Gharehdaghi v Trafalgar Group Pty Ltd

CERTIFICATE OF DETERMINATION OF MEMBER
CITATION:	Gharehdaghi v Trafalgar Group Pty Ltd [2025] NSWPIC 485
APPLICANT:	Mohammad Gharehdaghi
RESPONDENT:	Trafalgar Group Pty Ltd
MEMBER:	Parnel McAdam
DATE OF DECISION:	17 September 2025
CATCHWORDS:	WORKERS COMPENSATION - Workers Compensation Act 1987; medical expenses; claim for future surgery; sacro-iliac joint fusion; whether surgery reasonably necessary; Diab v NRMA Ltd applied; applicant had explored other options; applicant’s treating surgeon and independent medical expert of the view that treatment reasonably necessary; lack of recent radiology considered; Held – respondent pay the costs of left-sided fusion of sacroiliac joint.
DETERMINATIONS MADE:	The Personal Injury Commission (Commission) determines: 1. The respondent pay the costs of the proposed surgery, being a left-sided fusion of the sacroiliac joint pursuant to s 60 of the Workers Compensation Act 1987. A brief statement is attached setting out the Commission’s reasons for the determination.

STATEMENT OF REASONS

BACKGROUND

Mr Gharehdaghi was employed by the respondent as a welder. His work was physical, including frequent bending and lifting of heavy objects. Over time, he developed lower back pain, which first became noticeable in early 2020, before Mr Gharehdaghi attended his general practitioner on 7 April 2020, which is the deemed date of injury in this case.
After this first attendance, Mr Gharehdaghi worked on light duties (which were at times not particularly light), before being certified totally unfit in February 2021. Neurological investigations of the injury followed, with conservative treatments of different kinds, but pain persisted. Eventually A/Prof Ghahreman recommended a sacroiliac joint fusion to treat the ongoing complaints. A claim was made for the cost of that surgery, which was disputed by the respondent. It is not disputed that Mr Gharehdaghi suffered a back injury, but rather that the proposed surgery is reasonably necessary.

ISSUES FOR DETERMINATION

The parties agree that the following issue remains in dispute:
(a) whether the proposed surgery, being a left-sided fusion of the sacroiliac joint, is reasonably necessary pursuant to s 60 of the Workers Compensation Act 1987 (the 1987 Act).
For abundant clarity, at the hearing of this dispute, the applicant discontinued his claim for the same proposed surgery to the right side.

PROCEDURE BEFORE THE PERSONAL INJURY COMMISSION

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.
This matter proceeded to conciliation/arbitration on 25 August 2025. The applicant was represented by Mr Morgan of counsel, instructed by Turner Freeman Lawyers. The respondent was represented by Mr Stiles of counsel, instructed by Lee Legal Group.

EVIDENCE

Documentary evidence

The following documents were in evidence before the Personal injury Commission (Commission) and considered in making this determination:
(a)    Application to Resolve a Dispute and attached documents;
(b)    Reply and attached documents;
(c)    Application to Lodge Additional Documents, filed by the applicant on 19 August 2025, and
(d)    Application to Lodge Additional Documents, filed by the respondent on 19 August 2025.

The applicant’s statement

Mr Gharehdaghi provides a statement dated 10 January 2025. He sets out the injury and the history of its development. He discusses the treatment and investigations he undertook. He sets out how, after receiving an injection in his left hip joint, he experienced significant improvement in his pain. He states that he is prepared to undergo the procedure recommended by A/Prof Ghahreman.

Reports of Dr Khong

Dr Khong provides a report dated 6 November 2024 as an independent medical expert for the applicant. He sets out the history of the onset of pain in the back. He provides a diagnosis that the pain appears to be due to left sided sacroiliac joint dysfunction. Dr Khong supports the procedure going ahead, but on the left side only. He discusses the appropriateness, effectiveness, alternatives, cost benefit and acceptance of the surgery.
Dr Khong provides a further report dated 18 July 2025. This report is limited to a comment on whether the surgery should also proceed on the right side. In circumstances where that aspect of the dispute has been discontinued, that report is of limited utility.

Independent medical expert reports obtained by the respondent

As this claim has a reasonable procedural history, the respondent has obtained a number of reports concerning Mr Gharehdaghi’s injury, treatment, and recovery over time. For example, on 27 April 2021, Dr Casikar opined that Mr Gharehdaghi suffered mechanical back pain that had recovered.
Dr Needham provides a report dated 21 June 2024, that sets out a history of injury and treatment. At this point in time, the surgery now in dispute was not put to Dr Needham. He discusses what treatment he considers is reasonably necessary, including a comprehensive assessment at a pain management centre, including with a physiotherapist and psychologist. He recommends treatment aimed at Mr Gharehdaghi’s “dysfunctional pain coping” as opposed to interventional treatments.
The respondent also relies on the report of Dr Bentivoglio dated 6 August 2025. Dr Bentivoglio takes a relevant history of injury and treatment. He opines that Mr Gharehdaghi does not have significant sacroiliac joint dysfunction as the bone scan taken was perfectly normal. He acknowledges that Mr Gharehdaghi still has ongoing left sacroiliac joint pain, but ultimately he does not believe the proposed fusion will significantly help the situation.

Treating specialist reports

The surgery claimed by Mr Gharehdaghi has been recommended by A/Prof Gahreman. He provides two reports. The first is dated 31 January 2025, where he records continuing bilateral buttock pain with radiation to the lower extremities. The applicant had positive provocation tests for S1 joint pain and a positive left-sided injection, and a bone scan that revealed S1 joint inflammation, more on the right. He concludes:
“The treatment is reasonable and necessary part of improving his quality of life and capacity following his significant work related pain. Physiotherapy and rehabilitation will be required for approximately 3 months following the completion of the surgical process.”
A/Prof Gahreman provides a further report dated 28 April 2025. He reports a clinical picture of SI joint malfunction with presence of positive clinical provocation tests on both sides. He notes the history of SI join injection which resulted in the temporary resolution of symptoms and discusses why the surgery is recommended. He provides a prognosis of improvement in qualify of life, mobility, as well as domestic functioning. He then (briefly) discusses the appropriateness, effectiveness, alternatives, cost benefit and acceptance of the treatment.
There are also reports from other specialities engaged in Mr Gharehdaghi’s treatment. Dr Mohabbati, a pain specialist, provides a report dated 8 February 2024, which includes the following impression:
“The clinical presentation is a combination of mixed mechanical and neuropathic low back pain, including facetogenic and sacroiliac joint pain, cluneal nerve entrapment, and meralgia paraesthetica.”
Dr Mohabbati recommends a multidisciplinary pain management approach, including some interventional procedures. On 22 February 2024, Dr Mohabbati recommends radiofrequency ablation for the sacroiliac joint.
Earlier, Dr Ramachandran provides a report (dated 9 November 2021). He is also a pain specialist, and was engaged long before the present surgery was recommended. He opines that “there is not any sinister cause for his current presentation” and recommends psychological and physical therapy interventions as well as medical. In a further report dated 1 September 2022, Dr Ramachandran describes Mr Gharehdaghi as suffering from persistent pain, but on the background of imaging that “were relatively normal.” There are a number of other reports from Dr Ramachandran discussing his ongoing issues in that period up until September 2022.
There are a series of clinical records from Mr Gharehdaghi’s treating general practitioner as well as radiological investigations that will be discussed, where relevant, below.

SUBMISSIONS

The applicant confirmed at the commencement of submissions that the claim for the right‑sided surgery was discontinued. The applicant noted the issue in this case is confined to whether the surgery is reasonably necessary, with reference to the principles in Diab v NRMA Ltd [2014] NSWWCCPD 72 (Diab). The proposed surgery follows from a long history including diagnostic procedures.
The applicant then set out the history of the condition and the difficulty the worker has now found himself in. There has been treatment including physiotherapy, appointments with neurologists and pain physicians. Radiofrequency fact joint denervation was tried with failure.
Then treatment of the sacroiliac join involved improvement, which is why this surgery is now being proposed. A/Prof Gahreman reports positive clinical provocation tests on both sides. Dr Khong supports the surgery and also had similar positive provocation tests. Dr Bentivoglio gives “lukewarm support” but doesn’t appear to have completed sacroiliac joint provocation tests. His conclusion appears to be that if it helps on the left it should happen on the right.
Given the course of treatment, given the consistence of medical examiners supporting persisting issues after four years, and the fact that the applicant has tried all reasonable alternatives, the Commission would be satisfied that the surgery is reasonably necessary and appropriate.
In reply, the respondent submits that on a close analysis of the evidence there is no evidence to support the claim of the asserted pathology, and there are gaps in the treating evidence and chronology to get to where we are today. The applicant refers to the X-ray from 2020 which shows the sacroiliac joints as normal. From that point, the applicant undergoes investigations but there has been no attempt from treating doctors to further investigate the sacroiliac joints.
The respondent referred to the bone scan of 22 July 2021, which reveals only incidental findings, as well as the nerve conduction study which is again normal. Dr Ramachandran only recommends psychological assistance, and the earlies report of A/Prof Gahreman shows he was not sure what the source of the pain was. Dr Mohabati is uncertain about diagnosis and there is nothing objective in any of the radiology to support the applicant.
Dr Needham comes to a similar view as that expressed by Dr Casikar, that is he is unsure of the cause of the ongoing symptoms, and he recommends more pain management. There is a question of whether the applicant actually underwent left sacroiliac injection. It is referred to in Dr Khong’s report, but there is no treatment evidence of this. When all is said and done, Dr Khong relies on symptom relief following the injection, but he doesn’t talk about the bone scan.
With respect to A/Prof Gahreman’s reports, the bone scan does not support the things he says in his conclusion. It is accepted that the report is consistent with the report of symptoms, but if inflammation is recorded on the right, then why is the procedure recommended on the left? In respect of the report form 28 April 2025, the respondent submits that A/Prof Gahreman doesn’t deal with the criteria in Diab particularly well, and it doesn’t advance things far, nor does Dr Khong take it further.
Dr Bentivoglio’s opinion is consistent with the radiology. The respondent submits there is a big question as to what happened with the radiofrequency ablations and whether that in fact occurred. What’s clear is that Dr Bentivoglio does not accept that there is adequate objective evidence to support a conclusion that there is disfunction in the joint.
There has been no investigation of the spine since 2023, and why has A/Prof Gahreman not requested further radiology? The respondent submits that we don’t know what happened with the radiofrequency ablations and other investigations. In circumstances where the surgery is invasive we would want to know what alternatives have been explored.
In circumstances where there is no objective evidence of pathology in the sacroiliac and no attempts to confirm it then I would accept the opinion of Dr Bentivoglio. In respect of the Diab criteria, there is not a lot to go on as to whether alternatives have been attempted or what the outcome might be.
In reply the applicant briefly submitted that the respondent’s submissions seem to be based on that all other alternatives have not bee explored. The applicant submits that the alternative is we keep doing what we have been doing for the last four years. Mr Gharehdaghi has been offered an alternative to that, and there are no strident voices opposing. The fact that two neurosurgeons make recommendations for treatment after a long and involved course speaks for itself.

FINDINGS AND REASONS

The issue in dispute in this case is a narrow one – whether proposed surgery is reasonably necessary. The parties acknowledged the principles in Diab represent the starting point for the consideration of the issue raised in s 60 of the 1987 Act; that is whether the proposed surgery is reasonably necessary. There is, however, within this case, issues raised by the respondent as to whether the applicant has satisfied his onus to prove the claim made, and within that what the respondent says are gaps in the evidence.
There is little doubt that Mr Gharehdaghi presents with ongoing pain. He first experienced back pain in early 2020, before the deemed date of injury in this case of 7 April 2020. There is no dispute that Mr Gharehdaghi suffered an injury.
Mr Gharehdaghi’s injury followed a reasonably common path for the type of injury he suffered. He was referred for investigations, he underwent some physical therapy, and (potentially) some more interventional type treatments. In spite of this, Mr Gharehdaghi reports ongoing pain.
It has proved difficult to identify the source of Mr Gharehdaghi’s ongoing issues. A/Prof Ghahreman first suspected the involvement of facets joints, so injections and radiofrequency was tried, without success. A left sacroiliac joint injection provided temporary relief and Mr Gharehdaghi, on multiple occasions, has tested positive for relevant provocation tests in the sacroiliac area. This has led to the recommendation of surgery from A/Prof Ghahreman, now pursued in this claim.
This surgery is supported by the expert opinion of an independent neurosurgeon, Dr Khong. He also tested Mr Gharehdaghi for sacroiliac joint dysfunction, which was positive. He diagnosed left sided lower back pain, which “appears to be due to left sided sacroiliac joint dysfunction.”
The expert opinion of Dr Khong is opposed to that of Dr Bentivoglio. Dr Bentivoglio’s opinion was described by the applicant as “lukewarm” and I tend to agree with that. He states “there is no clinical evidence to suggest sacroiliac join pathology except for the improvement he had following the injections”, but this ignores the positive provocation tests recorded by both A/Prof Gahreman and Dr Khong. It is not clear whether Dr Bentivoglio performed the same tests. In the absence of any reference, it is presumed that he did not. He does not described such a test under “examination.”
On the other hand, the respondent casts doubt on whether any of the interventions recorded, in particular in the sacroiliac joint, have occurred. The opinions proceed on the basis that they did, but as the respondent submits, there is no treating evidence as to the occurrence of a left sacroiliac injection or radiofrequency ablations (which were at a different level and said to not help). In particular, the sacroiliac injection forms a key part of the diagnostic criteria adopted by both A/Prof Gharehman and Dr Khong. This is on the background of a lack of recent investigation into the affected area for a number of years (with the last MRI taken on 16 October 2023). Further, each radiological investigation has essentially returned a normal result. The only reference to the sacroiliac joint is in an X-ray on 25 February 2020, which reports the joints as being “intact and normal in appearance.” The bone scan taken on 22 July 2021 also reports no abnormalities, and this is discussed by Dr Bentivoglio.
The relatively normal studies of various kinds informed the recommendations of treating pain specialists. Dr Ramachandran records, in his report of 9 November 2021:
“I reassured him that there was not any sinister cause for his current presentation and the importance of incorporating not only medical, but also psychological and physical therapy interventions as part of his pain management.”
Mr Gharehdaghi continued with pain management under Dr Ramachandran, who provides the most recent report of 1 September 2022, which records:
“I attempted to try and explain to him about his Medical Imaging Scans, which were relatively normal and suggested that if he is still not content that there is no significant pathology, it may be worthwhile for him to obtain a second opinion.”
Mr Gharadehgahi then saw a different pain specialist, Dr Mohabati, who recommended a multidisciplinary pain management approach including physiotherapy, medical management, radiofrequency ablations and nerve radiofrequency. These recommendations appear in a report dated 8 February 2024, although it is not clear what of these recommendations were adopted.
I accept there is some uncertainty around the treatment regime Mr Gharehdaghi has undertaken, and in particular in respect of injections in the sacroiliac joint. However, this has consistently been reported and recorded by doctors including the treating specialist, so I accept, on balance, that they occurred. There is also a distinct lack of radiology for a number of years, which the respondent points out. In spite of this, surgery has been recommended by a treating specialist and supported by an independent neurosurgeon.
Turning to the Diab criteria, this has been addressed by a number of experts. The criteria in Diab, consistent with Rose v Health Commission (NSW) (1986) 2 NSWCCR 32, are:
“(a)   the appropriateness of the particular treatment;
(b)     the availability of alternative treatment, and its potential effectiveness;
(c)     the cost of the treatment;
(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.” (at [88])
Ultimately, the above heads for consideration do not represent the scope of the test in a statutory sense, but they do provide useful guidance. As much was said in Diab at [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) 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’.”

Appropriateness

Dr Khong suggests the left sided fusion is appropriate. He justifies this by pointing to clinically apparent left sided sacroiliac joint dysfunction, and that fusion is likely to help a component of the lower back pain.
Likewise A/Prof Gharehman (unsurprisingly) suggests the treatment is appropriate. He highlights the chronic pain affecting the applicant’s sacroiliac joint and the absence of improvement following conservative management.
Dr Bentivoglio suggests that the proposed surgery is not “going to significantly help the situation”, but does not explain why. He goes on to discuss the issues surrounding whether the right side should be performed at the same time.
I accept that, in the presence of ongoing pain in the relevant area, positive relevant tests, and the diagnostic injection showing short-term relief, the surgery is appropriate.

Alternative treatment

Dr Khong points out that alternatives, including analgesia, physiotherapy and steroid injections have been tried and failed. This is consistent with A/Prof Gahrehman. Dr Bentivoglio does not particularly comment on this issue.
From a review of the other expert and treating opinions provided (particularly those of the pain specialists), it appears that the only considered alternative is a multidisciplinary pain program, including psychological treatment. This was recommended by both pain specialists who have treated Mr Gharehdaghi as well as Dr Needham. It does not appear that this has been explored in a wholistic way, but Mr Gharehdaghi has undergone some of the treatment recommended, most notably physiotherapy, analgesia and pain specialist attendances.
As the applicant submits, this issue has been ongoing for four years without a great deal of improvement. The alternatives that have been tried have been ineffective in dealing with Mr Gharehdaghi’s ongoing pain and restriction. Pain management is generally targeted at better allowing a person to function whilst in pain, whereas this specific surgery has the goal of reducing Mr Gharehdaghi’s pain. I am satisfied that whilst there are alternatives proposed, in the circumstances those alternatives are likely to be less effective that the proposed surgery.

Cost of the treatment

This is addressed by both Dr Khong and A/Prof Gahrehman as being of a clear cost benefit. The amount of one-sided fusion is estimated to be $7,407.50, plus incidental’s which is not particularly high. The cost is not a prohibitive factor in this case.

Effectiveness

Dr Khong suggests that the surgery will likely be effective in helping some of Mr Gharehdaghi’s left sided lower back pain, whilst A/Prof Gharehman comments in a more general way, that fusion “is an effective measure for severe disabling SI joint pain.”
Dr Bentivoglio suggests it will not significantly help the situation, in part, it appears, on the basis that he doubts there is actual pathology arising from that area. He comments that there is no clinical evidence to suggest sacroiliac joint pathology except for the improvement following injections. As discussed above, I can see no evidence that Dr Bentivoglio performed the provocative tests discussed by Dr Khong and A/Prof Gharehman, which has informed both of their opinions. I accept there is an absence of recent radiological investigations, but there is general acceptance of ongoing pain, positive relevant indicators, and in part diagnostic injections that confirm the symptoms.
In those circumstances, I prefer the opinions of Dr Khong and A/Prof Gharehman.

Acceptance by medical experts

Both Dr Khong and A/Prof Gharehman suggest that a sacroiliac joint fusion is accepted as appropriate and likely to be effective by medical experts. Dr Bentivoglio does not particularly comment on this issue.
The greatest doubt cast on the acceptance of this treatment is from the pain specialists. Dr Needham is wary of interventional treatments in the absence of definite pathology identified on nerve conduction studies or scans. He believes treatment aimed at addressing dysfunctional pain coping should be preferred to interventional treatments as they may reinforce the applicant’s disability conviction.
In a “triage assessment report” from Pain Med dated 19 October 2021 and co-signed by a rehabilitation physician, a pain physiotherapist and a psychologist, the following opinion was expressed:
“Mr Gharehdaghi remains distressed and focused on a medical and/or interventionist solution to his current pain issue. His primary goal is to recover completely and to return to his previous job.”
This certainly represents a risk factor for the current proposed surgery. Mr Gharehdaghi has been searching for something like a “silver bullet” solution to his ongoing pain for many years. It is not clear that this surgery will have that desired outcome. It is likely to assist in reducing Mr Gharehdaghi’s ongoing pain, but there are doubts that it will improve functioning to the level that he will be able to return to his previous job.

Conclusion

The factors in Diab are not a checklist or weighing in a yes/no type list. Those criteria must be considered wholistically, but the essential question remains whether the treatment is reasonably necessary.
There are gaps in the applicant’s case here, including recent radiological evidence and whether certain treatments took place. There is a concern about whether the treatment will have the desired outcome of returning Mr Gharehdaghi to his pre-injury functioning, or have more success in reducing pain.
When considering all of the factors, I am satisfied that the proposed treatment is reasonably necessary. Those concerns do not outweigh the fact that Mr Gharehdaghi has been in pain for many years, has relevant confirming evidence of a source for his symptoms (in terms of positive provocation tests) and the treatment is likely effective in reducing pain.
I am satisfied on the balance of probabilities that the applicant has proven his case, and will make the necessary award.

[2025] NSWPIC 485

17 September 2025