1. On 18 October 2017, Dr Joo Lee, general practitioner, of Grace Medical Care noted that the applicant had completely ceased tobacco and marijuana intake (smoking) nine days earlier and that he had been smoking 28g of marijuana per week "for years". The applicant complained of symptoms that had commenced within 24 hours of ceasing marijuana and tobacco. Dr Lee diagnosed the applicant with drug withdrawal.[8]
2. On 7 November 2017, Dr Lee noted that the applicant had problems sleeping at night since ceasing marijuana.[9]
3. On 21 November 2017, Dr Nasim Romina, general practitioner, of Grace Medical Care noted that the applicant had been feeling anxious, thinking that someone had poisoned him. The doctor also noted that the applicant had been smoking marijuana since the age of 13 and had recently ceased smoking it. On examination, it was noted that the applicant was agitated. Dr Romina recorded a diagnosis of psychosis, prescribed Seroquel 25mg tablets and recommended a mental health plan and referral to a psychiatrist.[10]
4. On 6 December 2017, Dr Romina noted that the applicant stated that his mood was "ok". The reason for the applicant's visit was stated to be tinnitus. In respect of a plan for the applicant, the doctor recommended that the applicant quit smoking and that his mood be observed, noting his history of paranoid thoughts and anger outbursts.[11]
5. On 8 January 2018, Dr Romina noted that the applicant, amongst other things, had been experiencing flashbacks of childhood abuse. Dr Romina's diagnosis was one of

post-traumatic stress disorder.[12] 6. On 11 January 2018, Dr Romina noted the applicant's attendance in respect of hypercholesterolemia and regarding the symptoms complained of, provided a diagnosis of reflux. The doctor also referred to a mental health follow-up and Lexapro.[13] 7. On 2 May 2018, Dr Oliver Weir, general practitioner, of Grace Medical Care noted that the applicant had experienced multiple gastrointestinal symptoms over the past six months that had been extensively investigated. The doctor also noted that an ultrasound, colonoscopy and endoscopy had demonstrated gastritis. He further noted that the applicant denied alcohol abuse and had ceased cannabis nine months earlier.[14] 8. Except for the complaint referred to in [33] above, I could find no other reference to the applicant's disrupted sleep or insomnia in the Grace Medical Care clinical records prior to 18 September 2018.

The relevant post-injury treating medical evidence

1. On 29 September 2018, the day after the work-related incident described by the applicant at [20] above, he presented to Wyong Hospital with right great toe pain. The hospital discharge referral noted that the applicant had dropped a tow hitch plate onto his right foot the previous day. The injury was closed. X-rays did not show any bony injury. Mild redness over the dorsal surface of the first metatarsophalangeal (MTP) joint and tenderness over the first distal metatarsal and MTP joint was observed. The applicant was advised to follow-up with his general practitioner if there was no improvement in five to seven days.[15]
2. On 30 September 2018, the applicant consulted Dr Pushpa Padmakaran, general practitioner, of Grace Medical Care in respect of the pain in his big toe.[16]
3. On 2 October 2018, the applicant consulted Dr Michael Malek, general practitioner, of Grace Medical Care in respect of his work-related right foot injury to whom he provided a history that was consistent with his evidence. Dr Malek noted that the applicant was still in pain and walked with an antalgic gait. The doctor issued the applicant a certificate of capacity and referred him to Mr Patrick Hart, physiotherapist.[17]
4. On 2 October 2018, the applicant underwent a CT scan of his right foot on the referral of Dr Malek. The CT scan found no evidence of a recent fracture.[18]
5. On 20 December 2018, Dr Malek referred the applicant to Dr John Limbers, orthopaedic surgeon.[19]
6. On 22 January 2019, the applicant consulted Dr Limbers.[20]
7. On 5 February 2019, the applicant underwent an MRI scan of his right forefoot on the referral of Dr Limbers, which demonstrated degenerative changes at the first MTP joint without other significant abnormality.[21]
8. On 13 March 2019, the applicant underwent a CT guided cortisone injection into his right first MTP joint on the referral of Dr Limbers.[22]
9. On 13 March 2019, Ms Lesleigh Creech, podiatrist, reported to Dr Malek that excessive pronation increases weight bearing on the medial side of the feet which increases the load in the first MTP joint. As a result, this caused the development of osteoarthritis and delayed healing of the applicant's recent injury. She opined that the first MTP joint required offloading with orthotics and correct support of good quality footwear to allow healing and reduced pain in the first MTP joint.[23]
10. On 22 March 2019, the applicant consulted Dr Malek complaining of bilateral hip pain.[24]
11. On 21 May 2019, Dr Limbers reported to Dr Malek that the recent MRI scan demonstrated some chondral wear and evidence of injury to the first MTP joint at the site of the applicant's pain. The doctor noted that the recent CT guided cortisone injection into his right first MTP joint had helped the applicant significantly and that he was soon to be fitted with some orthotics.[25]
12. On 11 January 2020, Dr Malek referred the applicant back to Performance Podiatry for an opinion and ongoing management in respect of ongoing right foot pain.[26]
13. On 21 December 2020, Dr Hasher Kadavil, specialist pain management physician and specialist anaesthetist, examined the applicant at the request of EML. He took a history of the work-related incident on 28 September 2018 that was consistent with the evidence. The doctor noted that the applicant's unrelenting right foot pain had a severe impact on his daily functional activities and had an adverse effect on his mood. Dr Kadavil diagnosed the applicant with right foot pain with a mixture of nociceptive and neuropathic features. The doctor recommended referral to an orthopaedic surgeon and thereafter, a follow-up with the applicant to discuss pain management strategies. He also noted that the applicant had developed right hip pain after using footwear adjustment over the past six months.[27]
14. On 12 January 2021, Dr Limbers reported to Dr Malek that he had reviewed the applicant, who complained of ongoing pain in the right first MTP joint. The applicant informed the doctor that the CT guided cortisone injection into his right first MTP joint had helped significantly but had worn off. Dr Limbers noted that the applicant had right foot pain with walking, standing, working and at rest. He further noted that the applicant had tried orthotics, supportive shoes, paracetamol, anti-inflammatories and Panadeine Forte. Dr Limbers opined that the applicant likely had post-traumatic osteoarthritis of the right first MTP joint and discussed operative and non-operative options. He referred the applicant for weight-bearing X-rays in six weeks and that, if he did not settle non-operatively, a right first MTP joint arthrodesis would need to be considered.[28]
15. On 23 February 2021, Dr Limbers reported to Dr Malek that he had reviewed the applicant following repeat X-rays and another CT guided cortisone injection into his right first MTP joint. The injection helped him significantly for two to three days but wore off. The doctor recommended a right first MTP joint arthrodesis, pending EML approval.[29]
16. On 2 August 2022, the applicant underwent a right first MTP joint arthrodesis by Dr Limbers.[30]
17. On 10 November 2022, Dr Kadavil prepared a report for EML. He noted that, since the applicant's last consultation, he had consulted an orthopaedic surgeon, undergone some injections and undergone an MTP fusion with six screws by Dr Limbers. Dr Kadavil also noted that, due to unrelenting pain and change in posture because of his orthotics, the applicant developed pain in both hips. The doctor prescribed the applicant Lyrica 25mg tablets twice daily, which could be escalated to a maximum of 75mg twice daily. He also prescribed Lignocaine patches to be applied to the area of his recent surgery because the applicant had definite neuropathic pain in his operative scar area, mostly the saphenous nerve.[31]
18. On 21 December 2022, Dr Kadavil prepared a report for EML. The doctor noted that the applicant continued to have moderate to severe right foot pain. The Lignocaine patches at night provided some decent sleep but he suffered from a lot of pain during the day, especially with physical activity like walking. Dr Kadavil did not believe that he could contribute anything further for the applicant's pain relief at that time.[32]
19. On 23 May 2023, Dr Limbers reviewed the applicant following a recent bone scan and

X-rays. He felt that the imaging demonstrated that the right first MTP joint had not united and that this may have been the cause of the applicant's ongoing pain. Treatment options were discussed, one of which was a revision MTP joint arthrodesis. The doctor recommended repeat X-rays in six months if the applicant still experienced problems.[33] 20. On 25 May 2023, Dr Kadavil prepared a report for Dr Malek. He noted that the applicant had consulted him that day and advised that he was waiting to see Dr Limbers in respect of his right foot as he may require further surgery. The Lignocaine patches, for the time being, were providing significant pain relief. In respect of the applicant's hips, he had undergone bilateral hip joint injections and felt that the injections had provided him with noticeable pain relief. Dr Kadavil opined that the applicant could undergo hip injections up to three times per year.[34] 21. On 31 August 2023, Dr Limbers reviewed the applicant noting that, with pain modality treatment, his bilateral hips had improved and that the main issue was ongoing pain in the right first MTP joint where there had been non-union. The applicant had tried local anaesthetic patches and was due to receive some shoes and orthotics. He was taking pain relieving medication. Despite these measures, he experienced pain at rest and with walking in the right first MTP joint. Surgery was again discussed. The applicant was to continue with non-operative treatment for the time being and consider his options.[35] 22. On 19 October 2023, the applicant consulted Dr Mustafa Alttahir, orthopaedic surgeon, on the referral of Dr Malek. The doctor took a history of the work-related incident and noted that the pain in the applicant's right big toe had not resolved since. Pain could be so severe that it necessitated him stopping work. Pain affected his sleep and his day-to-day activities. He used pain relief patches. Pain was aggravated with walking, working and even with driving. The applicant used Panadeine Forte, oxycodone and anti-inflammatories to relieve the pain. He complained of hip and foot pain. Dr Alttahir reviewed the available investigations and opined that there was obvious non-union of the right big toe MTP joint that required revision surgery to perform re-fixation with a longer and bigger plate and bigger screws with some graft. In respect of the applicant's hips, Dr Alttahir opined that there were two options, namely, a resurfacing or a total hip arthroplasty bilaterally in a staged manner or in one stage.[36] 23. On 20 December 2023, Dr Malek referred the applicant to Dr Mustafa Alttahir, orthopaedic surgeon, for an opinion and management regarding ongoing severe pain, limited mobility and function in the right foot.[37] 24. On 25 January 2024, the applicant consulted Dr Alttahir for a review regarding his right first MTP joint problem. Given the changes on a recent scan, the doctor opined that the applicant required intervention with a revision plate fixation that may require the harvesting of some bone from his calcaneus. The applicant advised that he was happy to proceed with the surgery.[38] 25. On 5 February 2024, the applicant underwent a revision fusion of the right first MTP joint with calcaneal bone grafting by Dr Alttahir.[39] 26. On 19 February 2024, the applicant was reviewed by Dr Bessam Ahmad, orthopaedic fellow, on behalf of Dr Alttahir. Stitches from the dorsomedial scar of the right big toe were removed. There was no evidence of infection and the wound appeared healthy. The recent X-ray was satisfactory.[40] 27. On 21 March 2024, the applicant was reviewed by Dr Chandan Kulkarni, orthopaedic fellow, on behalf of Dr Alttahir. The doctor reviewed recent X-rays that revealed signs of bone bridging, indicating evidence of union between the two bones. On examination, it was noted that the stitch line was indurated and that there was redness around the surgical site. The commencement of antibiotics was advised.[41] 28. On 2 May 2024, the applicant consulted Dr Alttahir, who then reported back to Dr Malek. Dr Alttahir diagnosed the applicant with end-stage bilateral hip arthritis; right first MTP joint revision fusion with bone grafting from the right calcaneus; and post operative wound complication with stitch abscess. The doctor recommended hip resurfacing surgery, with total hip replacement as an alternative option.[42] 29. On 15 May 2024, the applicant underwent a CT guided injection into the left hip on the referral of Dr Malek.[43] 30. On 17 May 2024, the applicant underwent a CT guided injection into the right hip on the referral of Dr Malek.[44] 31. On 21 June 2024, Dr Malek referred the applicant to Dr Dev Banerjee, sleep and cannabinoid physician, for an opinion and management regarding severe insomnia.[45] 32. On the night of 7 July 2024, Dr Banerjee arranged for the applicant to undergo an overnight type II polysomnography, which was then followed up with a consultation on 8 July 2024[46] and a sleep study report.[47] 33. On 10 July 2024, Dr Banerjee sought EML's approval for the commencement of a

four-month, five stage cannabinoid treatment program of four months duration.[48] 34. On 17 September 2024, Dr Malek referred the applicant to Dr Kadavil for an opinion and management regarding ongoing pain concerns.[49] 35. On 27 October 2024, Dr Banerjee prepared a report at the request of the applicant's lawyers.[50] In the report, Dr Banerjee described himself as a sleep and respiratory physician and one of the top industry experts in cannabinoid medication and treatment of chronic sleep disorders. He explained that he and his team provide patient tailored cannabinoid treatment to people who are significantly unwell. 36. Dr Banerjee explained that his team of therapists provide clinical and medication titration support (the gradual adjustment of medication dosages to find the optimal therapeutic effect while minimising side effects) to manage every aspect of patient care under his direct supervision. The team partners with the patient and their families to navigate pathways to successful expert cannabinoid treatments. They investigate past treatment efforts, review diagnosed injury and illness to identify suitability for the cannabinoid treatment program and individually tailor, manage, implement medication, stabilise and return patients to health. 37. Dr Banerjee explained that ongoing triggers, social isolation and avoidance behaviour further impacts and exacerbates contributing injuries or illnesses such as insomnia, mental health, post-traumatic stress in sleep, depression, anxiety and chronic pain that may also result in abuse of alcohol, traditional medications and/or drug dependency. 38. Dr Banerjee reported that he first examined the applicant on 8 July 2024. He took a history from the applicant that was consistent with the evidence. The doctor noted that the applicant currently had issues with pain, worsening sleep issues and worsening anxiety and mood disturbance. He also noted the applicant's history of post-traumatic stress disorder in 2009 from previous events in his life and that he had been experiencing recent flashbacks from his past. He has struggled with the stress of trying to cope with the injury and deal with the workers compensation process. The doctor noted the applicant's current medications as Targin, Panadeine Forte, Endone, Lidocaine patches and Somac. He also noted medication related gastro-intestinal side effects. 39. Dr Banerjee diagnosed the applicant with mild severity obstructive sleep apnoea; insomnia; hyperarousal state; sleep deprivation; nightmare disorder; anxiety; depression;

post-traumatic stress disorder symptoms; and chronic toe, back and bilateral hip pain. 40. In respect of the applicant's prognosis, Dr Banerjee opined:

"With current insomnia and pain and PTSD, unable to work, will continue on opioids, with financial stress therefore I request alternative medication that can assist with both sleep, anxiety and pain ie medicinal cannabis."[51]

1. Dr Banerjee opined that the applicant's insomnia is a result of the post-traumatic stress disorder and anxiety secondary to the work injury. He further opined:

"The insomnia and nightmare disorder and hypervigilance which is my area of expertise is a direct consequence of the PTSD and anxiety arising from his work injury."[52]

1. As to whether the proposed medicinal cannabis treatment is an accepted treatment management method, Dr Banerjee stated:

"My primary reason for the expert opinion is to find a treatment for the insomnia and nightmares and it is reasonable to suggest medicinal cannabis as an alternative therapy, with growing research showing its benefits in insomnia and anxiety but will also assist with the pain although I am not a pain specialist but current treatments for his pain ie opioids have been unsuccessful."[53]

1. As to whether the applicant's employment materially contributed to the need for the proposed medicinal cannabis treatment, Dr Banerjee stated:

"He clearly describes how a metal plate fell on his toe and how there were issues regarding the processing of plates at work. He describes despite surgery how his pain has not resolved with surgery and therefore alternate medications such as medicinal cannabis is reasonable to undertake."[54]

1. As to whether the proposed medicinal cannabis treatment is an effective treatment management method to manage the applicant's chronic right foot and bilateral hip pain, Dr Banerjee opined:

"It is very reasonable to consider medicinal cannabis to treat his anxiety and insomnia and will also assist in addition his pain. He does not really have another choice on the matter."[55]

1. As to whether the proposed medicinal cannabis treatment is reasonably necessary, Dr Banerjee opined:

"Yes the treatment strategy of medicinal cannabis is necessary as an alternate therapy. Such therapy is TGA listed as medications to be considered and there is growing research showing how medicinal cannabis assists with sleep, anxiety, PTSD and pain."[56]

1. As to whether there are any treatment alternatives for the management of the applicant's chronic right foot and bilateral hip pain, Dr Banerjee opined:

"Raymond is on opioids for pain which has not been successful and his pain continues, as well as his anxiety PTSD and insomnia. Therefore therapy that can treat all of these issues which we have many successful patients like Raymond treated by myself and my team, it can only be right to have this considered for approval by his insurance company."[57]

1. As to the cost-effectiveness of the proposed medicinal cannabis treatment, Dr Banerjee stated:

"Raymond is at further risk of hospitalisation for his pain, and mental health, and there is risk of medical consequences of his high alcohol consumption and therefore the treatment with medicinal cannabis is very reasonable cost effective treatment to consider."[58]

1. Attached to Dr Banerjee's report dated 27 October 2024, was his team's sleep study report summary dated 8 July 2024.[59]
2. On 7 November 2024, Dr Malek prepared a report at the request of the applicant's lawyers.[60] Dr Malek reported that the applicant had been a patient of his at his current practice, Covenant Medical Hub, since 22 November 2023 and for several years prior to that at his previous practice, Grace Medical Care.
3. In his report, Dr Malek provided a history of injury and post-injury treatment that was consistent with the evidence. In respect of his findings on examination and diagnosis, Dr Malek reported as follows:

"Ongoing RIGHT toe/foot pain with more pronounced bilateral hip pain since his

above-mentioned RIGHT foot injury. Noted antalgic gait with limited functional ability & reduced range of movement with ongoing intermittent swelling of his foot and associated shooting pain and pins & needles."[61]

1. Dr Malek opined that, in his medical opinion, the proposed medicinal cannabis treatment is an accepted treatment method to manage the applicant's chronic right foot and bilateral hip pain. He further opined that the applicant's employment had materially contributed to the need for the proposed treatment. He noted that his above expressed opinions were supported by Dr Banerjee.
2. Dr Malek opined that, in his medical opinion, the proposed medicinal cannabis treatment is an effective treatment method to manage the applicant's chronic right foot and bilateral hip pain. He further opined that the proposed treatment is reasonably necessary. He noted that his above expressed opinions were supported by Dr Banerjee.
3. Dr Malek opined that the proposed medicinal cannabis treatment is suitable and that other treatment alternatives may be considered for the management of his chronic right foot and bilateral hip pain, but this is a question better addressed by Dr Banerjee and Dr Kadavil.
4. Dr Malek opined that, in his medical opinion, the proposed medicinal cannabis treatment is a cost-effective way to manage the applicant's injury and that further delays in the insurer's approval to the proposed medicinal cannabis treatment would increase overall costs. He noted that his opinion in this regard was supported by Dr Banerjee and Dr Kadavil.
5. On 25 November 2024, the applicant consulted Dr Kadavil complaining of ongoing bilateral hip pain, the left being worse than the right. He also complained of aches and pains under his right heel due to pressure. The previous pain in his foot, which he described as stepping on screws, had resolved following the surgery on 5 February 2024. Dr Kadavil recorded the applicant's current medications as Endone, Targin, Norspan patches and Lignocaine patches. Dr Kadavil requested EML to approve treatment by way of medicinal cannabis as recommended by Dr Banerjee and stated that:

"Regular follow-up appointments will be offered to monitor Raymond's pain levels, the effectiveness of medicinal cannabis, and his ability to wean off opioid medications. My experience with medicinal cannabis shows a 50% success rate in over 100 patients. If successful in Raymond's case, it would be a significant achievement."[62]

1. On 24 January 2025, the applicant underwent left total hip resurfacing by Dr Alttahir.[63]
2. On 28 February 2025, the applicant consulted Dr Alttahir for post-operative follow-up. The doctor noted that the applicant's post-operative course was complicated by constipation. The applicant described generalised pain and a reduced sensation over the anterolateral aspect of the left thigh. He complained of a sensation of clicking in the left hip. Examination revealed a well-healed surgical wound and global restriction in the left hip range of movement, which was mildly painful. X-rays revealed a well-fixed left hip resurfacing with satisfactory alignment. There was evidence of early osseointegration. Dr Alttahir referred the applicant for physiotherapy to assist with his ongoing pain and restricted range of movement in the left hip.[64]
3. On 11 April 2025, the applicant consulted Dr Alttahir reporting ongoing symptoms of

left-sided hip pain in the form of a deep ache radiating toward the anterior thigh and occasionally, to the ipsilateral knee. He also noticed a clicking sensation in the anterior hip region, particularly when rising from a seated position or after prolonged sitting. Dr Alttahir opined that the applicant's symptoms were suggestive of iliopsoas tendinitis, likely secondary to mechanical irritation of the iliopsoas tendon against the anterior rim of the resurfacing prosthesis. There were no radiographic signs of prosthetic complication. The clinical presentation was consistent with an overuse or impingement-type tendinitis. The doctor referred the applicant for a left hip MRI scan.[65] 4. On 22 April 2025, the applicant underwent a left hip MRI scan. The scan revealed that the iliopsoas insertion appeared probably intact but tendinotic.[66] 5. On 26 August 2025, the applicant consulted Dr Banerjee, who confirmed his diagnosis of mild severity obstructive sleep apnoea; insomnia; hyperarousal state; sleep deprivation; nightmare disorder; anxiety; depression; post-traumatic stress disorder symptoms; and chronic back, bilateral hip and right toe injury at work. Dr Banerjee noted that the applicant had recently tried THC whole extract and found it to be very helpful for sleep and his pain. He expressed a desire to reconsider the option of medicinal cannabis.[67]

1. On 17 January 2025, the applicant consulted Dr Mohammed Assem, rehabilitation specialist, at the request of his lawyers. In evidence, there is a report by Dr Assem dated 17 January 2025.[68] Relevant parts of that report are referred to below.
2. Dr Assem took a detailed history of injury and post-injury treatment that was consistent with the evidence. The doctor noted the following in respect of the applicant's consultation with Dr Banerjee:

"He consulted Dr Banerjee who noted considerable sleep disturbance, nightmares and hypervigilance caused by anxiety due to the work injury. He recommended the use of THC and CBD to manage his pain and sleep pattern. A sleep study on 8 July 2024 showed mild obstructive sleep apnoea. His states that he has found marijuana effective in relieving his symptoms when compared to his prescribed pain medication. He did not report any side effects."[69]

1. In respect of the applicant's present symptoms, Dr Assem recorded the following:

"Mr Pritchard complains of chronic pain in his right big toe that he rated as 8/10 on the pain scale. This is accompanied by stiffness and occasional tingling sensation in the medial aspect of his foot. The pain is exacerbated by standing or walking for more than 20 to 30 minutes. There is discomfort in the ball of his right foot when driving for extended periods and discomfort in rocker bottom shoes, the only footwear that he finds supportive. In addition, he has bilateral hip pain worse on the left side that is rated 9/10, increasing to 10/10 after standing from a seated position."[70]

1. Dr Assem conducted a physical examination, referred to the available medical investigations and then provided the following diagnosis:

"Mr Pritchard developed post traumatic osteoarthritis of the right first MTP joint as a consequence of a work related injury requiring an arthrodesis in 2022 followed by revision surgery and bone grafting in 2024. He has persistent foot pain limiting his mobility. As a result of his altered gait pattern, he has aggravated pre-existing and longstanding osteoarthritic changes in his hip rendering it symptomatic. He now has a chronic pain syndrome, anxiety and disturbed sleep pattern."[71]

1. As to whether the proposed medicinal cannabis treatment arises as a consequence of the applicant's work-related injuries, Dr Assem opined:

"The proposed treatment arose as a consequence of his work injuries. He has chronic right foot and bilateral hip pain as well as exacerbated PTSD and sleep disturbances all direct or indirect results of the workplace injury on 28 September 2018. CBD / THC is being proposed to address chronic pain, anxiety and insomnia which are established consequences of the injury and subsequent complications. Although he denied any illicit drug use, Dr Malek has noted a past history of drug abuse and ? psychosis. This raises concerns about safety but the primary focus of the treatment plan (pain and symptomatic relief) is clearly linked to the workplace injury.

There is emerging evidence supporting CBD / THC for managing chronic pain particularly neuropathic pain. It has also been investigated for anxiety and PTSD with some studies suggesting benefits for reducing hypervigilance and reducing [sic: improving] sleep. However, these are not universally accepted first line treatments. In possible history of drug misuse or psychosis, careful evaluation will be needed as THC can exacerbate psychotic symptoms and dependency in vulnerable individuals. If treatment is pursued, highly monitored, low THC regime would be prudent."[72]

1. Dr Assem opined that the work-related injury had materially contributed to the need for medical treatment.
2. As to whether the proposed medicinal cannabis treatment is an effective treatment management method for the applicant's condition, Dr Assem opined:

"The treatment can potentially be effective management with significant caveats. CBD / THC may provide relief for chronic pain, particularly in patients unresponsive to traditional analgesia. It may reduce anxiety and improve sleep, but THC could worsen psychiatric symptoms. The effectiveness varies significantly between individuals."[73]

1. As to whether the proposed medicinal cannabis treatment is reasonably necessary treatment for the applicant's condition, Dr Assem opined:

"Partially under certain conditions given the history noted above, a low CBD only formulation might be more appropriate."[74]

1. In respect of whether there are treatment alternatives for the applicant's condition, Dr Assem opined:

"Yes, there are certain alternatives that exist. This would include the continual use of multimodal analgesics and advanced interventional treatment such as nerve blocks. Psychological support including cognitive behavioural therapy would assist with anxiety and PTSD. Pharmacological options such as SSRIs or non-addictive anxiolytics can be used. Melatonin may assist with the sleep disturbance."[75]

1. In respect of the cost effectiveness of the proposed medicinal cannabis treatment, Dr Assem opined:

"The proposed treatment is potentially cost effective but with limitations. While CBD / THC may reduce reliance on high cost opioids and other medications, the long term outcome is uncertain particularly when he will require careful monitoring. There is a risk of adverse or misuse which could result in additional health care costs."[76]

1. Dr Assem concluded with the following observations:

"While CBD / THC treatment may be beneficial managing pain and psychological symptoms, it is not without risk. The history of drug misuse and possible psychosis requires cautious consideration emphasizing a low THC or CBD only formulation if treatment proceeds. Alternative treatment such as advanced pain management techniques, psychological support and sleep interventions should be fully explored before adopting CBD / THC as a primary treatment."[77]

Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists

1. In evidence, there is a statement on medicinal cannabis with particular reference to its use in the management of patients with chronic non-cancer pain issued by the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists in November 2021.[78] The statement highlights the following key points:

(a) Australia has updated regulations regarding medicinal cannabis and THC has been rescheduled to a controlled drug (S8) and licenses for cultivation and production have been granted;

(b) the Faculty of Pain Medicine states that current evidence does not support the efficacy of cannabinoids for managing chronic non-cancer pain, and this is unlikely to change due to challenges in conducting trials for such conditions;

(c) the Faculty of Pain Medicine highlights concerns about adverse effects of cannabis use, particularly in young people, including respiratory issues, psychotic symptoms and cognitive impairment, and

(d) the Faculty of Pain Medicine emphasises the importance of a sociopsychobiomedical approach to managing chronic pain, which includes active patient engagement and caution regarding polypharmacy, with cannabinoids in particular.

1. In evidence, there is a fact sheet regarding the prescription of medicinal cannabis for chronic non-cancer pain issued by the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists in March 2022. The fact sheet highlights the following key points:

(a) medicinal cannabis refers to cannabis products prescribed by healthcare practitioners to relieve medical symptoms and the common cannabinoids used are THC and CBD;

(b) the Faculty of Pain Medicine aligns with the International Association for the Study of Pain, which does not support the general use of cannabis for pain due to insufficient scientific evidence of its safety and effectiveness;

(c) medicinal cannabis products must meet government regulatory standards for purity, safety, and efficacy and currently, there is not enough robust evidence to support its use for chronic pain;

(d) cannabis can have negative effects, including impaired breathing, mental illness symptoms and altered brain function, especially in young people, with side effects that can be harmful and may worsen quality of life;

(e) people with chronic non-cancer pain are encouraged to explore non-medicinal treatments with their general practitioner or specialist team, as these may improve quality of life, and

(f) medicinal cannabis use for chronic pain should only occur within clinical trials, where potential harms, benefits and uncertainties are explained and outcomes are monitored.

1. The parties made oral submissions at the arbitration hearing which were sound recorded. The sound recording is available to the parties. Outlines of the parties' submissions are provided below.

1. The applicant's statement that, since the onset of the injury his sleep has continued to be disrupted, was inconsistent with the entries reporting insomnia in his general practitioner clinical records pre-dating 28 September 2018.
2. The applicant's statement that he had, in the past, resorted to occasionally taking marijuana to relieve his pain symptoms, was inconsistent with his reported longstanding use of marijuana in his general practitioner clinical records.
3. There were early references in the applicant's general practitioner clinical records to psychosis. The difficulty with this was the fact that neither treating medical specialists, Dr Banerjee or Dr Kadavil, had seen the applicant's early general practitioner clinical records. There is a concern, from a clinical perspective, that the proposed treatment may result in a psychotic episode.
4. In his report dated 8 July 2024, Dr Banerjee failed to reference the general practitioner clinical records that referred to the applicant's earlier marijuana use since the age of 15. Dr Banerjee noted that the applicant had a history of post-traumatic stress disorder in 2009 from previous events in his life and had recently been experiencing flashbacks. Whilst Dr Banerjee was confident that the proposed treatment would reduce the applicant's sleep disorder, he felt that it would also assist with the post-traumatic stress disorder and anxiety conditions.
5. In Dr Malek's report dated 16 November 2022, he noted that the applicant now suffers from depression and anxiety.
6. The applicant's own independent medical examiner, Dr Assem, was ambivalent when it came to expressing an opinion as to whether the proposed treatment would be efficacious and whether it was reasonably necessary because of the injury. Dr Assem noted emerging evidence supporting CBD/THC for the management of chronic pain, particularly, neuropathic pain. He also noted, however, that these were not universally accepted first line treatments and that in cases of the possible history of drug misuse or psychosis, careful evaluation was required as THC could exacerbate psychotic symptoms and dependency in vulnerable individuals. If such treatment were pursued, a highly monitored, low THC regime would be prudent. Dr Assem provided an opinion as to alternative treatments for the management of the applicant's condition.
7. In his report dated 7 November 2024, Dr Malek maintained his opinion that the proposed treatment was suitable and that other treatment alternatives may be considered for the management of his chronic right foot and bilateral hip pain but that it was a question better addressed to the applicant's treating specialists.
8. In his report dated 25 November 2024, Dr Kadavil supported the treatment recommended by Dr Banerjee. However, Dr Kadavil had not seen the applicant's pre-injury general practitioner clinical records referring to an earlier diagnosis of psychosis.
9. There were many references to the applicant's sleep disturbance condition in the clinical records in evidence.
10. The respondent accepts that the applicant has been in considerable pain, especially since the surgical procedures undergone by him. However, there are concerns about the proposed treatment possibly aggravating his pre-existing psychosis.
11. On 18 October 2017, Dr Yee recorded that the applicant had been smoking 28g of marijuana per week for years.
12. On 7 November 2017, Dr Yee recorded that the applicant was already suffering from insomnia.
13. On 21 November 2017, Dr Romina recorded a history of the applicant feeling anxious thinking that someone had poisoned him. The doctor further noted that the applicant had stopped smoking marijuana recently and had been smoking marijuana since the age of 13. On examination, he was agitated. Dr Romina's diagnosis was psychosis. This incident occurred some 10 months prior to the subject injury.
14. On 6 December 2017, Dr Romina recorded that the applicant was having paranoid thoughts.
15. On 8 January 2018, Dr Romina recorded that the applicant was having flashbacks of childhood abuse. The doctor diagnosed post-traumatic stress disorder.
16. On 11 January 2018, Dr Romina recorded a plan that included following-up a mental health plan and Lexapro.
17. The respondent referred to some academic documents in evidence from the Australian and New Zealand College of Anaesthetists in 2021 and 2022 that find that there are some disturbing trends in respect of medicinal cannabis, particularly with reference to exacerbations of psychotic conditions in patients that may have some clinical egg shell skull type process.
18. The respondent noted that, without doubt, the applicant is a man that is suffering considerably and to his credit, he has tried many regimes of treatment. However, as Dr Assem pointed out, there are other options available to him. Dr Assem raises the potential rejuvenation of a psychotic episode or psychosis and so, one must have great concerns about whether the proposed treatment will be efficacious.
19. The respondent referred to Diab v NRMA Ltd[79] (Diab) and the relevant criteria referred to in that decision, to which I will refer to later in some detail.
20. On the evidence and for the reasons referred to in submissions, there ought to be an award for the respondent in these proceedings.

1. The respondent does not have any medico-legal evidence in its case to resist this application.
2. The crux of the respondent's submissions is the possibility that the proposed treatment will aggravate the applicant's pre-existing psychosis. However, such argument overlooks the fact that the applicant is subject to the care and expertise of, at least, two treating specialists. He benefits from the care and expertise of a general practitioner, who has treated him for years and who is well aware of his medical history.
3. There is insufficient foundation in some of the reservations expressed by Dr Assem to enable the Commission to reach any conclusion that the proposed treatment is not reasonably necessary and that the treatment would not provide the applicant with any benefit.
4. In his report dated 17 January 2025, Dr Assem noted that the applicant stated that he had found marijuana effective in relieving his symptoms when compared to his prescribed pain medication. Importantly and of material relevance, Dr Assem noted that the applicant did not report any side effects in this regard. There is no evidence of any side effects experienced by the applicant. Therefore, in respect of his use of marijuana, the Commission would accept that as being an uncontroversial feature of the evidence. The Commission would also accept the applicant's evidence that resort to marijuana has a beneficial effect in relieving his symptoms when compared with his prescribed pain medication.
5. The applicant's pain medication has not been effective. The Commission would be aware of the effects of opiates on the digestive system. The applicant's evidence refers to the difficulties he has experienced in relation to that medication.
6. Dr Assem opined that the applicant now has a chronic pain syndrome, anxiety and a disturbed sleep pattern. Those elements of his condition may be relieved by the proposed treatment.
7. It should be borne in mind that the proposed treatment sought is a trial. The purpose of the four month trial is to consider whether the proposed treatment is of any benefit. It may well be that, during the trial, it is found not to be effective. In such circumstances, the applicant would not seek an extension of the treatment. If the applicant were to seek an extension of the treatment, the Commission might not be minded to extend the treatment on the basis that the evidence gathered during the treatment trial did not satisfy the Commission that the treatment is reasonably necessary.
8. The respondent is endeavouring to thwart the trial of the proposed treatment. The trial will be an important way of ascertaining whether the proposed treatment will be of benefit to the applicant and worthy of being sustained into the future.
9. Dr Assem opined that the proposed treatment arose as a consequence of the applicant's work injuries, namely, chronic right foot and bilateral hip pain, exacerbated post-traumatic stress disorder and sleep disturbances, all of which were direct or indirect results of the workplace injury on 28 September 2018. Now, comes the question of how to provide relief in respect of that work-related condition.
10. Dr Assem observed that the proposed treatment is to address chronic pain, anxiety and insomnia, which he established were consequences of the work-related injury. The question is whether there is a prospect of the proposed treatment relieving those symptoms. The respondent questioned whether this would be so and drew attention to the applicant's denial of drug abuse being inconsistent with Dr Malek's clinical records, which noted a history of drug abuse and psychosis in the past. In this regard, it is important to note that Dr Malek, having treated the applicant for years, was well aware of his patient's condition, prior use of marijuana and of, at least, one episode of psychosis. Having regard to that history, Dr Assem says that it raises concerns about safety but that the primary focus of the treatment (pain and symptomatic relief) is clearly linked to the workplace injury.
11. In respect of the issues of safety referred to by Dr Malek, the Commission can assume that Dr Banerjee, who specialises in this area, will exercise his professional responsibility and judgment in determining the relevant prescription that is to be applied in the course of the proposed treatment trial.
12. Dr Assem noted that there is emerging evidence supporting CBD/THC for managing chronic pain, particularly, neuropathic pain.
13. There are many decisions in the Commission where the precise treatment being sought in this application has been the subject of awards in favour of the worker. Harvey v KW Resort Management Pty Ltd [80]and White v Gilda Fabrics Pty Ltd[81] are two recent cases.
14. It should be borne in mind that the proposed treatment is a trial and one would assume that the responsible medical practitioners will have regard to all relevant aspects when they make the relevant prescriptions, the relevant dosage and importantly, monitor the response of the patient.
15. Dr Assem noted that CBD/THC treatment has also been investigated for anxiety and

post-traumatic stress disorder, with some studies suggesting benefits for reducing hypervigilance and sleep. He also noted that they were not universally accepted first line treatments. Whilst the treatment may not be a universally accepted first line treatment, with the evolution of medical science, such treatment is becoming common. This is borne out by a multitude of decisions of the Commission. 16. Dr Assem noted that in a possible history of drug misuse or psychosis, careful evaluation would be needed as THC can exacerbate psychotic symptoms and dependency in vulnerable individuals. The respondent referred to the entry in the general practitioner clinical records on 21 November 2017 made by Dr Romina wherein he diagnosed the applicant with psychosis. The plan involved a follow-up in respect of his agitation and anxiety. The reference in the clinical records to the applicant having smoked marijuana since the age of 13, is not of any relevance to his current practice of consumption. On review of the balance of the clinical records, it is not open for the respondent to suggest that the applicant has a psychotic history that was the subject of treatment and for that reason, can currently be considered to have a psychotic condition which is likely to be aggravated or triggered by the proposed treatment. 17. The entry in the general practitioner clinical records on 2 May 2018 made by Dr Weir recorded that the applicant denied alcohol abuse and had stopped cannabis use nine months earlier. The clinical notes reflect cannabis use as no longer being a feature. 18. There is no basis for the respondent to suggest that the applicant has any particular vulnerability to abuse of marijuana. 19. There is acceptance by Dr Assem of, at least, a low THC regime but he would need to defer to Dr Banerjee, who has specialist expertise in relation to the proposed treatment. 20. Dr Assem stated that the proposed treatment can potentially be effective management with significant caveats. Further, CBD/THC may provide relief for chronic pain, particularly in patients unresponsive to traditional analgesia. In this case, the applicant remains in chronic pain and the traditional treatment methodology has not assisted. 21. Importantly, Dr Assem stated that the proposed treatment may reduce anxiety and improve sleep but that the THC could worsen psychiatric symptoms. Again, this is a matter to be monitored in the course of the proposed trial. 22. Dr Assem noted that the effectiveness of the proposed treatment varies significantly between individuals. The respondent would have to concede that the variation may, for some individuals, involve significant improvement and for others, no improvement. If there is no improvement, the trial will provide relevant information as to whether the proposed treatment is of particular benefit to the applicant. 23. Dr Assem's suggestion that a low CBD dose or formulation might be more appropriate is a matter for the treating specialist, Dr Banerjee. 24. Dr Assem's opinion as to alternative treatments that might be appropriate, does not mean that CBD oil is not an appropriate method of treatment. 25. The respondent did not suggest that the proposed treatment is unreasonably expensive. It plainly is not. Dr Assem accepts that the treatment is potentially cost effective. Whilst Dr Assem's view that CBD/THC treatment may reduce reliance on high cost opioids and medications but that the long term outcome is uncertain particularly when careful monitoring will be required, such proper monitoring will be provided during the course of the trial of the proposed treatment. 26. Dr Assem's opinion that there is a risk of adverse or misuse that could result in additional healthcare costs is a possibility but again, it is a matter that is to be the subject of proper monitoring during the course of the proposed treatment trial. 27. In his report dated 27 October 2024, Dr Banerjee noted that he and his team are industry leading experts, providing patient tailored cannabinoid treatment. There was no evidence submitted by the respondent to the contrary. Accepting that Dr Banerjee is a leading expert in this particular field, the Commission would defer to his expertise. 28. Dr Banerjee provided a thorough account of the applicant's condition. He diagnosed the applicant with obstructive sleep apnoea of mild severity, insomnia, hyperarousal state, sleep deprivation, nightmare disorder, anxiety, depression, symptoms of post-traumatic stress disorder, chronic back and bilateral hip pain and a toe injury at work. Importantly, this opinion was provided after having had the benefit of a sleep study. 29. Dr Banerjee noted that with his current insomnia, pain and post-traumatic stress disorder and being unable to work, the applicant would continue on opioids. He, therefore, requested cannabis as an alternative medication that can assist with sleep, anxiety and pain. The respondent cannot challenge that opinion as it has no countervailing medico-legal evidence to suggest that the proposed alternative treatment cannot assist. The respondent's only refuge is to suggest that, notwithstanding those obvious benefits, there is a possibility of aggravating the applicant's psychosis. However, there is no underlying condition of psychosis as borne out in the general practitioner medical records. Those records demonstrated an episode in 2017. 30. Dr Banerjee reported that the applicant's insomnia, nightmare disorder and hypervigilance is within his area of expertise and opined that those conditions were a direct consequence of the post-traumatic stress disorder and anxiety arising from his work injury. 31. Dr Banerjee stated that the primary reason for his expert opinion is to find a treatment for the insomnia and nightmares and that it is reasonable to suggest medicinal cannabis as an alternative therapy. Growing research shows its benefits in insomnia and anxiety but will also assist with the pain. Dr Banerjee stated that, whilst he is not a pain specialist, the applicant's current treatment for his pain, opioids, have been unsuccessful. 32. Dr Banerjee opined that it is very reasonable to consider medicinal cannabis to treat the applicant's anxiety and insomnia. The treatment will also assist his pain. Dr Banerjee believed the applicant did not really have another choice on the matter. 33. Dr Banerjee opined that the proposed treatment is necessary as an alternate therapy, which is listed as medication to be considered by the Therapeutic Goods Administration (TGA). He further noted that there is growing research showing how medicinal cannabis assists with sleep, anxiety, post-traumatic stress disorder and pain. 34. Dr Banerjee opined that the applicant was at further risk of hospitalisation for his pain, mental and health and a risk of medical consequences because of his high alcohol consumption. Therefore, treatment with medicinal cannabis is a very reasonable cost effective treatment to consider. 35. In the absence of any competing medico-legal opinion from the respondent, Dr Banerjee's opinion is an undisputed expert opinion. The Commission would defer to Dr Banerjee's experience and his ability to speak with comparative knowledge of patients who are in a similar position to the applicant. The applicant should surely be given the option of the benefits of the proposed treatment that Dr Banerjee believes it can provide. 36. Dr Malek treated the applicant in two different medical practices over several years. In his report dated 7 November 2024, he confirmed all the relevant elements of s 60 in the 1987 Act in support of the treatment proposed by Dr Banerjee. 37. In his report dated 25 November 2024, Dr Kadavil referred to pain in the applicant's bilateral hips and right foot for six years. In respect of the treatment proposed by Dr Banerjee, he sought the insurer's approval of medicinal cannabis. Regular follow-up appointments would be offered to the applicant to monitor pain levels, the effectiveness of medicinal cannabis and his ability to wean off opioid medications. It follows that there would be a review of the relevant dosage and its effects. In so far as there are side effects, it would follow that any responsible medical practitioner would adapt the treatment to avoid any harm to the patient. 38. Dr Kadavil stated that his experience with medicinal cannabis showed a 50% success rate in over 100 patients and that, if the proposed treatment is successful, it would be a significant achievement. 39. Even if there is a success rate of 10%, the applicant should have the benefit of being one of those fortunate to secure relief through the proposed mode of treatment. If the outcomes are as effective as Dr Kadavil suggests, that would surely confirm that the proposed treatment is reasonably necessary and that the applicant should be afforded the prospect of relief. 40. Dr Banerjee and Dr Kadavil support the trial of the proposed treatment. Dr Assem supports a trial and assumes that the applicant will be properly monitored. 41. The applicant seeks a finding that the treatment proposed by Dr Banerjee is reasonably necessary as a result of the injury suffered on 28 September 2018 and an order under s 60 of the 1987 Act that the respondent pay the cost of the treatment as recorded in Dr Banerjee's quotation.

1. Section 60(1) of the 1987 Act relevantly provides that, if as a result of an injury received by a worker, it is reasonably necessary that any medical or related treatment be given, the worker's employer is liable to pay, in addition to any other compensation under the Act, the cost of that treatment or service.
2. Section 60(5) of the 1987 Act relevantly provides the Commission with jurisdiction to determine a dispute concerning any proposed treatment or service and the compensation that will be payable under s 60 of the 1987 Act in respect of any such proposed treatment or service. In this case, the proposed treatment is the five-stage cannabinoid treatment (CBD/THC) of four months duration proposed by Dr Banerjee on 10 July 2024.
3. The applicant bears the onus of proof to establish his case under s 60 of the 1987 Act on the balance of probabilities.
4. There are two elements to s 60(1) of the 1987 Act that must be considered. The first element is "as a result of an injury received by a worker". The second element is that of "reasonably necessary" treatment. The determination of these elements involve matters of impression and degree, having regard to the available evidence.
5. Dealing with the first element, namely, "as a result of injury received by a worker", I am required to conduct a common sense evaluation of the causal chain to determine whether the treatment proposed by Dr Banerjee is reasonably necessary treatment as a result of the injury sustained by the applicant on 28 September 2018 within the meaning of s 60 of the 1987 Act.
6. The issue of causation must be based and determined on the facts in each case and requires a common sense evaluation of the causal chain: Kooragang Cement Pty Ltd v Bates[82] (Kooragang). As I understand it, when referring to applying "common sense", Kirby, P in Kooragang was not suggesting that it be applied "at large" or that issues were to be determined by "common sense" alone but by a careful analysis of the evidence, including a careful analysis of the expert evidence: Kirunda v State of New South Wales (No 4)[83] (Kirunda). The legislation must be interpreted by reference to the terms of the statute and its context in a fashion that best effects its purpose.
7. Murphy v Allity Management Services Pty Ltd_[84]_ referred to Kooragang and is authority for the proposition that an injured worker must establish that the injury materially contributed to the need for the treatment or the surgery. The need for treatment or surgery can arise from multiple causes. The work injury does not have to be the only, or even a substantial, cause of the need for the relevant treatment before the cost of that treatment is recoverable under s 60 of the 1987 Act. The applicant only has to establish, applying the common sense test of causation, that the treatment is reasonably necessary "as a result of" the injury. That is, he has to establish that the injury materially contributed to the need for the surgery.
8. Turning to the "reasonably necessary" element, Roche DP in Diab set out the "standard" test adopted for determining if medical treatment is reasonably necessary in Rose v Health Commission (NSW)[85] (Rose) and he noted subsequent appellate authority with respect to the use of the words "reasonably necessary".
9. Roche DP's observations in Diab of the words "reasonably necessary", after noting the appellate authority, may be summarised as follows:

(a) reasonably necessary does not mean "absolutely necessary";

(b) depending on the circumstances, a range of different treatments may qualify as "reasonably necessary" and a worker only has to establish that the treatment claimed is one of those treatments;

(c) the relevant matters, according to the criteria of reasonableness, include, but are not necessarily limited to, the matters noted by Burke CCJ in Rose:

(i) the appropriateness of the particular treatment;

(ii) the availability of alternative treatment, and its potential effectiveness;

(iii) the cost of the treatment;

(iv) the actual or potential effectiveness of the treatment, and

(v) the acceptance by medical experts of the treatment as being appropriate and likely to be effective;

(d) in respect of the criteria referred to in (c)(iv) above, while the effectiveness of the treatment is relevant to whether the treatment was reasonably necessary, it is certainly not determinative as the evidence may show that the same outcome could be achieved by a different treatment, but at a much lower cost;

(e) bearing in mind that all treatment, especially surgery, carries a risk of a less than ideal result, a poor outcome does not necessarily mean that the treatment was not reasonably necessary, and

(f) while the above matters are useful heads for consideration, the essential question remains whether the treatment was reasonably necessary and as always, each case will depend on its facts.

The "as a result of injury" element of s 60(1) of the 1987 Act

1. There is no dispute that, on 28 September 2018, the applicant sustained an injury to his right foot arising out of or in the course of his employment with the respondent.
2. There is no dispute that the applicant sustained consequential conditions to his bilateral hips as a result of the accepted injury to his right foot.
3. The applicant's right foot injury resulted in him undergoing a right first MTP joint arthrodesis on 2 August 2022. Following this surgical procedure, the unchallenged evidence is that the applicant continued to suffer pain, discomfort and restriction in his right foot and bilateral hips.
4. Evidence emerged on medical imaging that there was obvious non-union of the applicant's right big toe MPT joint. The applicant then underwent a revision fusion of the right first MTP joint with calcaneal bone grafting on 5 February 2024. Following this surgical procedure, the unchallenged evidence is that the applicant continued to suffer pain, discomfort and restriction in his right foot and bilateral hips.
5. On 24 January 2025, the applicant underwent a left total hip resurfacing.
6. Dr Kadavil diagnosed the applicant with right foot pain with a mixture of nociceptive and neuropathic features.
7. Dr Banerjee diagnosed the applicant with mild severity obstructive sleep apnoea; insomnia; hyperarousal state; sleep deprivation; nightmare disorder; anxiety; depression;

post-traumatic stress disorder symptoms; and chronic toe, back and bilateral hip pain. He opined that the applicant's insomnia is a result of the post-traumatic stress disorder that dated back to 2009 from previous events in his life and anxiety secondary to the work injury. Dr Banerjee opined that the applicant's injuries materially contributed to the need for the proposed treatment in circumstances where current treatment of his pain with opioids had been unsuccessful. 8. I reject the respondent's submission that there was an inconsistency between the applicant's evidence regarding the onset of his sleep disruption after the work-related incident and the entries reporting his insomnia in the Grace Medical Care clinical records prior to 28 September 2018. There was only the one entry on 7 November 2017 that recorded the applicant having problems sleeping at night since ceasing marijuana. I accept the applicant's evidence that, since the work-related incident, his sleep has continued to be disrupted and that he finds it difficult to get comfortable during the night and fall asleep because of the pain in his right toe, right foot and bilateral hips. 9. Dr Malek diagnosed the applicant with chronic right foot and bilateral hip pain. He opined that the applicant's injuries materially contributed to the need for the proposed treatment. 10. Dr Assem opined that the applicant now has a chronic pain syndrome, anxiety and disturbed sleep pattern. He explained that the applicant had chronic right foot and bilateral hip pain as well as exacerbated post-traumatic stress disorder and sleep disturbances which were all direct or indirect results of the workplace injury. He further opined that the applicant's injuries materially contributed to the need for medical treatment. 11. In addition to the surgical procedures referred to above, the applicant underwent the following treatment since injury:

(a) fitting of orthotics;

(b) provision of supportive footwear;

(c) CT guided cortisone injections into the right first MTP joint;

(d) CT guided cortisone injections into the bilateral hips;

(e) pain management consultations;

(f) physiotherapy;

(g) use of boomerang pillows in bed;

(h) use of heat packs, and

(i) medications in the form of Lyrica, Lignocaine patches, Norspan Patches, Panadeine Forte, Oxycodone, Targin, Endone and Somac.

1. I accept the applicant's evidence that none of the above forms of treatment provided any lasting significant relief from his chronic right foot and bilateral hip pain. I also accept his evidence that the ongoing pain in his right foot and bilateral hips cause him difficulty in falling asleep and remaining asleep at night.
2. The unchallenged evidence is that, despite the surgical procedures and other treatment referred to above, the applicant has continued to suffer chronic pain in his right foot and bilateral hips that have significantly affected his quality of life and daily functional activities as described in his evidentiary statements and as he described to the medical practitioners he consulted.
3. In its submissions, the respondent quite properly noted that, without doubt, the applicant is a man that is suffering considerably and that, to his credit he had tried many regimes of treatment. The respondent accepted that the applicant has been in considerable pain, especially since the surgical procedures undergone by him.
4. The need for treatment can arise from multiple causes. The work injury does not have to be the only, or even a substantial, cause of the need for the relevant treatment before the cost of that treatment is recoverable under s 60 of the 1987 Act.
5. There is clearly a material contribution between the applicant's right foot injury, bilateral hip conditions and disturbed sleep condition and the need for the proposed medicinal cannabis treatment.
6. I find that the applicant has established, applying the common sense test of causation, that the proposed treatment is "as a result of" injury on 28 September 2018. That is, he has established that the injury materially contributed to the need for the proposed treatment.

The "reasonably necessary" element of s 60(1) of the 1987 Act

1. I will now deal with the second element in s 60(1) of the 1987 Act, that is, whether the proposed treatment is reasonably necessary.
2. It is important to note that the approval sought by Dr Banerjee is for a four month five-stage cannabinoid treatment. After the four month treatment period, the treatment is to be reviewed by Dr Banerjee and his team.
3. Dr Banerjee's expertise in cannabinoid medication and treatment is unchallenged.
4. All forms of medical and related treatment carry risks which must be balanced against the benefit that it may provide or has provided in the past.
5. The Grace Medical Care clinical records pre-dating the work-related incident referred to the applicant having experienced anxiety, a history of post-traumatic stress disorder symptoms in 2009 from earlier events in his life and a psychosis diagnosed on 21 November 2017. The unchallenged evidence is that the post-traumatic stress disorder symptoms included recent (post-injury) flashbacks and that his anxiety had worsened post-injury. The applicant also had a history of pre-injury gastro-intestinal symptoms recorded in the Grace Medical Care clinical records. The applicant's evidence, which I accept, was that his post-injury medications had caused him digestive side-effects.
6. The applicant's evidence was that he had resorted to occasionally taking marijuana to help relieve his pain symptoms. He found that marijuana was effective in relieving his pain and that it worked better than the prescribed pain medication he was taking. He did not experience any side-effects from his use of marijuana. He only relied on it for a very short time because of financial reasons. I do not accept the respondent's submission that the applicant's evidence in this regard was inconsistent with his reported longstanding use of marijuana in the clinical records. On 18 October 2017, Dr Yee noted in the Grace Medical Care clinical records that the applicant had been smoking 28g of marijuana for years but had ceased nine days earlier. On 21 November 2017, Dr Romina noted in the Grace Medical Care clinical records that the applicant had been smoking marijuana since the age of 13 years and had recently ceased. This was not inconsistent with the applicant occasionally taking marijuana to help effectively relieve his pain symptoms since the subject work-related injury. I accept the applicant's evidence that he was financially unable to continue privately accessing marijuana and that he would prefer to undergo the proposed cannabinoid treatment under the care and treatment of medical practitioners rather than obtaining marijuana independently.
7. On 26 August 2025, Dr Banerjee noted that the applicant had recently tried THC whole extract and found it very helpful for sleep and for his pain and had expressed a desire to reconsider the option of medicinal cannabis.
8. I do not accept the respondent's submission that the failure by Dr Banerjee or Dr Kadavil to reference the applicant's pre-injury Grace Medical Care clinical records in some way affects the opinions they expressed in their reports because they did not consider his pre-injury cannabis use, the one-off diagnosis of psychosis and other conditions that pre-dated the work injury. Dr Malek, having treated the applicant for several years in two medical centres, was familiar with the applicant's medical history and cannabis use. Even if such history had not been provided to Dr Banerjee and Dr Kadavil at the time of Dr Malek's referral, it is part of Dr Banerjee's process to investigate past treatment efforts, review diagnosed injury and illness to identify suitability for the cannabinoid treatment program and individually tailor, manage, implement medication, stabilise and return patients to health. Dr Banerjee and his team of therapists provide the gradual adjustment of medication dosages to find the optimal therapeutic effect while minimising side effects. Such a process must assuage the respondent's concern that the proposed treatment "may" result in a psychotic episode.
9. During the course of the proposed treatment, the applicant will be under the expert care of Dr Banerjee and his team of therapists. Dr Kadavil stated that regular follow-up appointments would be offered to monitor the applicant's pain levels, the effectiveness of the treatment and his ability to wean off opioid medications. Dr Kadavil's experience with medicinal cannabis demonstrated a 50% success rate in over 100 patients and that, if successful, it would be a significant achievement for the applicant. Dr Kadavil requested EML to approve treatment by way of medicinal cannabis as recommended by Dr Banerjee.
10. Dr Banerjee stated that the primary reason for his expert opinion is to find a treatment for the applicant's insomnia and nightmares and that it is reasonable to suggest medicinal cannabis as an alternative therapy. He noted that growing research shows its benefits in insomnia and anxiety but will also assist with pain. Dr Banerjee stated that, whilst he is not a pain specialist, the applicant's current treatment for his pain, opioids, have been unsuccessful.
11. Dr Banerjee opined that the proposed treatment is necessary as an alternate therapy, which is listed as medication to be considered by the TGA. He further noted that there is growing research showing how medicinal cannabis assists with sleep, anxiety, post-traumatic stress disorder and pain.
12. Dr Assem noted a history of drug abuse and (query) a psychosis which raised concerns about safety in respect of the proposed treatment. He further noted that there is emerging evidence supporting CBD / THC for managing chronic pain particularly neuropathic pain. It has also been investigated for anxiety and PTSD with some studies suggesting benefits for reducing hypervigilance and improve sleep. However, he conceded that these are not universally accepted first line treatments. In the applicant's case, where there was a possible history of drug misuse or psychosis, careful evaluation would be required as THC can exacerbate psychotic symptoms and dependency in vulnerable individuals. If treatment is to be pursued by the applicant, then a highly monitored, low THC regime would be prudent. In this regard, Dr Banerjee's proposed treatment regime fits in Dr Assem's suggestion that it be highly monitored.
13. Dr Assem opined that the proposed treatment could potentially be effective with the caveat that it could worsen psychiatric symptoms and that it is reasonably necessary treatment under certain conditions. Any such psychiatric symptoms would be highly monitored in the treatment program Dr Banerjee and his team of therapists routinely adopt as referred to in [208] above.
14. I acknowledge that there is a body of evidence that finds medicinal cannabis is not an effective treatment for chronic pain in non-cancer patients as set out in the statement and fact sheet issued by the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists and referred to at [111]-[112] above. However, in the fact sheet issued in March 2022, it was stated that medicinal cannabis use for chronic pain should only occur within clinical trials, where potential harms, benefits and uncertainties are explained and outcomes are monitored. This is the type of clinical scenario in which Dr Banerjee and his team of expert therapists will be conducting their treatment regime on the applicant.
15. Whilst there may not be universal acceptance for the prescription of medicinal cannabis to treat chronic pain, there is evidence to support its effectiveness as a treatment option to address pain, and I accept the unchallenged opinion of Dr Banerjee that the proposed treatment may assist with the applicant's insomnia, anxiety, post-traumatic stress disorder symptoms and pain.
16. Dr Assem provided an opinion on treatment alternatives for the applicant's condition. Whilst those available treatment alternatives may assist the applicant's condition, this does not preclude the proposed five-stage cannabinoid treatment of four months duration from being a reasonably necessary treatment alternative.
17. Applying the principles referred to in Diab above, different treatments may qualify as "reasonably necessary" and the applicant only has to establish that the treatment claimed is one of those treatments. The proposed five-stage cannabinoid treatment (CBD/THC) of four months duration is one of those treatments and I find as follows:

(a) the alternative treatment by way of conservative management (referred to in [194] above) which has failed over the last seven years is unlikely to be effective and on the balance of probabilities, will result in the applicant continuing to suffer the ongoing pain, discomfort and restrictions referred to in the evidence;

(b) without the proposed treatment, the applicant will continue to have right big toe, right foot and bilateral hip symptoms that will affect his sleep;

(c) the respondent raised no issue as to the cost of the proposed treatment;

(d) the potential effectiveness of the proposed treatment is the best chance the applicant has of improving his current and longstanding symptoms and improving his quality of life;

(e) the purpose and potential effect of the proposed treatment is to alleviate the consequences of the injury as far as possible by reducing the effect of right big toe, right foot and bilateral hip symptoms as well as sleep disruption, and

(f) the evidence of Dr Banerjee, Dr Kadavil and Dr Malek support the proposed treatment as being reasonably necessary and likely to be beneficial in the circumstances of this case and Dr Assem provides the qualified support referred to in his report and discussed at [212]-[213] above.

1. Accordingly, I find that the applicant has established that the proposed treatment is "reasonably necessary".

1. I find that the applicant has discharged the onus of proving that the five-stage cannabinoid treatment of four months duration proposed by Dr Banerjee on 10 July 2024 is reasonably necessary treatment as a result of the injuries sustained by the applicant in the course of his employment with the respondent on 28 September 2018 within the meaning of s 60 of the 1987 Act.
2. My determination and orders are set out in the Certificate of Determination attached to this Statement of Reasons.

[1] Application to Resolve a Dispute at page 97.

[2] Application to Resolve a Dispute at pages 14-20.

[3] Application to Resolve a Dispute at page 74.

[4] Application to Resolve a Dispute at pages 67-72.

[5] Application to Resolve a Dispute at page 73.

[6] Application to Resolve a Dispute at pages 60-66.

[79] Diab v NRMA Ltd [2014] NSWWCCPD 72.

[80] Harvey v KW Resort Management Pty Ltd [2025] NSWPIC 182.

[81] White v Gilda Fabrics Pty Ltd [2025] NSWPIC 192.

[82] Kooragang Cement Pty Ltd v Bates (1994) 35 NSWLR 452; 10 NSWCCR 796.

[83] Kirunda v State of New South Wales (No 4) [2018] NSWWCCPD 45 at [136].

[84] Murphy v Allity Management Services Pty Ltd [2015] NSWWCCPD 49.

[85] Rose v Health Commission (NSW) [1986] NSWCC 2; (1986) 2 NSWCCR 32.