Note: This is not a policy; it is a supplementary document to illustrate how the WSIB will administer the Workplace Safety and Insurance Act, 1997, (WSIA) and Policies 17-01-02, Entitlement to Health Care and 17-01-03, Choice and Change of Health Professional in practice. If there is a conflict between this Administrative Practice Document and the WSIA and/or WSIB policy, the decision maker will rely on the WSIA and/or WSIB policy, as the case may be. The practice and approach is applicable to musculoskeletal injuries not psychological or mental stress injuries.
- Injured or ill people are entitled to receive benefits for injuries and illnesses that result from incidents that arise out of and in the course of employment.
- Work-relatedness is established when determining initial entitlement. Decision- makers continue to evaluate the work- relatedness of a person’s ongoing impairment throughout the life of a claim.
- Decision-makers will gather relevant information and weigh evidence in order to make adjudicative decisions.
- The WSIB makes its decisions based on the merits and justice of each case.
- Return to work is part of the recovery process and acting early is the key to preventing permanent impairment.
- Recovery and return-to-work barriers will be addressed quickly through accessible, timely and intensive services.
Section 33 (1) and (2) of the Workplace Safety and Insurance Act (WSIA) state,
A worker who sustains an injury is entitled to such health care as may be necessary, appropriate and sufficient as a result of the injury and is entitled to make the initial choice of health professional for the purposes of this section.
The Board may arrange for the worker’s health care or may approve arrangements for his or her health care. The Board shall pay for the worker’s health care.
Decision-makers at the Workplace Safety and Insurance Board (WSIB) must decide a person’s entitlement to benefits and services under the WSIA. When initial entitlement for a work- related injury or illness is established, entitlement includes health care that is necessary and appropriate, based on the nature of the injury or illness, to promote the injured or ill person’s recovery.
Maximum medical recovery (MMR) means that the injured or ill person has reached a plateau in recovery and it is not likely that there will be any further significant improvement in the work-related injury/illness. When it is established that the injured or ill person has achieved MMR, it is generally considered that they have received sufficient health care.
Treatment requested after MMR is reached (and in the absence of a significant deterioration) is referred to as “maintenance treatment”. The purpose of this document is to further define the term “maintenance treatment” and to outline how the WSIB determines entitlement for “maintenance treatment” in accordance with s.33 of the WSIA and the health care principles set out in Policies 17-01-02, Entitlement to Health Care and 17-01-03, Choice and Change of Health Professional. Although the policies do not specifically address “maintenance treatment”, decision-makers use the guidelines set out in the policies to determine the appropriateness of this type of treatment.
What is maintenance treatment?
Someone who is entitled to benefits under the WSIA is entitled to such health care as may be necessary, appropriate and sufficient as a result of the injury or illness. The WSIB approves health care interventions that constitute a rehabilitation program. A rehabilitation program is a specific program of care for the purpose of restoring or enhancing function and quality of life to enable the return to suitable and safe work and promote optimal recovery of the work-related injury or illness.
Treatment requested post-MMR where a permanent impairment is evident and there is no evidence of a significant worsening is generally referred to as “maintenance treatment”. It may be requested by the treating health care professional, when in their opinion it would be of benefit to the injured or ill person. The purpose of maintenance treatment is to maintain function/recovery and quality of life by preventing deterioration of the work-related impairment, rather than to rehabilitate. Health care professionals may also recommend maintenance treatment to enable a reduction or avoidance of medication use.
Monitoring health recovery
When someone suffers a work-related injury or illness, the health care professional(s) involved in their case are required to submit medical information providing the diagnosis, prognosis for recovery, and the recommended treatment.
After initial entitlement for a work-related injury or illness is established, decision-makers continually monitor the medical information, take appropriate action to facilitate return to work (RTW) and promote full recovery, and continue to provide appropriate benefits and services. In accordance with the “Better at Work” principle, health care is integrated with return to suitable and safe work to minimize the impact of the work-related injury or illness and promote optimal recovery.
Health care interventions such as physiotherapy or chiropractic treatment are recommended for many work-related injuries or illnesses, when appropriate for the nature and degree of the injury or illness.
When assessing the clinical information about someone’s ongoing work-related impairment, decision-makers also consider the appropriateness and necessity of the health care interventions being provided or recommended by the treating health care professional(s). Generally, health care interventions are considered appropriate and necessary while they continue to improve the person’s functional abilities, and promote the integration of health care and RTW.
When someone has reached MMR, decision-makers must also determine if there is clinical evidence of continuing impairment as a result of the work-related injury or illness. Where someone has a permanent work-related impairment, return-to-work services may be provided to identify suitable work with the injury employer or a suitable occupation, with the injury employer or in the general labour market.
Where there is no clinical evidence of ongoing work-related impairment after MMR is reached, the injured or ill person is generally considered to have fully recovered from the work-related injury.
Is maintenance treatment appropriate?
When a health care professional requests treatment after the injured or ill person has reached MMR, decision-makers must gather information, including clinical evidence, to evaluate whether the recommended treatment is being requested due to the accepted work-related injury or illness, a significant worsening in a pre-existing condition or some other non-work-related condition.
Entitlement for maintenance treatment may be considered only for someone who has a permanent impairment resulting from the work-related injury or illness. A decision-maker may approve a request for maintenance treatment when they are satisfied, based on the clinical evidence, that the treatment is necessary to achieve one or more of the following objectives:
- enables the injured or ill person to continue working within their accepted permanent functional abilities as recognized by their permanent impairment (suitable work)
- leads to a reduction in the injured or ill person’s pain and/or decreases the injured or ill person’s use of medication
- maintains the inured or ill person’s level of functioning
- teaches the injured or ill person’s independent management of their condition
In order for decision-makers to consider a request for maintenance treatment, the health care professional must submit the request in writing, outlining the
- proposed treatment plan (including frequency and duration),
- goal of the treatment, and
- expected outcome.
When determining entitlement for maintenance treatment, decision-makers should consider the following factors:
- Is there current and specific medical information available to support the treatment? Is the health care professional’s rationale well described and clinically supported? Is it a form of treatment recognized by the WSIB? Is there other treatment not yet explored that might be more appropriate?
- Will the treatment enable the injured or ill person to continue working at suitable work or in the suitable occupation? Is further assessment required to verify the suitability of the current work to ensure it is within their accepted permanent functional abilities?
- Has the injured or ill person previously received a home exercise program? Has the injured or ill person engaged in home exercises to prevent and manage aggravation/exacerbation of symptoms?
- Have previous attempts at discontinuation of treatment resulted in the inability to maintain the injured or ill person’s functional level and return-to-work status? Is the inability to maintain the injured or ill person’s functional level and return-to-work status potentially related to unsuitable work or an unsuitable occupation?
- Is it expected that the proposed treatment will result in a decrease in the injured or ill person’s pain with a corresponding reduction in the frequency or dosage of medication?
- Is it expected that the proposed treatment will sustain the injured or ill person’s level of function? For example, will it sustain their ability to perform the activities of daily living, sustain ambulation distance, and maintain the ability to lift/carry?
- Will the treatment teach/reinforce independent self-management of their condition? For example, does it promote new home exercises or other suggested modifications in activity?
- Has the treatment to date prevented aggravation/exacerbation of symptoms and achieved the expected outcome? If so, is there an expectation that the proposed treatment will do so as well?
When considering requests for maintenance treatment, decision-makers may review the case with the nurse consultant or request an opinion from a case consult physician. In some cases, decision-makers may initiate additional return-to-work services to ensure the injured or ill person is continuing to work in suitable work or a suitable occupation.
In all cases, decision-makers will collect the relevant information, and assess and weigh the evidence to make a decision on entitlement for the maintenance treatment. In cases where there is differing or conflicting information/medical opinions relating to the benefits of the requested maintenance treatment, the decision- maker must assess and weigh the information or opinions as outlined in the Administrative Practice Document on weighing of medical evidence.
Communication of decisions
All adjudicative decisions should be communicated verbally to the injured or ill person and employer, wherever possible, and then confirmed in writing. The decision letter should:
- identify the issue decided,
- provide a summary of the facts of the case,
- provide the entitlement rules that apply to the issue (legislative and/or policy criteria, or standards),
- provide the rationale for the decision reached, explaining how the entitlement rules were or were not met,
- reference only evidence that is relevant to the decision, and
- include the timeframe for appealing the decision for all adverse decisions.
The decision-maker will make every effort to communicate decisions in plain language to ensure the injured or ill person and the employer fully understand the decision and reasons for the decision. The rationale should outline the evidence that was considered in the decision making process.
Decisions relating to requests for maintenance treatment should explain the evidence considered in making the decision relative to the factors and objectives noted earlier in this document. Where the decision-maker must weigh the significance of conflicting information or medical opinions, the decision letter should include an explanation of the decision-maker’s assessment and how the relevant information/opinions were weighed in arriving at their conclusion.
Where the request for maintenance treatment is approved, the letter should also clearly state the type of treatment, the frequency and duration of treatment approved, and the expected outcome. The letter should also outline what information is required for additional requests for maintenance treatment to be considered.
When an injured or ill person reaches MMR following a work-related injury or illness, further treatment is generally not appropriate or necessary as it is unlikely to result in further recovery. Additional treatment beyond that point requires the decision-maker to identify if the injured or ill person has suffered a significant worsening of their condition. If it is confirmed that there has been no significant worsening, further treatment is considered maintenance treatment and may be considered only in cases where the injured or ill person has a permanent work-related impairment
Maintenance treatment may be approved when there is evidence that demonstrates the requested treatment will be beneficial to the injured or ill person to maintain function/recovery by preventing deterioration of the work-related impairment. Based on the factors for consideration, the decision-maker must be satisfied that the maintenance treatment will achieve one or more of the objectives outlined earlier in this document.
Determining entitlement for maintenance treatment requires a thorough assessment of the request and the information contained in the file record. Where there is insufficient information, the decision-maker will gather additional relevant information from the worker, employer, and health care professionals, as appropriate, and evaluate each case on its own merits.
Decision-makers may request assistance from the nurse consultant or an opinion from a case consult physician with respect to the appropriateness of the requested treatment, when it is not clear that the benefits of treatment outlined by the health professional align with any of the goals and intended outcomes the WSIB considers appropriate for the approval of maintenance treatment. When assessing differing medical opinions, decision-makers should refer to the Administrative Practice Document on weighing of medical evidence.
December 2020 – Reviewed
April 2015 - replaces the Best Approaches Guide on Maintenance Treatment, December 2005