P A R T C D e c i s i o n u n d e r A p p e a l T h e d e c i s i o n u n d e r a p p e a l i s t h e M i n i s t r y o f S o c i a l " m i n i s t r y " ) r e c o n s i d e r a t i o n d e c i s i o n d a t e d M a y 9 , 2 r e q u e s t f o r f u n d i n g f o r m e d i c a l e q u i p m e n t a n d d e v m a t t r e s s ( t h e " R e q u e s t e d I t e m s " ) . T h e a p p e l l a n t i m i n i s t r y d e t e r m i n e d t h a t t h e a p p e l l a n t w a s n o t e l i g • t h e R e q u e s t e d I t e m s w e r e n o t m e d i c a l l y e s s f r o m b e d o r t o a d j u s t h e r p o s i t i o n i n g i n b e d , E m p l o y m e n t a n d A s s i s t a n c e f o r P e r s o n s w i • t h e R e q u e s t e d I t e m s w e r e n o t t h e l e a s t e x p a s r e q u i r e d b y s e c t i o n 3 ( 1 ) ( b } ( i i i ) o f S c h e d u l P A R T D R e l e v a n t L e g i s l a t i o n E A P W D R , S c h e d u l e C , s e c t i o n s 3 ( 1 } ( b } ( i i i ) a n d 3 . 6 E M T 0 0 3 ( 1 0 / 0 6 / 0 1 )'. A P P F A I " D e v e l o p m e n t a n d S o c i a l I n n o v a t i o n ( t h e 0 1 4 w h e r e i n t h e m i n i s t r y d e n i e d t h e a p p e l l a n t ' s i c e s i n t h e f o r m o f a h o s p i t a l b e d a n d b a r i a t r i c s a r e c i p i e n t o f d i s a b i l i t y a s s i s t a n c e , a n d t h e i b l e f o r t h e R e q u e s t e d I t e m s o n t h e b a s e s t h a t : e n t i a l t o f a c i l i t a t e t r a n s f e r s o f t h e a p p e l l a n t t o a n d a s r e q u i r e d b y s e c t i o n 3 . 6 ( 1 ) o f S c h e d u l e C o f t h e t h D i s a b i l i t i e s R e g u l a t i o n ( " E A P W D R " ) ; e n s i v e a p p r o p r i a t e m e d i c a l e q u i p m e n t o r d e v i c e , e C o f t h e E A P W D R . ( 1 )
PART E -Summ ary of Fac t s Th e inf or ma tion bef or e th e m in istry at the ti me of recons o A n as ses smen t repor t on the appe llant comp Au g u s t 30, 2013; • A Med ica l Equ ipment Reque st a nd J usti fic ati p hys ici an and OT#1; • A q uo t a t i on from a s u p pli er f or the Requ ested • A p resc ription f r om the ap pella nt's physi cian, needs a n e lec tric hos pital bed , due t o restri ct • An assessment report on the app e ll ant comp on March 11 , 201 4; • A letter fr om a disa b i li ty case m ana gement st • A lett er f rom OT# 2 date d Ap ril 29, 201 4; and • Th e appella nt 's Request fo r Recon sideration Admi s sibi l i ty o f N ew Inform a t ion On May 2 8 , 20 1 4 the ap pe l lan t made a written submis Tribuna l (the "Trib u nal") in c onju n ction w ith he r Noti sub mitted to the Tribu nal a l e tt er fro m OT# 2, providing ne ed for the Request e d Items . The ministry had n o objection to ad missibility o f the Ju The panel assessed th e above-noted d oc uments as tend that was before the ministry at the ti me of re co nside testimony in accordance with section 22(4 ) of the Employment and Assist The p an el ass essed the evidence as fo l lo ws: • In the MERJ, the appellant's physician described the appellan to move without difficulty." • In his re port of August 30, 2013, OT#1 wrote that ► the appellant is diag n os ed with morbid obesity (wei hypothyroidism, type 2 diabetes, depressi ► she is independently mobile with walker and her automobile, and mobilizes for short dis tances such a s from h er h o us e t o her car. ► in her home the app e llant uses furn i ture a she sits on her walker when in the kitchen. EMT 003(10/06/01) AP PEAL# '. ider a tion i nclu ded t h e f ol lo wi ng: let ed by a n occ upational ther apist ("O T#1") on on form ( "MERJ'') com pl eted by the a ppellant's I tem s i n the amount of $5 ,226.55. da ted M a y 1 5 , 2013 , stating th at "This person ed m obi lity is sues." let ed by a second occ u p at io nal the rapi st (" O T#2") udent date d A pril 5, 2014; date d Apr i l 7 , 20 14. sion to the Em ployment and Ass is tance Appeal ce o f Appea l . O n June 10, 2014 the ap pellant additi o n al d etail w ith respect to the ap pellan t's ne 10, 2 01 4 letter fr om OT#2. ing t o pro vide corr obora tion of informa t i on ration. The pan el admi tted t he m as sup porting ance Act. t as "severely overweight, unable : ght 4 33 p ounds); hypertension, o n. nd t he w alls for su p port wh i le wal king, and
APPEAL# : ► she struggles severely to get to a sitting position from lying position on her couch. ► the appellant reported going up 14 steps in her home once a day to bathe and shower and use her sewing machine, and she reported sometimes sleeping in her bed in her bedroom on the second floor of her home. ► the appellant stated she is independent and safe on the stairs. ► he trialed the appellant on different beds and mattresses. He recommended the Requested Items as they would afford the opportunity for the appellant to get her feet flat on the floor and to hold a railing for safe transfers and for improved bed mobility. • In her report of March 11, 2014, OT#2 wrote that: ► the appellant has difficulty with all transfers and must use a very wide base of support and a forward rocking momentum to get up from her toilet, bed and low couch. ► the appellant uses a tub transfer bench and grab bar for safe transfers into her tub. ► she ambulates slowly without a walking aid in her home, and uses a 4-wheel walker and car for outings. ► she has great difficulty with bed mobility, at times requiring her son to per her into a sitting position. She was observed to manage all aspects of bed mobility with effort, momentum, and using a bedside table to push up from. ► the appellant's beds break due to her weight. ► OT#2 referred to OT#1 's report in recommending the Requested Items in order to enable independent bed mobility consistently, and facilitate safe transfers; to maintain control of lower extremity edema, to prevent ulcers of the buttocks, to improve breathing with a CPAP mask at night through upright, dynamic positioning; and to provide more suitable/comfortable bladder positioning and ease of transfers, potentially reducing bladder incontinence. • In her letter of April 29, 2014, OT#2 wrote that: ► the appellant's bed broke under her weight, and community health workers can no longer safely perform personal hygiene treatments on the appellant because the couch that the appellant has been sleeping on is too low. ► it may be possible for the appellant to get a short term loan of a bariatric hospital bed from the , but the health care team is reluctant to initiate this plan if there is no long term plan or funding secured for a permanent bed and mattress. • In her letter of June 10, 2014, OT# 2 wrote that: ► with respect to the less expensive mobility devices suggested by the ministry in its reconsideration decision (bed wedge, foot pillows, floor-to-ceiling pole, triangle bar, bed leg extensions) the appellant would not have the upper body strength to lift her body and simultaneously reposition herself if she needed to change position in the night. OT#2 stated the opinion that the appellant requires a bed that offers multi and dynamic positioning rather than the static positioning offered by wedges and bolsters. ► OT#2 agreed that bed mobility devices such as a pole and trapeze would be beneficial in enabling increased ease and independence with moving in bed, but stated that the appellant currently has no bed to attach them to, and that they do not address the other identified issues around positioning -difficulty breathing, need for an appropriate and adjustable surface to provide care from, and ease of donning CPAP mask. ► at least 2 regular beds have collapsed under the appellant's weight. She is currently using a bariatric bed and mattress on load from the Red Cross which must be returned after 3 months, with no extensions on the loan. • In her letter of April 5, 2014, the disability case management student supported the appellant's EAAT003(10/06/01)
� APPEAL# application for the Requested Items, expressing (among other things) the opinion that an adjustable bed will help the appellant to transfer in and out of bed independently, which will help reduce the occurrence and severity of urinary incontinence the appellant experiences when trying to lift herself out of a regular bed. • In her Request for Reconsideration, the appellant wrote that she is not able to use a regular bed because it does not provide enough support to transfer independently in and out of bed. • In her written appeal submission, the appellant wrote that; ► the momentum required for her to be able to transfer herself (when she is able) is what is causing her beds, reclining chairs, and couch to break. ► her mobility limitations do not allow her to maneuver freely enough to adjust pillows, a bed wedge or other devices suggested by the ministry. ► a ceiling pole or triangle would not be appropriate as she does not have the strength required to pull up her own weight. ► she lives in subsidized housing and cannot affix permanent devices. • In her oral testimony, the appellant stated that: ► she does not have a bed or the money to buy one. ► the Recommended Items would reduce or avoid pressure sores. ► the less expensive medical devices and equipment suggested by the ministry sound alright but are very difficult to use. She said that she cannot put a wedge on her narrow couch and she doesn't have the mobility to put a pillow under her knees. ► her landlord would not permit the less expensive medical devices to be affixed in her residence. ► her health condition has worsened since the original assessment done by OT#1, and is likely to continue to deteriorate. ► it is not always possible for her to get out of bed by herself. Some days she is too weak. ► her son has a mental health condition and is not always available to help her. ► in response to a question from the panel, the appellant stated that she would usually brace her legs on the floor, and pull herself up by grasping the drawer on the bedside table. She said that because she no longer has a bed, she can't use the bedside table. The ministry relied on its reconsideration decision and provided no new information. EMT 003(10/06/01)
I APPEAL# PART F -Reasons for Panel Decision The issue on appeal is the reasonableness of the ministry's decision to deny the appellant the requested items on the bases that: • the Requested Items were not medically essential to facilitate transfers of the appellant to and from bed or to adjust her positioning in bed, as required by section 3.6(1) of Schedule C of the EAPWDR; • the Requested Items were not the least expensive appropriate medical equipment or device, as required by section 3(1 )(b)(iii) of Schedule C of the EAPWDR. The relevant legislation is as follows: EAPWDR, Schedule C Medical equipment and devices 3(1) Subject to subsections (2) to (5) of this section, the medical equipment and devices described in sections 3.1 to 3.12 of this Schedule are the health supplements that may be provided by the minister if (a) the supplements are provided to a family unit that is eligible under section 62 [general health supplements] of this regulation, and (b) all of the following requirements are met: (i) the family unit has received the pre-authorization of the minister for the medical equipment or device requested; (ii) there are no resources available to the family unit to pay the cost of or obtain the medical equipment or device; (iii) the medical equipment or device is the least expensive appropriate medical equipment or device. (2) For medical equipment or devices referred to in sections 3.1 to 3.8 or section 3.12, in addition to the requirements in those sections and subsection (1) of this section, the family unit must provide to the minister one or both of the following, as requested by the minister: (a) a prescription of a medical practitioner or nurse practitioner for the medical equipment or device; (b) an assessment by an occupational therapist or physical therapist confirming the medical need for the medical equipment or device. .. Medical equipment and devices -hospital bed 3. 6 (1) Subject to subsection (3) of this section, the following items are health supplements for the purposes of section 3 of this Schedule if the minister is satisfied that the item is medically essential to facilitate transfers of a person to and from bed or to adjust or maintain a person's positioning in bed: (a) a hospital bed; EAA T003(10/06/01)
( b ) a n u p g r a d e d c o m p o n e n ( c ) a n a c c e s s o r y a t t a c h e d t ( d ) a p o s i t i o n i n g i t e m o n a * T h e a p p e l l a n t ' s p o s i t i o n i s t h a t t h e e v i d e n c e , i n c l u d t h e a p p e l l a n t s a t i s f i e s t h e l e g i s l a t i v e c r i t e r i a f o r t h e I t e m s a r e m e d i c a l l y e s s e n t i a l t o f a c i l i t a t e t r a n s f e r s a s h e c a n n o t a n d s h o u l d n o t h a v e t o r e l y o n h e r s o n ' o r d e r t o t r a n s f e r i n d e p e n d e n t l y , a n d t h a t t h e m o m e o r d i n a r y b e d s t o c o l l a p s e . T h e a p p e l l a n t a l s o a r g u e e x p e n s i v e a p p r o p r i a t e m e d i c a l e q u i p m e n t o r d e v i c e t h e m i n i s t r y a r e n o t a p p r o p r i a t e b e c a u s e s h e d o e s s h e h a s n o b e d t o a t t a c h t h e m t o , a n d h e r l a n d l o r d r e n t e d r e s i d e n c e . T h e a p p e l l a n t a r g u e d t h a t t h e l e s n o t a d d r e s s o t h e r p o s i t i o n i n g p r o b l e m s s u c h a s u s e w h i c h c o m m u n i t y h e a l t h w o r k e r s c a n p r o v i d e t h e i r s d o e s n o t h a v e s u f f i c i e n t f u n d s t o b e a b l e t o p u r c h a s T h e m i n i s t r y ' s p o s i t i o n i s t h a t t h e o c c u p a t i o n a l t h e r a t r a n s f e r i n d e p e n d e n t l y w i t h e f f o r t , m o m e n t u m a n d u t h e a p p e l l a n t c u r r e n t l y s l e e p s o n a l o w c o u c h a n d i s w i t h o c c a s i o n a l a s s i s t a n c e f r o m h e r s o n . A c c o r d i n g a r e n o t m e d i c a l l y e s s e n t i a l f o r t r a n s f e r s o r p o s i t i o n i I t e m s a r e n o t t h e l e a s t e x p e n s i v e a p p r o p r i a t e m e d i c s u c h a s a b e d w e d g e , f l o o r t o c e i l i n g p o l e , a n d t r i a n b u t t h a t t h e s e i t e m s w e r e n o t t e s t e d b y e i t h e r o c c u p t h a t a n o n e l e c t r i c b a r i a t r i c b e d w o u l d p r o v i d e s u f f i c P a n e l D e c i s i o n I n t h e p a n e l ' s v i e w , t h e e v i d e n c e i n t h i s c a s e f a l l s s h t h e R e q u e s t e d I t e m s a r e m e d i c a l l y e s s e n t i a l t o f a c i l t o a d j u s t o r m a i n t a i n h e r p o s i t i o n i n g i n b e d . T h e e v i R e q u e s t e d I t e m s a r e t h e l e a s t e x p e n s i v e a p p r o p r i a t c i r c u m s t a n c e s . I n t h e p a n e l ' s v i e w , t h e l e g i s l a t i o n d o e s n o t c o n t e m p o c c a s i o n a l a s s i s t a n c e f r o m h e r s o n . H o w e v e r , t h e a e x p e n s i v e m e d i c a l e q u i p m e n t s u g g e s t e d b y t h e m i n i n h e r l e t t e r o f J u n e 1 0 , 2 0 1 4 t h a t t h e a p p e l l a n t w b o d y a n d s i m u l t a n e o u s l y r e p o s i t i o n h e r s e l f i s i n c o n s l e t t e r t h a t t h e l e s s e x p e n s i v e m e d i c a l e q u i p m e n t p r o e n a b l i n g i n c r e a s e d e a s e a n d i n d e p e n d e n c e w i t h m o e v i d e n c e t h a t t h e a p p e l l a n t i s a b l e t o l i f t h e r s e l f f r o m E M T 0 0 3 ( 1 0 / 0 6 / 0 1 )A P P E A L # � t o f a h o s p i t a l b e d ; o a h o s p i t a l b e d ; h o s p i t a l b e d . . . * * i n g t h e r e p o rt s o f O T # 1 a n d O T # 2 , c o n f i r m s t h a t R e q u e s t e d I t e m s . S h e a r g u e d t h a t t h e R e q u e s t e d s s h e c a n ' t a l w a y s m a n a g e o n h e r o w n a n d t h a t s h e l p . S h e s a i d t h a t s h e r e q u i r e s m o m e n t u m i n n t u m c o m b i n e d w i t h h e r w e i g h t e v e n t u a l l y c a u s e s d t h a t t h e R e q u e s t e d I t e m s a r e t h e l e a s t s . S h e s a i d t h a t t h e c h e a p e r i t e m s s u g g e s t e d b y n o t h a v e t h e s t r e n g t h o r m o b i l i t y t o u t i l i z e t h e m , w o u l d n o t a u t h o r i z e t h e m b e i n g a f f i x e d t o h e r s e x p e n s i v e i t e m s s u g g e s t e d b y t h e m i n i s t r y w i l l o f t h e C P A P m a s k a n d h a v i n g a s a f e p l a t f o r m o n e r v i c e s . F i n a l l y , t h e a p p e l l a n t s t a t e d t h a t s h e e h e r o w n b e d . p i s t s h a v e c o n f i r m e d t h a t t h e a p p e l l a n t i s a b l e t o s e o f a b e d s i d e t a b l e . T h e m i n i s t r y a r g u e d t h a t a b l e t o s i t u p i n d e p e n d e n t l y , f o r t h e m o s t p a r t , l y , t h e m i n i s t r y a r g u e d t h a t t h e R e q u e s t e d I t e m s n g . T h e m i n i s t r y a l s o a r g u e d t h a t t h e R e q u e s t e d a l e q u i p m e n t . T h e m i n i s t r y s u g g e s t e d t h a t i t e m s g l e b a r w o u l d p r o v i d e t h e n e c e s s a r y a s s i s t a n c e , a t i o n a l t h e r a p i s t . T h e m i n i s t r y a l s o s u g g e s t e d i e n t s u p p o r t . o r t o f p r o v i n g o n t h e b a l a n c e o f p r o b a b i l i t i e s t h a t i t a t e t r a n s f e r s o f t h e a p p e l l a n t t o a n d f r o m b e d o r d e n c e a l s o d o e s n o t d e m o n s t r a t e t h a t t h e e m e d i c a l e q u i p m e n t o r d e v i c e i n t h e a p p e l l a n t ' s l a t e t h a t t h e a p p e l l a n t s h o u l d h a v e t o r e l y o n p p e l l a n t h a s n o t d e m o n s t r a t e d t h a t t h e l e s s i s t r y i s n o t a p p r o p r i a t e f o r h e r . O T # 2 ' s s t a t e m e n t o u l d n o t h a v e t h e p h y s i c a l c a p a b i l i t y t o l i f t h e r i s t e n t w i t h h e r a c k n o w l e d g m e n t i n t h e s a m e p o s e d b y t h e m i n i s t r y w o u l d b e b e n e f i c i a l i n v i n g i n b e d . I t i s a l s o i n c o n s i s t e n t w i t h t h e a l o w b e d w i t h t h e a s s i s t a n c e o f a b e d s i d e t a b l e
I APPEAL II and that she is otherwise independently mobile. The term "medically essential" connotes a significant degree of necessity, such that the Requested Items cannot reasonably be done without. The evidence indicates that for the most part the appellant has the physical strength to manage her own transfers in and ou_ t of bed with effort, using a wide base of support, momentum, and a bedside table. For those "occasional" instances where she relies on her son for assistance, OT#2's letter of June 10, 2014 indicates that the less expensive medical equipment proposed by the ministry would be beneficial in enabling increased ease and independence with transfers and positioning in bed. OT#2 did not provide any basis for her belief that the appellant requires dynamic positioning for ease of donning the CPAP mask rather than the static positioning offered by wedges and bolsters. If the less expensive medical equipment is appropriate for the appellant, then the Requested Items cannot be said to be "medically essential." In the panel's view, the legislative language "to adjust or maintain a person's positioning in bed" is not so broad as to include the need to provide a platform of a particular height for the provision of services by community health care workers. Even if the legislative language is that broad, the evidence before the panel is insufficient to show that the Requested Items are the least expensive option for providing said platform. The appellant's argument with respect to her landlord's position on affixing the less expensive medical equipment is speculative. The panel acknowledges that the appellant's medical conditions affect her mobility, and understands that finances may be problematic for the appellant. However, for the reasons noted above, the panel finds that the ministry reasonably concluded that the evidence falls short of demonstrating that the Requested Items satisfy the legislative criteria of being medically essential to facilitate transfers of the appellant to and from bed or to adjust or maintain a person's positioning in bed, or of being the least expensive medical equipment or device. Accordingly, the panel confirms the ministry's decision. EAAT 003(10/06/01)
You are being directed to the most recent version of the statute which may not be the version considered at the time of the judgment.