Additional entitlement decision

The decision maker determines additional entitlement to benefits and services for TMJ disorders in consultation with a dental consultant, and if required, the medical consultant.

When investigating entitlement for TMJ, request the following:

• A report of the dental damage.
• A detailed dental history, including any pre-existing TMJ concerns and x-rays.
• A report with an outline of the proposed treatment.
• Complete medical (if appropriate) and dental history (work related and non-work related).
• List of medication prescribed as a result of the work-related injury.
• Information about the worker's future oral hygiene needs (e.g., will the worker need an electric toothbrush, special appliance or required aid).
• A report of anticipated TMJ disorder/dental damage, if any and its causes.
• A report of anticipated repairs, TMJ treatment and/or maintenance.

Once the information has been gathered, refer the claim for a dental medical review requesting an opinion to confirm:

• If a causal relationship exists between the work injury or activity and the TMJ problems,
• If the work injury or activity aggravated a pre-existing condition and whether the aggravation is temporary or permanent, and
• The recommended treatment.

The dental consultant provides a dental opinion in response to the questions outlined in the file note. If a dental opinion cannot be provided based on the claim information, the dental consultant refers the claim back to the decision maker to request the necessary information.

The decision maker reviews the dental consultant's opinion and makes a decision to accept or not accept the TMJ disorder as an additional injury/illness and recommended treatment.

A second injury is a new and distinct impairment or disease occurring as a consequence or complication of a compensable injury. The decision maker reviews entitlement for a second injury in accordance with Policy 03-01, Part II, Application 2.

When a second injury is reported, either by the worker, treatment provider or medical reporting, determine if the injury occurred as a direct result of:

• A WCB approved medical or rehabilitation treatment for a compensable injury, or
• A weakened limb or failure of a prosthesis or appliance related to a compensable injury.

If the above criteria do not apply, it is not a second injury.

If it is not a second injury, consider whether the injury is a separate concurrent conditionA concurrent condition is a non-compensable condition that exists at the same time as the compensable disability.. For more information on concurrent conditions, refer to the Policy 04-02, Part II, Application 1, Question 11.

If a worker reports that an incident occurred on a WCB owned or leased property (e.g., Millard Health), document the details, refer the worker back to that property to report the incident, and report it to Finance. 

When the injury is not accepted as a second injury, treatment for the second injury is not authorized. Continue to manage the claim for the compensable injury. If the injury occurred on property not leased or owned by the WCB, the worker may have a claim against the occupier or owner of the facility. The WCB does not have any involvement in the process.

When the injury is accepted as a second injury, continue to manage the second injury on the same claim and update the care plan, as needed. The worker is eligible for the same benefits and services as for the work-related injury. 

If there is a possibility of third-party action, notify the WCB Legal Department of the injury that has been accepted and the circumstances of the incident. Third-party actionFor WCB purposes, a third party is a person not covered under the WCA who causes or contributes to an accident. may be considered where the second injury occurred as a result of the fault of a third party not covered by the Act (e.g., medical malpractice, defective prosthesis, etc.).  Refer to Policy 07-02, Part II - Application 6 - Third party recoveries and the Third-party claims section in the 1-1 Initial entitlement decision procedure.

Review the claim for cost transfer if the second injury is accepted. Refer to Procedure 12-1 Cost relief, cost transfer and cost allocation.

When sexual dysfunction is reported, either by the worker, treatment provider or medical reporting, determine if the dysfunction occurred as a direct result of the compensable accident.

Identification of a work-related sexual dysfunction may come from:

• Family physician
• Hospital staff
• Canadian Paraplegic Association (CPA) counsellor
• CPA Registered Nurse
• Worker
• Spouse/adult interdependent partner
• Medical Consultant
• Counsellor
• Other sources

When there is no confirmed diagnosis, ask the worker to speak with their treating physician for a referral to a specialist (e.g., urologist or gynecologist).

Consult with a medical consultant, if assistance is needed to confirm the cause or severity of the sexual dysfunction, health implications, pre-existing conditions, non-organicNon-organic means there is no physical cause. based sexual dysfunction and permanent clinical impairment (PCI).

If accepted, the decision-maker assists the worker and spouse/adult interdependent partner in coping with sexual dysfunction by providing counselling, medical treatment, and aids for sexual function and reproduction.

Treatment/Counselling

Once the issue has been identified, the decision maker can refer the worker for counselling specializing in sexual dysfunction which can provide education on conservative and invasive treatments.  

Authorize the purchase of an appliance(s) or medication prescribed for sexual dysfunction. Medications are authorized if prescribed by a physician. For worker/spouse/adult interdependent partner appliance purchases, a report from the service provider or prescription from the treating physician is required.

Family Planning

Under Policy 04-07, Part II Application 3, we may provide assistance for family planning to severely injured workers if the worker has a functional disability resulting from their compensable injury.

Encourage the worker to speak with the treating physician for a referral to a facility for family planning. Discuss the WCB responsibility for family planning assistance and explain the authorization process.

Contact the Health Care Consultant for fertility clinic service providers. The treating physician will make the referral. Notify the fertility clinic of pending WCB responsibility for family planning assistance and request a report on the treatment plan and estimated costs.

Review the fertility treatment plan and estimated costs. Consult with the medical consultant for clarification of the treatment plan, if needed.

Authorization of the treatment plan and costs is based on an appropriate treatment facility nearest to the worker's place of residence. If the worker requests to change to a different facility, the difference in cost may be the responsibility of the worker.

Review and action recommendations from the supervisor as appropriate. Communicate the decision verbally and in writing including the rationale to approve or not approve the treatment. Be sensitive to the circumstances of the injury and treatment. Send a copy of the letter to the treating physician and the fertility clinic. Include the following information:

• All accepted costs for treatment.
• The level of entitlement for treatment.
• When further WCB approval is required (e.g., repeat treatment, change in treatment, etc.).
• That the worker is responsible for any medical complications of conception, pregnancy, and delivery, pre-natal and post-natal care for mother and child, the child's health or medical treatment, custody issues and other child rearing or medical costs.
• Review and appeal information. 

Monitor the treatment and review and action requests for repeat treatment and/or cost overruns. Obtain approval from the appropriate level of authority when additional costs for treatment are identified.

When a worker has a compensable physical injury and develops a psychological injury as a result of the compensable physical injury, the worker may be eligible for additional entitlement in the following circumstances:

• Traumatic onset psychological injury on a physical injury claim. A worker may suffer a traumatic onset psychological injury on an already accepted claim when the circumstances that led to the physical injury meet the criteria to be considered a traumatic incident under Policy 03-01, Part II, Application 6. For additional information, refer to the traumatic onset psychological injury on a physical injury claim section below.
• Emotional reaction to compensable physical injury or treatment on a physical injury claim. A worker may develop a psychological condition due to difficulty adjusting to the physical injury and/or its treatment. For additional information, refer to the emotional reaction to compensable physical injury or treatment on a physical injury claim section below.

A worker may suffer a traumatic onset psychological injury on an already accepted claim for a physical injury when the date of accident mechanism of injury (MOI) for that compensable physical injury meets the criteria to be considered a traumatic incident under Policy 03-01, Part II, Application 6, Question #5. 

Under Policy 03-01, Part II, Application 6, traumatic onset psychological injury is compensable when it is an emotional reaction in response to a single traumatic work-related event or a cumulative series of traumatic work-related events experienced by the worker. A traumatic event(s) is defined as a direct personal experience of an event or directly witnessing an event that, reasonably and objectively assessed, is: 

• sudden/unexpected,
• frightening or shocking,
• having a specific time and place, and
• involving actual or threatened death or serious injury to oneself or others or threat to one’s physical integrity (i.e., assault).

Call the worker to discuss the psychological issues or stressors they are experiencing. Explain that a questionnaire and release of medical information form will be sent to them. Ask that they complete and return these documents.

Questions to ask the worker:

• How are you feeling? How are you sleeping?
• What is going well? What is not going well?
• Do you have any concerns about return to work?
• What does a typical day look like for you?

When the accepted MOI for the compensable physical injury was:

• Not a traumatic incident, review the claim to determine if the psychological/psychiatric condition may be a reaction to the worker's injury or compensable treatment. Refer to the Emotional reaction to compensable injury/treatment on a physical injury claim.
• A traumatic incident, the worker may be offered 5 counselling sessions.

Notes: 

• When there will be a delay in making an entitlement decision for a psychological injury, five counselling sessions are offered to gather information.
• When a significant psychological barrier is clearly not related to work, but it hinders the worker's recovery from a compensable injury, up to five sessions of counseling may be offered. This is applicable if the worker cannot obtain suitable treatment due to financial constraints or limited community resources. These sessions aim to address the barrier and facilitate progress in the care plan for the compensable injury.

If the worker accepts the offer of counseling, approve treatment with an authorized provider. Should they decline, continue to monitor and consider repeating the offer in two weeks if symptoms persist or do not improve.

If the worker has completed five counselling sessions, determine if an extension is required or if the symptoms are resolving/resolved. 

An entitlement decision for psychological injury should be completed after no more than ten counselling sessions. Review the claim to determine if medical information/evidence supports: 

• A confirmed DSMDSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders.  DSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders.psychiatric or psychological diagnosis. A DSM psychological diagnosis is required to determine entitlement for a psychological injury.
• A pre-existing psychiatric/psychological diagnosis

If presumptive coverageWCB recognizes that certain occupations (i.e., first responders, emergency dispatch, correctional officers) routinely expose workers to traumatic events. Presumptive coverage means that the Workers' Compensation Board (WCB) presumes that a confirmed DSM psychological or psychiatric injury occurred due to an incident at work or work exposures.   WCB recognizes that certain occupations (i.e., first responders, emergency dispatch, correctional officers) routinely expose workers to traumatic events. Presumptive coverage means that the Workers' Compensation Board (WCB) presumes that a confirmed DSM psychological or psychiatric injury occurred due to an incident at work or work exposures. applies. Refer to the Policy 03-01, Part II, Application 6 and the 1-1 Initial entitlement decision procedure, psychological injury section for information on presumptive coverage.

Request clarification or additional information from the treating physician, psychiatrist or psychologist if the diagnosis is unclear or there is evidence of a pre-existing condition.

Note: A psychiatric or psychological condition can be diagnosed by a physician (including psychiatrists), psychologist, a clinical social worker or a nurse practitioner. Psychiatric diagnoses are made by psychiatristsPsychiatrists are medical doctos who can prescribe medications as a course of treatment.. Psychological diagnoses are made by psychologistsPsychologists are not medical doctors and cannot prescribe medications. Their focus is on treating emotional and mental suffering in patients with therapy and behavioral intervention.. Both psychologists and psychiatrists use the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose conditions. Policy 03-01 Part II - Addendum A provides the current DSM version for WCB use.

Once all the medical and psychological information has been gathered, determine entitlement for the DMS psychiatric/psychological diagnosis. If assistance is required in determining entitlement, consider:

• A referral to a medical consultant when the majority of the available reporting is from a physician (including psychiatrists) or there is a combination of physician, psychiatric and psychological reporting.
• A referral to a psychological consultant when the majority of the available reporting is from a psychologist.
• Whether further psychological assessment is needed to confirm a DSM diagnosis and relationship to the work injury. Refer to the Psychological/Psychiatric Assessments section below.

Psychological/Psychiatric Assessments

Assessments to consider may include:

• A comprehensive psychological assessment (CPA),
• A psychiatric independent medical examination (IME) or
• Both, a CPA followed by a psychiatric IME.

WCB uses the “but for” test to determine if a worker has developed a traumatic onset psychological injury on a compensable physical claim. A CPA is not always required to confirm the physical injury/treatment was necessary for the development of the psychological/psychiatric condition (i.e., A CPA may or may not be necessary to confirm the "but for" standard of causation is met). Refer to the 4-1 Medical testing, referrals and program support procedure.

When referring for both a CPA and an IME the CPA should be completed first, so the IME examiner has the information available. 

Consider a CPA when:

• There is no DSM diagnosis, or the diagnosis is unclear.
• There is a delayed onset of the psychiatric or psychological condition.
• Causation must be confirmed.
• The worker's symptoms are not resolving with treatment.
• There are concerns about validity issues.

Consider a psychiatric IME when:

• There is no DSM diagnosis, or the diagnosis is unclear.
• There is a significant pre-existing or concurrent psychiatric condition.
• There are medical factors that may be contributing to the psychiatric presentation.
• It has been recommended by a CPA, medical consultant or psychological consultant. 

Review all the information including psychological assessment results, medical or psychological consultant's opinion, and make a decision to accept or not accept the psychological/psychiatric diagnosis.  

Upon confirmation of a DSM psychological diagnosis, review all pertinent information, including the results of the psychological assessment and the medical or psychological consultant's opinion. Make a decision to accept or not accept the psychological diagnosis. Call the worker to discuss the decision including additional recommendations for treatment and the next steps in their care plan. When speaking with the employer, only information related to the accepted psychological injury should be discussed.  Information related to non-compensable psychological issues should not be disclosed. Communicate the decision in writing.  

If the psychological or psychiatric diagnosis is not accepted, recommend the worker consult with their treating or family physician to organize support and treatment. Additionally, if the worker consents, consider a referral to Community Support Services.

An emotional reaction to a compensable physical injury or its treatment occurs when a worker develops a psychological or psychiatric condition due to difficulty adjusting to the compensable physical injury and/or its treatment. This includes situations involving re-employment services when a career change is necessary or when the worker is engaged in complex, long-term planning.

Review the information that indicates a worker is experiencing stress or psychological barriers. Indicators of stress or psychological barriers may include:

• Reports from the treating physician, return-to-work provider, other treatment providers (e.g., medical status examination (MSE), functional capacity evaluations (FCE), psychological counselling reports or other medical assessments).
• Observations from the re-employment provider, family members, the employer, co-workers etc.
• Reports from review/appeal bodies who recommend investigations into a psychological disability.
• Requests to approve payment for new prescriptions, anti-anxiety medication or sleep disturbances. 

Call the worker to discuss the psychological issues or stressors they are experiencing. Ask:

• How are you feeling?
• How are you sleeping?
• What is going well? What is not going well?
• Do you have any concerns about return to work?
• What does a typical day look like for you?

When the barriers are related to the compensable injury or it if is unclear if there is a relationship, offer up to five psychological counselling sessions. Five counselling sessions can be approved at a time when there will be a delay in making an entitlement decision for a psychological injury. An entitlement decision should be completed after no more than ten counselling sessions.

Note:  In rare circumstances, up to five sessions of psychological counselling can be offered where:

• There is a significant psychological barrier preventing recovery of the compensable physical injury, and
• The barrier is clearly unrelated to the compensable injury, and
• The worker is unable to access appropriate treatment due to financial issues or lack of community access.

Monitor and determine entitlement for psychological injury

Monitor the worker's progress in counselling to determine if the worker's symptoms are resolving. After completing five counselling sessions review the worker's status.  

If the worker's symptoms have resolved, do not continue with this procedure.

Review any requests for an extension of treatment.  Refer to the 4-3 Psychological counselling procedure to determine if an extension of treatment can be authorized.  

Whether a treatment extension is approved or not, if the worker's symptoms have not resolved after five counselling sessions, review the claim information to determine if the medical information supports a confirmed DSMDSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders.  DSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders.psychological diagnosis. 

Notes: 

• A DSM psychological diagnosis is required prior to determining entitlement for a psychological injury. This may include entitlement for an aggravation of a pre-existing psychological/psychiatric diagnosis.
• A psychiatric or psychological condition can be diagnosed by a physician (including psychiatrists), psychologist, a clinical social worker or a nurse practitioner. Psychiatric diagnoses are made by psychiatristsPsychiatrists are medical doctos who can prescribe medications as a course of treatment.. Psychological diagnoses are made by psychologiPsychologists are not medical doctors and cannot prescribe medications. Their focus is on treating emotional and mental suffering in patients with therapy and behavioral intervention.sts Both psychologists and psychiatrists use the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose conditions. Policy 03-01, Part II,  Addendum A provides the current DSM version for WCB use.
   

When the information is unclear or does not provide a DSM diagnosis, call the physician or psychologist to obtain additional information or clarification and send the appropriate letter.  

If assistance is required to determine entitlement or whether further psychological assessment is needed, consider:

• A referral to a medical consultant when the majority of the available reporting is from a physician (including psychiatrists) or there is a combination of physician, psychiatric and psychological reporting.
• A referral to a psychological consultant when the majority of the available reporting is from a psychologist.

Psychological assessments can help confirm the DSM diagnosis and relationship to the work injury. Assessments to consider include:

• A comprehensive psychological assessment (CPA),
• A psychiatric independent medical examination (IME) or
• Both a CPA followed by a psychiatric IME.

WCB uses the “but for” test to determine if a worker has developed a psychological condition due to their compensable physical injury or treatment of their compensable physical injury claim. A CPA is not always required to confirm that the physical injury/treatment was necessary for the development of the psychological/psychiatric condition (i.e., a CPA may or may not be necessary to confirm the “but for” standard of causation is met).  Refer to the Policy 03-01, Part 2, Application 6, Question 2  and Policy 02-01, Part II, Application 7, Questions 5 and 7 

When referring for both a CPA and an IME the CPA should be completed first, so the IME examiner has the CPA information available. 

Consider a CPA when:

• There is a delayed onset of the psychiatric or psychological condition.
• Causation must be confirmed.
• There are concerns about validity issues.

Consider a psychiatric IME when:

• There is a significant pre-existing or concurrent psychiatric condition.
• There are medical factors that may be contributing to the psychiatric presentation.
• It has been recommended by a CPA, medical consultant or psychological consultant. 

Upon confirmation of a DSM psychological diagnosis, review all pertinent information, including the results of the psychological assessment and the medical or psychological consultant's opinion. Decide to accept or not accept the psychological diagnosis. Call the worker and the employer to discuss the decision including additional recommendations for treatment and the next steps in the care plan. When speaking with the employer, only information related to the accepted psychological injury should be discussed.  Information related to non-compensable psychological issues should not be disclosed. Communicate the decision in writing.

If the psychological or psychiatric diagnosis is not accepted, recommend the worker consult with their treating or family physician to organize support and treatment. Additionally, if the worker consents, consider a referral to Community Support Services.