DECISION NUMBER:
20220124
OBJECTING PARTY:
WORKER
REPRESENTED by:
WORKER REPRESENTATIVE
RESPONDENT:
EMPLOYER (PARTICIPATING)
REPRESENTED by:
EMPLOYER REPRESENTATIVE
HEARING:
HEARING IN WRITING
HEARD by:
HELEN SHAW, APPEALS RESOLUTION OFFICER
DATED: SEPTEMBER 21, 2022
ISSUE
The worker is objecting to the denial of coverage for a cervical pillow and noise reducing ear plugs, in the Nurse Consultant decision of April 26, 2021.
BACKGROUND
The worker was employed as a child and youth worker at a secondary school. On October 2, 2020, while escorting a student down the hall, the worker was punched in the back and then head-butted in the head and face. Entitlement was allowed for bruises/contusions of the left shoulder and left knee, facial trauma, concussion and a cervical strain. The worker was in their early thirties at the date of injury.
The worker was off work and was paid full loss of earnings (LOE) benefits beginning October 5, 2020. Partial LOE benefits were paid from January 3, 2022 to July 1, 2022, based on the development of a graduated return to work plan.
The worker was assessed at the Neurology Specialty Program in November 2020 and participated in treatment through the Specialty Program. In addition to the physical injuries, a Neurology Specialty Program Psychiatry Assessment Report dated April 7, 2021 diagnosed the worker with posttraumatic stress disorder (PTSD), Adjustment Disorder with Mixed Anxiety and Depressed Mood and pre-existing Generalized Anxiety Disorder with an exacerbation post-injury. On May 31, 2021, entitlement was accepted for a psychotraumatic disability for PTSD, partial remission. On June 2, 2021, entitlement was accepted for nasal surgery to correct a deviated septum.
On April 20, 2021, the worker sent a request for two health care items: a cervical pillow and noise reducing ear plugs. On April 21, 2021, an estimate was received from Hearing Centre for custom hearing protection at a cost of $250.
In a decision dated April 26, 2021, a Nurse Consultant denied coverage for the cervical pillow and noise reducing ear plugs. The cervical pillow was considered to be non-medical equipment and the need for noise reducing ear plugs was to be revisited as part of return to work planning. The denial was confirmed in a reconsideration decision dated November 4, 2021.
In a decision dated February 2, 2022, it was determined that the worker had recovered from the concussion and cervical strain but had not yet recovered from the nasal deviation and PTSD. The worker continues to have some ongoing psychological restrictions.
AUTHORITY
Operational Policy Manual
Published
17-07-06 Health Care Equipment and Supplies
April 6, 2009
ANALYSIS
I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision and find there is no entitlement to coverage for a cervical pillow and noise reducing ear plugs. My reasons are explained below.
Operational policy 17-07-06 states in part that section 33 of the Workplace Safety and Insurance Act provides that a worker who sustains an injury is entitled to such health care as may be necessary, appropriate, and sufficient as a result of his or her injury. The WSIB shall determine all questions concerning the necessity, appropriateness and sufficiency of health care provided to a worker or that may be provided to a worker, and payment for health care provided to a worker. The WSIB may authorize the purchase of one or more health care products that fall into the category of health care equipment/supplies when an injured worker requires the health care product(s) as a result of a work- related injury/disease. Health care equipment/supplies are products used:
as a treatment or functional aid during the worker’s recovery, or
to improve or maintain the worker’s independent living.
The WSIB may authorize health care equipment/supplies prescribed by a health professional when:
the claim is allowed and there is ongoing entitlement to benefits and/or services, and
recent health care reports provide objective clinical findings, confirm the need for the health care equipment/supplies, outline treatment goals including duration of use and need, and
the health care equipment/supplies are required as a result of a work-related injury/disease, and
the health care equipment/supplies are used to treat and/or alleviate the effects of the work- related injury/disease, or are used to improve or maintain the worker’s independent living.
The worker representative submitted an Intent to Object Form dated November 2, 2021 and an Appeal Readiness Form on April 27, 2022, objecting to the denial of coverage for the cervical pillow and noise reducing ear plugs. No new evidence or submissions were provided with the Appeal Readiness Form.
The employer representative provided a Respondent Form dated August 5, 2022, with an attached submission. It is their position that the decision to deny coverage for the cervical pillow and noise reducing ear plugs was correct and should be confirmed.
The worker’s letter of April 20, 2021 indicated that the cervical pillow and noise reducing ear plugs were prescribed by Dr. Cucutti, the worker’s family doctor, and prescription notes were attached dated
April 15, 2021. The prescription notes indicated that the cervical pillow was required for cervical muscle spasms resulting from the workplace head and neck injuries and the ear plugs were required due to hyperacusis arising as a result of the head injury.
Although the prescription notes identified a need for the cervical pillow and ear plugs for the work related injuries, no detailed explanation was provided to clarify how the devices were necessary and appropriate in the treatment of the workplace injuries or how they would support the worker’s recovery. Noting the absence of detailed information provided in the prescription notes, I have turned to the reports from the Neurology Specialty Program to assist in determining if the requested health care items are necessary and appropriate. I place significant weight on those reports, noting the Specialty Program had been providing multidisciplinary treatment and follow up for the worker since November 2020.
The treatment discharge report from the Neurology Specialty Program was dated March 22, 2021. The treatment team consisted of a physiotherapist, occupational therapist, kinesiologist and psychotherapist. The report confirmed the worker’s symptoms continued to include neck pain, contributing to headaches, and noise sensitivity. The worker reported having to cover their ears to ease the sensitivity and using ear plugs in bed. An Allied Health consultation was recommended, as well as consultations with psychiatry and a neuro specialty physician. Further treatment needs were to be determined based on the results of the specialty consultations. There was no recommendation in the treatment discharge report of
March 22, 2021 that a cervical pillow and noise reducing ear plugs were necessary for the treatment of the injury.
The worker had a follow-up assessment at the Neurology Specialty Program on April 6, 2021. The report confirmed the worker’s ongoing complaints of neck pain and noise sensitivity, but no recommendation was made for a cervical pillow and noise reducing ear plugs.
In order to clarify the recommendations of the Neurology Specialty Program, the Nurse Consultant spoke to an Occupational Therapist (OT) at the Specialty Program on April 26, 2021. The OT indicated that the assessment team at the Specialty Program did not prescribe the cervical pillow to manage cervical spine symptoms.
Regarding the noise reducing ear plugs, the OT indicated that they had not been prescribed by the Specialty Program, but the need for them could be reviewed in the future when the worker was ready to return to work in the classroom, if it was needed to help reduce background noise. The OT noted that noise reducing ear plugs were not being recommended prior to the worker returning to work because the worker needed exposure to noise, to build up tolerance to sound. Based on the information from the OT at the Specialty Program, noise reducing ear plugs were not necessary, appropriate, and sufficient treatment for the injury, and may have been contraindicated at that stage in the worker’s recovery.
Although the worker had ongoing entitlement to benefits as a result of the work injury, the weight of the medical evidence does not confirm the need for a cervical pillow and noise reducing ear plugs to treat and/or alleviate the effects of the work-related injury. Because the evidence does not establish that a cervical pillow and noise reducing ear plugs were necessary, appropriate, and sufficient health care treatment as a result of the work injury, I find entitlement is not in order.
CONCLUSION
I conclude there is no coverage for a cervical pillow and noise reducing ear plugs, as prescribed on April 15, 2021.
The worker’s objection is denied.
DATED September 21, 2022
Helen Shaw
Appeals Resolution Officer Appeals Services Division