I APPEAL# PART C Decision under Appeal The decision under appeal is the ministry's Reconsideration Decision dated April 24, 2012, wherein the ministry denied the appellant's request for full coverage for the amount paid by Dr. A to Dr. B, for a consultation examination for the appellant which took place September 14, 2011, and for the amount of $332.50 also paid by Dr A on behalf of the appellant respecting the fees for an anesthetic facility where the appellant's tooth was extracted on September 28, 2011. The ministry determined that based on the information provided, and the applicable legislation set out in the Employment and Assistance for Persons with Disabilities (EAPWD) Regulation, sections 63 and 64, Schedule C, sections 1,4 and 5, and the Schedules of Fee Allowance-Dentist and Emergency Dental-Dentist, it is not authorized to provide coverage for fees in excess of those found in the Schedules of Fee Allowance-Dentist and Emergency Dental-Dentist or for services that are not set out in the Schedules. The ministry determined that as the appellant is in receipt of disability assistance she is eligible for dental supplements under sections 63 and 64 and Schedule C, sections 4 and 5 of the EAPWDR. The ministry also determined that Pacific Blue Cross (PBC) records indicate that the appellant has no funds remaining in her $1000.00 limit for basic dental services during the current period ending December 31, 2012. While not raised as issues in the appellant's Request for Reconsideration, the ministry also reviewed and determined that the appellant is not eligible to receive a Crisis Supplement as set out in section 57 of the EAPWD Regulation; or eligible for coverage as a Life-Threatening Health Need as set out in section 69 of EAPWD Regulation. PART D Relevant Legislation Employment and Assistance for Persons with Disabilities (EAPWD) Regulation, sections 63 and 64. EAPWD Regulation, Schedule C, sections 1, 4 and 5. Schedule of Fee Allowances-Dentist and Emergency Dental-Dentist EAPWD Regulation sections 57 and 69 EAA T003( 10/06/01)
I APPEAL# PART E Summary of Facts Information and records before the ministry relevant to its reconsideration decision include the following: • A copy of a letter from Dr. A dated September 16, 2011, addressed to whom this may concern, reporting that the appellant requires a complicated dental extraction to be performed at a private dental surgical clinic on September 28, 2011, under general anesthesia. The letter states that the minimum fee for the facility use is $380.00 and that this fee is charged by the surgical clinic, not the doctor. He concludes stating that the appellant is in extreme pain and that the facility fee cost will be a financial hardship to her. Ministry notes indicate that Dr A is a General Practitioner whose practice is limited to oral surgery. • A copy of a prescription from a Family Physician dated September 15, 2011, which states that the appellant requires an emergency grant to cover the cost of an operating room for an emergency dental extraction. • A copy of a letter dated February 9, 2012, from Dr A's office manager to the appellant's advocate enclosing a statement dated November 18,2011, showing the appellant's outstanding balance owing to Dr. A as $447.50. ($115 consultation fee and $332.50 Clinic Facility Fee) and offering a repayment plan to Dr. A requiring 10 post dated cheques in the amount of $44. 75 • A copy of a Pacific Blue Cross (PBC) Dental Claim Form, showing date of service as September 28. 2011. Procedure code 71201, Service, surgical removal of tooth number 37 fee $130.27. It also included a charge for September 28, 2011, procedure code 92223, fee for facilities used during surgery, required general anesthetic (GA) for this procedure as it was a complicated and difficult extraction, fee $332.50 • Copy of PBC Dental Claim Details which indicates that the extraction fee for the appellant's tooth number 37 was $130.27 and was paid in full by the ministry November 5, 2011. • A copy of PBC Dental Remittance Statement dated January 14, 2012, indicating that the claim for extraction of tooth number 37 was previously processed and that the anesthetic facility fees, see code 92223 is not a benefit of the appellant's dental plan. • A copy of PBC Dental Remittance Statement dated September 24, 2011, indicating that $115.00 ($75.00 + $40.00) for Dr. B's consultation was billed $75.00 tooth number 37 fee code 01204, eligible amount noted in the Schedule of Fee Allowance Dental $23.93 and $40.00 for tooth number 37 fee code 02111, eligible amount in the Schedule of Fee Allowance Dental $10.95. The difference between the amount claimed and the amount paid by PBC is $80.12. • A copy of Ministry of Children and Family Development Request for Over-Limit Funding for Children in Foster Care Dated September 27, 2011, denying the appellant's eligibility for this service. • A copy of Employment and Assistance Request for Reconsideration Dated March 1, 2012. • A copy of a letter from the appellant's advocate dated March 23, 2012 requesting an extension of 20 working days to complete the appellant's Request for Reconsideration submission. • A copy of a letter from Dr. B to Dr. A dated September 14, 2011, providing an analysis and explanation of the necessity to extract the appellant's tooth number 37. • A copy of an explanatory message form from PBC regarding Dr A's claim for $332.50 for Anesthetic facility Procedure Code-92223 which states this service is not an eligible benefit under this plan. • A copy of a list of Community Dental Partners Program, Anesthetic Facility Service for Non-Cosmetic Restorative Dentistry for Ministry of Housing and Social Development Clients. The list is valid from April 1, 2012, until March 31 2013, and provides the names and locations of 5 approved facilities. • A copy of the Advocate's submission dated April 23, 2012. • A copy of Schedule of Fee Allowance Dentist April 1, 2010. Information included in the Appeal Record provided the following background information: • On September 21, 2011, letters from a doctor and a dentist were submitted to the ministry by the appellant stating that she required a dental extraction under general anesthesia and requesting an ememencv a rant of $380.00 to cover the cost. EAA T003( 10/06/01)
I APPEAL# • On September 21, the appellant was advised by the ministry to have her dentist send the information to Pacific Blue Cross (PBC) who would determine if her coverage would pay for the procedure. • PBC claim history shows that the extraction was performed on September 28, 2011 and that Dr. A submitted a claim on October 11, 2011 for the anesthetic facility fee which was denied by PBC November 5, 2011. • On January 31, 2011 the appellant contacted the ministry and requested a Crisis Supplement of $380.00 to cover the cost of dental surgery which was completed in September 28, 2011. The request was denied because, per legislation, a crisis supplement may not be provided for the purpose of obtaining a supplement described in Schedule C or any other health care services. • On January 31, 2012 a reconsideration package was prepared for the appellant to pick up. • On February 13, 2012 the appellant's advocate advised the ministry that her request was more in the nature of a variance to the legislated dental fee schedule rather than a crisis supplement. • The advocate was asked to have the appellant submit a written request. • A written request for a variance was submitted by the advocate on February 15, 2012, and was reviewed on February 27, 2012. • On February 27, 2012, a new Request for Reconsideration was prepared by the ministry and mailed to the appellant. • On March 23, 2012, the appellant's Request for Reconsideration was submitted. The appellant requested an extension of the period for reconsideration to April 23, 2012, in order to submit additional information, which the ministry received on April 23, 2012. • On April 24, 2012, the ministry completed its review of the appellant's Request for Reconsideration. The advocate's submission accompanying the appellant's Request for Reconsideration is comprised primarily of argument as to why the ministry's decision not to provide the maximum fee permitted ($23.93) under the dental schedule fee (item #01205) and full coverage for $332.50 to pay for the surgical facility fee was unreasonable. The submission also provides a chronology of events leading up to the appellant's dental surgery which is consistent with the information listed above. In her Notice of Appeal the appellant states, "the ministry has made an unreasonable decision that failed to consider the specific nature of my request". The appellant has also signed a Release of Information indicating she would like information about her appeal sent to both her and her advocate, and that she wants her representative to attend the hearing and make decisions on her behalf. At the hearing the appellant's advocate requested that the ministry present its case prior to the appellant. The ministry notes in its Reconsideration Decision that documents submitted with the appellant's Request for Reconsideration included a copy of a statement dated November 18, 2011, from Dr. A's office setting out the balance owing by the appellant and suggesting a repayment plan. The ministry also notes that the appellant did not contact the ministry until January 31, 2012, to request a reconsideration package. The appellant submitted her reconsideration package March 23, 2012, well beyond the 20 business day time period, however the ministry has completed the review of the appellant's Request for Reconsideration. The ministry stood by the information contained in the Appeal Record, however the ministry added that the ministry had not done a great job of assisting the appellant to work though a complex process. The advocate for the appellant submitted a 12 page document at the hearing which was comprised of background information which was consistent with information and records that were before the ministry at the time of reconsideration, along with arguments as to why he believed the appellant had not been treated fairly by the ministrv. The ministrv did not obiect to the admission of the advocate's submission, with the exception EAA T003(10/06/01)
I APPEAL# of parts 9 and 10 of the submission which state: "9. No request for variance in the legislated dental fee schedule was ever made as it is a well known fact that the ministry does not have the power to provide a variance to legislated benefits provided under either the Employment and Assistance for Persons with Disabilities Act or the Regulation. 10. Ministry staff advised the advocate that they would be unable to produce a reconsideration form for the denial of the requested denial procedure as they did not have access to the remittance forms adjudicated by the ministry's own agent PBC. The advocate obtained the documents from Dr A's office and submitted the PBC remittance form to the ministry on February 19, 2012". The ministry stated that neither statement was supported by the evidence in the Appeal Record. Based on the evidence contained in the File Record the panel concurred with the ministry's opinion. The panel finds that the new written information provided by the appellant in her Notice of Appeal, and the advocate's submission at the hearing, is further information relating to the appellant's request for dental coverage, and is therefore in support of the information and records that were before the ministry at the time of reconsideration. The panel therefore admitted these records as evidence pursuant to section 22(4) of the Employment and Assistance Act. The panel made the following findings of fact: • The appellant is in receipt of disability assistance, she is eligible for dental supplements under sections 63 and 64 Schedule C, sections 4 and 5 of the EAPWD Regulation. • The extraction fee for the appellant's tooth number 37 was $130.27 and was paid in full by the ministry November 5, 2011. The ministry paid $22.80 of the fee as a basic dental service, and $107.47 as an emergency dental service as her PBC claims history shows the appellant's $1000.00 limit for basic dental services was exhausted with the submission of the claim on November 5, 2011. • The appellant has continued eligibility for emergency dental services as set out in the Schedule of Fee Allowances-Emergency Dental-Dentist, at ministry rates. • Anesthetic Facilities Fee (fee code 92223) is not set out in the Schedule of Fee Allowances-Dentist or Emergency Dental-Dentist. • There is no approved private Anesthetic Facility Service for Non-Cosmetic Restorative Dentistry for Ministry of Housing and Social Development Clients located in the city where the appellant resides. • There are public hospitals with Anesthetic Facility Service, for Non-Cosmetic Restorative Dentistry, for Ministry of Housing and Social Development Clients, located in the city where the appellant resides • There are five approved private facilities located within in a half days travel from the city where the appellant resides. • The cost of private facilities may be covered if pre-approval is given by the Provincial Health Services Authority (PHSA) Children's and Women's Health Centre. EAA T003(10/06/01)
I APPEAL# PART F Reasons for Panel Decision The issue in this appeal is whether the ministry reasonably determined that the appellant was not eligible to receive full coverage for the amount paid by Dr. A to Dr. B ($115.00) for a consultation examination on September 14, 2011, and for the amount of $332.50 also paid by Dr A on behalf of the appellant respecting the fees for an anesthetic facility where the appellant's tooth was extracted on September 28, 2011. In arriving at its decision the ministry relied upon the following legislation. General health supplements 62 (1) Subject to subsections (1.1) and (1.2), the minister may provide any health supplement set out in section 2 [general health supplements] or 3 [medical equipment and devices] of Schedule C to or for a family unit if the health supplement is provided to or for a person in the family unit who is (a) a recipient of disability assistance, Dental supplement 63 (1) Subject to subsections (2) and (3), the minister may provide any health supplement set out in section 4 {dental supplements] of Schedule C that is provided to or for a family unit if the health supplement is provided to or for a person in the family unit who is eligible for health supplements under (a) section 62 (1) (a), (b) (iii), (d) or (e) [general health supplements], Emergency dental and denture supplement 64 (1) Subject to subsections (2) and (3), the minister may provide any health supplements set out in section 5 of Schedule C to or for a family unit if the health supplement is provided to or for a person in the family unit who is eligible for health supplements under (a) section 62 (1) (a), (b) (iii), (d) or (e) [general health supplements], Schedule C Health Supplements Definitions 1 In this Schedule: "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, 2010 and is on file with the office of the deputy minister, (ii) is provided at the rate set out for the service in that Schedule, (b) if provided by a denturist, (i) 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 (ii) is provided at the rate set out for the service in that Schedule, and (c) if provided by a dental hygienist, (i) is set out in the Schedule of Fee Allowances a Dental Hygienist that is effective April 1, 2010, and is on file with the office of the deputy minister, and (ii) is provided at the rate set out for the service in that Schedule; "emergency dental service" means a dental service necessary for the immediate relief of pain that, (al if orovided bv a dentist, EAAT003(10/06/01)
I APPEAL# (i) is set out in the Schedule of Fee Allowances Emergency Dental Dentist, that is effective April 1, 2010 and is on file with the office of the deputy minister, and (ii) is provided at the rate set out in that Schedule, and (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances Emergency Dental -Denturist, that is effective April 1, 2010 and is on file with the office of the deputy minister, and (ii) is provided at the rate set out in that Schedule; Dental supplements 4 (1) In this section, "period" means (a) in respect of a dependent child, a 2 year period beginning on January 1, 2009, and on each subsequent January 1 in an odd numbered year, and (b) in respect of a person not referred to in paragraph (a), a 2 year period beginning on January 1, 2003 and on each subsequent January 1 in an odd numbered year. (1.1) The health supplements that may be paid under section 63 {dental supplements] of this regulation are basic dental services to a maximum of (a) $1400 each period, if provided to a dependent child, and (b) $1 000 each period, if provided to a person not referred to in paragraph (a). (c) Repealed. [B.C. Reg. 16312005, s. (b).] Emergency dental supplements 5 The health supplements that may be paid for under section 64 [emergency dental and denture supplements] of this regulation are emergency dental services. Crisis supplement 57 (1) The minister may provide a crisis supplement to or for a family unit that is eligible for disability assistance or hardship assistance if (a) the family unit or a person in the family unit requires the supplement to meet an unexpected expense or obtain an item unexpectedly needed and is unable to meet the expense or obtain the item because there are no resources available to the family unit, and (b) the minister considers that failure to meet the expense or obtain the item will result in (i) imminent danger to the physical health of any person in the family unit, or (ii) removal of a child under the Child, Family and Community Service Act. (2) A crisis supplement may be provided only for the calendar month in which the application or request for the supplement is made. (3) A crisis supplement may not be provided for the purpose of obtaining (a) a supplement described in Schedule C, or /bl any other health care •cods or services. EAAT003(10/06/01)
I APPEAL# Health supplement for persons facing direct and imminent life threatening health need 69 The minister may provide to a family unit any health supplement set out in sections 2 (1) {a) and (I) {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 {I) of section (2) (1); (ii) sections 3 to 3.11, other than paragraph (a) of section 3 (1). Schedule C General health supplements 2 (1) The following are the health supplements that may be paid for by the minister if provided to a family unit that is eligible under section 62 [general health supplements] of this regulation: (a) medical or surgical supplies that are, at the minister's discretion, either disposable or reusable, if the minister is satisfied that all of the following requirements are met: (i) the supplies are required for one of the following purposes: (A) wound care; (B) ongoing bowel care required due to loss of muscle function; (C) catheterization; (D) incontinence; (E) skin parasite care; (F) limb circulation care; ... Medical equipment and devices Sections 3.1 -3.11 set out the legislative requirements for the provision of canes, crutches and walkers, wheelchairs, wheelchair seating systems, scooters, bathing and toileting aids, hospital bed, pressure relief mattresses, fioor or ceiling lift devices, positive airway pressure devices, orthoses, hearing aids. There is no dispute that the appellant is in receipt of disability assistance and is eligible for dental supplements under sections 63 and 64 Schedule C, sections 4 and 5 of the EAPWD Regulation. The ministry's position is that while the appellant is in receipt of disability assistance, and is eligible for dental supplements under sections 63 and 64 Schedule C, sections 4 and 5 of the EAPWDR, she has no funds remaining in her $1000.00 limit for basic dental services during the current period ending December 31, 2012; however she is eligible for emergency dental services which are set out in the Schedule of Fee Allowances-Emergency Dental-Dentist, at ministry rates. As the health supplements that may be paid by the ministry under sections 63 and 64 Schedule C, sections 4 and 5 of the EAPWDR are "basic dental services", and "emergency dental services" as defined in Schedule C, section 1 of EAPWDR, the ministry is not authorized to cover fees in excess of those set out in the Schedule of Fee Allowances-Dental and Emergency Dental-Dentist. In addition the ministry is not authorized to provide coverage for services that are not set out in the Schedules. EAAT003(10/06/01)
IA PPEAL# The advocate's position is that the appellant should have been approved for coverage up to the amount allowable under the ministry dental fee schedule for emergency dental for GA and for emergency oral extraction. He submits that the ministry erred in denying her this coverage by violating the ministry policy and procedure with regard to its "duty to accommodate". Specifically the advocate stated that the appellant is eligible for emergency dental supplements prescribed under section 64 of EAPWD Regulation as she is eligible for General Health Supplements under section 62 of the same Regulation. This allows her the full benefit of emergency dental supplements provided by section 5 of Schedule C. The appellant is therefore entitled to $23.93 under dental schedule fee item 01204 and $332.50 to pay for the Anesthetic Facility (fee code 92223) paid on the appellant's behalf by Dr. A to a private Surgical Clinic on September 28, 2011. As to the appellant's eligibility for coverage of $115 paid by Dr. A to Dr. B, an Endodontist, on the appellant's behalf, the ministry argued that Dr. B submitted a claim to PBC on September 14, 2011, for a specific exam (fee code 01204) and a perlapical x-ray (fee code 0211) in the amount of $75.00 and $40.00 respectively. The ministry rate for these services is $23.93 and $10.95 (10% more than the normal fee for these services is added because Dr. B is a specialist). PBC remitted $34.88 to Dr. B on September 24, 2011. As stated previously the ministry is not authorized to approve coverage for fees in excess of the rates set out in the Schedule of Fee Allowances-Dentist. Therefore the ministry argued that it can not pay Dr. A $115.00 on the appellant's behalf. As $34.88 has been paid to Dr. B the appellant remains responsible for the balance of $80.12 ($115.00 -$34.88). In the advocate's original submission he argued that the appellant was told by Dr. A that she had an abscessed tooth which would require an immediate extraction. The appellant was advised by Dr. A to see Dr. B (Endodonist) and that she would need to have a, "complicated and difficult extraction", requiring GA The appellant was informed that the cost of the consultation with Dr. B would be $115.00 and that due to her limited financial resources Dr. A would pay the fee on her behalf pending repayment. The appellant then met with Dr. B September 14, 2011, who recommended an immediate extraction under GNIV to be conducted on September 28, 2012, at a private surgical facility, and that there was no electable endodontic treatment. The advocate argued that the appellant was not aware that either Dr. A or Dr. B made a request for coverage of this consultation and the appellant was not informed of the process to have this covered under the ministry Fee Schedule. The advocate argued in his original submission for reconsideration that as Dr. B is a specialist the ministry must allow for a fee of 10% over the allowable noted on line item #01204 bringing the amount of coverage for consultation from $21.75 to $23.93. The panel finds statements made by the appellant at the hearing to be inconsistent with information provided by her advocate in his submission. The appellant told the panel that after seeing Dr. A she was in such pain she couldn't remember how she managed to find Dr. B, never the less she stated that she managed to do this on her own. The record shows that not only did Dr. A refer the appellant to Dr. B, but Dr. A also agreed to temporarily cover the consultation fee of $115.00 on the appellant's behalf. The appellant also mentioned that her daughter had previous dealings with Dr. B. The panel also finds that the PBC Dental Remittance Statement dated September 24, 2011, included in the File Record, shows that $115.00 ($75.00 + $40.00) was billed for Dr. B's consultation with the appellant on September 14, 2011. Dr. B invoiced $75.00 for tooth number 37 fee code 01204 and $40.00 for tooth number 37 fee code 02111. The Schedule of Fee Allowance Dental rate for these two services respectively is $23.93 and $10.95 (10% more than the normal fee for these services was added because Dr. B is a specialist). PBC remitted $34.88 to Dr. B on September 24, 2011, resulting in the appellant remaining responsible for a balance of $80.12, ($115.00 -$34.88). The panel further finds that as the health supplements that may be paid by the ministry under sections 63 and 64 and Schedule C, sections 4 and 5 of the EAPWD Regulation are "basic dental services" and "emergency dental services", as defined in Schedule C section 1 of the EAPWD Regulation, the ministry determined that it does not have the legislative authority to provide coverage for fees in excess of the rate set out in the Schedules of Fee Allowances-Dentist and Emergency Dental-Dentist. EAA T003(10/06/01)
IA PPEAL# As to the appellant's eligibility for of $322.50 for the Anesthetic Facility Fee (fee code 92223) paid on the appellant's behalf by Dr. A to a private Surgical Clinic September 28, 2011. The advocate argued that the appellant should be eligible for coverage of the $332.50 required for her GA procedure as this amount is less than the $1000.00 that she is eligible for in a one year period as outlined in the ministry Fee Guide. At the hearing the advocate acknowledged that the ministry Dental Fee Schedule does not have a procedure for GA covered by fee code 92223, however the advocate argued that the ministry should have been proactive in determining her eligibility for GA sedation under the ministry Dental Fee Schedule which provides, "GA and intravenous sedation (in office) per hour per portion thereof at $50.57," under fee code 92215 of the Dental Fee Schedule. Therefore the advocate submits that the ministry was unreasonable in determining that there is no statutory discretion on the part of the ministry to pay up to $50.57 per hour for a dental procedure that requires GA in an approved private facility. The ministry policy requires that the private facility that performs the GA be "an approved private facility or hospital". According to the Provincial Health Services Authority (PHSA), there are only five approved facilities in BC, none of which are located in the city where the appellant resides. As none of these served as a possibility, and given the urgent need of the appellant, the advocate argued that the ministry should have accommodated her request to cover the surgery at the private facility where the tooth was removed on September 28, 2011. At the hearing the ministry agreed with the advocale's statement that (fee code 92223) is not set out in the Schedule of Fee Allowances-Dentist or Emergency Dental-Dentist April 1, 2010, and that it has no legislative authority to provide coverage under the fee code. However the ministry argued that even if fee code 92215 of the Dental Fee Schedule had been submitted to PBC for payment, the result would have been the same as the Preamble to the Schedule of Fee Allowances-Dentist clearly sets out that the ministry does not cover GA or IV sedation facility fees. Dental officei; are referred to the Provincial Health Services Authority (PHSA) Children's and Women's Health Centre for information on coverage for facility fees. The ministry argued that no evidence was presented indicating this process had been followed and there was no way of determining what the outcome of such an application would have been. The ministry further argued that in an effort to assist the appellant it contacted PBC to explore options for coverage of facility fees and was informed that the private Surgical Clinic the appellant used was not accredited by the PHSA, and that funding would not be available. The panel finds that the Preamble in the Schedule of Fee Allowances-Dentist or Emergency Dental-Dentist April 1, 2010, clearly states that the ministry does not cover GA or IV sedation facility fees and dental offices are referred to the Provincial Health Services Authority (PHSA) Children's and Women's Health Centre for information on coverage for facility fees. As no evidence was presented documenting that this process was followed by either Dr. A or Dr. B there is no way to determine if the appellant would have received preauthorizalion, and if so, whether her tooth would have been removed in a public or private facility. While the appellant argued at the hearing that a minimum of 4 teeth would have to be needing treatment under IV/GA sedation, in order to receive approval for the procedure to take place in a public hospital and be covered by the Medical Service Plan (MSP), no documental evidence was offered to support her statement. As to the appellant's eligibility for an additional $1000.00 coverage of Basic Dental Services, the panel finds that in order to receive this, the appellant would have needed to have been found eligible and preauthorization given to have dental treatment preformed under GA/IV sedation in hospital through the MSP, or in an approved private facility by the above noted agency. Furthermore, PBC records contained in the Appeal Record show that as of November 5, 2011, the appellant had exhausted all of the funds remaining in her Basic Dental Services for the period ending December 31, 2012, and as no evidence was presented indicating that preauthorization was requested or approved to cover the cost of GA/IV sedation facility fees, the panel finds the ministry reasonably determined that the appellant was not eligible to receive any further funding for Basic Dental Services as set out in section 63 and Schedule C section 4 of the Regulation. The panel also finds that service (fee code 92223) submitted to PBC by Dr. A is not set out in the Schedule of Fee Allowances-Dentist or Emergency Dental-Dentist April 1, 2010, and that the ministry reasonably determined there is no provision under Emergency Dental Services as set out under section 64 and Schedule C section 5 of the EAPWD Regulation allowing the ministry to pay for services which are not set out in the Schedules. EAA T003(10/06/01)
IA PPEAL# While not raised as issues in the appellant's Request for Reconsideration, in an effort to explore all possible options to assist the appellant, the ministry further determined that the appellant is not eligible to receive financial support to cover the cost of GA/IV sedation facility fees as a Crisis Supplement as set out in section 57 of the EAPWD Regulation or for coverage as a life-Threatening Health Need as set out in section 69 of EAPWD Regulation. Neither the appellant nor her advocate disputed the ministry's findings. The panel finds the ministry reasonably determined that the appellant is not eligible for a Crisis Supplement as set out in section 57 of the EAPWD Regulation, orfor coverage as a Life-Threatening Health Need as set out in section 69 of EAPWD Regulation as neither section provides coverage for dental services. As to the advocates position that the ministry must give a fair, large and liberal interpretation of the EAPWD Regulation and follow its own policy in regards to its "duty to accommodate". The advocate argued that the ministry made an unreasonable decision to deny GA sedation for an emergency dental procedure in an approved private facility as ministry staff ignored the evidence of the specialist in the PBC dental claim form, and in the letter from Dr. A's offices dated September 16, 2011. The ministry determination was unreasonable in that ministry staff in making the determination failed to practice the duty to accommodate the appellant in determining how she could receive the benefit as set out in the Regulation as it is discriminatory to offer a benefit to one region of the province over another and that any determination that is discriminatory in nature is an unreasonable determination. As such the advocate argued that the ministry determination to deny coverage for GA sedation as provided under section 63 and 64 of the Regulation was unreasonable and should therefore be rescinded. The ministry acknowledges that its "duty to accommodate" policy provides guidelines and that they did not do a great job of assisting the appellant. However the ministry argued that it has given a fair, large and liberal interpretation of the EAPWD Regulation in its determination of the appellant's Request for Reconsideration. For example, the ministry argued that the appellant did not contact the ministry until January 31, 2012 to request a reconsideration package. The appellant submitted her reconsideration package March 23, 2012, well beyond the 20 business day time period which is required, however the ministry still proceeded and completed the review of the appellant's Request for Reconsideration. The ministry also argued that it made inquires trying to assist the appellant to find a way to have the cost of GA/IV sedation facility fees covered, however the ministry could not find an avenue because the language with in the legislation and the fee schedule is determinative. Finally the ministry looked at all alternative legislative means of covering the cost of GA/IV sedation facility fees under the EAPWD Regulation. The panel finds that based on the information provided the ministry has given a fair, large and liberal interpretation of the EAPWD Regulation in its determination of the appellant's Request for Reconsideration. As to the extent to which the ministry has followed its own policy on its "duty to accommodate", the panel accepts the ministry's position that it did not do a great job of assisting the appellant however under the circumstances the ministry has exhausted all legislated options to assist the appellant. . As such, the panel finds the evidence presented reasonably supports the ministry's decision, and that there has been a reasonable application of the EAPWD Regulation, section 63 and 64, and Schedule C, sections 1, 4 and 5, Schedule of Fee Allowances-Dentist and Emergency Dental-Dentist, and EAPWD Regulation sections 57 and 69 in the circumstances of the appellant, and confirms the ministry's decision. EAAT003(10/06/01)
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