Case Title: IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF: MICHAEL TARRAFERRO V. STATE OF WYOMING, ex rel., WYOMING MEDICAL COMMISSION and WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION

Citation: 

Docket Number: 05-53

State: wyoming

Court: Wyoming Supreme Court

Date: 2005-12-02T00:00:00Z

Document:
IN THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF: MICHAEL TARRAFERRO V. STATE OF WYOMING, ex rel., WYOMING MEDICAL COMMISSION and WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION2005 WY 155123 P.3d 912Case Number: 05-53Decided: 12/02/2005
OCTOBER 
TERM, A.D. 2005

 
 
IN THE 
MATTER OF THE WORKER'S

COMPENSATION 
CLAIM OF:

 
 
MICHAEL 
TARRAFERRO,

 
 
Appellant

(Petitioner),

 
 
v.

 
 
STATE OF 
WYOMING, ex rel., WYOMING

MEDICAL 
COMMISSION and WYOMING

WORKERS' 
SAFETY AND COMPENSATION

DIVISION,

 
 
Appellee

(Respondent).

 
 

Appeal 
from the DistrictCourtofLaramieCounty

The 
Honorable E. James Burke, Judge

 
 
Representing 
Appellant:

 
 
Bill G. 
Hibbler, Cheyenne, 
Wyoming.

 
 

Representing 
Appellee:

 
 
Patrick 
J. Crank, Attorney General; Steve Czoschke, Senior Assistant Attorney General; 
and J.C. DeMers, Special Assistant Attorney General.  Argument by 
Mr. DeMers.

 
 
Before 
HILL, C.J., and GOLDEN, KITE, and VOIGT, JJ., and GUTHRIE, 
D.J.

 
 

HILL, 
Chief Justice.

 
 
[¶1]      Appellant, 
Michael Tarraferro (Tarraferro), contends that the Medical Commission 
(Commission) erred in considering inadmissible and incompetent evidence that it 
generated after the hearing on this matter had concluded, and that its decision 
that Tarraferro failed to meet his burden of proof that his use of the 
medication Marinol "was not experimental," as well as that its use "was 
necessary and reasonable," is erroneous.  
The only competent evidence of record requires that we reverse the 
Commission's order, as well as the district court's order affirming that 
decision, and direct that this matter be remanded to the Commission with 
directions that it void its decision to deny Tarraferro his Marinol 
prescription, and enter an order to the opposite effect.

 
 
ISSUES

 
 
[¶2]      Tarraferro raises 
these issues:

 
 
            
I.          
Whether the Medical Commission order is supported by substantial 
evidence?

 
 
            
II.          
Whether the Medical Commission order is contrary to law because it is 
based upon evidence gathered sua sponte by the panel outside of the hearing, in 
violation of Wyoming Statute § 16-3-107(j), (o) or (r) and/or § 16-3-108(c) or 
(d)?

 
 
            
III.         
Whether the Medical Commission order is contrary to law because it is 
based upon an issue not referred to and before it?

 
 
            
IV.        
Whether the Medical Commission order is arbitrary or capricious because 
it ordered payment of medical benefits even though it concluded payment of those 
benefits is contrary to Wyoming Statute § 
27-14-102(a)(xii)?

 
 
            
V.        
Whether the Medical Commission order is contrary to law because the 
Workers' Compensation Division violated Wyoming Statute § 27-14-605(a), by 
improperly redetermining either the necessity, reasonableness or experimental 
use of Mr. Tarraferro's Marinol prescription?

 
 
The 
Workers' Compensation Division (Division) poses these 
issues:

 
 
            
Is [Tarraferro] aggrieved or adversely affected for purposes of judicial 
review when the Medical Commission ordered payment of the actual claim at 
issue?

 
 
            
Is the Medical Commission's finding that [Tarraferro] failed to prove 
entitlement to Marinol, a prescription drug, as a result of his 1998 left 
inguinal hernia reasonable and supported by substantial 
evidence?

 
 
FACTS 
AND PROCEEDINGS

 
 
[¶3]      On February 28, 
2003, Tarraferro submitted a claim to the Division so as to be reimbursed for a 
pain medication, Marinol, prescribed for him by his attending physician, a pain 
management specialist.  At the time 
he submitted this claim, he had been taking Marinol for 22 months.  The cost of a 30-day supply of Marinol 
at that time was $1,037.74.

 
 
[¶4]      The Division 
denied the claim on the basis that:  
"THIS MEDICATION IS DENIED AS IT IS TO BE USED TO ASSIST CANCER AND AIDS 
PATIENTS.  CURRENT SYMPTOMS DO NOT 
APPEAR TO MEET THE CRITERIA FOR MARINOL USE PER THE FDA GUIDELINES."  That notice advised Tarraferro of his 
right to a hearing if he disagreed with that determination.  On March 19, 2003, Tarraferro asked for 
a hearing.  The Commission issued an 
order appointing counsel for Tarraferro on June 5, 2003, and scheduled a hearing 
for February 18, 2004.  A hearing 
was held and the Commission issued findings of fact and conclusions of law, 
affirming the Division's denial of Tarraferro's claim.  Tarraferro further appealed his case to 
the district court, and the district court issued an order affirming the 
Commission's order.

 
 
[¶5]      We need not 
detail the severe and disabling injury that Tarraferro suffered, because the 
fact that he suffered such an injury, and was receiving worker's compensation 
benefits for it, is not at issue here.  
The only issue was whether Tarraferro's attending physician properly 
prescribed Marinol for his patient's pain symptoms.  The following is a physician's 
description1 of what brought Tarraferro to the 
use of Marinol:

 
 
This is 
a 40 year old gentleman who reports significant pain in the penis, scrotal and 
perineal areas ever since a severe pelvic crush injury 2 ½  years ago.  This pain is always there, it is up to a 
10 out of 10.2  He describes it as a vise grip squeezing 
to the penis and testis.  It seems 
to be worse following treatment with FLOMAX or SAW PALMETTO.  No alleviating factors except pain 
medications.  Associated symptoms 
are pain, nausea, rash.

 
 
STANDARD 
OF REVIEW

 
 
[¶6]      Our review of an 
administrative decision is limited to those matters specified in Wyo. Stat.  Ann. § 16-3-114(c) (LexisNexis 
2005):

 
 
      (c)  To 
the extent necessary to make a decision and when presented, the reviewing court 
shall decide all relevant questions of law, interpret constitutional and 
statutory provisions, and determine the meaning or applicability of the terms of 
an agency action.  In making the 
following determinations, the court shall review the whole record or those parts 
of it cited by a party and due account shall be taken of the rule of prejudicial 
error.  The reviewing court 
shall:

(i)  Compel 
agency action unlawfully withheld or unreasonably delayed; 
and

(ii)  Hold 
unlawful and set aside agency action, findings and conclusions found to 
be:

(A)  Arbitrary, 
capricious, an abuse of discretion or otherwise not in accordance with 
law;

(B)  Contrary 
to constitutional right, power, privilege or immunity;

(C)  In 
excess of statutory jurisdiction, authority or limitations or lacking statutory 
right;

(D)  Without 
observance of procedure required by law;  
or

(E)  Unsupported 
by substantial evidence in a case reviewed on the record of an agency hearing 
provided by statute.

 
 
The 
standard of review we apply when both parties present evidence at an 
administrative hearing was set forth in Newman v. State ex rel. Wyoming Workers' 
Safety and Compensation Division, 2002 WY 91, 49 P.3d 163 
(Wyo.2002).

 
 
      In appeals where 
both parties submit evidence at the administrative hearing, Newman mandates that appellate review be 
limited to application of the substantial evidence test.  Newman, 2002 WY 91, ¶22, 49 P.3d 163.   This is true regardless 
of which party appeals from the agency decision.  In addition, this court is required to 
review the entire record in making its ultimate determination on appeal. Newman, at ¶19 and 
¶¶24-26.

 
 
            
The substantial evidence test to be applied is as 
follows:

 
 
"In 
reviewing findings of fact, we examine the entire record to determine whether 
there is substantial evidence to support an agency's findings.  If the agency's decision is supported by 
substantial evidence, we cannot properly substitute our judgment for that of the 
agency and must uphold the findings on appeal.  Substantial evidence is relevant 
evidence which a reasonable mind might accept in support of the agency's 
conclusions.  It is more than a 
scintilla of evidence."

 
 

Newman, at ¶12 
(quoting State ex rel. Workers' Safety 
and Compensation Div. v. Jensen, 2001 WY 51, ¶10, 24 P.3d 1133, ¶10 
(Wyo.2001)).

 
 
Even 
when the factual findings are found to be sufficient under the substantial 
evidence test, Newman further 
concludes this court may be required to apply the arbitrary-and-capricious 
standard as a "safety net" to catch other agency action which prejudiced a 
party's substantial right to the administrative proceeding or which might be 
contrary to the other [Wyoming Administrative Procedural Act] review 
standards.

 
 

Loomer 
v. State ex rel. Wyoming Workers' Safety and Compensation 
Division, 2004 
WY 47, ¶15, 88 P.3d 1036, ¶15 (Wyo.2004).

 
 

Berg v. 
State ex rel. Wyoming Workers' Safety and Compensation Division, 2005 
WY 23, ¶7, 106 P.3d 867, 870 (Wyo. 2005).

 
 
DISCUSSION

 
 
[¶7]      It was agreed by 
all parties and the Commission that the sole issue at the hearing was, "Whether 
Employee Claimant's use of Marinol is necessary and 
reasonable."

 
 
Is 
Tarraferro Aggrieved or Adversely Affected by the Commission's 
Decision

 
 
[¶8]      Because this 
poses a threshold question which would render unnecessary further consideration 
of the other issues raised in this matter, we will address this question 
first.  At the outset, we note that 
this issue was not called to the attention of the Commission, nor was it 
addressed by the district court.  Until this appeal was brought before this 
Court, the Division, the Medical Commission, Tarraferro, and the district court 
perceived this to be a justiciable controversy, as well as that he was aggrieved 
and adversely affected by the Division's and the Commission's respective 
decisions.    This 
contention is premised upon the Commission's following finding:  "However, because the Division paid for 
22 months of medication and denied further benefits after Mr. Tarraferro 
refilled his prescription, this last prescription refill should 
be paid by the Division."  (Emphasis 
added.)  It was apparently the 
Medical Commission's conclusion that, given these circumstances, the Division 
should have paid for the immediate prescription, but it further determined that 
any future benefits in this regard should be denied.   To conclude that the Medical 
Commission's digression deprives this Court of jurisdiction to hear this appeal 
elevates form over substance to an extent with which we simply cannot 
agree.  In Jacobs v. State ex rel. Workers' Safety and 
Compensation Division, 2004 WY 136, ¶8, 100 P.3d 848, 850-51 (Wyo. 2004) we 
held:

 
 
            
Until Jacobs is actually denied benefits for his abdominal pain, that 
issue is not ripe for our review.

 
 
The 
ripeness doctrine is a category of justiciability "developed to identify 
appropriate occasions for judicial action."  13 Wright, Miller & Cooper, Federal 
Practice 

and 
Procedure:  Jurisdiction § 3529, p. 
146 (1975).  The basic rationale of 
the ripeness requirement, like that of the justiciability 
requirement,

 
 
" * * * 
is to prevent the courts, through avoidance of premature adjudication, from 
entangling themselves in abstract disagreements over administrative policies, 
and also to protect the agencies from judicial interference until an 
administrative decision has been formalized and its effects felt in a concrete 
way by the challenging parties.  The 
problem is best seen in a twofold aspect, requiring us to evaluate both the 
fitness of the issues for judicial decision and the hardship to the parties of 
withholding court consideration."  
Abbott Laboratories v. 
Gardner, 387 U.S. 136, 87 S. Ct. 1507, 1515, 18 L. Ed. 2d 681 (1967).

 
 

Industrial 
Siting Council of State of Wyo., 660 P.2d  at 779.   Benefits for 
Jacobs' chronic abdominal pain have not been denied and no decision determining 
that issue has been formalized.  
Until a final determination is made by the appropriate administrative 
agency, the issue is not fit for our review.  This Court cannot reverse or affirm a 
denial of benefits that has not occurred.

 
 
[¶9]      We conclude that 
Tarraferro's circumstances are readily distinguishable from the concerns we 
expressed in Jacobs.  Here, the Commission paid the immediate 
claim, but added an unequivocal conclusion that no future benefits would be paid 
in that regard.  Our resolution of 
the issues brought before the Court is not premature, and a refusal to consider 
them at this juncture would operate as a hardship to this claimant, as well as 
similarly situated future claimants.  
By issuing conclusions such as those at issue here, the Division and the 
Commission could introduce delay in the final resolution of worker's 
compensation claims for years at a time.  
The instant claim was denied on March 13, 2003, and some two and one-half 
years have already passed since that decision was made.  During that time, Tarraferro has been 
deprived of the benefits of the Marinol prescription.

 
 
Is the 
Medical Commission's Decision Based on Competent 
Evidence

 
 

[¶10]   An independent medical examination 
commissioned by the Division revealed that, " Dr. Perakos believed that Mr. 
Tarraferro was in fact suffering from chronic pain and there was a causal 
relationship between his complaints and the occupational injury."  On April 12, 2000, Tarraferro began 
seeing Harlan Ribnik, M.D.  Dr. 
Ribnik is a pain management specialist, and that was Tarraferro's sole reason 
for consulting with him.  Dr. Ribnik 
identified Marinol as an appropriate and documented treatment for pain, although 
he was unable to cite to specific literature or studies at his deposition.  He also noted that such treatment is not 
"experimental."  Dr. Ribnik also 
testified that he did not prescribe it as a treatment for nausea, but that 
turned out to be a secondary benefit of the Marinol, as Tarraferro also 
complained of nausea that accompanied his pain.  Dr. Ribnik testified that Tarraferro had 
not responded well to narcotic drugs and continued him on Marinol because it was 
"efficacious," meaning, of course, that it worked.  Available literature indicates that many 
different medications are used to treat pain, including non-narcotic analgesics, 
acetaminophen, non-steroidal anti-inflammatory drugs, Alpha2 
agonists, Ketamine, Dextromethorphan, Lidocaine, anticonvulsants, narcotic 
analgesics, and antidepressants.  6B Lawyers' Medical Cyclopedia of Personal 
Injuries and Allied Specialties, § 44A.4- 44 A. 11 (LEXIS 
2000).

 
 
[¶11]   The essence of the Medical 
Commission's findings was that Marinol was not reasonable and necessary, was 
contraindicated in Tarraferro's case, and it was experimental.  For this proposition, the Medical 
Commission relied on the Physicians' Desk 
Reference (Thomson 2005) (generally known as the PDR) and "FDA guidelines," although 
there are no "FDA guidelines" in the record (nor can we locate any such 
authority by that citation).  A 
brief perusal of the Forward to the PDR reveals that the PDR is not designed to function in the 
way the Commission applied it:

 
 

Physicians' 
Desk Reference is 
published by Thomson PDR in cooperation with participating manufacturers.  The PDR contains Food and Drug 
Administration (FDA) approved labeling for drugs as well as prescription 
information provided by manufacturers for grandfathered drugs and other drugs 
marketed without FDA approval under current FDA policies.  Some dietary supplements and other 
products are also included.

 
 
Each 
full-length entry provides you with an exact copy of the product's FDA-approved 
or other manufacturer supplied labeling.  
Under the Federal Food, Drug and Cosmetic (FD&C) Act, a drug approved for marketing may be 
labeled, promoted, and advertised by the manufacturer for only those uses for 
which the drug's safety and effectiveness have been established.  The Code of Federal Regulations Title 21 
Section 201.100(d)(1) pertaining to labeling for prescription products requires 
that for PDR content "indications, 
effects, dosages, routes, methods, and frequency and duration of administration, 
and any relevant warnings, hazards, contraindications, side effects, and 
precautions" must be "same in language 
and emphasis" as the approved labeling for the products.  The FDA regards the words same in language and emphasis as 
requiring VERBATIM use of the approved labeling providing such information.  Furthermore, information that is 
emphasized in the approved labeling by the use of type set in a box, or in 
capitals, boldface, or italics, must be given the same emphasis in PDR.

 
 

The FDA 
has also recognized that the FD&C Act does not, however, limit the manner in 
which a physician may use an approved drug.  Once a product has been approved for 
marketing, a physician may choose to prescribe it for uses or in treatment 
regimens or patient populations that are not included in approved labeling.  The FDA also observes that accepted 
medical practice includes drug use that is not reflected in approved drug 
labeling.  In the case of over-the-counter dietary 
supplements, it should be remembered that this information has not been 
evaluated by the [FDA], and that such products are not intended to diagnose, 
treat, cure, or prevent any disease.

 
 
The 
function of the publisher is the compilation, organization, and distribution of 
this information.  Each product 
description has been prepared by the manufacturer, and edited and approved by 
the manufacturer's medical department, medical director, and/or medical 
consultant.  In organizing and 
presenting the material in Physicians' 
Desk Reference, the publisher does not warrant or guarantee any of the 
products described, or perform any independent analysis in connection with any 
of the product information contained herein.  Physicians' Desk Reference does not 
assume, and expressly disclaims, any obligation to obtain and include any 
information other than that provided to it by the manufacturer.  It should be understood that by making 
this material available, the publisher is not advocating the use of any product 
described herein, nor is the publisher responsible for misuse of a product due 
to typographical error.  Additional 
information on any product may be obtained from the manufacturer.  [Emphasis added.]

 
 
Physicians' 
Desk Reference (59th ed. 2005).  The Commission's reference to the PDR 
does not support its decision.

 
 
[¶12]   The Medical Commission also 
referenced the use of Medline® as a part of its independent gathering of 
evidence after the hearing concluded.  
Tarraferro was not given notice of that independent research.  We take note here that the record 
reveals that the Commission had no "specialized knowledge" as to the medical 
specialty of pain management.  
Indeed, its misuse of the PDR 
and Medline® specifically demonstrates a lack of expertise.  Moreover, Wyo. Stat. Ann. § 
16-3-107(o)(p)(q) and (r) (LexisNexis 2005) provide:

 
 
(o)  The 
record in a contested case must include:

(i)  All 
formal or informal notices, pleadings, motions and intermediate 
rulings;

(ii)  Evidence 
received or considered including matters officially 
noticed;

(iii)  Questions 
and offers of proof, objections and rulings thereon;

(iv)  Any 
proposed findings and exceptions thereto;

            
(v)  Any opinion, findings, decision or order of the agency and 
any report by the officer presiding at the hearing.

(p)  In 
all contested cases the proceeding including all testimony shall be reported 
verbatim stenographically or by any other appropriate means determined by the 
agency or the officer presiding at the hearing.

(q)  Oral 
proceedings or any part thereof shall be transcribed on request of any party 
upon payment of the cost thereof.

(r)  Findings 
of fact shall be based exclusively on the evidence and matters officially 
noticed.

 
 
[¶13]   Wyo. Stat. Ann. § 16-3-108(c) and 
(d) (LexisNexis 2005) provide:

 
 
(c)  A 
party may conduct cross-examinations required for a full and true disclosure of 
the facts and a party is entitled to confront all opposing 
witnesses.

(d)  Notice 
may be taken of judicially cognizable facts.  In addition notice may be taken of 
technical or scientific facts within the agency's specialized knowledge or of 
information, data and material included within the agency's files.  The parties shall be notified either 
before or during the hearing or after the hearing but before the agency decision 
of material facts noticed, and they shall be afforded an opportunity to contest 
the facts noticed.

 
 

[¶14]   The product of the Commission's 
independent gathering of evidence is not reflected by the record.  We consulted the Medline® website, but 
it appears to be little more than the information contained in the PDR, but in a more abbreviated 
format.  However, through access to 
an authoritative database available through the Wyoming State Library, we found 
information on clinical pharmacology that corroborated Dr. Ribnik's 
testimony, i.e., that studies have identified Marinol as an appropriate 
medication for pain management, Alzheimer's disease, and muscle spacticity/spasm 
associated with multiple sclerosis (Search:  http://www-wsl.state.wy.us/; select 
"WYLD Databases;" select EBSCO Host; select "clinical pharmacology;" search 
Marinol (Dronabinol, THC)).  In 
addition, the U.S. Drug Enforcement Administration has a website devoted to 
"Medical Marijuana" (i.e., Marinol), wherein it states:  "In the meantime, the DEA is working 
with pain management groups, such as Last Acts, to make sure that those who need 
access to safe, effective pain medication can get the best medication 
available." (Search:  
http://www.usdoj.gov/dea/ongoing/marinol.html).  Of course, this Court cannot gather 
evidence off the record to support its decision any more than may the Medical 
Commission.  We make reference to 
these authorities to demonstrate only that the Commission not only acted 
improperly and contrary to governing law, but to the extent it did so, was also 
wrong.  Thus, there is nothing in 
the record to sustain a conclusion that Dr. Ribnik's testimony was flawed, as 
the Commission concluded.  His 
credentials as a pain management expert and his avowed knowledge of 
pharmacology, particularly as it relates to pain, are unchallenged by any 
evidence properly of record.

 
 
[¶15]   The Commission's findings 
continued:

 
 
Because 
the panel finds the use of Marinol under these facts is experimental, we need 
not reach the issue of whether the use of Marinol is necessary and 
reasonable.  Contrary to assertions 
by counsel for Mr. Tarraferro, this decision is not based on the cost of 
Marinol.  Several medications 
routinely approved for injured workers are more expensive than 
Marinol."

 
 
Not all 
"off label" uses of medications are experimental.  The conclusion of Marinol being 
experimental under these facts is based on the lack of any studies, 
publications, etc., which indicate such use for pain control is recognized or 
effective.  As to the issue of 
whether such is necessary and reasonable, given Mr. Tarraferro's weight, other 
health issues, some history of substance abuse, and depression, Marinol is 
contraindicated.  As such, the Panel 
would find Marinol as not being necessary and reasonable under the facts 
presented.

 
 
Mr. 
Tarraferro has not met his burden of proof that his use of Marinol was not 
experimental and that its use was necessary and 
reasonable.

 
 
[¶16]   The issue of whether Marinol was 
experimental in these circumstances finds its origin in Wyo. Stat. Ann. § 
27-14-102(a)(xii) (LexisNexis 2005):

 
 
            
(xii)  "Medical and hospital care" when provided by a health 
care provider means any reasonable and necessary first aid, medical, surgical or 
hospital service, medical and surgical supplies, apparatus, essential and 
adequate artificial replacement, body aid during impairment, disability or 
treatment of an employee pursuant to this act including the repair or 
replacement of any preexisting artificial replacement, hearing aid, prescription 
eyeglass lens, eyeglass frame, contact lens or dentures if the device is damaged 
or destroyed in an accident and any other health services or products authorized 
by rules and regulations of the division.  
"Medical and hospital care" does not include any personal item, 
automobile or the remodeling of an automobile or other physical structure, 
public or private health club, weight loss center or aid, experimental medical or surgical 
procedure, item of furniture or vitamin and food supplement except as 
provided under rule and regulation of the division and paragraph (a)(i) of this 
section for impairments or disabilities requiring the use of wheelchairs; 
[Emphasis added.]

 
 
[¶17]   What the statute intends to convey 
by "experimental" is not further defined.  
However, we conclude that it is a term of art in this context, and that 
the Commission was incorrect as to that matter as well.  1A Lawyers' Medical Cyclopedia of Personal 
Injuries and Allied Specialties, § 2.53 at 2-138  139 (LEXIS 2001) provides 
just the sort of context that is needed in a case such as 
this:

 
 
            
To understand this area of law, it is important to distinguish between 
concepts that are frequently commingled and confused.  Unfortunately, there is no universally 
accepted terminology, so that it is often difficult to know what any one author 
means when using the words "experimentation," "research," and "novel 
technique."  For the sake of clarity 
and understanding, these terms will have the following definitions in this 
discussion unless stated otherwise.

 
 
            
Experimentation is the use of 
a medicine or procedure, which is yet to be adequately tested for the purpose 
for which it is intended.  An 
experiment may or may not have a therapeutic goal, and it may or may not be 
designed to yield useful scientific information.  Thus, "experimentation" has a very broad 
definition.  In the legal and 
medical literature, "experimentation" is used to mean everything from the 
malicious use of patients as guinea pigs to the noble treatment of an incurable 
patient by the most scientifically advanced methods.

 
 
            
Research is a form of 
"experimentation" that includes only studies designed to produce useful 
scientific data.  A research project 
may or may not offer therapeutic benefits to the human subjects involved, but it 
is always designed to obtain information beneficial to humankind in 
general.

 
 
            
Novel techniques,  on the other hand, are always intended 
to be therapeutic or diagnostic, relative to a particular patient's medical 
problem.  Like experimentation, 
novel techniques have varying degrees of incomplete prior testing.  The categories of novel techniques may 
be divided into (1) new approaches to otherwise untreatable conditions and (2) 
new approaches to treatable conditions (where it is hoped that the new technique 
will offer some new advantage). 

 
 
[¶18]   It is clear from Dr. Ribnik's 
testimony that the use of Marinol to treat severe and persistent pain was 
reasonable, necessary, and not experimental.  It is also clear from his testimony, 
based on an unchallenged expertise in the area of pain management, that its use 
in Tarraferro's case was not experimental.  
On the continuum described above, its use might be considered a "novel 
technique," but according to Dr. Ribnik's testimony, it was an accepted practice 
among physicians specializing in pain management.

 
 
[¶19]   Despite the fact that the 
Division's own evidence confirmed that Tarraferro's pain was caused by his 
industrial accident, as well as the surgeries necessitated by that accident, and 
despite the Commission's specific finding that the pain was caused by the 
accident, the Division continues to argue in its brief that the pain was not a 
result of the work-related accident and its aftermath.  In addition, the Division and the 
Commission have ignored Dr. Ribnik's unequivocal testimony that Marinol was not 
prescribed to treat nausea (only the pain, but that as an additional benefit it 
did help control Tarraferro's pain-associated nausea) and conclude that Marinol 
is not a reasonable or necessary anti-nausea medication.  That argument simply is beside the 
point.  The Division and the 
Commission conclude that the pain may also have been caused by Tarraferro's 
prostatitis.  There is evidence that 
Tarraferro suffered from prostatitis, but it suggests that it was at most a 
secondary source of Tarraferro's pain problems.  The Division and the Commission want to 
blame the pain on Tarraferro's obesity, even though the only evidence on this 
point was to the effect that he was always a very large man, although he did 
steadily gain weight after he became almost completely sedentary after suffering 
his injuries.  Dr. Ribnik testified 
only that weight gain could "potentially" increase Tarraferro's 
pain.

 
 
[¶20]   In sum, the evidence properly of 
record will support only one conclusion:  
That Marinol was a reasonable and necessary, non-experimental treatment 
for Tarraferro's pain.

 
 
CONCLUSION

 
 
[¶21]   We reverse the order of the 
district court affirming the Medical Commission's decision. We remand this 
matter to the district court with directions that it enter an order reversing 
the Commission's decision.  That 
order shall include further directions that the Medical Commission enter an 
order reversing the Division's decision to disallow Tarraferro's claim for 
Marinol.

 

FOOTNOTES

 
 

  
1Of course, one of the 
limitations of medical science is that the body's five classic senses cannot 
provide any information to a diagnostician:  "The examiner cannot see the pain, hear 
the pain, touch the pain, taste the pain, or smell the pain.  Worse yet, though in an age of medical 
miracles, we cannot X-ray the pain, measure it like serum levels of hemoglobin 
or sodium, plot it on graph paper like an EEG, or cut it out like a tumor.  There are no measuring devices like 
voltmeters to tell us whether a patient is experiencing mild, moderate, or 
severe pain.  In short, there is no 
objective direct tangible physical evidence for pain itself."  6B Lawyers' Medical Cyclopedia of Personal 
Injuries and Allied Specialties, § 44 A. 1, at 251 (LEXIS Publishing 
2000).

 
 

   2This one to ten scale is 
recognized as a measurement tool, wherein "they could probably assign a value of 
eight on a scale of ten to the usual pain level on the first day after 
surgery."  6B Lawyers' Medical Cyclopedia of Personal 
Injuries and Allied Specialties, 
supra, at 253.