24 March 2022, 11 July 2024 and 29 October 2024. 3. On 2 December 2025, the applicant lodged an Application to Resolve a Dispute in respect of a claim for the costs of medicinal cannabis. 4. On 7 January 2025, the respondent lodged a Reply. 5. On 3 March 2025, the applicant lodged an Application to Lodge Additional Documents. 6. On 4 March 2025, the respondent lodged an Application to Lodge Additional Documents.

(a) whether prescription and trial of medicinal cannabis, recommended and overseen by Dr Lahz and Dr Woods is reasonably necessary as a result of the accepted injury on 4 February 2002 (s 60 of the 1987 Act).

1. The applicant is in receipt of ongoing weekly payments of compensation. The parties agree that s 59A of the 1987 Act is not in issue.

PROCEDURE BEFORE THE PERSONAL INJURY COMMISSION

1. On 30 January 2025, the parties attended a preliminary conference.
2. On 20 March 2025, the parties attended a conciliation conference and arbitration hearing. Mr Stephen Hickey, of counsel, appeared for the applicant instructed by Ian Roche Lawyers.

Mr John Gaitanis, of counsel, appeared for the respondent instructed by Hicksons Lawyers. 3. During the proceedings:

(a) the applicant discontinued the claim for past medical expenses;

(b) the applicant sought to particularise the claim for future medical expenses. The applicant confirmed that the claim was for a prescription and trial of medicinal cannabis recommended and overseen by Dr Lahz and Dr Woods. The respondent raised no objection;

(c) the applicant's Application to Admit Late Documents, dated 3 March 2025, was admitted into the proceedings, and

(d) the respondent's Application to Admit Late Documents, dated 4 March 2025, was admitted into the proceedings.

1. The parties were unable to reach a resolution of the dispute and counsel provided oral submissions during the hearing. Following the hearing, a direction was issued for supplementary submissions.
2. I am satisfied that the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied that the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.

1. The following documents were in evidence before the Personal Injury Commission (Commission) and considered in making this determination:

(a) Application to Resolve a Dispute, dated 2 December 2024, and attached documents;

(b) Reply to Application to Resolve a Dispute, dated 7 January 2025, and attached documents;

(c) Direction issued on 30 January 2025;

(d) Application to Lodge Additional Documents and attachments, lodged by the applicant on 3 March 2025;

(e) Application to Lodge Additional Documents and attachments, lodged by the respondent on 4 March 2025;

(f) Direction issued on 2 April 2025;

(g) Applicant's supplementary written submissions, dated 9 April 2025, and

(h) Respondent's submissions in response, dated 16, 22 April and 2 May 2025 (there was a delay in registration of these submissions which are largely identical in substance due to the method of lodgment).

1. The above documentation was admitted into the proceedings, by consent.

1. In evidence are two statements made by the applicant, dated 14 November 2024 and

27 February 2025. The applicant states that in 1985 he was involved farming accident, which resulted in a below the right knee amputation. He adjusted to life using prosthetics, and did not experience any phantom leg pain. 2. On 4 February 2002, while working for the respondent the applicant was required to work in wet weather conditions. His skin became irritated on the stump of his right leg. This resulted in ulcerations and recurring infections, requiring minor stump revision surgery called "shaving". 3. The applicant states that he experienced the occasional infective flare up until 2021, when his stump broke down due to chronic infections. As a result, he states he was required to undergo further surgery and a further amputation of his right leg called a "knee disarticulation procedure". He described this as an amputation through the knee, as the knee to the stump was not salvageable. Since this surgery, the applicant states he has "been experiencing severe, intolerable stump and phantom leg pain". He states he has become "very depressed" and no longer able to work and has intrusive memories from the original injury. 4. The applicant states that he had "trailed many different treatments" and on "many different medications in attempt to manage" his pain. He described the pain as:

"unrelenting with many variations of the type of pain. At time it feels like there is a driving hot sensation through the stump, painful cramping, electric shocks, pins and needles and ... phantom leg pains."

1. The applicant asserts that the treatments have not worked and he is in a lot of pain. He gets easily frustrated, angry and depressed. He states that the treatment that has helped the most was "medical Cannabis products" under the management of Dr Woods. He states he has been self-medicating, since the insurer declined to fund the treatment and he has not always been able to access CBD products as he cannot afford it. He notes he has purchased THC cannabis products on the black market, but does not consider that this is the best course. He considers medicinal cannabis to be safer compared with alcohol, Endone, morphine and codeine. He adds that he feels that he would be able to sleep better and have a better quality of life if his pain was under better control.
2. In a supplementary statement dated 27 February 2025, the applicant explains that he has developed a "deep seeded fear of needles" from 1993 when he heard people screaming in agony when receiving nerve block treatments. He notes that the doctors would attempt to find the nerves in the patient's amputated limb by sticking the needles into the area that was causing pain to find the nerves where the nerve blocks were required. He was traumatised by this experience and refuses to allow doctors to stick needles into the stump of his leg. He does not consider this is appropriate treatment.
3. The applicant confirms that since the surgery in 2021 he has been "experiencing unrelenting and intolerable pain in the stump of his right leg". He adds that the pain is "excruciating" when he uses the prosthesis as the nerves are very close to the surface of his skin.
4. The applicant explains that he experiences phantom leg and nerve pain, which he described to feel like his "ankle is being twisted behind" him. He states that this can also occur when he is asleep and he will wake up screaming in excruciating pain. He also states that he experiences a burning sensation with severe pain, like extreme pins and needles. He adds that it feels like fireworks are going off in the end of the stump and the pain can be unbearable.
5. The applicant states that he has taken prescribed medications, and has had side effects on physical and mental health. He states that he has smoked cannabis for most of his life and that this has helped with his pain and mental health, but it is very expensive. He trialled different forms of medicinal cannabis under the care of Dr Woods, which was helpful but he found the dosage was not high enough at the start of the trials. He stated that he believed his body was immune to low dosages of medicinal cannabis due to using cannabis for many years.
6. The applicant describes the pain as "relentless" and that he would often spiral into depression and have suicidal thoughts.
7. The applicant explains that his medical team were working with him to figure out the best dosage of medicinal cannabis, but that there was a miscommunication. Dr Woods had not explained the procedure for dispensing of medicinal cannabis. He had travelled from Windsor to Bondi to Basgers Pharmacy about 1.5 hrs in each direction to renew his prescription but told on arrival that he was three days too early. He had not experienced this issue previously and did not understand why he could not have his prescription renewed at that time. He states that he was frustrated and angry, at the thought of returning back to constant pain, that he lost his temper and started yelling and had to leave.
8. The applicant explains that he understood that the pharmacist and the insurer then tried to contact Dr Woods, who was on extended leave. The Therapeutic Goods Administration (TGA) became involved, and that he was required to go through a clinic that specialises in this form of treatment.
9. The applicant states that the best combination that works is 1ml CBD / THC oil in the morning; cannabis flowers 3g inhaled during the day; 1ml CBD / THC oil at night. He adds that he still uses Lyrica with the cannabis, but has no need for any other heavy medications. He notes that he has also stopped drinking. He considers that this is the best dosage and combination that works for him, but he cannot not always afford this due to the cost of the products.
10. He feels that the largest benefit is that the nerve and phantom leg pain is reduced to a manageable level. His mood is lifted and it helps with his depression. He no longer has suicidal thought and his appetite is increased, and he can sleep. He states it "puts me back into the brighter side of life". He states that it helps him "immensely".

1. In evidence is a statement from Jane Ferry, the applicant's partner and carer, dated

27 February 2025. She records a history of events, consistent with the applicant's statement evidence. She records that the difference she noticed in the applicant following the medicinal cannabis trial was phenomenal. She states that following the trial the applicant was eating, sleeping, his mood was improved, and no longer spiralling into a depressive and suicidal state. 2. Ms Ferry states that following the Basgers pharmacy incident, Dr Woods referred the applicant to CDA clinics to manage his treatment.

1. In evidence are three documents providing guidance on cannabis use, by the TGA dated 28 November 2024 and the Faculty of Pain Medicine (FPM) in March 2022 and 2021. These documents have been considered and will be referred to where relevant.

1. In evidence is an email from Basgers Pharmacy of Bondi Junction, dated 5 March 2022, to the insurer. It records that the applicant had been a difficult client and recommended that his scripts be filled elsewhere. The email noted that the applicant requested medicinal cannabis prior to the allocated time and became aggressive when they refused to supply. It also notes that the applicant had hung up on staff when they tried to explain the procedure, swore at staff members, and that there was difficulty contacting Dr Woods to clarify prescriptions and review intervals between refills.
2. There is a list of medical payments made by the insurer. Contained in that list are two entries for medicinal cannabis medications at Basgers Pharmacy. On 8 February 2022, three items under PHS300 medicinal cannabis medications are noted together totalling $640. The following month, on 8 March 2022, four items under PHS300 medicinal cannabis medications are noted together totalling $1,280.

1. On 7 April 2022, Dr Marin Brewster, CDA Clinics - Cannabis Doctors Australia, issued a letter to Dr Woods. In that letter, Dr Brewster states that the applicant had been reviewed for opinion and management with medicinal cannabis. It states that the letter was to confirm the applicant had been legally prescribed medicinal cannabis products and referred back to Dr Woods' care. It noted that the prescription had been considered in relation to the applicant's insomnia, anxiety with depression, disorder (attention deficit, personality (aggressive), dystrophy (reflex sympathetic), and amputation (below knee).
2. Dr Brewster records generally that cannabis can and should be ceased while evaluating for potential side effects. He also records the prescription of CannaTrek T12 C12 Ruby Balanced Oil 30 ml (THC 12mg/ml: CBD 12mg/ml) 1 drop (.05ml) initially, increase slowly as directed.

1. On 12 October 2023, Dr John Estell, consultant physician in rehabilitation medicine, issued a letter to Dr Woods. In that letter, Dr Estell records that he had known the applicant for the last decade. He also records the applicant's continuing pains which he "finds the best relief from medical cannabis, but overall he is finding that the stump socket interface is not working".

1. In evidence are a series of records from the applicant's treating general practitioner, Dr Woods.
2. On 30 September 2024, Dr Woods issued a letter to the applicant's solicitor which stated that it is "now very accepted and advised practice to treat intractable pain with CBD and THC products". He adds that he considers that "it is a reasonable and necessary treatment of [the applicant's] illness related to his 1987 Workers compensation claim".
3. On 24 February 2025, Dr Woods issued a further letter to the applicant's solicitor. Dr Woods stated that the applicant's "pain has been very difficult to stabilise. He is not able to take high does [sic] opioid analgesia due to his other medical conditions and interactions. We have been trying to organize CBD THC type analgesia for him, which has been problematic from a cost issue". He adds that the applicant has "received significant benefit" in the past from using medicinal cannabis. He further adds that the applicant has exhausted all other avenues to try and treat his pain. He considers that medicinal cannabis is the "best option" for the applicant. He further adds that Dr Lahz and Dr Jungfer support the use of medicinal cannabis for the applicant, and he endorses the proposed medical trial described by Dr Lahz.
4. Dr Woods records the applicant's current problems to include aggressive personality, asthma, depression, emphysema, anxiety with depression, post-traumatic stress disorder and insomnia. He also records his medication, including Breo Ellipta, Duloxetine, Lyrica and other analgesics.

1. On 8 October 2021, Dr Tim Ho, pain management specialist qualified by the respondent, issued a report.
2. Dr Ho records the applicant's medical history. He records that the applicant had chronic pain following a "right through knee amputation" in March 2021. The applicant tried a series of pain medications but reported side effects, such as suicide ideation. Most of his medications had ceased and he was self-medicating with cannabis and marijuana, with reported benefit for pain reduction and no side effects.
3. Dr Ho reports describe the applicant's pain as severe. He reports significant activity, mood and sleep interferences due to pain and nocturnal pain. Dr Ho records the applicant reported persistent depression and stress related to pain following the injury.
4. Dr Ho diagnoses the applicant with:

(a) chronic neuropathic right stump and phantom pain secondary to post amputation pain syndrome and central sensitization;

(b) cortical augmentation with catrophisation, reduced self-efficacy and adjustment disorder, and

(c) daily dependent heavy use of illicit cannabis and reported medication sensitivity.

1. Dr Ho finds that the primary physiological process for chronic pain is a dysfunction and maladaptation of the pain nervous system, triggered by the workplace injury.
2. Dr Ho states that the overall evidence is poor in the usage of medicinal cannabis for chronic non-cancer pain, and this is not an endorsed treatment by the College of Pain Medicine due to the lack of evidence. Dr Ho then refers to evidence in support. He adds that medicinal cannabis is accepted by some pain specialists based on personalised medication and compassionate grounds under TGA guidance. He notes a possible contraindication of possible opioid use disorder but needed further evidence to support.
3. Dr Ho states that:

"A trial of medicinal cannabis as an adjunct to a pain management program in this case is appropriate given [the applicant] has failed more conservative treatment, based on personalised medicine (NOT evidence medicine) on compassionate grounds. I note his significant persisting oncoplastic/neuropathic pain has been refractory to multiple medication treatments (see above), as well as, psychology and physiotherapy treatments. This should be used as an adjunct to a pain management program.

I note that a trial of cannabis may be appropriate in some cases based on patient value and clinical judgement (individualised medicine based on compassionate ground, or harm reduction principle) but, at this stage, it does not satisfy all the reasonably necessary criteria for the following reasons: -

• - The targeted treatment is injury related, and the goal of treatment is to improve pain and function;
• - The treatment has not been proven to be effective or cost effective;
• - The treatment is not endorsed by the majority of the expert in the same field.

An accepted alternative is a pain self-management program with a functional focus."

1. In his supplementary report dated 3 March 2025, Dr Ho records, medicinal cannabis is not reasonably necessary for the applicant's condition. Dr Ho states that the TGA guidance (November 2024) explicitly states that medicinal cannabis should not replace first-line treatments for chronic non-cancer pain. Dr Ho also states that the FMP does not endorse medicinal cannabis due to insufficient high-quality evidence supporting its efficacy. Given the lack of demonstrated functional improvement and potential for harm, the requested treatment does not meet the standard of reasonably necessity.
2. Dr Ho states that the effectiveness of medicinal cannabis remains limited, but states there are risks and modest pain relief at best. He states cannabis use carries significant risks, which are dose-dependent risks and exacerbated by comorbidities. Given the applicant's chronic pain condition and multiple comorbidities, such as psychological, these risks outweigh the limited potential benefit. He states that other established treatment remains available.
3. In terms of the side effects of long-term medicinal cannabis use, Dr Ho states this includes cognitive impairment, dependence and withdrawal symptoms, psychiatric effects, cardiovascular effects and respiratory complications (if inhaled). He further states that:

(a) there is limited clinical relevance and appropriateness, referring briefly to the TGA and FPM guidance which does not support use as a first-line treatment;

(b) multimodal pain management programs and functional rehabilitation are recommended over cannabis by the TGA and FPM. He latter adds a pain self-management program with a functional focus remains the preferred treatment at a cost of $15,000;

(c) the TGA notes a lack of cost-effectiveness compared to standard pain management interventions;

(d) the TGA review found no improvement in physical function or quality of life, and

(e) the FPM and major pain medicine authorities do not recognise medicinal cannabis as an established treatment.

1. Dr Ho contends that the use of CBD and THC products is not a direct result of the work injury.

1. Dr Hasher Kadavil, pain management specialist, issued a report on 14 December 2021. He records that since the latest surgery, the applicant's pain had worsened. He noted that the applicant "[t]ried the medicinal cannabis which did not provide him with the expected benefit". He noted that the applicant asked whether he could prescribe him with medicinal cannabis flower for inhalation, but he explained that none of the clinicians provided that prescription at his clinic, and the applicant "was visibly frustrated and left". He did not think that he could contribute anything else for the applicant's pain management.

1. Dr Patricia Jungfer, treating psychiatrist, prepared a report for Dr Woods on 3 April 2024. In that report, Dr Jungfer notes the applicant's current symptoms. She states that the applicant has been taking Duloxetine 60mg but has not noticed any benefit. She further states that the applicant's pain remains a major issue. He has poor pain control and cannot afford medicinal cannabis. She adds that while the applicant "does not feel that the duloxetine has made any difference, he does seem to be less explosive in the appointment". He also notes that the applicant had decreased his alcohol intake.
2. Dr Jungfer recommends that the applicant increase Duloxetine to 120mg per day, await assessments by Dr Lahz and the pain specialist and assessment and treatment for his post-traumatic stress disorder.

1. Dr Sophia Lahz, rehabilitation physician qualified by the applicant, issued a report on

11 April 2024. She reports that she had a 70-minute video link with the applicant to discuss his suitability for medicinal cannabis. She also notes that she read a very helpful letter from the applicant's treating psychiatrist, Dr Jungfer, prior to the review. 2. Dr Lahz takes a history of the 1985 farm accident, the stump infection in 2001/2002, infective flare ups, chronic infection leading to further amputation in 2021. She records that the applicant has had high levels of stump and phantom pain, which he had not previously experienced. She also records a history of the applicant's alcohol use, psychological treatment, including admissions for depression in early 2000's and intrusive recollections of the original injury from 2021. She refers to Dr Jungfer's report which records the applicant's main psychiatric issues are depressed mood, irritability and social withdrawal, for which she commenced him on Duloxetine five weeks ago, with current dose 120 mg daily. Dr Lahz records that the applicant says he is unsure if that medication is helpful for either pain or sleep. 3. Dr Lahz also takes a history of the applicant's "short fuse" and notes that he is "very short with certain providers, causing them sometimes to have withdrawn services". She notes that the applicant had been referred to a psychologist and Ms Sharp has been working with the applicant. Dr Lahz also notes that the applicant has too much time on his hands and this along with pain leads to "angry, aggressive, off putting outbursts". 4. In respect of the pain, Dr Lahz records that the applicant "complains of unrelenting pain in the stump, various kinds of pain including a 'driving hot sensation through the stump', painful cramping in the stump, electric shocks, pins and needles and phantom pains." She adds that the applicant said his stump also sometimes visibly twitches and he sometimes has to grab it to stop painful movements. She states that prior to 2021, the applicant wore a prosthesis for up to 12 hours per day, but now only 5-6 hours. 5. Dr Lahz records the numerous analgesics the applicant has trialled. She also notes that Dr Jungfer has referred the applicant to a clinic for consideration of pain management interventional procedures such as nerve blocks. She adds that the applicant is not "enthused" about nerve blocks as he considered they "are very painful (based on a previous experience of hearing other patients whilst in hospital)". 6. Dr Lahz, records that the applicant had considerable pain and sleep disturbance. She records that the applicant's only pain medications are Lyrica 300 mg bd and medical cannabis products (three THC Indica (relaxing) flowers, using a good quality vaporizer). She adds that the applicant reports that he is "very tolerant to THC and never stoned". 7. Dr Lahz notes that, prior to CDA clinic involvement, Dr Woods had been prescribing medical cannabis (with Workcover funding) but that there was a misunderstanding with the pharmacist leading to contact with the TGA. The applicant has been self-funding cannabis products that he can afford since CDA started prescribing in late 2022. Dr Lahz also records that the applicant had used "recreational Cannabis from about 1986 to help with some physical discomfort and sleep disturbance after the original accident". She adds that cannabis was very effective, but he does not use black market products if he has access to medical ones. 8. Dr Lahz records the dosages and types of medicinal cannabis oils taken by the applicant, which she records were taken "with good effect in conjunction with the various cannabis flowers". She records that the applicant said when using "both sublingual oils and vaped flowers, he was more involved in the care of his birds, could get out of the house and mow his lawn". She notes that the applicant has not been on any CBD dominant oils. 9. Dr Lahz records that the applicant has "some smoking-related chronic airways disease for which he uses Breo and Ventolin inhalers". 10. Dr Lahz notes that if the applicant's pain was better controlled, he would sleep better and could engage in more enjoyable activities and even possibly consider a return to part-time work. 11. Dr Lahz summarises that, the applicant has no physical or psychological contraindications to medicinal cannabis. She notes his "experience with cannabis (which is extensive) has been very positive with respect to chronic pain, sleep promotion and calming". She adds that there have not been any adverse effects from his use of cannabis. She further adds that it has advantages over conventional painkillers in that it does not depress breathing. She notes that while THC has addictive properties, in comparison with alcohol and other painkillers it is considerably less. She adds that Dr Jungfer is supportive of the medicinal cannabis treatment. 12. Dr Lahz states that the cannabis oils and flower can complement one another, "the oil evening out the symptomatic peaks and troughs whilst the flower is very useful for acute painful exacerbations". She adds that it is important that a CBD containing oil be prescribed along with THC flower because CBD negates ill effects of THC, which she notes have not been problematic for the applicant who has used cannabis for many years. The addition of THC to the CBD is more likely successful with neuropathic pain of the intensity the applicant is experiencing (as well as having benefits on sleep and irritability). 13. The current usage of medicinal cannabis has been beneficial for the applicant with respect to pain, anxiety and sleep. Although, Dr Lahz states some adjustments should be made. She proposes an initial prescription of 80 mg of THC oil daily, 100-300 mg daily of CBD oil and a maximum vaporized Indica flower dosage of not more than 2 g daily. She states that the most effective dosage will be "determined by titration, starting low dose and slowly moving upwards until ideal dose is found". She further states that the applicant will need to be regularly medically reviewed.

1. The applicant and respondent provided detailed oral submissions during the hearing which were recorded. Those submissions will not be repeated in full but have been considered and will be referred to where relevant.

1. The applicant refers to his statement evidence, dated 14 November 2024. The applicant refers to the events leading up to and after the accepted injury. He notes the medications he has trialled in an attempt to manage the pain, which he describes as unrelenting. The applicant refers to the variations of pain experienced, hot sensation, painful cramping, electric shocks, pins and needles and phantom leg pain.
2. The applicant notes the use of a pain management team, which was not successful and left him in a lot of pain. He also notes that he found medicinal cannabis, managed by Dr Woods, was the most helpful but has not been able to access the medication due to costs. He also refers to his pain being "better controlled" and that he could sleep better and had a better quality of life when using medicinal cannabis, as opposed to alcohol, endo morphine and codeine.
3. The applicant refers to his supplementary statement, dated 27 February 2025. He notes his deep-seated fear of needles. He refers to the medication undertaken, which he states caused psychological symptoms, supressed his appetite, adversely affected his skin, teeth and bowels.
4. The applicant states that the insurer initially approved a trial of medicinal cannabis, under the care of Dr Woods. The medicinal cannabis was somewhat helpful, but the dosage was not high enough due to cannabis use of the years. He explains the events surrounding the incident at the pharmacy and insurer's latter withdrawal of approval for the medicinal cannabis trial.
5. The applicant submits that his nerve and phantom leg pain is reduced to a manageable level, his mood is lifted and no longer suicidal, appetite has increased, and he can sleep because of the medicinal cannabis. He considers that he has reached the best dosage and combination that works, but can't always afford it and sometimes resorts to prescribed drugs and alcohol to help alleviate the pain. The applicant refers to his partner's statement, Ms Ferry in support.
6. The applicant notes the report of Dr Kadavil, dated 14 December 2021. This is contemporaneous with the attendance at the pharmacy. It takes a history that the pain has worsened and that the trial of medicinal cannabis did not provide him with the expected benefit, and he sought a prescription of medicinal cannabis flower for inhalation. However, the doctor said he did not prescribe that form of medication and the applicant left frustrated. This must be read with the applicant's statement and Ms Ferry's statement, and the applicant seeking medicinal cannabis of a different variation.
7. The applicant refers to Dr Lahz's report, dated 11 April 2024. He refers to the detailed history recorded. The applicant submits that Dr Lahz refers to the variation of medicinal cannabis, and notes that the applicant had tried a balanced oil but had not been on any CBD dominant oils. She also notes that he has some airways disease but that there is no physical or psychological contraindications to medicinal cannabis. She notes that there has been no adverse side effects from the use of cannabis.
8. The applicant refers to the TGA guidance use for medical cannabis documentation and published evidence of treatment outcomes, as providing support for treatment of chronic pain for non-cancer patients. The applicant submits that there is evidence of change in physical functioning and emotional functioning and evidence of how the treatment affects him, which satisfies the criteria for use.
9. The applicant contends that Dr Lahz considered the individual risk in use of the products for long periods of time. Dr Lahz also considered that medicinal cannabis had advantages over conventional painkillers. The applicant submits that he has taken far less in terms of the prescription recommended and the much lower level of intake satisfies him and is of great assistance. Dr Lahz notes that the most effective dose of oil will be determined by titration, starting with a low dose and moving upwards until the ideal dose found with regular reviews.
10. The applicant refers to Dr Wood's evidence. Dr Woods notes that the applicant's pain has been very difficult to stabilise and he is not able to take high dose of opioid analgesia due to other medical conditions and interactions. He notes that the applicant has had significant benefit from using medicinal cannabis in the past and he has tried to organise CBD THC analgesia but this has been problematic from a cost issue. He further notes all other treatments have been exhausted, and supports the trial proposed by Dr Lahz.
11. The applicant refers to the report of Dr Ho. Dr Ho thought that the primary physiological process for chronic pain is a dysfunction and maladaptation of pain in the nervous system. There is existing evidence in the usage of medicinal cannabis for neuropathic pain and this is endorsed by some jurisdictions. Dr Ho notes that a trial of medicinal cannabis is an adjunct to pain management program and considers it is appropriate, given the applicant has failed more conservative treatment based on personalised medicine. However, Dr Ho did not consider it was reasonably necessary at that stage because of the harm reduction principle.
12. The reports of Dr Jungfer and Dr Woods support the proposed use of cannabis medication. The applicant has had a long history of trialling other medications which has caused significant complaints. He has only continued use of Lyrica.
13. The applicant relies on the decisions in Diab v NRMA Limited,[1] Rose v Health Commission (NSW),[2] Bartolo v Western Syndey Area Health Service[3] and Siladi v Health Scope Operations Pty Ltd.[4] The applicant submits that reasonably necessary does not mean absolutely necessary, citing the decision in Moorebank Recyclers Pty Ltd v Tanlane Pty Ltd.[5] That is because reasonably necessary is a lesser requirement than necessary, and, depending on the circumstances, a range of different treatments may qualify as reasonably necessary.
14. The applicant submits that the evidence provides that the proposed treatment is appropriate. It does not have an adverse effect on him. It alleviates taking the medication that would have an adverse effect on him.
15. The applicant submits that he has tried everything except the regime of pain management that is prescribed by Dr Ho. However, the applicant provides reasons for not seeking to undergo this treatment which is understandable.
16. The applicant refers to the costs of the treatment. The insurer was prepared to pay for the costs of the treatment until early 2022. The costs of the proposed treatment will be far less than what it may be as proposed treatment by Dr Lahz, having regard to the applicant's concession of a far reduced amount of cannaboid oils that he takes to relieve his pain.
17. The applicant submits that his evidence should be accepted, where he states it relieves his pain as to the actual or potential effectiveness of the treatment. This is supported by the evidence of Dr Woods.
18. Lastly, the applicant submits that there is acceptance by medical experts that the treatment is appropriate and likely to be effective. Dr Woods, Dr Jungfer and Dr Lahz accept and support the treatment as appropriate.
19. On the above basis, the applicant submits that there should be a finding that the proposed treatment is reasonably necessary.
20. Following clarification that the respondent sought to press both limbs of s 60, the applicant provided submissions on the "results from" test. The applicant submitted that it is a commonsense approach on the chain of causation, relying on Kooragang Cement Pty Ltd v Bates.[6] The applicant submits that his further amputation results from the injury on 4 February 2002. Applying the chain of causation test, the applicant submits that, without the second amputation the phantom pains would not have been so significant. They became heightened after that procedure. There is no evidence that the chain of causation has been broken. The causal follow on effect of the 2002 injury necessitating the amputation in 2021 after which the applicant has had a significantly detrimental time.

1. The respondent submits that the proposed treatment is not reasonably necessary and that it is not a direct result of the work injury.
2. The respondent contends that there is not significant support for the proposed treatment or any valid views as to the results from question, and, secondly, the reasonably necessity of the cannabis treatment. There are significant difficulties with the evidence and there are a number of inconsistencies.
3. The respondent submits that the test to be applied is one of commonsense, referring to Kooragang Cement Pty Ltd v Bates.[7] The respondent contends that it is erroneous to call it a low bar, relying on the decision in Pinchm v Crew On Call Australia Pty Ltd.[8] In each case where causation is an issue it must be determined on its own facts. What is required is a commonsense evaluation of the causal chain, which requires an evaluation of the evidence.
4. The respondent refers to the medical evidence. The respondent submits that Dr Kadavil is not supportive of the applicant's case. There is no evidence to support ongoing approval for medicinal cannabis. The applicant essentially says he has used cannabis before and it works, but he is not going to have nerve blocks or pain management or any alternative treatments. The applicant says the only thing that really works is cannabis for treatment of his conditions. However, this is not really dealt with by Dr Lahz, Dr Jungfer, Dr Estell or Dr Brewster.
5. The respondent refers to the evidence of Dr Woods, who is not an expert in pain management or the use of medicinal cannabis. His evidence is not weighty. He states that the applicant is not able to take high dose opioid analgesia due to other medical conditions and interactions but there is no explanation in that report or other reports. He notes that the applicant has received significant benefit in the past from medicinal cannabis, but the respondent submits it is also recreational cannabis or from the black market.
6. The respondent submits that Dr Woods' says that medicinal cannabis is the best option, when the applicant has not exhausted all other avenues. Dr Woods' then states that there is support for the use of medicinal cannabis from Dr Jungfer and Dr Lahz, however Dr Jungfer does not say that. Dr Lahz says perhaps a trial on low dose might be helpful.
7. The respondent submits that cannabis seems to be some kind of comfort to remedying the applicant's difficulties. However, Dr Ho says that long term medicinal cannabis use carries significant risks which are dose dependant and exacerbated by comorbidities. The TGA and FMP emphasise the lack of high quality long term studies on the safety and efficacy and dependency risk of medicinal cannabis. In certain circumstances it is useful, but Dr Ho says when you look at the balance of all the evidence it is insufficient to explain or justify the use of medicinal cannabis. The key risks are psychiatric effects. The respondent submits that the applicant has significant psychological problems and refers to Dr Woods' evidence. One of the key risks of cannabis treatment is psychiatric effects, but no one explains how the problem would be alleviated. Dr Woods is alive to the psychiatric issues, Dr Lahz doesn't deal with it or provide sufficient explanation and this is important to the reasonableness of the treatment.
8. Dr Woods also states that the applicant has emphysema. Dr Lahz says the applicant has smoking related chronic airway disease. However, Dr Lahz does not address the impact cannabis may have on that condition or chronic airways disease. Dr Ho says that a key risk is respiratory complication if cannabis is inhaled. Dr Lahz does not deal with the respiratory complications that Dr Ho says if the cannabis was inhaled. On this basis, there are deficiencies and her opinion should not be accepted.
9. Dr Woods refers to a list of medications, including Lyrica. The applicant also refers to a list of medications in his statement evidence. The applicant states that he did not take all the medications at once but there could be a combination of many different medications. However, the respondent submits that this is difficult to measure against what is reported to the medical practitioners. Dr Jungfer recommends an increase in Duloxetine, assessment by Dr Lahz and the pain specialist and an assessment for post-traumatic stress disorder. There is no pain specialist or post-traumatic stress disorder assessment, other than from Dr Lahz.
10. Eight days after Dr Jungfer's report, Dr Lahz says the applicant's only pain medication is Lyrica and medicinal cannabis products. Dr Ho says the applicant had tried a series of medications and reported side effects such as suicidal ideation. The medications had mostly stopped and he had commenced self-medicating smoking cannabis, which he describes as daily dependent heavy use of illicit cannabis. He also reported medication sensitivity.
11. The respondent refers to Dr Brewster and queries the weight to be given to that report as a provider of medicinal cannabis products.
12. Dr Lahz is a rehabilitation physician, referred by Dr Woods. She has not been introduced to talk about rehabilitation, but about medicinal cannabis. Dr Lahz states in the first sentence of her report that she had a 70-minute video link to deal with his suitability for medicinal cannabis.
13. The respondent submits that the medical evidence is inadequate. The evidence does not deal with the applicant's psychiatric issues or risks of respiratory issues. There are alternative remedies that have not been explored, including pain management such as a nerve block. The applicant has provided submissions on subjective matters about the applicant's fear of nerve block treatments in the absence of medical support.
14. The respondent submits that Dr Ho's opinion raises alarm bells, noting the applicant's high tolerance for cannabis and the reference to ghost dependency. Dr Ho says medicinal cannabis should not replace first line treatments for chronic non-cancer patients. It is not endorsed by the FPM due to insufficient high quality evidence support its efficacy in chronic pain. He adds that the effectiveness is limited. He notes that the TGA review found the risk of harm is likely to outweigh any benefit. It is not suitable given the risks in patients with psychological comorbidities. As Dr Ho explains, the respondent submits that the treatment should not be considered first line or routine. This is particularly in a case where the pain management regime has not been undertaken.
15. Medicinal cannabis was tired but did not have the expected benefit. The respondent submits, that this presumably relates to the applicant's high tolerance which will further develop and only manifest in risk areas in terms of emphysema and the psychiatric aspect. The applicant has explained what happened at the pharmacy, Dr Woods talks about this and notes the applicant's aggressive personality, and this was seen at the pharmacy. Dr Ho should be preferred over Dr Lahz. Dr Ho is supported by medical literature, which is attached. Dr Lahz refers to medical literature, but it is not attached in the evidence.

1. The applicant refers to the decision in Murphy v Allity Management Services Pty Ltd.[9] Medical treatment may have multiple causes, and all the applicant needs to establish is that injury materially contributed to the need for the treatment.
2. The applicant was working in wet weather condition which caused his skin to become irritated on the stump of the right leg. This resulted in ulcerations and recurring infections, and latter an above knee amputation. The applicant submits that if it is accepted that the irritation from working in wet weather caused ulcerations and recurring infections, the minor stump revision surgery and further knee amputation surgery, there is no doubt that the accepted injury caused the need for surgery. The event of 2002 can be seen to be causative of the need for surgery and the need for medicinal cannabis to treat the heightened condition after that amputation. The applicant refers to several case authorities.[10]

1. The respondent was invited to provide further submissions in reply, given the applicant's submissions in reply referenced case law not referred to previously in submissions in chief.
2. The respondent does not dispute the irritation of the applicant's skin, and the further surgeries that he undertook. The issue is whether there is sufficient evidence in terms of the causal connection between that and the introduction of cannabis oil. There is a significant gap between the injury and the link to the use of medicinal cannabis.
3. The respondent did not seek to make any further submissions, other than to point out that the "results from" argument is not as strong as the reasonably necessary argument. The respondent concedes, that while Dr Ho says the use of cannabis oil is not related to a work injury he does not provide a fulsome explanation and that there is not much other evidence to countenance the applicant's position on "results from".

1. The applicant bears the onus of proof, to establish his case under s 60 of the 1987 Act, on the balance of probabilities.[11] Section 60 of the 1987 Act requires two questions to be answered in the affirmative. Namely, whether the proposed treatment "results from" the accepted injury, and, also, whether it is "reasonably necessary". These are questions which involve matters of impression and degree, having regard to the available evidence.[12]
2. Deputy President Roche, in Diab v NRMA Limited,[13] considered the application of s 60 of the 1987 Act and the phrase "reasonably necessary". Deputy President Roche stated:

"Reasonably necessary does not mean 'absolutely necessary' (Moorebank at [154]). If something is 'necessary', in the sense of indispensable, it will be 'reasonably necessary'. That is because reasonably necessary is a lesser requirement than 'necessary'. 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. A worker certainly does not have to establish that the treatment is 'reasonable and necessary, which is a significantly more demanding test that many insurers and doctors apply. Dr Bodel and Dr Meakin were both wrong to apply that test."[14] (footnotes omitted)

1. Deputy President Roche then considered the criteria of reasonableness:

"[88] In the context of s 60, the relevant matters, according to the criteria of reasonableness, include, but are not necessarily limited to, the matters noted by Burke CCJ at point (5) in Rose (see [76] above), namely:

(a) the appropriateness of the particular treatment;

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

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

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

[89] With respect to point (d), it should be noted that while the effectiveness of the treatment is relevant to whether the treatment was reasonably necessary, it is certainly not determinative. The evidence may show that the same outcome could be achieved by a different treatment, but at a much lower cost. Similarly, 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. As always, each case will depend on its facts.

[90] While the above matters are 'useful heads for consideration', the 'essential question remains whether the treatment was reasonably necessary' (Margaroff v Cordon Bleu Cookware Pty Ltd [1997] NSWCC 13; (1997) 15 NSWCCR 204 at 208C). Thus, it is not simply a matter of asking, as was suggested in Bartolo, is it better that the worker have the treatment or not. As noted by French CJ and Gummow J at [58] in Spencer v Commonwealth of Australia [2010] HCA 28, when dealing with how the expression 'no reasonable prospect' should be understood, '[n]o paraphrase of the expression can be adopted as a sufficient explanation of its operation, let alone definition of its content'."[15] (footnotes and citations omitted)

1. In Rose, Burke CCJ, dealing with the term "treatment" made the following comments:

"... treatment must be reasonable if it is to fall within the purview of the subsection. But that is not solely because of the words 'reasonably necessary' but is rather inherent in the concept of 'treatment' itself. Treatment is necessarily purposive. Treatment, in the medical or therapeutic context, relates to the management of disease, illness or injury by the provision of medication, surgery or other medical service designed to arrest or abate the progress of the condition or to alleviate, cure or remedy the condition. It is the provision of such services for the purpose of limiting the deleterious effects of a condition and restoring health. If the particular 'treatment' cannot, in reason, be found to have that purpose or be competent to achieve that purpose, then it is certainly not reasonable treatment of the condition and is really not treatment at all."

1. The applicant sustained an accepted injury to his right amputated stump, resulting in further surgeries including a further amputation which had a significant impact on his life. It is not disputed that the applicant, as a consequence of the accepted injury and the further surgeries undertaken, suffers pain symptoms in the right leg for which he seeks ongoing treatment. These symptoms are varied but include hot sensations, painful cramping, electric shocks, pins and needles and phantom right leg pain. The evidence demonstrates that the applicant suffers from ongoing chronic pain in the right leg, which impacts his quality of life.
2. The applicant seeks a trial of medicinal cannabis to alleviate his symptoms, having undertaken an insurer approved trial of medicinal cannabis and self-funded medicinal and recreational cannabis. The respondent disputes that medicinal cannabis is reasonably necessary as a result of the accepted injury. This dispute is largely founded on the following bases:

(a) the evidence does not support use of medicinal cannabis, particularly, in view of the events at Basgers Pharmacy, historical usage and high tolerance of cannabis;

(b) the evidence does not address the applicant's comorbidities, namely, psychological issues and respiratory condition and related risks associated with medicinal cannabis use;

(c) the availability of alternative treatments, and

(d) there is a significant gap between injury and the link to the use of medicinal cannabis.

1. The submissions focused initially and mainly on the test of reasonable necessity. In these circumstances, I will first address this limb of the test under s 60 of the 1987 Act.
2. It is helpful to set out the applicant's history of cannabis use and related events:

(a) Firstly, the applicant disclosed past recreational use of cannabis to alleviate his symptoms following the 1985 farming accident. The applicant was forthcoming and consistent in this disclosure in his statement evidence and histories reported to the medical practitioners.

(b) Secondly, following the accepted injury and surgeries the respondent approved for the applicant to undergo a medicinal cannabis trial for a period of six months from late 2021.

(c) Thirdly, the applicant travelled in December 2021 for 1.5 hours to attend on a pharmacy to collect the insurer approved medicinal cannabis. However, the pharmacy refused to dispense the medication because the applicant was three days too early. The applicant was ignorant to the procedure for prescription renewal and continued dispensing. This caused the applicant to become frustrated and angry and he was asked to leave the pharmacy.

(d) Fourthly, at some point following this event the applicant was no longer able to obtain medicinal cannabis from the pharmacy and arrangements had to be made elsewhere. The insurer was unable to contact the applicant's treating general practitioner Dr Woods, as he was on leave for three months through to March 2022. Following these events, the insurer ceased ongoing approval for the cost of the trial of medicinal cannabis from March 2022.

(e) Fifthly, following the denial of liability for medicinal cannabis in March 2022 the applicant has been prescribed medicinal cannabis which he self-funds. He has also sourced cannabis from the black market, which he does not consider to be the best course.

(f) Lastly, the applicant is unable to maintain ongoing self-funded medicinal cannabis use due to financial reasons.

1. I draw no adverse inference in respect of the applicant arising from the events at the pharmacy or past use of medicinal cannabis (see also [133] below). The applicant acknowledges his behaviour and that he lost his temper. Understandably, the applicant was frustrated after being told his medication could not be dispensed because he was three days too early, having travelled 1.5 hours to collect his treatment and needing to travel the same distance to return home while in pain. While I note the email from the pharmacy indicates that there was difficulty with the applicant over the phone and that he swore at pharmacy staff, it is unclear whether this is a result of the events on the day in December 2021 or otherwise.
2. I further note that report of Dr Kadavil, dated 14 December 2021, which records that following advice that his clinic did not prescribe medicinal cannabis the applicant was visibly frustrated and left. I accept the applicant's submission that this must be read with the evidence that indicates that around this time the applicant's pain had worsened and he was seeking a different variation of medicinal cannabis as the version he was prescribed was not providing the expected benefit. This is supported by the lay statement evidence and medical evidence of Dr Woods and Dr Lahz.
3. It is not disputed that the applicant has an aggressive personality. The events at the pharmacy and while attending Dr Kadavil, which were clearly not desirable, demonstrate the applicant's aggressive personality. The applicant acknowledges his short temper. Dr Woods, Dr Brewster and Dr Lahz note the applicant's aggressive personality and/or "short fuse", and despite this recommend medicinal cannabis for the applicant's treatment of pain arising from the right leg. It is not clear whether the applicant is specifically undertaking treatment for this condition but there is no evidence to indicate that this is caused or contributed to (or will be exacerbated) by medicinal cannabis. I also note that the applicant is being treated by psychiatrist Dr Jungfer who reports in April 2024 over two years post these events that the applicant is "less explosive" and had decreased his alcohol intake. I further note that the above events occurred over three years ago and I have not been taken to any recent evidence of a similar nature.
4. Dr Lahz provides a comprehensive report dealing with the applicant's complete history. Contrary to the respondent's submission, Dr Lahz was aware of the applicant's psychological history, chronic airways disease (emphysema), fear of needles, and the medications used to address his pain and separate conditions. Having had regard to this history, Dr Lahz recommends medicinal cannabis to treat the applicant's ongoing symptoms in the right leg.
5. I do not accept the respondent's submission that Dr Lahz's recommendation for medicinal cannabis was made in the absence of adequate consideration of the risk factors associated with the applicant's psychological and respiratory conditions. I do not consider it necessary that Dr Lahz explain how the risk of psychiatric effect or respiratory distress with use of cannabis could be addressed, in circumstances where she did not consider there were any physical or psychological contraindications to the use of medicinal cannabis. Dr Lahz had a complete background of the applicant's psychological history and respiratory condition, noting specific medication taken to treat those conditions. With that awareness of history and co-morbidities, Dr Lahz still recommended a trial of medicinal cannabis. She also states that there has been no adverse side effects from the use of cannabis in the past. While Dr Ho indicates a key risk in psychological effect in use of medicinal cannabis and also respiratory complication if cannabis is inhaled, these matters are not adequately addressed. Dr Ho does not addressed these risks in the context of the applicant's medical history or actual conditions or the proposed form of medicinal cannabis sought to be approved. For these reasons, I do not consider that Dr Lahz's opinion should be given less weight or not accepted as the respondent submits.
6. Dr Lahz's report is detailed, well-reasoned and balanced. She explains that the applicant's experience with past use of medicinal cannabis had been very positive with respect to his chronic pain, sleep promotion and calming. She discusses the variation of dosage and form of medicinal cannabis, noting that the trial of balanced CBD oil was not effective but that the applicant had not tried dominant CBD oil which would be an enhancement to his prescription that is much more likely successful with neuropathic pain of the intensity he experienced.
7. Dr Lahz's recommendation for medicinal cannabis is supported by Dr Woods, who has been the applicant's treating general practitioner over many years. Dr Woods also confirms that the applicant has received significant benefit from using medicinal cannabis to address his symptoms in the past. It is also supported by Dr Brewster, with whom prescribed medicinal cannabis for the applicant having noted his complete history.
8. While Dr Brewster, Dr Jungfer and Dr Estell do not comment on whether medicinal cannabis is reasonably necessary, I do not consider this fatal to the applicant's case. That is because their reports were not obtained for the purpose of providing a medicolegal opinion. In any event, they confirm the applicant's undisputed history and do not find medicinal cannabis is not effective or not suitable for the applicant's treatment of his right leg symptoms.
9. There is no evidence to indicate that the applicant's past use of cannabis has not been effective in treating his symptoms in the right leg. While Dr Kadavil and Dr Lahz report that the trial of medicinal cannabis did not provide the applicant with the expected benefit, as the applicant submits, this must be read in context. The applicant attended on Dr Kadavil in December 2021, at the request of the insurer, during which he sought a prescription of a variation of medicinal cannabis as the trial prescription did not provide the expected benefit. Dr Lahz confirms that the applicant would benefit from an enhancement on his previous prescription of medicinal cannabis to treat his chronic pain. Further, the applicant has now found a new dosage and type of medicinal cannabis that is effective to treat his symptoms.
10. Dr Ho provides the only opinion that is in direct contradiction to the applicant's case. Dr Ho's opinion is founded on the position that use of medicinal cannabis for chronic non-cancer pain is not endorsed by the FPM. However, he notes that medicinal cannabis may be appropriate as an adjunct to a pain management program given the applicant had failed more conservative treatment and on compassionate grounds under TGA guidance. Although, he did not consider the applicant had satisfied all of the criteria and on this basis it was not reasonably necessary.
11. Dr Ho provides a detailed report. However, I do not consider that it is as persuasive as the report of Dr Lahz. I do not consider that Dr Ho has adequately addressed the applicant's history of demonstrated past benefit of medicinal cannabis use to treat his chronic pain. A significant focus of the respondent's submissions dealt with the applicant's psychological and respiratory contraindications for cannabis use. Dr Ho indicates that given the applicant's comorbidities the risks associated with medicinal cannabis outweigh the limited potential benefit. I accept that the applicant has comorbidities that may place him at a higher risk of complications, but Dr Ho only provides general observation of risks without any precision on how the applicant's specific conditions place him at a higher risk and what those risks might entail in that particular context.
12. The evidence supports that the applicant has received an actual benefit and improvement in his symptoms with the use of medicinal cannabis, albeit at a lower dosage then that recommended now by Dr Lahz. It has reduced his pain to a more manageable level, improved his sleep and mental health. This evidence is set out in the applicant's statements and supported by the evidence of Ms Ferry and the medical reports. While the applicant's symptoms have fluctuated overtime, and there is evidence to suggest that this is because he was not undertaking the needed form of medicine or dosage of medicinal cannabis until recently.
13. There is no evidence to suggest that medicinal cannabis has not provided the relief asserted by the applicant. The evidence demonstrates the applicant is able to better control his pain with medicinal cannabis which is a compelling reason to support the likely effectiveness of the proposed treatment. In any event, it is not essential to demonstrate an actual benefit before medicinal cannabis may be found to be reasonably necessary under s 60 of the 1987 Act.
14. The applicant has been forthright in his disclosure of historical cannabis and/or recreational cannabis use, and his views that this has resulted in a high tolerance of the substance. To the extent that there was a suggestion that the applicant's high tolerance will further develop and only manifest in the psychological and respiratory risk areas this submission is a bare assertion without any evidence in support. At most, the evidence demonstrates a past use of cannabis for treatment following the 1985 accident and that because of this the applicant has a higher tolerance for the drug. Indeed, as Dr Ho records, there is no evidence to suggest that the applicant has a cannabis substance disorder.
15. The applicant has considered nerve block treatments but does not consider it appropriate, given his fear of needles and as a result of being traumatised from hearing other patients undergoing that treatment at St George Hospital. There is nothing to dispute this evidence, and in the circumstances the applicant's response to this treatment is not unreasonable. Even if it were appropriate treatment, this does not result in a finding that medicinal cannabis is unreasonable or not reasonably necessary.
16. The applicant states that the majority of the medications he was taking were not effective, as it caused depression, supressed his appetited, adversely affected his skin, teeth and bowels. Dr Wood states that the applicant has exhausted all treatment options. He adds that the applicant is not able to take high doses of opioid analgesia due to other medical conditions and interactions. Dr Wood does not explain why the applicant cannot take high dose opioid analgesia, but I do not consider this to be significant and that comment must be read against the entire evidence. The evidence supports that the applicant has had adverse side effects from some medication taken to address his chronic pain and that he is undertaking other treatment and medication for his respiratory and psychological conditions.
17. There may be several treatment options available to the applicant that will provide relief. Medicinal cannabis may not be absolutely necessary or the only treatment that may provide relief for his chronic pain. However, this does not precluded the proposed trial of medicinal cannabis from being a reasonably necessary treatment option.[16]
18. All forms of treatment carry risks which must be balanced against the benefit that it may provide or has provided in the past. The overwhelming evidence indicates that despite these risks the applicant has derived benefit from medicinal cannabis in the past in the management of his chronic pain without any adverse effect, and that this would likely continue. The evidence demonstrates that the provision of this treatment has the "purpose of limiting the deleterious effects" of the applicant's condition of chronic pain in his right leg and restoring the applicant's health and wellbeing.[17] The proposed treatment in the nature of medicinal cannabis is appropriate and likely to be effective.
19. I accept that there is a body of evidence that finds medicinal cannabis is not an effective treatment for chronic pain in non-cancer patients. It is not accepted by certain bodies, such as FPM. Although, I note that the TGA accepts chronic pain as an indication for medicinal cannabis use. While 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 there is acceptance among some practitioners in the medical profession. Indeed, as the applicant submits, there is evidence of the applicant's change in physical and emotional functioning and how the treatment affects him which satisfies the criteria for use under the TGA guidance.
20. The applicant has a serious condition which has arisen as a result of the accepted workplace injury. To address this condition a significant amount of medical treatment has been paid by the insurer, totalling almost $450,000 as of November 2024. This medical treatment included an incomplete trial of medicinal cannabis, which ceased in March 2022. The cost of that trial is not clear nor is the recent self-funded medicinal cannabis, despite evidence of the past incurred medical expenses.
21. The applicant seeks a further trial of medicinal cannabis, but did not identify the duration of the proposed trial. A trial is generally for a limited period. It is not an indefinite arrangement. As the applicant submits, the cost of the trial would likely be less than the cost of the initial dosage and type recommended by Dr Lahz because the applicant states that he has found a lower dosage to be most effective. However, the evidence does not address the proposed duration of the trial or the estimated cost. While the cost of medicinal cannabis will likely vary between the type and dosage required, it is unlikely to be prohibitive and the respondent has not put cost of the treatment in issue.
22. The applicant only seeks an order for the provision of medicinal cannabis over a "trial" period and this is understandable as the evidence does not address whether medicinal cannabis will continue to be reasonably necessary into the future. Given that the most effective dosage of medicinal cannabis will be determined by titration during a period of regular medical review, I am satisfied that a trial period of six-months would be a sufficient period of time to determine the efficacy of the treatment. That is, it will provide sufficient time in a controlled setting to identify the ideal dosage and form of medicinal cannabis and whether it provides ongoing relief to address the applicant's symptoms.
23. Having regard to the totality of factors set out in Diab v NRMA Ltd,[18] I am satisfied that the applicant has discharged his onus of proof on the balance of probabilities that a trial of medicinal cannabis (under management and supervision of an appropriate practitioner/s) is reasonably necessary to address his chronic pain in his right leg.

1. I am satisfied that the reasonable necessity of a trial of medicinal cannabis arises as a result of the accepted injury in 2002.
2. It is not disputed that the 2002 injury resulted in recurring infections which required further surgeries on the applicant's right leg. It is also not disputed that in 2021 the applicant's right stump broke down due to the chronic infections and as a result he was required to undergo knee disarticulation surgery. As a result, it is accepted that the applicant has been experiencing severe intolerable stump and phantom leg pain (or chronic pain). The applicant did not experience this level of pain or phantom leg pain post the 1985 farming accident which resulted in amputation of his right leg, but only after the further amputation surgery.
3. I do not accept that there is a significant gap between the injury and the link to the use of medicinal cannabis. While the workplace injury occurred in 2002, the applicant did not undergo his latest surgery until 2021. After that surgery the applicant has continued to experience significant pain in the right leg requiring various forms of treatment (including, a trial of medicinal cannabis approved by the respondent and which ceased in March 2022). Following that period, the respondent denied liability for treatment of medicinal cannabis, the applicant self-funded cannabis treatment, and commenced proceedings in the Commission for the payment of past and future medical expenses for medicinal cannabis. I draw no adverse inference from the gap in the period of time between the 2002 injury, the 2021 surgery and now.
4. There is clearly a material contribution between the right knee injury and the need for medicinal cannabis. The only evidence identified in contradiction was that of Dr Ho, who finds the use of cannabis oil is not related to the accepted work injury. However, as the respondent properly concedes, Dr Ho does not provide a detailed and balanced explanation (or fulsome explanation) for his opinion. For the reasons set out above, I prefer the opinion of Dr Lahz and Dr Woods over Dr Ho.
5. I have found that the proposed treatment is reasonably necessary to treat the applicant's right leg symptoms and chronic pain. For the reasons discussed above, the applicant's present leg symptoms arose from the 2002 injury. There are no other events on the evidence that contribute to the applicant's symptoms, other than the 1985 accident. In any event, the applicant is not precluded from the payment of the cost of medicinal cannabis because the accepted injury is not the only cause for the need for treatment. That is because a condition can have multiple causes and treatment may still be recoverable under s 60 of the 1987 Act.[19]
6. It follows that the reasonable necessity of medicinal cannabis results from the 2002 injury.

1. A trial of medicinal cannabis, recommended and overseen by Dr Lahz and Dr Woods for a period of six-months, is reasonably necessary treatment pursuant to s 60 of the 1987 Act, as a result of the applicant's right leg injury on 4 February 2002.
2. It follows that the respondent is to pay the costs of the six-month trial.
3. Accordingly, I make the orders set out above.

[2] [1986] NSWCC 2; (1986) 2 NSWCCR 32.

[4] [2022] NSWPIC 381, [46] (per Principal Member Bamber).

[5] [2012] NSWCA 445.

[6] (1994) 35 NSWLR; (1994) NSWCCR 796.

[7] (1994) 35 NSWLR; (1994) NSWCCR 796.

[8] [2024] NSWPIC 679.

[9] [2015] NSWWCCPD 49.

[10] Mahony v J Kruschich (Demolitions) Pty Ltd [1985] HCA 37; (1985) 156 CLR 522; State Government Insurance Commission (Western Australia) v Oakley (1990) 10 MVR 570; Ozcan v Macarthur Disability Services Ltd [2021] NSWCA 56.

[11] Nguyen v Cosmopolitan Homes [2008] NSWCA 246, [44] (per McDougall J (McColl and Bell JJA agreeing)); Department of Education and Training v Ireland [2008] NSWWCCPD 134.

[12] Kooragang Cement Pty Ltd v Bates (1994) 35 NSWLR 452; 10 NSWCCR 796; Diab v NRMA Ltd [2014] NSWWCCPD 72.

[14] Diab v NRMA Limited [2014] NSWWCPD 72, [86] (per Roche DP).

[15] Diab v NRMA Limited [2014] NSWWCPD 72, [88]-[90] (per Roche DP).

[16] Diab v NRMA Limited [2014] NSWWCCPD 72, [86] (per Roche DP).

[17] Rose v Health Commission (NSW) [1986] NSWCC2; [1986] NSWCC 2; 2 NSWCCR 32, [52] (per Burke CCJ).

[18] [2014] NSWWCCPD 72, [76]-[90] (per Roche DP).

[19] Murphy v Allity Management Services Pty Ltd [2015] NSWWCCPD 49, [57]-[58] (per Roche DP).