DETERMINATION OF REVIEW PANEL	
	
CITATION:	Stojkovski v QBE Insurance (Australia) Limited [2023] NSWPICMP 174	
		
CLAIMANT:	Danica Stojkovski	
		
INSURER:	QBE Insurance Australia Limited	
		
REVIEW Panel	 	
		
MEMBER:	Alexander Bolton	
		
MEDICAL ASSESSOR:	Margaret Gibson	
		
MEDICAL ASSESSOR:	Drew Dixon	
		
DATE OF DECISION:	1 May 2023	
		
CATCHWORDS:	MOTOR ACCIDENTS –  Review of decision of Medical Assessor (MA) Young; consideration of request for eight sessions of physiotherapy treatment; whether or not requested physiotherapy treatment is reasonable and necessary; claimant injured in a motor vehicle accident on 29 January 2018 as a pedestrian who was collided into by a car; claimant in hospital for 2 to 3 weeks following accident; claimant received physiotherapy treatment following the accident for lower back pain, knee pain and bilateral ankle pain; the MA determined that it was not reasonable to continue with physiotherapy treatment as it was not providing a benefit; medical assessor concluded that the requested for treatment was not appropriate in the circumstances of long-term chronic pain; the Panel considered that if treatment is being provided but not resulting in any benefit then it cannot be said to be reasonable and necessary; the request for physiotherapy treatment was two years post-accident; Held – the Panel determined that the request for eight sessions of physiotherapy treatment in an allied health recovery request of 16 October 2020 was not reasonable and necessary in the circumstances. 	
DETERMINATIONS MADE:  	CERTIFICATE OF DETERMINATION
Determination
1.	The following treatment and care is not reasonable and necessary in the circumstances:
a.	eight sessions of physiotherapy treatment requested in the Allied Health Recovery Request number 6 dated 16 October 2020.

STATEMENT OF REASONS
THE REVIEW
1.	This is an application for review of a certificate of Medical Assessor Young (the Medical Assessor) dated 20 December 2021.
2.	The following treatment and/or care dispute was referred by the Personal Injury Commission (Commission) for assessment:
a.	whether eight sessions of physiotherapy treatment requested in the Allied Health Recovery Request number 6 (AHRR 6) dated 16 October 2020 is reasonable and necessary in the circumstances.
3.	Danica Stojkovski (the claimant) had requested eight sessions of physiotherapy treatment, for which the Medical Assessor found was not reasonable and necessary.
THE ACCIDENT
4.	The claimant was injured on 29 January 2018. The claimant was a pedestrian in a car park, who was collided into by a car.
CLAIMANT’S SUBMISSIONS
5.	The claimant submits that in determining whether treatment is "reasonable and necessary" it is not just a matter of whether the treatment will improve the claimant's condition.
6.	The claimant submits that medical or related treatment is reasonably necessary if it maintains a claimant's health and slows or prevents deterioration – see Casey v NSW Police Department (1999) 18 NSWCCR 592.
7.	The claimant says that since she ceased physiotherapy treatment, there has been a marked deterioration in function in the injured body parts. This is said to be particularly so in relation to ambulation.
8.	The claimant says that the Medical Assessor said that the physiotherapy treatment which she had was not beneficial, yet the claimant told him that she felt that such treatment was helpful in that it helped her to "walk better".
THE INSURER’S SUBMISSIONS
9.	The Medical Assessor determined that eight sessions of physiotherapy treatment proposed under AHRR 6 by Workers Doctors dated 16 October 2020 were not reasonable and necessary.
10.	The insurer says that the Medical Assessor highlighted that AHRR 6 did not specify the condition for which the treatment was intended and any benefits previously gained from treatment or SMART (Specific, Measurable, Achievable, Relevant and Time bound) goals and anticipated discharge date. He also found that the claimant's injuries had not significantly improved over the last plan period and there had been no improvement in functional capacity as a result of physiotherapy treatment. He noted that there may be more effective alternatives such as pain management.
11.	The insurer referred to the claimant’s allegation that there had been a marked deterioration in function since she ceased physiotherapy and in particular in relation to ambulation. The insurer noted that it is alleged that the claimant could walk for one hour as at AHRR 5 dated 2 September 2019 and that she could no longer do so. To this allegation the insurer says that the claimant is incorrect. The insurer says that according to AHRR 5 and AHRR 6, the claimant could walk for up to one hour pre-accident (reviewed by the Medical Assessor at page 8 and page 9 of the certificate) and she reported that she could only walk for three minutes or five minutes, if pushing her walker, as at the date of AHRR 5 dated 2 September 2019.
12.	The insurer says that the claimant reported to the Medical Assessor that she could walk up to five or six minutes at the Personal Injury Commission (Commission) examination on 7 December 2021. The insurer submits that the Medical Assessor did not err in finding no significant improvement over the last plan period as the treating clinical records do not support the alleged deterioration and, the insurer submits, support no significant improvement or no benefit over each plan period and continued reporting of high levels of pain. 
13.	The insurer submits that the Medical Assessor noted, at page 3 of his certificate, that the claimant reported that she could "walk better" as a result of treatment including hot packs, hydrotherapy, physiotherapy, massage and instruction in leg exercises. Having considered this report, the clinical records and having performed an examination, the insurer says that the Medical Assessor found no significant improvement in functional capacity or any benefit over time despite extensive physiotherapy sessions. From this, the Insurer submits that the Medical Assessor did not err in finding the treatment requested was not reasonable and necessary.
14.	The Insurer submits that physiotherapy treatment has not been effective and will not assist the claimant in returning to normal as it has been of no benefit over time despite extensive physiotherapy sessions. The insurer says that the Medical Assessor was correct in finding that physiotherapy was not reasonable and necessary.
15.	The insurer also provided submissions in its initial response to the claimant’s treatment dispute. In that response, the insurer submitted that the proposed treatment was not reasonable and necessary because the subject accident did not cause the need for the treatment.
16.	The insurer further submitted that in the event its primary submission was not accepted, then the treatment was not reasonable and necessary because:
(a)	the treatment had not been effective and will not assist the claimant in returning to normal, and
(b)	the treatment was not recommended by the experts.
17.	With regard to what is reasonable and necessary treatment the insurer referred to s 3.24(2) of the Motor Accident Injuries Act 2017 (the Act) which says:
“No statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the accident concerned.”
18.	The insurer says that the judicial consideration of what 'reasonable and necessary' means is well-settled; it is not the ideal requirements of the injured person, it is the reasonable requirements per Barwick CJ in Arthur Robinson (Grafton) Pty Ltd v Carter [1968] HCA 9.
19.	The insurer referred to the judgment of Gibbs and Stephens JJ in Sharman v Evans [1977] HCA 8 at [573], where they said:
“The touchstone of reasonableness in the case of the cost of providing nursing and medical care for the plaintiff in the future is, no doubt, cost matched against health benefits to the plaintiff. If cost is very great and benefits to health slight or speculative the cost involving treatment will clearly be unreasonable…”
20.	The insurer also referred to the SIRA website which also sets out the criteria for determining whether treatment is 'reasonable and necessary':
(a) 	The treatment is directly related to the injuries sustained in the motor vehicle accident.
(b) 	The treatment is aimed at helping the injured person get back to their usual activities.
(c) 	The treatment is appropriate for the type of injury.
(d) 	The treatment is provided by an appropriately qualified health professional.
(e) 	The treatment is cost-effective.
21.	The insurer says that a decision-maker must have regard to the Clinical Framework for the Delivery of Health Services in accordance with s 4.76 of the Act. The insurer says that guiding principles are set, namely:
(a) 	measure and demonstrate the effectiveness of treatment;
(b) 	adopt a biopsychosocial approach;
(c) 	Empower the injured person to manage their recovery;
(d) 	implement goals focussing on optimising function, participation and, where applicable,
(e) 	return to work, and
(f) 	base treatment on the best available research evidence.
22.	The insurer says that the claimant had longstanding complaints which were present before the accident. The insurer notes that Dellwood Clinical notes recorded that within the 12 months before the accident, the claimant attended due to chronic pain and neurogenic pain on;
(a) 	4 April 2017;
(b) 	2 June 2017;
(c) 	27 June 2017;
(d) 	21 August 2017;
(e) 	20 September 2017;
(f) 	13 November 2017;
(g) 	13 December 2017, and
(h) 	29 December 2017.
23.	The insurer submits that the claimant was also ingesting pain medication before the accident including Lyrica or using Norspan patches to deal with these complaints of pain.
24.	The insurer submits the treatment undertaken throughout AHRR's 1-6 has not been effective. The insurer referred to the comparison of the claimant's functionality noted in the 'Clinical Assessment' and 'Capacity' sections of the AHRRs which show very little improvement. A comparison table follows.
Type of Capacity	Initial Assessment	AHRR 4	AHRR 6	
Home	Daughters assist with meals.
Carer comes 3 days per week for 1 hour to assist with showering.
1 hour per week of cleaning assistance provided by Insurer.
Claimant able to make tea, sandwich, put on tops but has difficulty
donning/doffing socks.	Carer comes 3 days per week for 1 hour to assist with showering.
1 hour per week of cleaning assistance provided by Insurer.
Claimant able to make tea, sandwich, put on tops but has difficulty donning/doffing socks.	Self-caring: unable to support in standing in shower.
Domestic: unable to do clening/laundry, able to make simple sandwich and tea
Caring: nil required.	
Community Transport	Walking: 15 – 20 minutes
Sitting: 10 minutes	Walking: 10 minutes but 20 minutes if pushing.	Gardening: Nil
Sitting: 15 – 30 minutes	
	Gardening: Nil.	Sitting: 10 – 15 minutes.	Standing: 0 - 5 minutes	
		Standing: Nil.	Walking: 10 – 15 minutes	
		Gardening: Not disclosed.		

25.	The insurer says that the absence of any real improvement was the subject of commentary in the approval of AHRR 4 to the provider, where it was said;
“Please note this is the 4th plan and Danica has limited improvement after 4 plans, please review if alternate treatment such as exercise physio would be more appropriate”.
26.	The Insurer submits that the AHRR 6 is not reasonable and necessary because it has shown to be ineffective.
27.	The insurer also submits that the treatment is not recommended by the medical experts;
a)	Dr Gehr (orthopaedic surgeon) did not recommend any ongoing physiotherapy or muscular therapy (see page 16 of his report), "Future treatment would be arthroscopic surgery of the right knee".
b)	Dr Powell (orthopaedic surgeon) said on page 15 of his report,
i.	With respect to treatment for her orthopaedic condition associated with the motor vehicle accident of January 2018 there is no indication for any further treatment that is likely to assist her.
ii.	She does not have ongoing musculoskeletal pathology that requires treatment.
28.	The insurer submits any further treatment is not reasonable or necessary.
The medical evidence
29.	The Medical Assessor provided a certificate dated 20 December 2021. The claimant reported that she was in hospital for two to three weeks and then in a rehabilitation hospital. Thereafter she had a physiotherapist visiting her home. Since that time she has had hip pain, lower back pain, knee pain and bilateral ankle pain. She has had further physiotherapy at the physiotherapy practice. She said that she felt better because of this treatment and would walk better.
30.	In 1970 the claimant had a lumbar spine operation. She said she had no problems with her lower back since that time up to the time of the accident.
31.	The claimant said that she had been on Lyrica since the accident due to chronic pain. This pain was in her lower back as well as her arms legs and hips.
32.	On examination there was no dysmetria, no non-verifiable radicular complaints but there was guarding of spinal movements however no spasm.
33.	The Medical Assessor noted several allied health rehabilitation reports.
34.	Regarding the report of AHRR 6 dated 4 February 2020 it was commented by the Medical Assessor that the treatment methods of giving strengthening exercises and development of self-management strategies are usual in the circumstances. AHRR 6 was received by the insurer on 11 November 2020 but was completed by the provider in February 2020.
35.	AHRR 5 dated 2 September 2019 was reported as showing no significant improvement over the last plan period.
36.	AHRR 4 dated 18 April 2019 again reported no significant improvement over the last plan period. The Medical Assessor said that this report from early 2019 also indicated that the treatment had not been beneficial. The report recommended hydrotherapy followed by a land-based program and also a pain management program. The report actually said that the claimant had been receiving physiotherapy for over 12 months but this had led to minimal or no improvement symptomatically. It was said though that the treatment she had received had been reasonable and necessary, despite a lack of progress.
37.	Symptoms reported in AHRR 3 dated 21 January 2019 were no worse than in AHRR 6. This noted that there had been no improvement over the period of physiotherapy treatment.
38.	There was an E discharge from St Joseph’s Hospital on 16 March 2018. The Medical Assessor referred to a diagnosis of chronic arachnoiditis since 2012 and chronic low back pain. There was also said to be a minimal problem in the knee at the time of discharge. This discharge summary is almost illegible in the bundle of documents.
39.	The Medical Assessor reported that since discharge, the claimant had not made significant improvement the same areas of injury but remained with a high level of reported pain.
40.	The Medical Assessor reported that prior to the accident the claimant had chronic pain in her low back and that the accident only provided an acute exacerbation of that pain. The Medical Assessor said that the proposed hydrotherapy was not appropriate in circumstances of long-term chronic pain. The treatment type proposed consisted of instruction and exercises and education as outlined by the physiotherapist in AHRR 6. 
41.	The Medical Assessor said that it was not reasonable to continue with physiotherapy treatment as it was not providing a benefit. He said that it is not appropriate in the circumstances of long-term chronic pain. 
42.	This is also not appropriate as the delivery previously of this same treatment had not provided a benefit.
43.	The Medical Assessor said that the physiotherapy treatment in AHRR 6 was not reasonable and necessary in the circumstances as there was pre-existing pain and disability in the areas being treated. The claimant has not benefited from the treatment significantly under the AHRR plans preceding AHRR 6 and there has been no improvement in functional capacity with the physiotherapy treatment. The treatment was said to be not usual in the circumstances and there may be more effective alternatives.
44.	There is a report from a treating physiotherapist, Margaret Wordsworth dated 20 November 2020. She said the claimant needed to recommence her physiotherapy treatment. She said the claimant had no physiotherapy in Parramatta for nine months and has only returned to hydrotherapy in the last few months. Physiotherapy treatment was requested once weekly for two months and then once per month pending further review.
45.	A social work report in the St Joseph’s Hospital discharge summary noted that pre-accident the claimant was previously independent.
46.	The claimant’s claim form when asked if she was suffering an illness or injury at the time of the accident, she said that she had middle to lower back pain.
47.	There is a report from Dr Soo to Dr Lim noting complaints of pain to lower back, right knee and right ankle. The right knee showed a lateral meniscus tear. An MRI of the right ankle showed subcutaneous oedema and lateral ligament scarring but no osteomyelitis. Dr Soo recommended continuing physiotherapy and starting hydrotherapy so as to prevent the need for surgery.
48.	There is a reference to the claimant seeing Professor Barnesly for her chronic low back pain but there is no report from him. His clinical records should be obtained.
49.	There is a report of Dr Grujic, orthopaedic surgeon, dated 13 March 2019. He was treating the claimant’s ankles. He noted that the claimant had a pre-existing history of low back pain but never any pain radiating to her legs. The claimant reported that her back was worse since the accident. She was seeing a spinal surgeon.
50.	The claimant was observed to have an unsteady gait requiring the use of a frame.
51.	An MRI of the left ankle dated 5 March 2019 was reviewed. There was a medial malleolus fracture which had now healed. There was some mild scarring over the lateral ankle ligaments and some mild low-grade tendinopathy but this was not said to contribute to any pain.
52.	Dr Grujic volunteered that her rehabilitative efforts should continue, and a canal stenosis type lesion of the lumbar spine be excluded by a spine specialist.
53.	There is a report of Dr Muratore dated 19 March 2019. He is a sports physician. Several reports were referred to including clinical notes from 1993 to 2011, hand written and reproduced poorly, from Dellwood Medical  Practice
54.	A whole body bone scan of 1 February 2006 showed a crush fracture of L2 with mild osteoarthritis of the cervical spine, lower lumbar spine, both shoulders, both knees, ankles and mid tarsal joints. There was also mentioned in the notes about the claimant having back pain since before 2005.
55.	There are also computer-generated notes from Dellwood Medical Practice from 1 April 2000 to 27 April 2018. Throughout these notes there is mention of chronic back pain due to chronic arachnoiditis, osteoporosis and a fracture of L2. There was reference to being seen at the pain clinic at Concord Hospital on 7 April 2010 at which time the claimant had been complaining of back pain for 27 years.
56.	The claimant had been prescribed Norspan patches just prior to the accident on 17 January 2018 and had commenced Lyrica on 13 December 2017 after having been on Gabapentin for nine years.
57.	It was reported that the claimant had spinal surgery in either 1973 or 1974 after having sustained a lumbar disc injury while working in a steel production factory. Following the surgery, she was able to resume her pre-injury duties after a period of about 12 months. In 2004 she sustained a fracture of L2 following a fall.
58.	The claimant was described as having chronic body pain which she had been experiencing since sustaining the fractures of the vertebral body of L2 and was under the care of Professor Barnsley, consultant rheumatologist at Concord Hospital. There was also reference from the documentation attributable to the previous spinal surgery.
59.	It was noted that despite the chronic pain, the claimant reported that she was able to do her gardening, cleaning, normal housework and cooking for her extended family until the car accident.
60.	The claimant was reported to have changed treating doctors was referred to Dr Lim as she was told he was experienced in dealing with injuries such as she had sustained. She saw her usual general practitioner (GP), Dr Yildrim, for coughs and colds and Dr Lim for the management of the accident related injuries.
61.	Dr Lim referred the claimant for physiotherapy on site. It was said that the claimant was also referred to a second orthopaedic surgeon, Dr Soo, for her feet and knees. He was said to have suggested that she continue with physiotherapy.
62.	The claimant said that she was most worried by lumbar back pain involving the whole of the lumbar spine which he described as like a numbness and just pain. She said the leg pain is different to the back pain. The back pain is aggravated by any and all activity.
63.	 Dr Muratore said that in the accident the claimant sustained;
a)	soft tissue injury of the lumbar spine with exacerbation of underlying degenerative changes at L4/5 and L5/S1;
b)	fracture of the left medial malleolus;
c)	laceration of the right ankle, and
d)	soft tissue injury of the right knee with tear of the medial meniscus. 
64.	This report was prepared for the case manager and workers compensation insurer. The claimant was reported to have had exacerbation of pre-existing the generative changes of the lumbar spine. There was evidence of increased uptake at the facet joints at L4/5 and L5/S1 and it was reported that this may, on the balance of probabilities, have been exacerbated by the subject accident.
65.	It was said that the claimant had pre-existing degenerative changes throughout the lumbar spine as well as an old crush fracture at L2. She had a past history of arachnoiditus following spinal surgery in 1974. She has osteoarthritis in the hip joints and possibly the knee joints. She has a chronic pain syndrome which has, on the balance of probabilities, been exacerbated by the accident. The extent of the exacerbation is difficult to gauge due to her presentation and a number of non-organic features.
66.	Dr Muratore noted that the claimant had been receiving physiotherapy for over 12 months which he said had led to minimal or no improvement symptomatically. He said the treatment which she had received so far had been reasonable and necessary, despite the lack of progress. He made no suggestion that the claimant have further physiotherapy but rather, discussed hydrotherapy, a pain management assessment and the possibility of facet joint blocks at L4/5 and L5/S1. However, when estimating the likely cost of treatment he said that physiotherapy may cost a further $2,000-$3,000.
67.	Report from Dr Singh to Dr Lim of 27 August 2019. He referred to the claimant having an 
X-ray which showed a collapsed L2 fracture with wedging and scoliosis and L3. She was reported as having a significant deterioration of her function since the accident.
68.	Dr Singh said that the claimant may have to accept permanent functional restrictions from the aggravation of the lumbar spondylosis, her L2 fracture, and her other injuries from the accident.
69.	Report of Dr Gehr dated 2 September 2019. This report was prepared for the claimant’s solicitors.
70.	The claimant reported that she had pain in her lumbar spine which had increased by at least 100% after the accident. She also said that she had pain radiating down to the level of her feet from her back. Lumbar spine injections were recommended by Dr Singh which took place but did not assist.
71.	The doctor diagnosed:
a)	left ankle fracture with residual pain and stiffness of ankle and hindfoot;
b)	aggravation of long standing low back pain with left radicular pain and dysmetria;
c)	right knee pain with stiffness with imaging demonstrating meniscal pathology, and
d)	bilateral shoulder pain that has not been investigated with residual pain and stiffness.
72.	Regarding the lumbar spine, the doctor deducted 50% for previous symptomatic history.
73.	He assessed a total whole person impairment of 40%. He did not estimate specifically a need for future treatment other than to say that within 12 to 18 months the claimant would need arthroscopic surgery of the right knee.
74.	The claimant was not examined by the Panel. The parties were informed that an assessment of the issues would be undertaken on the papers and no objection was taken to this by either party.
75.	This dispute is about the insurers refusal to fund eight treatments of physiotherapy. For the reasons earlier provided, the Panel sees no benefit in physiotherapy occurring two or more years post accident, overlying a chronic condition of pain commencing in 2004 when she fractured her L2 vertebra in a fall and had subsequently come under the care of Professor Barnsley, and from whom no medical evidence has been provided by the claimant.
PANEL CONSIDERATIONS
Reasonable and necessary
76.	The claimant is required to establish that the treatment is both (1) reasonable and (2) necessary. This test differs from the workers compensation legislation which requires a worker to establish that the treatment is “reasonably necessary”. There is a stricter requirement under the motor vehicle accidents legislation because there is no moderation of the requirement that the treatment is “necessary ”.
77.	Barwick CJ in Arthur Robinson (Grafton) Pty Limited v Carter [1968] HCA 9 said:
“The question here is not what are the ideal requirements but what are the reasonable requirements of the respondent… The jury, in my opinion, should be told to consider what the respondent, on the assumption that he was spending his own money, and assuming that he had sufficient to do as he would and was well advised and reasonably careful for his own welfare, would be likely to expend in protection of himself and his condition. It is neither fair nor just to award a sum which might be expected by others in different circumstances but which it is realized the injured person will not spend for the purposes in question”
78.	The issue involves consideration of two stages. There is little specific law on the point for the assistance of the Panel.
79.	Dictionary definitions provide some assistance. The word “necessary” is described as “indispensable, requisite, needful, that cannot be done without” – (Shorter) Oxford English Dictionary, 3rd edition and “that cannot be dispensed with” – Macquarie Dictionary.
80.	The recommendation for eight sessions of physiotherapy treatment came from AHRR 6 which issued from the claimant’s medical practice. The insurer correctly highlights that this recommendation did not specify the condition for which the treatment was intended. Furthermore, there is no indication of benefits previously gained from treatment, or likely to be gained.
81.	In the guiding criteria of the SIRA website to determine whether treatment is reasonable and necessary, a notable objective is that the treatment must be cost-effective. Since the accident the claimant has been previously treated with physiotherapy with limited improvement demonstrated, if at all.
82.	Dr Powell said that there was no indication for further treatment that was likely to assist the claimant. Dr Gehr only referred to a need for future treatment or way of arthroscopic surgery to the right knee. The Medical Assessor said that it was not reasonable to continue with physiotherapy treatment as this was not providing a benefit. He said that it was not appropriate in the circumstances of long-term chronic pain.
83.	Ms Wordsworth, physiotherapist, in her report of 20 November 2020 said that the claimant needed to recommence her physiotherapy treatment but did not take this point further. Dr Soo recommended continuing physiotherapy and starting hydrotherapy to prevent the need for surgery.
84.	Dr Muratore, in his report of 19 February 2019 said that the treatment which the claimant had received to that point had been reasonable and necessary despite the lack of progress. However, he made no suggestion that the claimant have further physiotherapy but rather, discussed hydrotherapy, a pain management assessment and the possibility of facet joint blocks.
85.	Dr Muratore in his report said that the claimant had been receiving physiotherapy for over 12 months however, he said that this had led to minimal or no improvement symptomatically. Dr Muratore made no suggestion that the claimant have further physiotherapy but rather, discussed other modes of treatment.
86.	In the claimant’s submissions, she refers to the reference by the Medical Assessor that the physiotherapy treatment which she had was not beneficial. The claimant says though that she told the Medical Assessor that she felt that such treatment was helpful in that it helped her to “walk better”.
87.	The issue of whether certain treatment is reasonable and necessary must be considered in light of the claimant’s pre-existing pain and medical history. The insurer in its submissions listed eight consultations before the motor vehicle accident between 4 April 2017 and 29 December 2017 when the claimant attended her GP due to chronic pain and neurogenic pain. General practitioner clinical notes also refer to the claimant taking pain medication before the accident including Lyrica and taking pain patches to deal with her complaints.
88.	The claimant had spinal surgery around 1973 or 1974 following a lumbar disc injury whilst working in a factory. In 2004 she suffered a fracture of her L2 vertebra following a fall. The claimant has been under the care of Professor Barnsley, consultant rheumatologist at Concord Hospital, since sustaining the fractures of the vertebral body of L2. The claimant said though that despite chronic pain, she was able to do gardening, cleaning, normal housework and cooking for her family until the car accident.
89.	The insurer submits that the treatment undertaken by the claimant throughout AHRR 1-6 has not been effective and showed very little improvement. The claimant argues that whilst there may not have been improvement, the treatment helped her to “walk better” and on that basis it was reasonable and necessary.
90.	The Medical Assessor said that the accident only provided an acute exacerbation of her chronic pain and low back. The Medical Assessor said that it was not reasonable to continue with physiotherapy treatment as it was not providing a benefit. He said that in the circumstances of long-term chronic pain, physiotherapy treatment was not appropriate.
91.	It is the Panel’s observation that if treatment is being provided but it is not resulting in any benefit of note then it cannot be said to be reasonable and it cannot be said to be necessary. On the SIRA guidelines, it could also not to be said to be cost-effective on that basis.
Review Panel’s findings – assessment of treatment – causation
92.	The accident was a car versus pedestrian collision. The Panel accepts that in such circumstances, the claimant would have suffered injuries requiring medical treatment following the accident. This has occurred however, such treatment would have been of a short term benefit given that the claimant since at least 2004 has been receiving medical treatment for pain in her back. Within a period of four weeks before the accident the claimant was prescribed strong pain medication and in the eight months before the accident the claimant sought regular treatment from her GP due to chronic pain and neurogenic pain. 
93.	In the opinion of the Panel, the claimant is now suffering the same pain which she was enduring before the accident.
94.	The accident caused a short-term aggravation of pain which after treatment, would have subsided to the level of pain she was being treated for by way of medication relatively constantly before the accident.
95.	The Panel is not of the finding that a recommendation of treatment, by way of physiotherapy on 4 February 2020, more than two years post-accident, would provide an appreciable benefit or at all. At best, the claimant said that physiotherapy enabled her to walk better but the cumulative AHRR’s show no appreciable increase in walking ability.
Conclusion
96.	The request for physiotherapy was two years post-accident. The Panel accepts that it would have been reasonable for the claimant to have physiotherapy within a reasonable period of the accident but to undergo such treatment two years or more later is not in the opinion of the Panel, reasonable and necessary.
97.	There is however, little medical evidence in support of eight further physiotherapy treatments, apart from her physiotherapist but a preponderance of opinion against this from Dr Powell, the Medical Assessor, and by Dr Gehr by virtue of recommending other treatment or no treatment at all.
Review Panel decision/determination
98.	The following treatment and care is not reasonable and necessary in the circumstances;
(a)	eight sessions of physiotherapy treatment requested in the Allied Health Recovery Request number 6 dated 16 October 2020.