I APPEAL PART C Decision under Appeal In a reconsideration decision dated 11 April 2012, the Ministry denied the Appellant full coverage for dentures because it determined the submitted cost of the Appellant's denture replacement exceeded the rates as set out in the EAPWDR Schedule of Fee Allowances -Denturist. PART D Relevant Legislation Employment and Assistance Persons with Disabilities Regulation, Section 63 and 69 Employment and Assistance Persons with Disabilities Regulation, Schedule C, Section 1 and 4 Employment and Assistance Persons with Disabilities Regulation, Schedule of Fee Allowances -Denturist EAAT 003(10/06/01 I
I APPEAL PART E Summary of Facts The evidence before the Ministry at the time of the reconsideration decision included: • The Appellant's Dental Claims History from January 1, 2011 -April 11, 2012 (3 pages). • A Request of Reconsideration dated February 17, 2012. • A letter from an Infectious Disease Specialist dated January 17, 2012. • A letter from the Appellant's General Practitioner (GP) dated December 15, 2011. • A Pre-Authorization Standard Dental Claim Form -Denturist. • A Dental Pre-Authorization Remittance Statement dated December 29, 2011 (3 pages). In the Notice of Appeal, the Appellant states it has been almost 6 years since his last set of dentures. He states the denturist told him dentures are only made to last that long. Furthermore, he has improper digestion of food without bottom dentures that affect his AIDS, liver and kidney cancers. The Dental Claims History shows a claimed total of $1,168 and a paid amount of $677.25. The Appellant writes in his reasons for reconsideration that it has been 5.5 years since the initial dentures were made. He says he is unable to chew food, he has no way to cut food into smaller pieces and his dietician has suggested a high protein, high carbohydrate diet. He has attached letters from his local doctor and a specialist. He also notes that he cannot pay his bills, he has only $99 left because he had to pay the outstanding denturist bill. The letter from the Infectious Disease Specialist states she has cared for the Appellant for 10 years with respect to his HIV and hepatitis C. She says the Appellant is extremely malnourished and anything that would help the Appellant ingest calories would be beneficial. The letter from the Appellant's GP recommends replacement dentures. The Pre-Authorization staement shows a total fee submitted of $1290. The dental pre authorization statement shows an approval cost of $7 41.25. The new dentures were approved at $581.25 from a bill of $1,000 and $160 from a bill of $290. In the reconsideration decision, the Ministry stated the Appellant had submitted a Standard Dental Claim Form on November 28, 2011 for $1,290. On December 15, 2011 the Ministry received a letter from the Appellant's GP confirming the need for dentures. On December 29, 2011 the Appellant denturist received pre-authorization approval for replacement of lower dentures at $581.25 and a reline of the upper dentures at $160. The Ministry summarized that the legislated rate for the services provided as follows: Dentu rist Rate Ministry Rate New Patient Exam: $24 $24 Upper Denture Repair: $72 $72 Lower Dentures: $1,000 $581.25 Total: $1,096 $677.25 The Ministry concluded they cannot provide coverage for fees in excess of the rates as set out in the Schedule of Fee Allowance -Denturist. The Ministry acknowledged that the Appellant's GP and specialist reported the Appellant's health was EAAT 003( 10106101)
I APPE seriously compromised without dentures however concluded that denture supplements are not covered under EAPWDR, Section 69 as a life-threatening health need. At the hearing the Appellant said his dentures are over 5 years old and he was in dire need of bottom dentures because they broke when he dropped them. His understanding of the regulations led him to believe that he would be reimbursed by the Ministry for the cost of replacement dentures. He has the receipt for $418.75 from the denturist that represents the balance owing between the total cost and the portion the Ministry covered. He said he was left with $99 for food and other necessities after paying the balance owing. The Appellant acknowledged the pre-authorization statement showed an approved cost of $741.25 but he assumed he would get full coverage because he had his dentures over 5 years and his doctors recommended them. He also stated he has telephone and other bills owing because he had to pay the $418.75. The Appellant insisted no examination or upper dental repair was performed by the denturist so the invoice should only reflect the new set of bottom dentures at $1,000. The Appellant also insisted some of the dates as specified in the reconsideration decision were wrong. At the hearing the Ministry stated the Appellant as a designated Persons with Disabilities, is eligible for medical and dental supplements, however only at the legislated rates. The Ministry acknowledged that frequently those eligible for the supplements must pay a portion for dentures because the total cost is often in excess of the covered cost. From the information presented, the Panel finds: • The Appellant designated as a PWD and as such is eligible for dental supplements. • The Appellant's GP and specialist confirm the need for new dentures. • The denturist invoiced the Appellant for a new patient exam, upper denture repair and lower denture replacement for a total cost of $1,096. EMT 003(10/06/01)
I APPEAL PART F Reasons for Panel Decision The issue in this case is the reasonableness of the Ministry's decision to deny the Appellant full coverage for dentures because it determined the submitted cost of the Appellant's treatment plan exceeded the rates as set out in the EAPWDR Schedule of Fee Allowances -Denturist. The relevant legislation in the EAPWDR is as follows: Schedule C "basic dental service" means a dental service that (a) if provided by a dentist, (i) is set out in the Schedule of Fee Allowances -Dentist that is effective April 1, 201 0 and is on file with the office of the deputy minister, and (B.C. Reg. 65/2010) (ii) is provided at the rate set out for the service in that Schedule, (b) if provided by a denturist, (1) is set out in the Schedule of Fee Allowances -Denturist that is effective April 1, 2010 and is on file with the office of the deputy minister, and · (B.C. Reg. 65/2010) (ii) is provided at the rate set out for the service in that Schedule, and (B.C. Reg. 315/2006) 4 (2) Dentures may be provided as a basic dental service only to a person (a) who has never worn dentures, or (b) whose dentures are more than 5 years old. 4 (3) The limits under subsection (1.1) may be exceeded by an amount necessary to provide dentures, taking into account the amount remaining to the person under those limits at the time the dentures are to be provided, if (a) a person requires a full upper denture, a full lower denture or both because of extractions made in the previous 6 months to relieve pain, (b) a person requires a partial denture to replace at least 3 contiguous missing teeth on the same arch, at least one of which was extracted in the previous 6 months to relieve pain, or (c) a person who has been a recipient of disability assistance or income assistance for at least 2 years or a dependant of that person requires replacement dentures. (B. C. Reg. 94/2005) EAA T003(10/06/01)
r Schedule of fee Allowances -Denturist Denture Relines and Rebases Note: Relines and rebases are limited to a combined maximum of once per arch in a two-year period and are not billable within the six-month post-insertion period of the dentures. Section 69 The minister may provide to a family unit any health supplement set out in sections 2 (1) (a) and (f) [general health supplements] and 3 [medical equipment and devices] of Schedule C, if the health supplement is provided to or for a person in the family unit who is otherwise not eligible for the health supplement under this regulation, and if the minister is satisfied that (a) the person faces a direct and imminent life threatening need and there are no resources available to the person's family unit with which to meet that need, (b) the health supplement is necessary to meet that need, (c) the person's family unit is receiving premium assistance under the Medicare Protection Act, and (d) the requirements specified in the following provisions of Schedule C, as applicable, are met: (i) paragraph (a) or (f) of section (2) (1); (ii) sections 3 to 3. 11, other than paragraph (a) of section 3 (1 ). The Ministry argues that although the dentures are a "basic dental service", the Ministry is not authorized to provide coverage for fees in excess of rates for health supplements such as dentures, other than at the rate provided by the Schedule of Fee Allowances -Denturist. Furthermore the Ministry argues denture supplements are not covered under the legislation (EAPWDR, Section 69) as a life-threatening need. The Appellant argues that his GP and specialist verify the need for denture replacement and that he cannot afford to pay the excess cost. The Panel acknowledges the Appellant needs denture replacement however the Panel finds that Schedule C, Section 1 defines "basic dental service" to mean a dental service that is provided by a dentist, is set out in the Schedule of Fee Allowances-Denturist and is provided at the rate set out for the service in that Schedule. The Panel finds the Ministry must provide funding at the rate as set out in the Schedule of Fee Allowances and to apply the remaining dental benefits would cause the funding to be higher than the rate set out in the schedule. EMT 003(10/06/01)
I APPEi The Panel finds although the Appellant's GP and specialist confirmed that the Appellant's health was seriously comprised by the lack of dentures, Section 69 of the EAPWDR specifies coverage as a life-threatening need only for the specific health supplements set out in Schedule C, section 2(1)(a) medical supplies, section 2(1)(f) medical transportation and section 3 medical equipment. The Panel finds the Ministry reasonably concluded that dentures are not set out in these sections. The Panel finds the Ministry made a reasonable decision to deny the Appellant full coverage for dentures. The Panel finds the Ministry's decision was a reasonable application of the applicable legislation and confirms the decision. EMT 003( 10/06/01)
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