Highlights of Noteworthy Decisions

Decision 2159 14
S. Netten
  • Health care (necessary)
  • Health care (medical aid) (drug formulary)

The Board granted the worker entitlement for right shoulder tendonitis in 1999. In Decision No. 2809/07, the Tribunal found that the worker did not have entitlement for the neck or left shoulder or for chronic pain disability.

The worker now appealed a decision of the Appeals Resolution Officer denying payment for the medication Cesamet.
The Board found that Cesamet was not included in the Board's drug formulary in that it did not have clinical or economic advantages in the treatment of pain as compared to other covered alternatives. The Vice-Chair noted information from the Tribunal's Medical Liaison Officer that the only approved use of Cesamet is for treatment of nausea and vomiting associated with cancer chemotherapy.
The use by the Board of an expert Drug Advisory Committee to review medical literature on the efficacy, safety and cost-effectiveness of prescription medication is a reasonable method to determine the general necessity, appropriateness and sufficiency of medication. It is also incumbent on the Board to consider both clinical expertise and best available evidence from medical literature. The use of Cesamet for pain is an unapproved use, with common side effects, an absence of controlled clinical trials. There are a number of available alternatives. The Vice-Chair accepted the Board's determination that the type of use in this case is generally not necessary or appropriate.
A determination in the specific case to accept an off-label use would require more than a simple prescription from the worker's doctor. In this case, there was no indication that Cesamet was required for chronic shoulder tendonitis, that the doctor was aware of possible interaction with other medication being taken by the worker or that the doctor conducted an extensive evaluation before deciding to prescribe Cesamet.
In the absence of evidence explaining the necessity for off-label use of Cesamet, an exception to the rule against funding of Cesamet in these circumstances was not warranted.
The appeal was dismissed.