Issued under ss 7.23(1)) of the Motor Accident Injuries Act 2017

1. whether the treatment requested by Dr John Prickett on 6 September 2023, namely, a need for a trial of CBD cannabis product to assist with the management of the claimant's accident-related injuries:

(a) relates to the injuries caused by the accident, and

(b) whether such treatment is reasonable and necessary in the circumstances.

1. The Review Panel revokes the certificate of Medical Assessor Murray Hyde Page dated

29 July 2024 and issues a replacement certificate as follows:

• the treatment requested by Dr John Prickett on 6 September 2023, namely, a need for a trial of CBD cannabis product to assist with the management of the claimant's accident-related injuries:

(a) relates to the injuries caused by the accident, but > > (b) is not reasonable and necessary in the circumstances.

A statement of the Review Panel's reasons for the determination is attached to this certificate.

1. On 5 August 2021, the claimant, CUB, was injured in a motor accident when a vehicle (insured by NRMA) collided with the motorcycle he was riding through a roundabout.
2. As a result of the accident, the claimant sustained significant physical injuries and subsequently developed a psychological injury.
3. The insurer accepted liability to pay the claimant statutory benefits arising from his injuries, under the Motor Accident Injuries Act 2017 (the MAI Act). These benefits include payments for treatment and care.
4. As part of the claimant's claim for treatment, a request was made to the insurer on

6 September 2023, by specialist pain management physician, Dr John Prickett, seeking approval for a trial of cannabis (CBD) oil treatment to assist with the management of the claimant's accident-related injuries, in particular chronic pain (the proposed treatment). 5. In an original decision on 13 September 2023, the insurer declined the request. Following an internal review on 12 October 2023, the insurer confirmed its original decision. 6. To resolve the dispute, the claimant on 29 November 2023, made an application pursuant Division 7.5 of the MAI Act, for a medical assessment by the Personal Injury Commission (Commission). 7. According to Schedule 2, cl 2 of the MAI Act, a treatment and care dispute is declared to be a medical assessment matter. 8. A medical assessment matter is determined in accordance with Division 7.5. According to

s 7.20 of the MAI Act, the matters is determined at first instance by a Medical Assessor and according to s 7.26 of the MAI Act, on review, by a review panel. 9. The dispute was referred at first instance to Medical Assessor Murray Hyde Page for assessment. 10. On 29 July 2024, Medical Assessor Hyde Page issued a Medical Assessment Certificate (MAC), finding that the proposed treatment relates to the injuries caused by the accident and that such treatment was reasonable and necessary in the circumstances.

1. On 28 August 2024, pursuant to s 7.26 of the MAI Act, the insurer made an application to the President of the Commission to refer the medical assessment of the Medical Assessor to a review panel for review. The Commission was satisfied that the application was made within the time prescribed by s 7.26(10) of the MAI Act because Medical Assessor Hyde Page's MAC was issued to the parties on 30 July 2024.
2. The President referred the medical assessment to a review panel for review, being satisfied that there was reasonable cause to suspect that it was incorrect in a material respect, having regard to the particulars set out in the application.

1. According to s 7.26(5A) of the MAI Act, the review panel consists of two Medical Assessors and a Member of the Motor Accidents Division of the Commission. On this occasion, the review panel is constituted by Medical Assessor Gorman, Medical Assessor McGrath and Member Castagnet (the Panel).
2. Part 5 of the Personal Injury Commission Act 2020 (the PIC Act) enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor.[1]
3. Pursuant to Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules), the Panel determines how it conducts and determines the proceedings. The Panel may determine the proceedings solely based on the written application.[2]
4. The review is not limited to only that aspect of the assessment that is alleged to be incorrect and is by way of a new assessment of all the matters with which the medical assessment is concerned.[3]

"(1) An injured person is entitled to statutory benefits for the following expenses (treatment and care expenses) incurred in connection with providing treatment and care for the injured person -

(b) reasonable and necessary travel and accommodation expenses incurred by the injured person in order to obtain treatment and care for which statutory benefits are payable,

(2) No statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the motor accident concerned.

1. Accordingly, in order to receive statutory benefits the claimant must establish that the treatment concerned:

(a) is reasonable and necessary in the circumstances;

(b) relates to an injury resulting from the subject accident;

(c) that the cost of the treatment is reasonable, and

(d) if applicable, that any travel and accommodation expenses incurred in obtaining the treatment are reasonable and necessary.

1. As a medical assessment matter under Sch 2, cl 2 (b) of the MAI Act, the Panel has jurisdiction to determine disputes relating to matters (a) and (b). Disputes relating to matters relating to matters (c) and (d) are determined by others.[4]
2. The expression "reasonable and necessary" is not defined in the legislation. It follows that the expression falls to be considered in its statutory context and in accordance with the objects of the MAI Act. These include:

_"_to encourage early and appropriate treatment and care to achieve optimum recovery of persons from injuries sustained in motor accidents and to maximise their return to work or other activities."[5]

1. "Treatment and care" is defined in the MAI Act to mean:

"(a) medical treatment (including pharmaceuticals),

(k) workplace and educational facility modifications,

(l) such other kinds of treatment, care, support or services as may be prescribed by the regulations for the purposes of this definition,

but does not include any treatment, care, support or services of a kind declared by the regulations to be excluded from this definition."[6]

1. The expression "reasonable and necessary" in relation to treatment occurs elsewhere in the MAI Act, notably at ss 3.17 and 6.5.
2. Section 3.17 provides:

"(1) An insurer must require an injured person who is in receipt of weekly payments of statutory benefits under this Division to undertake such reasonable and necessary treatment, rehabilitation or vocational training as the Motor Accident Guidelines may require.

(2) If an injured person fails without reasonable excuse to comply with a requirement of an insurer under this section, the person's entitlement to weekly payments of statutory benefits under this Division is suspended while the failure continues."

"(1) A claimant has a duty to take all reasonable steps to minimise loss caused by injury resulting from a motor accident.

(2) This duty of a claimant includes the following duties -

(a) the duty to undergo reasonable and necessary treatment and care and do all such things as may be reasonable and necessary for the claimant's rehabilitation,

(b) the duty to commence or return to work as soon as reasonably practicable.

(3) If a claimant fails to comply with a duty arising under this section, the insurer may, if authorised to do so by the Motor Accident Guidelines, suspend payment of weekly payments of statutory benefits to the claimant during any period that the failure to comply continues. The person forfeits their entitlement to weekly payments of statutory benefits during the period of any such suspension."

1. Informed by those provisions, and the objects of the Act, the Panel finds that for the proposed medical treatment in dispute, to be considered "reasonable and necessary in the circumstances", as required by s 3.24(2), it should be:

(a) medically indicated, and not, for example, scientifically unproven, or given in circumstances where the risks of undertaking the treatment are likely to outweigh any benefit to the claimant, and

(b) likely to optimise the claimant's prospects of recovery and maximise their return to work or to their other activities.

1. While the Panel considers "reasonable and necessary" to be a composite expression, the same result may be obtained by giving each of the words "reasonable" and "necessary" a discrete area of operation. A treatment is reasonable if it conforms to paragraph 27(a) and necessary if it conforms to paragraph 27(b).

1. When considering the prospects of recovery, cl 4.80 of the Motor Accident Guidelines[7]( the Guidelines) relevantly stipulates that an insurer must manage claims in a manner that is tailored to the claimant's individual circumstances and needs. In doing so, cl 4.81 stipulates that the insurer must apply the principles of nationally endorsed Clinical Framework for the Delivery of Health Services, which sets out five guiding principles for consideration by health professionals and insurers when reviewing treatment plans and requests for services:
   1. measure and demonstrate the effectiveness of the treatment
   2. adopt a biopsychosocial approach
   3. empower the injured person to manage their recovery
   4. implement goals focused on optimising function, participation and where applicable, return to work
   5. base treatment on the best available research evidence

1. The Medical Assessor noted that the claimant was involved in a high-speed motor accident which resulted in injuries including a closed transverse fracture of the proximal shaft of left femur requiring surgery with an intramedullary nail and screws. He went on to a delayed union, needing further surgery. This progressed to a non-union and further surgery again.
2. The Medical Assessor noted that the claimant has had five surgical procedures from the time of the accident to the final surgery in March 2024. Throughout this period of time, he has been in constant pain in his left thigh, hip and knee. He has developed persistent low back pain as well.
3. The Medical Assessor was of the view that in those circumstances, the proposed treatment related to the claimant's injury.
4. In concluding that the proposed treatment was reasonable and necessary, the Medical Assessor expressed the following opinion:

"He (the claimant) has needed to be under the care of a Pain Specialist (Dr Prickett) since September 2023 and has maximised the use of opioid pain medication. This has subsequently been supplemented with the use of CBD cannabis products with a positive effect. It has allowed reduction in the amount of opioid he has been taking. Dr Prickett has given a sound reasoning as to the use of CBD products, as I have commented earlier in the report. There appear to be no negatives to its use. I should also add that (the claimant) appears to be very responsible in the way he has been using the CBD product. This is all on the background of the use of CBD products as being experimental and where there are no absolute rules about its use. Instead, it appears essential that any use of CBD products should be ascertained on a patient by patient basis. With this in mind I consider the use of CBD product by (the claimant) has been appropriate."

1. The insurer submitted that in considering whether the proposed trial of CBD oil in the present case was reasonable and necessary, the Medical Assessor did not consider the adverse effects of the treatment.
2. The Medical Assessor said: 'there appear to be no negatives to its use.' In coming to that conclusion, the Medical Assessor overlooked the potential adverse effects, in particular habituation and addiction which were considered by the review panel in Bradley v Allianz Australia Insurance Ltd [2021] NSWPICMP 226 (Bradley).
3. The insurer noted that in Bradley the review panel had noted the recommendations against the use of medicinal cannabis other than for the terminally ill or as part of a clinical trial. The two main concerns with the use of medicinal cannabis were noted to be firstly that it is generally ineffective in reducing pain and secondly, adverse effects of the use of CBD include habituation / addiction, sedation and dizziness.
4. The insurer submitted that taking into account adverse effects is significant when considering whether the treatment is both reasonable and necessary. This is also more significant in the present case noting that the claimant is now on the CBD/THC oil.
5. The insurer further submitted that the proposed treatment also has the potential to impact on the claimant's ability to drive, the treatment therefore potentially impacting on the optimization of the claimant's function, participation and return to work.

1. The claimant noted that the insurer relies on various medical papers largely over the course of 2017 through to 2022, together with the decision of Bradley which is now nearly five years old.
2. The claimant submitted in response, that he relies on competing medical evidence in support of the treatment for chronic pain. The Medical Assessor has applied his own assessment having regard to the claimant's specific circumstances, his clinical expertise and the medical evidence to hand. The Medical Assessor noted there has been no known negative side effects to the use of CBD oil whilst the claimant has been utilising the recommended treatment and that the claimant has been responsible in his use of the treatment.
3. The claimant submitted that when determining the reasonableness of the proposed treatment as demonstrated in Diab v NRMA Ltd [2014] NSWWCCPD 2, the Medical Assessor has considered the appropriateness of the treatment, the alternate treatment (opioid which carried adverse effects), the fact that the treatment has been effective and he has considered the medical evidence available.
4. The claimant submitted that the Medical Assessor ccorrectly noted there is no legislated rules regarding the use of the proposed treatment and this must be considered having regard to the person's specific circumstances.

1. Both parties filed an indexed and paginated bundle of documents. The claimant's bundle comprised 790 pages and the insurer's bundle,168 pages.
2. As part of his bundle, the claimant referred the Panel to the following literature:
   • Article by the Australian Government Department of Health Therapeutic Goods Administration "Medicinal cannabis products: Patient information"- 29 May 2018.
   • Article by the Australian Government Department of Health Therapeutic Goods Administration "Medicinal cannabis products: Patient information" - 21 May 2020.
3. As part of its bundle, the insurer referred the Panel to the following literature:
   • Australian Government, Department of Health and Aged Care Therapeutic Goods Administration (2017), 'Guidance for the use of medicinal cannabis: Overview.'- 1 December 2017.
   • Australian Government, Department of Health and Aged Care Therapeutic Goods Administration (2017), 'Guidance for the use of medicinal cannabis in Australia: Patient information.' - 1 December 2017.
   • Australian Government, Department of Health and Aged Care Therapeutic Goods Administration (2017), 'Guidance for the use of medicinal cannabis in the treatment of chronic non-cancer pain in Australia.' - 1 December 2017.
   • Royal Australian and New Zealand College of Psychiatrists, 'Therapeutic use of medicinal cannabis products.'- 31 January 2021.
   • Faculty of Pain Medicine ANZCA, 'Prescribing medicinal cannabis for chronic non-cancer pain.'- March 2022.
   • International Association for the Study of Pain, 'International Association for the Study of Pain Presidential Task Force on Cannabis and Cannabinoid Analgesia Position Statement.'- July 2021.
   • Henderson LA, Kotsirilos V, Cairns EA, Ramachandran A, Peck CC, McGregor IS, 'Medicinal cannabis in the treatment of chronic pain.' AJGP, Volume 50, Issue 10, October 2021: doi:10.31128/AJGP-04-21-5939 - October 2021.
   • Prof Ian Cameron, Dr Mohit Arora, Prof James Middleton, 'Better Pain Management Approaches', The University of Sydney, Version 2.1- 21 May 2020.
   • Xu DH, Cullen BD, Tang M, Fang Y, 'The Effectiveness of Topical Cannabidiol Oil in Symptomatic Relief of Peripheral Neuropathy of the Lower Extremities.' Curr Pharm Biotechnol, 202 Volume 21(5):390-402. PMID: 31793418 (abstract) - 2020.
4. The Panel considered all the material filed by the parties.

1. Considering the issue in dispute, the evidence before the Panel may be conveniently summarised as follows.
2. Following the accident, the claimant was taken by ambulance to John Hunter Hospital for treatment. He was found to have suffered a fracture of the upper shaft of his left femur. He had also sustained a fractured right third rib.
3. On the same day, the fractured femur was fixed with an intramedullary nail and proximal and distal screws. He stayed in hospital for four days until 9 August 2021 and then discharged on crutches.
4. On 13 October 2021, the claimant was followed up by orthopaedic surgeon, Dr Richard Harbury for the fractured femur. By that stage, the claimant had progressed to walking partially weight bearing on a cane. He reported that he was getting anterior left knee pain and a "grabbing feeling" in his hip by which he meant that there was feeling of slipping or moving in the iliotibial band/ trochanteric region.
5. On 21 October 2021, the claimant was seen again by Dr Harbury with the MRI of his left knee which was performed during his stay at John Hunter Hospital. Reviewing the scan, Dr Harbury believed that there was some bone bruising on the proximal tibia. He was of the view that the claimant had possibly sustained an anterior cruciate ligament (ACL) injury to the left knee, but he recommended that it was best to leave this alone until the femur injury had healed in the first instance. An ACL reconstruction could then be considered.
6. It was found that there was delayed union of the femur and in a second operation in December 2021, Dr Harbury removed the distal lock-in screws to dynamize the fracture site. However, this resulted in the claimant experiencing a lot of pain, and he had to go back on crutches.
7. On 23 December 2021, the claimant saw Dr Harbury reporting a lot of knee pain radiating down in his knee and that he had been prescribed Endone which was causing vomiting.

Dr Harbury recommended that he ceases this medication immediately and prescribed instead an anti-inflammatory medication, Celebrex. Dr Harbury indicated that Panadol Osteo and could also be used at the same time. 8. The claimant saw Dr Harbury on 17 March 2022 after an updated MRI of the left knee was performed on 23 February 2022 which showed no significant gross pathology. Despite this, the claimant reported ongoing knee pain. Dr Harbury believed that the cause of the pain remained unclear and indicated that other pathologies such as chondral lesions and meniscal tears can be missed on MRI. A diagnostic arthroscopy may be necessary. 9. The claimant came under the care of another orthopaedic surgeon, Dr Christopher Dunkley who investigated his left femoral fracture and determined there was a non-union. In June 2022, the claimant had a third operation which was a revision of the intramedullary nail. On this occasion, it was reamed at three sizes bigger than the original nail. He also had further proximal and distal cross screws inserted. 10. After this operation, in November 2022, the claimant also came under the care of Dr Prickett for pain management at the request of Dr Dunkley. 11. In his report dated 18 November 2022, Dr Prickett noted that the claimant was slowly recovering from a non-union of the left femoral fracture. He had also developed some biomechanical pain from his pelvic girdle. He was receiving physical treatment at the time. Subsequently, he had a sacroiliac joint injection. He was having multi-disciplinary care, including a psychologist, exercise physiologist and occupational therapist. For his pain, he was on Palexia and Panadeine Forte. As far as medication was concerned, Dr Prickett did not recommend any alternative medication approaches at this stage. 12. In June 2023, Dr Dunkley undertook further surgery (the claimant's fourth operation) to try and stabilise the fracture by putting in further proximal and distal locking screws to stop rotation at the fracture site. However, this was unsuccessful, and the claimant continued to have a lot of pain in the thigh and had to use a walking stick. 13. The claimant was reviewed by Dr Prickett on 6 September 2023. In his report of the same date, Dr Prickett noted the recent surgery and that the non-union of the femoral fracture was going to continue to be a long-term burden, both from a biomechanical gait alteration as well as the slow healing of the fracture site. He noted that further surgical treatment was foreshadowed by Dr Dunkley. The claimant reported significant ongoing pain that needed Palexia slow-release and Panadeine Forte. 14. In his report, Dr Prickett also recorded that he had discussed with the claimant, the role of CBD cannabis product as part of his treatment program. Dr Prickett made the following comments:

"Whilst the evidence for its use in pain is limited, I do find anecdotal benefit with agitation and improvement in sleep quality. These are definitely two components that I think are definitely impacting on (the claimant's) day to day life and I believe there is a good chance he would benefit with sleep and agitation metrics from a trial of CBD. This also might have some indirect beneficial effect on his pain experience."

1. Dr Prickett went on to say that on that basis, he was happy to be involved in a trial of this therapy but indicated that he did not usually facilitate ongoing prescription and that he has left it to the claimant to contact him if he finds a facility to support a trial of this therapy.
2. The claimant was reviewed by Dr Prickett on 8 December 2023. In his report of the same date, Dr Prickett noted that the claimant was on the maximum amount of Panadeine Forte and Palexia and that he would not be supporting an increase in the doses of the opiates, despite the claimant's chronic pain, due to the risk of increasing addiction. In any event, Dr Prickett believed that there was a degree of dependency that would need to be addressed at some point in the future.
3. Dr Prickett reported that at this stage, the claimant was also using some CBD to help him with sleep and that the claimant perceived some benefit from this.
4. On 23 March 2024, Dr Dunkley undertook a fifth operation when he supplemented the nail and screws with an eight-hole lateral plate and screws to bridge the fracture site. Dr Dunkley used local bone graft to supplement this.
5. The claimant was reviewed by Dr Prickett on 12 June 2024. In a report of the same date, Dr Prickett noted that the claimant has had repeat MRI of his left hip which showed a degree of progression of his osteoarthritis. On that basis, Dr Prickett believed the claimant is likely at some stage to have an accelerated progression to a hip replacement.
6. Dr Prickett made the following comments:

"I was pleased from a pain management perspective that he has a much more contained use of medications using 2 to 4 x Panadeine Forte tablets per day and 2 to 4 x Advil tablets per day. He is using CBD oil to sleep but has no significant increase in agitation and anxiety. There is a concern with chronic cannabinoid use in exacerbating anxiety but he does perceive a benefit to sleep quality. This is obviously a double edged sword and the science is yet to be fully understood. He is keen to see if there are any additional benefits from a THC/CBD product. This is not my clinical experience but I think it is not unreasonable to try as he has made significant other rationalisations in his self-management for what is likely to be a persisting pain vulnerability."

1. The claimant was re-examined in person by Medical Assessor Gorman on behalf of the Panel at the Commission's medical suites on 13 February 2025. The claimant attended the assessment alone.
2. The examination report of Medical Assessor Gorman now follows.

1. The claimant was 38 years of age at the time of the assessment. He is separated from his wife and has three children, aged 2, 3 and 15 years. He is right hand dominant. He does not smoke having ceased in May 2021. He ceased alcohol in June 2021.
2. Prior to the motor accident, he worked as a self-employed handyman for 20 to 30 hours a week. He had started the business only two weeks before the accident and had previously been employed as a handyman. He had also previously worked as an underground miner. He ceased that occupation after a right leg injury which severed his peroneal nerve.
3. The claimant also did a lot of volunteer work recently for his local church. He has not been able to get back to that work since his accident. He has only done "physical" roles before and could not do them.
4. The claimant looks after his children for three days and two nights per week. He is currently receiving weekly benefits from the insurer and a small payment from Centrelink.
5. The claimant was involved in a motorbike accident in 2001 when he had a head injury and an injury to his right thumb. He said that he made a good recovery from these injuries.
6. In the years before 2021, he said that he had a severe ICE addiction. He reported that he was "not in a great place". He stated that he gave "his life to the Lord" in 2021.

1. The claimant states that about 8.00am on 5 August 2021, he was riding his motorbike on a roundabout with full protective gear. A car came in on his left and collided with him. He was thrown over the roof of the car onto the roadway on the other side. He had no loss of consciousness. He was immediately aware of injury to his left thigh and femur.

Details of any relevant injuries or conditions sustained since the motor accident

1. There are no relevant injuries or conditions sustained since the motor vehicle accident.

1. Since the fifth operation in March 2024, the claimant said that there has been a big improvement in his pain in the left thigh and leg over the last four months. He can now walk without a walking stick and has increased general mobility.
2. The claimant presents now with minimal left thigh pain since that operation. He says that the pain is the best that it has been. He is developing a different pain in the groin thought to be from the left hip.
3. The claimant can still get some general pain around his left knee. He finds it difficult walking up and down steps and has to use a rail. He avoids going for long walks. He also gets some low back pain and some neck pain.
4. The claimant has some interscapular pain and he has just started with a chiropractor as the physiotherapy was not helping.

1. The claimant has just started chiropractic treatment and he gets support from a psychologist. He takes two to four Panadeine Forte a day. Usually however it is two Panadeine Forte per day with two Advil. He also takes Rennies for indigestion and he has stopped Nexium.
2. During the last nine months, Dr Prickett was concerned by the amount of pain medication that the claimant was needing in the form of Palexia and Panadeine Forte. The claimant also had to take Nexium for his gastrointestinal symptoms.
3. Therefore, he was started on CBD oil in mid-2023 with Dr Prickett's support.
4. The claimant says that the medicinal cannabis allowed the strong pain medication to be cut-back. It has also had a calming effect and allows him to sleep better he reported.
5. In early 2024 the CBD/THC was added. The claimant is driving and is aware that this is illegal and he could be picked up by the Police.
6. The claimant is on 0.5ml to 1.0ml of CBD/THC oil per day at night-time to help him sleep. The cost is $100-$150 for 30mls - he reports that this lasts for one to two months on average.
7. The claimant is on Sertraline one a day.

1. The claimant is 179 centimetres tall and weighs 89.1 kilograms. His gait was normal - there was no limp.

1. The claimant indicated some interscapular pain and upper lumbar pain. He had a mild thoracic scoliosis concave to the left. The cervical, lumbar and thoracic spine all had a normal range of motion with no dysmetria.

1. There was no thigh pain or tenderness over the fracture site. Stressing the fracture caused no pain.
2. The thigh circumference was 44.5cm on the right and 44cm on the left measured 10cm above the patella. The calf circumference measured 10cm below the tibial tubercle was 40.5cm on the right and 38.5cm on the left.
3. The claimant has a 21cm lateral surgical scar that is well healed and nontender over the left thigh. It was pale with some visible suture marks. It was slightly depressed. He has surgical scars around his left hip (11cm) and left knee.
4. The claimant has some tenderness over the tip of the proximal end or tip of the intramedullary nail at the level of his left greater trochanter. He however had a normal range of hip movements on the left compared with the right except internal rotation on the left was limited to 10 degrees while on the right it was 30 degrees.
5. In his left knee, he had no crepitus, no swelling, no pain or tenderness with a full range of movement. The knee is stable and normally aligned. There is no rotation deformity in the left leg.
6. The right knee was normal.

Summary of relevant radiological and medical imaging and other investigations

1. There are multiple X-rays and scans of the left femur and leg. The original fracture was in the proximal shaft of femur, and this was a transverse fracture with displacement.
2. Subsequent X-rays and scans show the progress of the fracture healing and the various surgical procedures that were undertaken.
3. MRI scan of the left knee on 23 February 2022 - showed the soft tissue structures around the knee were largely intact. There were only mild early degenerative changes. There was some increased signal in the superior patella margin and insertion of the quadriceps tendon.
4. A further MRI scan of the left knee on 30 September 2022 showed there was no change.
5. The claimant's X rays taken recently by his chiropractor were reviewed. There was a loss of disc height at C4/5. There was L5/S1 degeneration. There was some increased sclerosis in the left hip with no loss of cartilage evidence - it was described as "mild arthrosis".

1. The Panel reconvened on 13 August 2025 to deliberate on the re-examination report of Medical Assessor Gorman and the evidence generally. The Panel's determinations now follow.

Does the proposed treatment relate to the injury caused in the accident?

1. The claimant was involved in a high-speed motor accident resulting in a closed transverse fracture of the proximal shaft of left femur. This was treated surgically with an intramedullary nail and screws. He went on to a delayed union, needing further surgery. This progressed to a non-union which required further surgery again. The claimant has had five surgical procedures from the time of the accident and the final surgery in March 2024.
2. The evidence shows that throughout that period, the claimant has experienced significant and persistent pain in his left thigh, hip and knee. Throughout this period, he has also developed persistent low back pain. Constant pain has affected the claimant's ability to sleep. These symptoms were caused by the injury sustained in the accident. The proposed treatment is therefore related to the injury caused by the accident.

Is the proposed treatment reasonable and necessary in the circumstances?

1. As a result of his chronic pain symptoms, the claimant has come under the care of pain specialist, Dr Prickett since November 2022.
2. The claimant needed to continue to use opioid pain medication. This has subsequently been supplemented with the use of CBD cannabis products with a reported positive effect. It may have allowed reduction in the amount of opioid he has been taking but has not allowed cessation of opioids in the form of Panadeine Forte.
3. Medical Assessor Gorman found, and the Panel accepts, that the claimant is a genuine man who had turned his life around after ICE addiction.
4. However, medicinal cannabis is only weakly analgesic, and the Panel believes that it is likely that he will need to continue taking opioid medications.
5. The Faculty of Pain Medicine in Australia is not supportive of medicinal cannabis for chronic pain. The International Association for the Study of Pain is also not supportive of medicinal cannabis for chronic pain.
6. While the Medical Assessor states "there appear to be no negatives to its use", the Panel believes in the claimant's case, that this is incorrect. In a patient like the claimant, with a long and significant history of "Substance Use Disorder" (ICE addiction), there is a significant risk of induction of a "Cannabis Use Disorder". This will make it difficult to cease the medicinal cannabis and make him liable to dose escalation.
7. "Cannabis Use Disorder" is now well documented in a significant number of medicinal cannabis users - in this disorder there are features of ongoing use despite lack of objective improvement in function and with harm, including financial harm. Those with a past history of "Substance Abuse Disorder" are at much higher risk of developing overuse and even abuse of medicinal cannabis.
8. Medical Assessor Hyde Page stated that "I should also add that the claimant appears to be very responsible in the way he has been using the CBD product". The product is however addictive and will be difficult to cease - this is even if he is responsible and not showing aberrant behaviours (such as using it in doses to achieve intoxication, escalating doses or diverting it for sale).
9. Medical Assessor Hyde Page stated "This is all on the background of the use of CBD products as being experimental and where there are no absolute rules about its use. Instead, it appears essential that any use of CBD products should be ascertained on a patient by patient basis".
10. This justification based on the claimant's report of benefit cannot be accepted without question in this treatment with such a psychoactive and addictive compound - naturally one may feel better taking it even if there is no pain relief. Many patients with chronic pain overuse alcohol because it masks the pain and makes them feel better - however, one would never argue that this is an appropriate-treatment.
11. While there may be cases where cannabis could be considered a reasonable and necessary treatment, the particular circumstances of the claimant, including his dependence on opioid medication and his previous ICE addiction, mean that cannabis use is inappropriate in his case. The risks of adverse effects, such as addiction, sedation and impact on function, discussed above, outweigh the slight benefits.

1. The Panel conducted a new assessment of all the matters with which the medical assessment is concerned.
2. The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: See Insurance Australia Group Ltd v Keen [2021] NSWCA 287 at [40], [41] and [45] and Insurance Australia Ltd v Marsh [2022] NSWCA 31 at [11], [21], and [64].
3. The Panel finds treatment requested by Dr John Prickett on 6 September 2023, namely, a need for a trial of CBD cannabis product to assist with the management of the claimant's accident-related injuries:

(a) relates to the injuries caused by the accident, but

(b) is not reasonable and necessary in the circumstances.

1. The Review Panel revokes the certificate of Medical Assessor Murray Hyde Page dated

29 July 2024 and issues a replacement certificate which is attached at the commencement of these reasons.

1. These reasons contain sensitive personal information. Having weighed the matters referred to in r 132(4) of the PIC Rules, including the safety, health and wellbeing of the claimant, and whether the public interest in giving the direction significantly outweighs the public interest in open justice, the Panel is satisfied that its decision should be de-identified before it is published.

1. The Panel directs that, pursuant to r 132 of the Rules, the decision be de-identified prior to publication.

[5] Subsection 1.3(2)(a) of the MAI Act.

[7] The reference is to Version 10 of the Guidelines which commenced on 15 September 2025.