PART C-Decisio n un der Appe al The d e cis ion unde r a ppeal is t he minis try's r e c o nside that th e appell a n t is not elig ible fo r a buyout of a continuous positive airway pre machine, ma sk and fil te rs a s a heal th supp leme nt as 3.9(2)(c) of Schedule C, o f t h e Employm e nt and Assist (EAPWDR) were not met. The m i n i stry deter mined tha t all nec essar y le gislati with th e exce ption of the crit eria set out in Schedul the ministry must be sa tis fie d that t he item i s m edi call severe sl eep apnea. T he ministry deter m ined th a t ra n ge with an apnea/hy popn ea index ( AH i ) of 10. 1, reques ted benefit. The criteri o n o f section 6 9 was also not me t b ecaus required to mee t a di re c t and imm inent life -threaten P AR T D -Relevant L e gisla tion Em plo y me nt a n d Assi sta nce fo r pe rsons wit h D i s a bili Em plo y me nt and Assi stan ce f or persons with D isabi I APPE /l ra t i o n decision da ted Ju n e 4 , 2 0 14 whi ch hel d ss ure (CPA P) the cr ite ria purs uant t o section 69 or se ct ion an ce for Pe rsons w i th Di sabi liti es Regu lat ion ve requ ir emen t s ha d been met by t he ap pell an t e C , se c tio n 3.9(2)(c). This l egis lati o n requir e s that y e sse ntia l f or t he treatment of mode r a te to t he app e l lan t 's sleep apn ea fal ls withi n t he m ild and for th i s reason s h e is i n e l i gib l e to receive th e e the C P A P m ach i n e, m ask and filters a r e no t ing he a lt h need . t i e s Re g ulation ( EAPWDR), S ections 62 a n d 69. lities Re gu lat ion (EAPWDR), Sche d ule C .
I APPEAl PART E -Summary of Facts The evidence before the ministry at reconsideration consisted of the following: • An Overnight Polysomnography and Multiple Sleep Latency Report dated July 1, 2008 which indicated that the appellant has obstructive sleep apnea and periodic limb movements and has fragmented non-refreshing sleep as a result. • A Respiratory Services Requisition dated July 2, 2013 by the appellant's physician for Obstructive Sleep Apnea (OSA) screening and treatment. • A letter from the appellant's physician dated August 27, 2013 which indicated that she has proven sleep apnea and requires a CPAP machine. • A Medical Equipment Request and Justification dated October 24, 2013. • An Apnea Link Report dated November 3, 2013. • A Therapy Data Summary of 30 days usage with a Remstar Auto device dated December 2, 2013. • A quote from a respiratory care center dated December 2, 2013 for a CPAP machine at $2200, a full face mask at $350 and 12 filters@ $4.50 each= $54. Total cost of all items is $2604. • A purchase request on behalf of the appellant by the respiratory care center dated December 2, 2013. • A letter from the appellant's physician dated May 16, 2014 which indicated that the appellant has mild OAS and has found that a CPAP has made a difference to her sleep quality. "She also feels better during the day. She has noted that with CPAP she has fewer sleep interruptions (apnoea spells), less muscle stiffness, burning sensation." • The appellant's Request for Reconsideration dated June 2, 2014 with a 2-page letter written by the appellant. In her letter the appellant writes that; • Her diagnoses are Chronic Fatigue Syndrome and mild OSA with a Respiratory Disturbance Index (ROI) of 10.1. • She experienced 132 micro arousals and 24 awakenings during her overnight Polysomnography test. 62 were respiratory, 31 due to leg movements and 29 were spontaneous. • She had 3 apneas during the test which meant that she stopped breathing for an extended period of time, 3 times during the test. • She also had 71 hypopneas during the test which meant that her blood oxygen saturation level fell significantly 71 times during the night because she was only breathing half her usual intake. • She also had mild periodic limb movements and respiratory event related leg movements. • The description of how this feels is; being jerked awake all night long, having dreams of being too tired to move, some nights her legs have painful jolts from the calves to the toes that last several hours or all night long, awakened by any little noise, she clenches her jaw and grinds her teeth nightly, sore lower back, stiffness accompanied by a burn sensation, if she has tossed and turned a lot she will have displaced her upper cervical spine which often results in migraine headaches and she requires 5-6 hours to manage the pain in the morning before she can leave her house. • She has had 2 unsuccessful attempts with the CPAP due to sound and touch however, this is her 3 rd attempt and she is at the point where she finds it not so intrusive.
e U s ing CPAP has made a difference to both her qu e xperienced a dramatic drop in i n ci dence of her interrupt fi bro b urn . • She attributes her pos itive results to the A -Flex Prior to t h e s tart of the hearing, the appe l lant faxed a 45 pa informati o n from intern a t ional researc h done on Chronic Fati E ncephalo m ye l itis (CFSME) that s he h oped t he pa review in or der t o be tter understand he r m edi c al conditions At the he ar in g, t h e a ppellant e xp lained that h er actual doc t ors agree on its definition and treat m ents. The appellant i Syndrome r un s i n h er famil y. She stated that Sleep Apne together the symptoms are "e xponentially multi p li ed exhau stion an d she get s 2-3 h ours o f sl ee p a ni g ht withou CP A P m ac hine sin c e las t Au g u st and has recently ha denied th e opportuni ty to have it w ork. Alt hough she finds trialed t h at just interr u pted h e r sleep. Wi th this p artic has h ad about 4 e f fective nights and awo k e th e follo question by the p a nel , t h e app e ll ant st at ed t hat in the sh e feels lik e sh e h as a slu r in her throa t and a b r ick The pan e l fi nds that th e new informat ion prov ided by informa t io n pu rposes o nly and th e refore not adm i ss Em pl oyment an d A s sis ta nce A ct. Fi ndin gs o f Fact The appella nt is a P erson with Disabi liti es an d th e sup plements set out under the EAPWD Regulation, Section 62 and S The item has bee n prescribe d by a medical practitioner. The appellant's AHi is 10.1 events per hour. I APPEA ality of sleep and waking. She has e d sleep pattern as w e ll as a drop in machine. ge document t hat consisted of g ue Syndrome and Myalgia n e l and t he ministry would ha v e time t o br i efl y . diagnosis was C F SM E a nd that no two ndicated t hat Chr on i c Fatigue a is par t of or secondary to CFS ME and ". She has a hy per sensitivity to stimuli, profou nd t disruption. T he ap pellant h as t r ia led th e d t o return i t, she belie v e s th at sh e has been it i nt rus i v e, i t i s u nlike o thers sh e ha s ular m achi ne, t h e Re sp iron ics Flow-Gen , she w i ng mornings feelin g rest e d. I n r esponse to a mo r nings aft er n ot usin g t h e C PAP mac hine, on h e r chest . the app e ll ant just p rio r to th e hearin g wa s for i b le as eviden ce purs uant to sect ion 2 2(4) of the fami ly un it i s el igible to r eceive h ealth c hedule C.
APPEA I PART F -Reasons for Panel Decision The issue in this appeal is whether the ministry's determination that the appellant is not eligible to receive a health supplement for a buyout of a continuous positive airway pressure (CPAP) machine, mask and filters was a reasonable application of the legislation or reasonably supported by the evidence. Specifically, the ministry determined that all necessary legislative requirements had been met by the appellant with the exception of the criteria set out in Schedule C, section 3.9(2)(c). This legislation requires that the ministry must be satisfied that the item is medically essential for the treatment of moderate to severe sleep apnea. The ministry determined that the appellant's sleep apnea falls within the mild range with an apnea/hypopnea index (AHi) of 10.1, and for this reason she is ineligible to receive the requested benefit. The criterion of section 69 was also not met because the CPAP machine, mask and filters are not required to meet a direct and imminent life-threatening health need. Relevant Legislation The following sections of the EAPWDR and Schedule C apply to this appeal: Medical equipment and devices 3 (1) Subject to subsections (2) to (5) of this section, the medical equipment and devices described i n 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. Medical equipment and devices� breathing devices 3.9 (1) Subject to subsection (4) of this section, the following items are health supplements for the purposes of section 3 of this Schedule: (a) if all of the requirements set out i n subsection (2) of this section are met, (i) a positive airway pressure device, (ii) an accessory that i s required to operate a positive airway pressure device, or (iii) a supply that is required to operate a positive airway pressure device; (b) if the minister is satisfied that the item is medically essential to monitor breathing, (i) an apnea monitor, (ii) an accessory that is required to operate an apnea monitor, or (iii) a supply that is required to operate an apnea monitor; (c) if the minister is sat isfied t hat the item is medically essential for clearing respiratory airways, (i) a suction unit, (ii) an accessory that is required to operate a suction unit, or (iii) a supply that is required to operate a suction unit; (d) if the minister is satisfied that the item is medically essential for clearing respiratory airways, (i) a percussor, (ii) an accessory that is required to operate a percussor, or (iii) a supply that is required to operate a percussor; (e) if the minister is satisfied that the item is medically essential to avoid an imminent and substantial danger to health, (i) a nebulizer, (ii) an accessory that is required to operate a nebulizer, or (iii) a supply that is required to operate a nebulizer; (f) if the minister is satisfied that the item is medically essential to moisturize air in order to allow a tracheostomy patient to breathe, (i) a medical humidifier,
( i i ) a n a c c e s s o r y t h a t i s r e q u i r e d t o o p e r a t e a m e d i c a l h u m i d ( i i i ) a s u p p l y t h a t i s r e q u i r e d t o o p e r a t e a m e d i c a l h u m i d i f i e r ; ( g ) i f t h e m i n i s t e r i s s a t i s f i e d t h a t t h e i t e m i s m e d i c a l l y e s s e n ( i ) a n i n h a l e r a c c e s s o r y d e v i c e , ( i i ) a n a c c e s s o r y t h a t i s r e q u i r e d t o o p e r a t e a n i n h a l e r a c c e s ( i i i ) a s u p p l y t h a t i s r e q u i r e d t o o p e r a t e a n i n h a l e r a c c e s s o r y ( 2 ) T h e f o l l o w i n g a r e t h e r e q u i r e m e n t s i n r e l a t i o n t o a n i t e m r ( a ) t h e i t e m i s p r e s c r i b e d b y a m e d i c a l p r a c t i t i o n e r o r n u r s e p ( b ) a r e s p i r a t o r y t h e r a p i s t h a s p e r f o r m e d a n a s s e s s m e n t t h a t ( c ) t h e m i n i s t e r i s s a t i s f i e d t h a t t h e i t e m i s m e d i c a l l y e s s e n t i a H e a l t h s u p p l e m e n t f o r p e r s o n s f a c i n g d i r e c t a n d i m 6 9 T h e m i n i s t e r m a y p r o v i d e t o a f a m i l y u n i t a n y h e a l t h s u p p s u p p l e m e n t s ] a n d 3 [ m e d i c a l e q u i p m e n t a n d d e v i c e s ] o f S c h p e r s o n i n t h e f a m i l y u n i t w h o i s o t h e r w i s e n o t e l i g i b l e f o r t h e s a t i s f i e d t h a t ( a ) t h e p e r s o n f a c e s a d i r e c t a n d i m m i n e n t l i f e t p e r s o n ' s f a m i l y u n i t w i t h w h i c h t o m e e t t h a t n e e d , ( b ) t h e h e a p e r s o n ' s f a m i l y u n i t i s r e c e i v i n g p r e m i u m a s s i s t a n c e u n d e r t h s p e c i f i e d i n t h e f o l l o w i n g p r o v i s i o n s o f S c h e d u l e C , a s a p p l i c s e c t i o n s 3 t o 3 . 1 2 , o t h e r t h a n p a r a g r a p h ( a ) o f s e c t i o n 3 ( 1 ) . 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 s h e h a s r e c e n t l y h a m a c h i n e d e n y i n g h e r t h e o p p o r t u n i t y t o h a v e i t w o r d i f f e r e n c e t o b o t h h e r q u a l i t y o f s l e e p a n d w a k i n g . S o f h e r i n t e r r u p t e d s l e e p p a t t e r n a s w e l l a s a d r o p i n a p p e l l a n t h a s h a d a b o u t 4 e f f e c t i v e n i g h t s a n d a w o T h e m i n i s t r y ' s p o s i t i o n i s a s f o l l o w s : 1 . t h e m i n i s t e r i s n o t s a t i s f i e d t h a t t h e C P A P m m o d e r a t e t o s e v e r e s l e e p a p n e a a s s e t u n d e s l e e p l a b o r a t o r y s e n t t o t h e a p p e l l a n t ' s p h y s 1 0 . 1 w h i c h i s c o n s i s t e n t w i t h m i l d s l e e p a p n e 2 . t h e c r i t e r i o n o f s e c t i o n 6 9 w a s n o t m e t b e c a u t h a t t h e a p p e l l a n t i s f a c i n g a d i r e c t a n d i m m i m a c h i n e i s n e c e s s a r y t o m e e t a d i r e c t a n d i m 3 . t h e i n f o r m a t i o n p r o v i d e d t o t h e a p p e l l a n t ' s p h a p p e l l a n t ' s c o n d i t i o n a s m i l d o b s t r u c t i v e s l e e t h e r e q u i r e m e n t s s p e c i f i e d i n s e c t i o n s 3 t o 3 T h e p a n e l f i n d s t h a t w h i l e t h e a p p e l l a n t ' s p h y s i c i a n t h e a p p e l l a n t h a s p r o v e n s l e e p a p n e a a n d r e q u i r e s 1 6 , 2 0 1 4 , t h e p h y s i c i a n w r o t e t h a t t h e a p p e l l a n t h a s m a d e a d i f f e r e n c e t o h e r s l e e p q u a l i t y . 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" T h e p a n e l f i n d s t h a t a f t e r u s i n g t h e C P A a p p e l l a n t a d m i t t e d t o h a v e a b o u t 4 m o r n i n g s t h a t s h n o t m e n t i o n t h a t w i t h o u t t h e m a c h i n e s h e h a s h a d m A P P E A I i f i e r , o r t i a l t o d e l i v e r m e d i c a t i o n , s o r y d e v i c e , o r d e v i c e . e f e r r e d t o i n s u b s e c t i o n ( 1 ) ( a ) o f t h i s s e c t i o n : r a c t i t i o n e r ; c o n f i r m s t h e m e d i c a l n e e d f o r t h e i t e m ; l f o r t h e t r e a t m e n t o f m o d e r a t e t o s e v e r e s l e e p a p n e a . m i n e n t l i f e t h r e a t e n i n g h e a l t h n e e d l e m e n t s e t o u t i n s e c t i o n s 2 ( 1 ) ( a ) a n d ( f ) [ g e n e r a l h e a l t h e d u l e C , i f t h e h e a l t h s u p p l e m e n t i s p r o v i d e d t o o r f o r a h e a l t h s u p p l e m e n t u n d e r t h i s r e g u l a t i o n , a n d i f t h e m i n i s t e r i s h r e a t e n i n g n e e d a n d t h e r e a r e n o r e s o u r c e s a v a i l a b l e t o t h e l t h s u p p l e m e n t i s n e c e s s a r y t o m e e t t h a t n e e d , ( c ) t h e e M e d i c a r e P r o t e c t i o n A c t , a n d ( d ) t h e r e q u i r e m e n t s a b l e , a r e m e t : ( i ) p a r a g r a p h ( a ) o r ( f ) o f s e c t i o n ( 2 ) ( 1 ) ; ( i i ) d t o r e t u r n t h e R e s p i r o n i c s F l o w G e n C P A P k . U s i n g t h i s C P A P m a c h i n e h a s m a d e a h e h a s e x p e r i e n c e d a d r a m a t i c d r o p i n i n c i d e n c e f i b r o b u r n . W i t h t h i s p a r t i c u l a r m a c h i n e , t h e k e t h e f o l l o w i n g m o r n i n g s f e e l i n g r e s t e d . a c h i n e i s m e d i c a l l y e s s e n t i a l f o r t h e t r e a t m e n t o f r s u b s e c t i o n 3 . 9 ( 2 } ( c ) , a s t h e r e p o r t f r o m t h e i c i a n i n d i c a t e d t h a t t h e a p p e l l a n t h a s a n A H i o f a ; s e t h e i n f o r m a t i o n p r o v i d e d d o e s n o t e s t a b l i s h n e n t l i f e t h r e a t e n i n g h e a l t h n e e d o r t h a t a C P A P m i n e n t l i f e t h r e a t e n i n g h e a l t h n e e d ; a n d y s i c i a n a n d t h e s l e e p l a b o r a t o r y c h a r a c t e r i z e s t h e p a p n e a a n d t h e r e f o r e t h e r e q u e s t d o e s n o t m e e t . 1 2 o f S c h e d u l e C . i n d i c a t e d i n h i s l e t t e r d a t e d A u g u s t 2 7 , 2 0 1 3 t h a t C P A P f o r t h i s c o n d i t i o n , i n h i s l e t t e r d a t e d M a y m i l d O S A a n d h a s f o u n d t h a t t h e C P A P h a s e l s b e t t e r d u r i n g t h e d a y . S h e h a s n o t e d t h a t w i t h a s p e l l s ) , l e s s m u s c l e s t i f f n e s s , b u r n i n g P m a c h i n e f o r a p p r o x i m a t e l y 1 1 m o n t h s , t h e e h a d a w o k e n f e e l i n g r e s t e d ; h o w e v e r , s h e d i d u s c l e s t i f f n e s s o r a b u r n i n a s e n s a t i o n o n l v t h a t
I APPEA she has a slur in her throat and a weight on her chest. The panel finds that given the appellant's testimony that Sleep Apnea is part of or secondary to CFSME, and that she has mild OSA with a Respiratory Disturbance Index of 10.1, the ministry has reasonably determined that pursuant to the above noted legislation, the appellant is not eligible for a buyout of the CPAP machine, mask and filters as it is not required to treat moderate to severe sleep apnea as is required under section 3.9(2)(c) of Schedule C. Additionally, the panel finds that although the appellant was required to return the CPAP machine after having used it for 11 months and admitted at the hearing that she had only had limited success with its use, no additional medical information was presented indicating that the requested item was required to meet a direct and imminent life threatening health need. Therefore, the panel finds that the CPAP machine, mask and filters were reasonably determined by the ministry as not required to meet a life-threatening health need and that therefore the ministry reasonably determined that this criterion in addition to the need to meet the criterion of 3.9(2)(c) make the appellant ineligible under section 69. The panel finds that the ministry's decision that the appellant was not eligible for a buyout of a CPAP machine, mask and filters was a reasonable application of the applicable enactment in the circumstances of the appellant and therefore confirms the ministry's decision.
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.