Pharmaceutical cannabinoids and medical cannabis

Review the request for pharmaceutical cannabinoids for approval (from the worker or physician via reporting). For pharmaceutical cannabinoids or medical cannabis determine if the worker has any of the designated conditions for which pharmaceutical cannabinoids or medical cannabis may be considered, as outlined in Policy 04-06, Part II, Application 6 - Pharmaceutical Cannabinoids and Cannabis Authorized for Medical Use, Question 6. If there is a Health Canada approved usage, monitor as usual for medication use.

If unsure whether a worker has one of the designated conditions, request a medical consultant opinion. Once the opinion is received determine if the worker has one of the designated conditions. 

If the worker does not have one of the designated conditions, contact them to explain the decision not to approve coverage. Communicate the decision in writing.

Discuss the following details with the worker:

Pharmaceutical cannabinoids

• The worker must have a designated condition (Question 6 in policy) and meets the criteria for approval (Question 7 in policy). If the worker is being prescribed pharmaceutical cannabinoids for off-label use, discuss the additional criteria for off-label use (Question 7 of policy). 
• The dosage and administration routes must align with Health Canada's Information for the Health Care Professions and relevant Standard(s) of Care and Advise to the Professions developed by CPSA (Question 12 in policy). 

Medical cannabis only 

• The worker must have a designated condition (Question 6 of the policy) and meet the criteria for approval (Question 8 of the policy). 
• If the worker has not completed an appropriate trial (3 months) of pharmaceutical cannabinoids that was unsuccessful (unless pharmaceutical cannabinoids are contraindicated), advise the worker that a trial must be completed before approval for medical cannabis can be considered. 
• If pharmaceutical cannabinoids are contraindicated, advise the worker that a medical consultant must review the claim before approval for medical cannabis can be considered to ensure the same contraindications for pharmaceutical cannabinoids do not prevent the worker from safely using medical cannabis.
• The worker’s responsibilities that must be met to approve medical cannabis (Question 11 in policy).
• The WCB approved dosage and administration route for dried cannabis (Question 12 in policy).  
• An information package will be issued which includes the documents required for approval, including forms that must be completed with the physician that is authorizing medical cannabis.
• When the worker expects to see their physician to have the forms completed.
• Coverage starts when all the required forms in the information package are signed by the worker and their physician and received on file.
• Continued approval will be reviewed every three months and the criteria that must be met to continue approval (Question 13 in policy).
• When the WCB is considering suspending or ending coverage (Question 14 in policy).

When reviewing for approval for medical cannabis only, send the appropriate letter documenting the discussion and plan to determine entitlement and attach the appropriate forms to be completed by the worker and the authorizing physician. A letter is not required when reviewing for approval for pharmaceutical cannabinoids.

If the worker could not complete a trial of pharmaceutical cannabinoids because they are contraindicated, request a medical consultant review to ensure medical cannabis is not also contraindicated.

Pharmaceutical cannabinoids

When reviewing for approval of pharmaceutical cannabinoids, determine if the request meets the criteria identified in policy (Policy 04-06, Part II-Application 6).  

If the request does not meet the criteria, call the worker to explain why and send the appropriate letter.  Do not continue with this procedure.

Medical cannabis

When reviewing for approval of medical cannabis, review the forms to ensure they are completed and signed by the worker and physician. If all required forms are not received or information is missing, contact the worker to request the information. Send the appropriate letter and monitor for the missing information.

Note: The authorizing physician is the treating physician who is responsible for the ongoing care of the worker's compensable medical condition or symptoms for which the medical cannabis is authorized.

Determine if the request meets the criteria identified in policy including dosages, THC content, administration route, etc. (Questions 7, 8 and 12 in policy). 

If the worker is taking a higher dose than what is allowed in policy, WCB will pay up to the amount that policy allows and the worker is responsible for paying the remainder

If the request does not meet the criteria, contact the worker to explain why and send the appropriate letter. Do not continue with this procedure.

Contact the worker and explain that pharmaceutical cannabinoids or medical cannabis is approved.

Pharmaceutical cannabinoids

Confirm that the medication will be approved for one year, at which time an annual review will be completed. Communicate the decision and discussion in writing.

Transfer the claim to the case assistant, when appropriate, to monitor until the next annual review. Do not continue with this procedure.

Medical cannabis

Discuss (and document) the following:

• Approval is for the initial three months. 
• After three months, a review will be completed to determine if coverage can continue.  This will be repeated every three months.  After one year, an annual review will also be completed.
• The worker’s physician must submit reporting every three months demonstrating functional improvement with medical cannabis. Coverage will continue if there is sufficient evidence the medical cannabis is effective, measurable treatment goals are reached and/or maintained and there are no adverse effects that outweigh the benefits.  
• Costs will include the purchase of a vaporizer if dried cannabis is being authorized. 
• Itemized receipts are required, including the amount of product purchased, the THC content or percentage of the cannabis. If the cannabis is in a form other than dried product (such as oil or edibles), the receipt must include the equivalency factor of dried cannabis for calculation purposes.

Communicate the decision and discussion in writing.

Transfer the claim to the case assistant, when appropriate to monitor and review the claim every three months.

Review the transfer file note and add a task to review the claim in three months from the approval date.

On the review date, confirm that:

• A clinical reassessment was completed, and the Medical Cannabis Management Report (C1446) was submitted by the physician. Request reporting from the physician if it is not available on the claim for the review; monitor for its submission. 
• The medical reporting is consistent, and the dosage, administration routes and prescribing/authorizing physician remains the same. (Question 12 in policy)
• The plan is effective, showing evidence of improvement in pain levels, improvement in functional scoring and the pain and functional scores correlate with opinion of other physicians involved in the worker's care (e.g., functional capacity evaluation (FCE) reports, other medical reports on file and the decision maker's impression from discussion with the worker.)  The treating physician's Medical Cannabis Management Report (C-1446) must demonstrate this information every three months (Question 13 in policy). 
• Measurable treatment goals are reached and maintained (Question 13 in policy).
• There are no adverse effects that outweigh the benefits (Question 13 in policy).
• If being used to decrease opioid use, there is a decrease in opioid use and not an increase. The decrease in opioid use should be 30% or showing progression towards that (Question 13 in policy).
• There is no evidence that the use of medical cannabis is impeding return to work or of misuse and the physician continues to indicate it is necessary/appropriate. (Question 14 in policy).

If the worker continues to meet the criteria to receive medical cannabis, document the outcome of the review in eCO. Repeat this step until the approval end date.

If it appears that the worker no longer meets the criteria to approve medical cannabis, transfer the claim to the decision maker. 

If the report is not received, follow the 11-1 Requesting medical reports procedure.

Annual review

Four weeks prior to the annual review date, review the claim to confirm a recent Medical Cannabis Management Report (C1446) is on file from the physician. If the report is not on file, send a request to the physician for the report. Follow the 11-1 Requesting medical reports procedure.

Transfer the claim to a decision maker two weeks prior to the approval end date.  

Confirm that:

• Clinical reassessments are being completed and the Medical Cannabis Management Report (C-1446) is being submitted by the physician every three months.
• The medical reporting is consistent, and the dosage and physician remains the same (Question 12 in policy).
• The plan is effective, showing evidence of improvement in pain levels.
• Measurable treatment goals are reached and maintained.
• There are no adverse effects that outweigh the benefits.
• If being used to decrease opioid use, there is a decrease in opioid use (by 30% or showing progression towards that) and not an increase.
• There is no evidence that the use of medical cannabis is impeding return to work or of misuse and the physician continues to indicate it is necessary/appropriate. 

If unsure whether a worker continues to meet the criteria, request a medical consultant opinion. Once the opinion is received determine if the worker continues to meet the criteria.

Contact the worker to discuss the decision. If the worker meets the criteria for extension, explain that authorization will be provided for another year with reviews every three months to ensure the worker continues to meet the criteria for approval. 

If the worker does not meet the criteria for extension, explain why they no longer meet all of the criteria. Document the discussion and communicate the decision in writing.

When an extension is approved, transfer the claim to the case assistant to monitor and review the claim every three months, when appropriate. Repeat steps 5 and 6 until authorization ends.