APPEALS RESOLUTION OFFICER DECISION
Decision number: 20250054
OBJECTING PARTY: WORKER
REPRESENTED by: Worker Representative
RESPONDENT PARTY: Employer (not participating)
REPRESENTED by: Employer representative
HEARING: HEARING IN WRITING
HEARD by: S. Waters, appeals resolution officer DATED: JULY 17, 2025
ISSUE
The worker objects to the Nurse Consultant’s (NC’s) June 12, 2024 decision denying entitlement for Botox injections.
BACKGROUND
Prior Appeals Resolution Officer (ARO) and Workplace Safety and Insurance Appeals Tribunal (WSIAT) decisions provide detailed summaries of the worker’s claim. I will only provide a summary of details relevant to the issue in dispute to avoid repetition. The worker’s date of hire was September 12, 2000. On September 5, 2016 while working as a housekeeper, the worker was leaning sideways to pull a hotel television plug when the right side of their head struck the corner of the television.
The operating area accepted entitlement for a neck strain and cervicogenic headaches, but denied entitlement for pain in the worker’s arms, elbows, forearms, and hands. The worker received periods of loss of earnings benefits since September 10, 2016 to date and ongoing.
In a decision of November 22, 2018, an ARO concluded there was no evidence of an ongoing work-related organic impairment beyond January 2017. The ARO also denied entitlement for chronic pain disability (CPD). On October 18, 2019, the WSIAT granted entitlement for CPD from the workplace accident and returned benefits flowing from their decision to the WSIB. The operating area determined the worker’s CPD condition reached maximum medical recovery on April 26, 2017, and granted a 10% Non-Economic Loss (NEL) benefit for the permanent CPD impairment in a letter of April 13, 2022.
An ARO wrote a decision on May 23, 2023, denying entitlement for maintenance massage and acupuncture treatment because they determined this treatment was not necessary or appropriate. The operating area accepted a permanent worsening of the worker’s CPD as of February 10, 2022. The worker’s NEL benefit for CPD increased to 20% on February 13, 2024 as a result. In another decision dated November 12, 2024, an ARO increased the NEL benefit for the worker’s permanent CPD impairment from 20% to 30%.
In terms of the specific issue in dispute in this appeal, the worker submitted a prescription for a Botox injection on June 10, 2024. The NC denied entitlement for Botox injections in a letter of June 12, 2024, explaining the worker did not meet any of the criteria for coverage of Botox injections. The worker and their representative objected to this decision. The NC confirmed their decision to deny entitlement for Botox injections in letters dated June 28, 2024 and March 4, 2025.
Worker’s Position
In an Intent to Object Form dated December 17, 2024, the worker’s representative stated their position that the worker is entitled to benefits for Botox injections to treat their compensable condition. They argued the worker experiences chronic migraines and the doctor prescribed Botox injections to treat this condition. The representative also noted the worker’s NEL benefit increased based on the worker’s symptoms related to their CPD condition including headaches.
The worker’s representative restated their position in submissions dated February 4, 2025. They argued the worker’s initial claim was accepted for cervicogenic headaches and neck pain, and medical evidence demonstrates headaches are part of the worker’s CPD experience. The worker’s representative stated the worker has tried many treatments without success and noted multiple clinicians recommended Botox injections to treat the worker’s persistent headaches. To support their position, the representative included and referenced a research paper that discusses the efficacy of botulinum toxin type-A for the treatment of cervicogenic headaches.
In the event the appeal is allowed, the worker’s representative seeks entitlement and coverage/ reimbursement of the worker’s Botox injection treatment.
Employer’s Position
The employer’s representative did not return the Participant Form dated February 3, 2025. They are not participating in the appeal.
AUTHORITY
Operational Policy Manual
Published
17-01-02 Entitlement to Health Care
January 3, 2023
Reference Material
Drug formulary listing decision – Butolinumtoxin-A (https://www.wsib.ca/en/drug-formulary-listing-decision-botulinumtoxin)
Prior authorization and non-formulary drugs (https://www.wsib.ca/en/prior-authorization-and-non-formulary-drugs)
ANALYSIS
I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision. I find entitlement is not in order for Botox injections.
The worker’s appeal is denied.
Assessment of Entitlement
It is the worker representative’s position that the worker is entitled to Botox injections to treat their compensable condition. Information on file does not support this position. When making this decision, I considered the policy that explains when entitlement for health care may be considered and approved.
Policy 17-01-02 (Entitlement to Health Care) states that 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.
I reviewed guidance provided by the Drug Advisory Committee (renamed to the Drug and Therapeutics Advisory Committee in 2024) regarding the coverage of butolinumtoxin-A (Botox) for work-related conditions:
The Drug Advisory Committee recommended that butolinumtoxin-A products not be listed for people with the following conditions: neuropathic pain, low back pain, neck pain, myofascial pain, episodic migraine, or any other headache disorders.
The Drug Advisory Committee recommended that butolinumtoxin-A products be listed for people with cervical dystonia, blepharospasm/hemifacial spasm, focal spasticity (including upper and lower limb spasticity), neurogenic detrusor overactivity, and chronic migraine, provided the following criteria are met:
A. Product being prescribed has an official indication for use in the above condition(s)
B. Doses for each product should reflect product monograph recommendations
C. For neurogenic detrusor overactivity, the following additional criteria must also be met…
D. For chronic migraine, the following additional criteria must also be met:
i. Patient is experiencing chronic migraine (15+ days/month, with continuous headache lasting 4+ hours and 4+ distinct headache episodes each lasting 4+ hours); and
ii. Botox is being requested by a physician with training in management of headache, and will be administered by a physician with appropriate qualifications and experience; and
iii. Patient has failed 3+ oral prophylactic medications, with failure being defined as <30% reduction in frequency of headache days to adequate doses and adequate durations.
I also reviewed the research paper submitted by the worker’s representative titled The Efficacy of Butolinum Toxin in Patients with Cervicogenic Headache: a Placebo-Controlled Clinical Trial. The paper stated the study’s results indicated this product could be a beneficial treatment for patients with cervicogenic headaches. Although I considered this when making my decision, I placed additional weight on the recommendations provided by the Committee for multiple reasons. This is a multidisciplinary team of medical professionals with expertise in their respective fields. The Committee completes independent external reviews of research studies and data to provide evidence-based recommendations on drugs and therapeutics based on benefits, value, and safety.
In the case of their recommendations regarding butolinumtoxin-A, the Committee indicated they completed an external, independent review of data related to the efficacy and safety of these products for multiple conditions. The Committee concluded there were no high-quality studies available demonstrating butolinumtoxin-A was effective in reducing neck pain or myofascial pain. The Committee also determined there was insufficient evidence to recommend these products for headache disorders. The Committee noted there was moderate-quality evidence that Botox may reduce the number of migraine days per month by two days compared to placebo, but there was a lack of consensus from clinical guidelines of Botox for chronic migraine prophylaxis. Lastly, the Committee highlighted that butolinumtoxin-A products are generally considered safe but there have been rare cases of the toxin spreading to other parts of the body, which could cause serious side effects such as breathing difficulties.
The worker’s representative highlighted that multiple clinicians recommended Botox injections to treat the worker’s headaches. This included two physiatrists in December 2018 and Dr. Dao, a doctor working with the Clinic A (report highlighted by the representative dated August 24, 2019) and Clinic B (report recommending Botox dated March 28, 2023).
Dr. Dao is the clinician who provided a written prescription on June 10, 2024 for two 100u bottles of Botox. This document does not include any information about the condition being treated with Botox, the proposed treatment plan (whether this would be a one-time treatment or a treatment with repetitions), the goal of the treatment, or the expected outcome. Dr. Dao provided another written prescription dated July 15, 2024 for two 100u bottles of Botox. This document states Botox was recommended to treat chronic migraine headaches but again did not list the proposed treatment plan, the goal of the treatment, or the expected outcome.
In a letter dated June 26, 2024, the worker requested coverage of Botox injections since their doctor recommended it in relation to the worker’s headaches, neck pain, and myofascial pain. In another letter dated October 17, 2024, the worker stated their doctor recommended Botox injections due to their chronic migraine headaches.
I find entitlement to benefits is not in order for Botox injections for multiple reasons.
I acknowledge the worker’s claim was originally accepted for entitlement to a neck strain and cervicogenic headaches. However, an ARO concluded in November 2018 that there was no evidence of an ongoing work-related impairment related to these organic/physical conditions after January 2017. Similarly, the WSIAT determined in October 2019 that the worker’s ongoing pain and headaches were non-organic in nature. I am bound by these final findings of fact that the worker’s pain, headaches, and impairment was not caused by the physical conditions of a neck strain or cervicogenic headaches beyond January 2017. Dr. Dao also did not indicate that they were prescribing Botox injections to treat a neck strain or cervicogenic headaches. These details, and the Committee’s recommendation that Botox not be listed for coverage to treat neck pain or headache disorders, means I am unable to conclude Botox injections were necessary, appropriate, or sufficient to treat a neck strain or cervicogenic headaches in 2024.
I also acknowledge the worker’s NEL benefit for their permanent CPD impairment increased to 30% based on an ARO decision in November 2024. However, a NEL benefit is determined based on a prescribed rating schedule and is intended to compensate a worker for the effects of a permanent impairment other than those associated with a wage loss, health care costs, and rehabilitation costs. An increase in the NEL benefit rating does not automatically lead to an approval for new or additional treatment.
The worker’s representative argued the worker’s symptoms related to their CPD condition includes headaches. I do not dispute that the worker experiences headaches. Still, I cannot approve entitlement for Botox injections based on this argument. In their October 2019 decision, the WSIAT made the final finding of fact that the worker’s ongoing neck pain and headaches were myofascial in nature. Although the worker’s representative stated the worker tried many other treatments without success, the Committee concluded available studies and evidence did not support Botox was effective in reducing myofascial pain. Additionally, Dr. Dao did not indicate they were prescribing Botox injections to treat myofascial pain. Considering the above, I find there is insufficient evidence to conclude Botox injections were necessary, appropriate, or sufficient to treat the work-related permanent CPD impairment.
Lastly, the worker’s representative argued entitlement should be granted for Botox injections since a doctor prescribed it to treat the worker’s chronic migraines. The July 2024 prescription document confirms Dr. Dao recommended Botox injections to treat the worker’s chronic migraine headaches. With that said, I am unable to approve entitlement to Botox injections to treat chronic migraine headaches since there is currently no entitlement in the claim for chronic migraines. Cervicogenic headaches and migraine headaches are distinct conditions that differ in terms of cause and resulting symptoms. Since chronic migraine headaches are not accepted as compensable in the claim, I am unable to conclude the Botox injection prescription constitutes health care that would be necessary, appropriate, or sufficient to treat a work-related condition.
For the reasons described above, I find evidence does not support entitlement for Botox injections in accordance with Policy 17-01-02. As such, I am unable to grant approval for coverage or reimbursement of Botox injections as requested by the worker’s representative.
CONCLUSION
I find entitlement is not in order for Botox injections.
The worker’s appeal is denied.
DATED July 17, 2025
S. Waters
Appeals Resolution Officer
Appeals Services Division