing symptoms. The treating Specialist advised that the worker received benefit from the injections that lasted approximately five months. He recommended continued injections at six month intervals.
Ongoing treatment was reviewed by a Nurse Consultant who obtained an opinion from an External Medical Consultant. The External Consultant concluded that the Durolane injections should not be covered on a permanent basis as they were for treatment of the underlying chondromalacia. Additionally, the Consultant noted that the clinical efficacy of the treatment in providing permanent improvement had not been demonstrated. The Nurse Consultant accepted the External Medical Consultant’s opinion and denied entitlement for further Durolane injections.
The Worker Representative is objecting to the above decision and has elected to proceed with a hearing in writing based on the information currently on file.
AUTHORITY
Policy 17-01-02 – Entitlement to Health Care
Policy 11-01-03 – Merits and Justice
ANALYSIS
In considering the issue of entitlement to further Durolane injections, I have taken into consideration
- the accepted entitlement;
- the opinion of the treating Specialist;
- the External Medical Consultant’s opinion;
- the Workplace Safety Insurance Act (WSIA); and
- the applicable WSIB Policy.
I find that further Durolane injections are an allowable healthcare treatment for the Worker’s work-related right knee injury.
The denial of the injections was based on the External Medical Consultant's opinion. The rationale for the Consultant’s conclusion was two-pronged:
- the Worker's pain was most likely the result of the pre-existing chondromalacia; and
- clinical studies did not demonstrate clear efficacy of Durolane injections in providing permanent improvement of symptomatic osteoarthritis.
I find the External Consultant’s opinion does not accurately recognize the Worker’s accepted entitlement. The WSIAT decision accepted that the pre-existing asymptomatic chondromalacia was rendered symptomatic by the accepted work injury. Therefore, the denial of any injections on the basis that the treatment was for the pre-existing condition cannot be sustained.
Additionally, I find that the second rationale for denial is not consistent with WSIB Policy or general practice.
The WSIA provides:
A worker entitled to benefits under the insurance plan is entitled to such health care as may be necessary, appropriate, and sufficient as a result of the injury.
WSIB Policy does not provide any further direction or limitation on determining entitlement to healthcare. There is no requirement that treatment result in “permanent improvement”. The WSIB regularly covers analgesic medications for symptomatic relief as opposed to permanent improvement. The treating Specialist has indicated that the worker receives four to five months relief/reduction of symptoms, and additionally, the Specialist noted the treatment helps the Worker remain at work.
I recognize that in general the WSIB practice is to limit active treatment such as physiotherapy or chiropractic treatment to the period before a worker reaches maximum medical recovery; however, there is no directive in either the WSIA or Policy to do so. Also, in my view, the Durolane injections are more analogous to analgesic medication used to provide symptom relief.
In the absence of any clear Policy directive, regard must for the efficacy of a given treatment and the relative costs/benefits with each case determined on the individual fact situation. In this case, the evidence from the treating Specialist is that the Worker receives significant symptomatic relief from the injections and that the treatment helps the worker to remain in the workplace. The fact that the treatment does not result in permanent improvement is not, in my view, a bar to entitlement. The treatment has both a quality of life component and a cost benefit as the worker is able to sustain employment and possibly avoid the need for more costly treatments or lost time form work.
On the balance of probabilities, I find the evidence indicates that the treatment is necessary, appropriate and sufficient as a result of the injury. Therefore, I find it reasonable that the Worker be granted ongoing entitlement for the injections at 6 month intervals.
CONCLUSION
For the reasons stated above, I find the Worker is entitled to Durolane injections once every six months.
The ongoing efficacy of the treatment can be reviewed two years from the date of this decision.
The Worker's objection is granted.
DATED
November 23, 2015
B Craddock Appeals Resolution Officer Appeals Services Division