Despite Helpful Effects, Evidence didn’t Support Worker’s Need for Codeine Prescription

Federal Focus

Because a federal worker failed to submit rationalized medical evidence establishing a causal link between her accepted injury and her requested prescription medication, ECAB found that OWCP properly denied authorization.

Case

B.V. and Department of the Air Force, No. 23-0906 (ECAB 03/23/26)

What Happened?

A quality assurance evaluator filed a traumatic injury claim alleging that she injured her arms, left knee, right ankle, back, and abdomen when slipped on wet paint and fell while in the performance of duty. The Office of Workers' Compensation Programs accepted the claim.

Some 30 years later, due to pain, the worker sought benefits for the use of butalbital/acetaminophen/caffeine with codeine. Although the evaluator had been taking the medication, OWCP denied authorization for it, finding that the evidence of record was insufficient to establish that it was medically necessary to address the effects of her work-related injury or condition.

The evaluator sought review from the Employees' Compensation Appeals Board.

Rule of Law

The Federal Employees' Compensation Act provides that OWCP shall furnish to an employee who is injured while in the performance of duty the services, appliances, and supplies prescribed or recommended by a qualified physician, which OWCP considers likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening in the amount of monthly compensation.

When it comes to a prescription medication, ECAB requires identification of accepted conditions and a rationalized explanation of how the medication treats those conditions.

What ECAB Said

According to ECAB, OWCP properly denied authorization for a prescription medication because it was unrelated to the accepted employment conditions.

Although the evaluator's doctor indicated that the evaluator was better with medication than without, that the evaluator was using her medications properly, and that the medications provided the evaluator with pain relief and allowed her to perform her activities of daily living, the doctor did not provide a reasoned medical opinion explaining that the codeine medication was prescribed to treat her accepted conditions nor did he provide a reasoned medical opinion as to how any additional condition was causally related to the accepted employment injury.

ECAB emphasized that the lack of a reasoned medical opinion tying the medication to the evaluator's accepted conditions sunk her claim.

"The medical evidence of record is therefore insufficient to establish that the requested prescription ... is for treatment of an employment-related injury or condition," ECAB wrote.

Verdict: ECAB upheld OWCP's decision denying authorization for the prescription.

Takeaway

Treating physician statements about pain relief and daily functioning are not enough. Instead, OWCP requires a reasoned explanation linking the medication to the accepted condition.

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