PART C -Deci sion und er Appeal The decisi o n unde r ap peal is th e Mi nistr y of S o cial D evel opment and Social In novation (ministry) reco n s id er a tion decision dated A ugus t 19, 2 0 14 which denied the appellant's request for a sup ple ment to cover t h e cost of gluco s e sensors. The ministry found that the following requirements of Schedul e C of the Employm e nt and Assistance for Persons With Disabiliti e s Regu lation ( E AP WDR ) were not met: o the suppl y is not required for one of the purposes as set out in Section 2(1 )( a )( i ); a nd, • the su p ply is c o n s ide r e d an a ccessory and d o e s not fit with in t h e def inition of a "non conventional glucose me ter" pursuant to Section 3 .12(1 ). P ART D -Rel evant Legisl ation Employm e n t and Persons with Dis a bil ities R e g ul ation (EAPWD R), S ections 6 2 a nd 69 and Sch edu l e C, Section s 2 a nd 3.12
P A R T E S u m m a r y o f F a c t s T h e e v i d e n c e b e f o r e t h e m i n i s t r y a t t h e t i m e o f t h e r 1 ) Q u o t e b y t h e m a n u f a c t u r e r f o r m i n i l i n k t r a n s 2 ) L e t t e r d a t e d J u n e 1 0 , 2 0 1 4 f r o m t h e a p p e l l a n e n d o c r i n o l o g y ( " e n d o c r i n o l o g i s t " ) , ' T o w h o m o f c o n t i n u o u s g l u c o s e s e n s i n g d e v i c e s . T h e • T h e a p p e l l a n t h a s b e e n u n d e r h e r c a r d i a b e t e s o v e r t h e p a s t 1 8 y e a r s . • T h e a p p e l l a n t s u f f e r s h y p o g l y c e m i c u n h y p o g l y c e m i a i n c l u d i n g r e c u r r e n t n i g h • H e h a s b e e n h o s p i t a l i z e d o n m a n y o c c o n t i n u o u s l y ; • S h e a n d h e r c o l l e a g u e s i n t h e d i v i s i o n i n t h e h i g h a c u i t y u n i t ( H A U ) , h a v e s t r u p u m p s a u g m e n t e d b y c o n t i n u o u s g l u c • A n y d i s c h a r g e p l a n h i n g e s o n a w a r n i n • T h i s i s t r u l y a n e x c e p t i o n a l c a s e . 3 ) L e t t e r d a t e d J u l y 3 0 , 2 0 1 4 f r o m t h e e n d o c r i n o m i n i s t r y f u n d i n g o f c o n t i n u o u s g l u c o s e s e n s i n i n f o r m a t i o n i n h e r J u n e 1 0 , 2 0 1 4 l e t t e r a n d a d • S h e a n d h e r c o l l e a g u e s f e e l t h a t i t w o u h o s p i t a l w i t h o u t c o n t i n u o u s g l u c o s e m • S e n s o r s a r e a b s o l u t e l y n e c e s s a r y t o a a p p e l l a n t ' s h e a l t h b y w a y o f h y p o g l y c e 4 ) R e q u e s t f o r R e c o n s i d e r a t i o n d a t e d A u g u s t 5 , I n h i s R e q u e s t f o r R e c o n s i d e r a t i o n , t h e a p p e l l a n t w r • T h e i t e m s r e q u e s t e d a r e n e c e s s a r y t o a v o i d i • H e i s a T y p e I d i a b e t i c w i t h h y p o g l y c e m i c u n a o u t i n p u b l i c . H e w a s o n c e u n c o n s c i o u s i n t h e p i s o d e s a r e i n c r e a s i n g o v e r t h e y e a r s . • T h e s e n s o r s w i l l a l l o w h i m a n e a r l y w a r n i n g w a l l o w i n g h i s b o d y t o r e c o u p h i s s u g a r l e v e l s . • W i t h o u t t h e s e n s o r s , h e m a y n o t s u r v i v e t h e n I n t h e f a x d a t e d A u g u s t 6 , 2 0 1 4 , t h e a p p e l l a n t ' s a d v o o n l y r e q u i r e s f u n d i n g f o r t h e s e n s o r s a n d n o t t h e t r a n u n t i l t h e f u n d i n g i s r e c e i v e d . I n h i s N o t i c e o f A p p e a l d a t e d S e p t e m b e r 3 , 2 0 1 4 , t h m i n i s t r y ' s r e c o n s i d e r a t i o n d e c i s i o n a n d w r o t e : • H e h a s b e e n h o s p i t a l i z e d s i n c e J a n u a r y 8 , 2 0 • A l l a l t e r n a t i v e s h a v e b e e n r u l e d o u t a n d s t i l l h • T h i s h a s a l i f e o r d e a t h s i t u a t i o n e v e r y d a y o f c e r t a i n l y d i e .e c o n s i d e r a t i o n d e c i s i o n i n c l u d e d : m i t t e r ( $ 7 9 9 ) a n d g l u c o s e s e n s o r s ( 5 / b o x ) a t $ 3 2 5 ; t ' s p h y s i c i a n , a s p e c i a l i s t i n i n t e r n a l m e d i c i n e a n d i t m a y c o n c e r n ' r e g a r d i n g t h e P h a r m a c a r e f u n d i n g p h y s i c i a n w r o t e i n p a r t t h a t : e f o r a s s i s t a n c e i n s e l f m a n a g e m e n t o f T y p e I a w a r e n e s s w i t h r e c u r r e n t e p i s o d e s o f s e v e r e t s e i z u r e s . c a s i o n s , i n c l u d i n g c u r r e n t l y s i n c e J a n u a r y 8 , 2 0 1 4 o f e n d o c r i n o l o g y , i n t h e c l i n i c a l t e a c h i n g u n i t a n d g g l e d t o d e s i g n a s o l u t i o n , n o w i n v o l v i n g t w o o s e s e n s i n g d e v i c e s . g s y s t e m . l o g i s t ' T o w h o m i t m a y c o n c e r n ' r e g a r d i n g t h e g d e v i c e s . T h e p h y s i c i a n r e p e a t e d m u c h o f t h e d e d : l d b e u n s a f e t o d i s c h a r g e t h e a p p e l l a n t f r o m o n i t o r i n g a u g m e n t e d b y a l a r m a m p l i f i c a t i o n . v o i d i m m i n e n t a n d s u b s t a n t i a l d a n g e r t o t h e m i a i n d u c e d s e i z u r e , c o m a a n d d e a t h ; a n d , 2 0 1 4 a n d f a x d a t e d A u g u s t 6 , 2 0 1 4 . o t e : m m i n e n t a n d s u b s t a n t i a l d a n g e r t o h i s h e a l t h . w a r e n e s s a n d h a s f o u n d h i m s e l f u n c o n s c i o u s e m i d d l e o f a b u s y i n t e r s e c t i o n i n t h e c i t y . T h e s e i t h a n a l a r m a n d w i l l s h u t d o w n h i s p u m p , e x t 5 y e a r s . c a t e , a s o c i a l w o r k e r , s t a t e d t h a t t h e a p p e l l a n t s m i t t e r . T h e a p p e l l a n t w i l l r e m a i n i n h o s p i t a l e a p p e l l a n t e x p r e s s e d h i s d i s a g r e e m e n t w i t h t h e 1 4 f o r b l o o d s u g a r c o n t r o l . e c a n n o t g e t a d e q u a t e c o n t r o l . h i s l i f e . W i t h o u t t h e s e n s o r s , h e w i l l m o s t
P r i o r t o t h e h e a r i n g , t h e a d v o c a t e s f o r t h e a p p e l l a n t 1 ) S p e c i a l A u t h o r i t y R e q u e s t t o t h e M i n i s t r y o f H e n d o c r i n o l o g i s t o n b e h a l f o f t h e a p p e l l a n t o n a n d d i a g n o s i s a n d o t h e r p a t i e n t s p e c i f i c i n d i c 2 ) S p e c i a l A u t h o r i t y R e q u e s t t o t h e M i n i s t r y o f H e n d o c r i n o l o g i s t o n b e h a l f o f t h e a p p e l l a n t o n i n d i c a t o r s , i n c l u d i n g : T y p e I d i a b e t e s , h o s p i t a s e i z u r e s , r e c u r r e n t l o s s o f c o n s c i o u s n e s s , u n u n c o n s c i o u s l o w s o n a n y i n s u l i n r e g i m e n s o s e i z u r e s u n l e s s h e h a s a c c e s s t o t h e c o n t i n u a n d i m p e n d i n g l o w g l u c o s e a l a r m ; 3 ) L e t t e r d a t e d A u g u s t 8 , 2 0 1 4 f r o m t h e e n d o c r r e g a r d i n g P h a r m a c a r e c o v e r a g e o f c o n t i n u o u p h y s i c i a n w r o t e i n p a r t t h a t : • T h e a p p e l l a n t ' s i n s u l i n p u m p h a s b e e t h e p a s t f e w w e e k s . • W i t h o u t t h e s e n s o r , t h e a p p e l l a n t w a s w i t h t h e h e l p o f n u r s i n g s t a f f t h r o u g h t • H o s p i t a l R e c o r d s o f g l u c o m e t e r r e a d i n 2 0 1 4 w e r e e n c l o s e d ; 4 ) L e t t e r d a t e d S e p t e m b e r 1 6 , 2 0 1 4 t o t h e M i n i s • S i n c e J a n u a r y 8 , 2 0 1 4 h e h a s b e e n c o t r y i n g t o c o n t r o l h i s b l o o d s u g a r s w i t h • S i n c e h i s d i a g n o s i s f o r T y p e I D i a b e t e n u m b e r o f h o s p i t a l i z a t i o n s a n d l i f e t h r e d o w n i n t h e m i d d l e o f a b u s y i n t e r s e c t i • H e h a s n o w b e e n c l a s s i f i e d a s ' h y p o g l d i a b e t i c ' . • H i s d o c t o r h a s t r i e d m a n y d i f f e r e n t t r e a i n c l u d e d , b u t n o t l i m i t e d t o , b e d s i d e a • O n e t r e a t m e n t p l a n t h a t h a s s h o w n s u t r a n s m i t s h i s b l o o d s u g a r s t o h i s i n s u l i d r o p s b e l o w a p r e s e t l i m i t . • T h e c o s t o f t h e s e n s o r s i s e s t i m a t e d a t t h e h o s p i t a l i s $ 1 , 3 0 4 p e r d a y . • H e i s n o t e l i g i b l e f o r d i s c h a r g e f r o m t h e • H e h a s c u r r e n t l y e x h a u s t e d a n y o f h i s P h a r m a c a r e h a s d e n i e d t h e r e q u e s t s o 5 ) R e p o r t d a t e d S e p t e m b e r 2 0 1 4 b y t h e m a n u f a s y s t e m s f o r p a t i e n t s w i t h T y p e I d i a b e t e s . T h • D i a b e t e s m e l l i t u s i s a c h r o n i c m e t a b o l i a l o s s o f b l o o d g l u c o s e c o n t r o l . • C o m p l i c a t i o n s a s s o c i a t e d w i t h d i a b e t e c o m p l i c a t i o n s i n c l u d e h y p o g l y c e m i a a n l i f e t h r e a t e n i n g . • H y p o g l y c e m i a i s c a u s e d w h e n t h e g l u c c o n c e n t r a t i o n a n d c a n r e s u l t i n s e i z u r e p r o v i d e d t h e f o l l o w i n g a d d i t i o n a l d o c u m e n t s : e a l t h d a t e d M a r c h 1 , 2 0 1 4 m a d e b y t h e t h e b a s i s o f t r e a t m e n t f a i l u r e o n r e f e r e n c e d r u g a t o r s ; e a l t h d a t e d A p r i l 1 1 , 2 0 1 4 m a d e b y t h e t h e b a s i s o f d i a g n o s i s a n d o t h e r p a t i e n t s p e c i f i c l i z e d r e p e a t e d l y w i t h s e v e r e h y p o g l y c e m i c a b l e t o d i s c h a r g e d u e t o r e c u r r e n t u n p e r c e i v e d f a r , d e s p i t e i n s u l i n p u m p , b u t r e c u r r e n t n i g h t o u s g l u c o s e s e n s o r w i t h a u t o o f f p u m p f e a t u r e i n o l o g i s t t o t h e D i r e c t o r o f S p e c i a l A u t h o r i t y s g l u c o s e s e n s i n g d e v i c e f o r t h e a p p e l l a n t . T h e n r e g i s t e r i n g a l l o f h i s g l u c o s e m e t e r t e s t i n g o v e r l o g g i n g i n t h e r a n g e o f 3 0 g l u c o s e t e s t s p e r d a y h e n i g h t . g s f o r t h e p e r i o d A p r i l 5 , 2 0 1 4 t h r o u g h J u n e 1 , t e r o f H e a l t h i n w h i c h t h e a p p e l l a n t w r o t e i n p a r t : n f i n e d t o h o s p i t a l a n d h i s d o c t o r s h a v e b e e n v e ry l i t t l e s u c c e s s . s M e l l i t u s i n t h e l a t e 1 9 7 0 ' s , t h e r e h a v e b e e n a a t e n i n g e m e r g e n c i e s , i n c l u d i n g b e i n g f o u n d f a c e o n i n t h e c i t y . y c e m i c u n a w a r e ' a n d a s b e i n g a s e v e r e ' b r i t t l e t m e n t p l a n s w i t h l i t t l e s u c c e s s , w h i c h h a v e l a r m s , h e p a r i n w i t h h i s i n s u l i n , a n d d i e t c h a n g e s . c c e s s i s t h e s e n s o r / t r a n s m i t t e r d e v i c e w h i c h n p u m p w h i c h w i l l a l a r m w h e n h i s b l o o d s u g a r $ 3 2 5 p e r m o n t h w h i l e t h e c o s t o f h i m b e i n g i n h o s p i t a l u n t i l h e h a s t h e s y s t e m i n p l a c e . a n d h i s f a m i l y ' s p e r s o n a l f i n a n c e s a n d f h i s e n d o c r i n o l o g i s t . c t u r e r r e g a r d i n g C o n t i n u o u s G l u c o s e M o n i t o r i n g e R e p o r t i n c l u d e d t h e f o l l o w i n g p o i n t s : c d i s o r d e r c a u s e d b y a l a c k o f i n s u l i n r e s u l t i n g i n s a r e c l a s s i f i e d a s a c u t e o r c h r o n i c . A c u t e d d i a b e t i c k e t o a c i d o s i s , b o t h o f w h i c h c a n b e o s e l e v e l f a l l s b e l o w t h e n o r m a l b l o o d g l u c o s e / c o m a , c o a n i t i v e d v s f u n c t i o n a n d c a n e v e n b e
fatal. The average estimated direct cost of a single severe hypoglycemic event in Canada is $2,074 per episode. • The current standard of care in patients with Type I diabetes on insulin is to self-monitor blood glucose levels with finger-stick measurements at least 3 times per day, though for many patients they may conduct it up to 12 times per day. • Finger-stick blood glucose measurements and conventional blood glucose meters provide patients with only a single point in time measurement of the current blood glucose level and not its trending (increasing or decreasing) nor its rate of change (fast or slow). o The cornerstone of the diabetes technology system is the insulin pump, which · continuously delivers rapid-acting insulin 24 hours a day. This eliminates the need for manual insulin injections and allows for insulin delivery to more closely mimic the function of a healthy pancreas. • An insulin pump and continuous glucose monitoring system consists of: 1) a sensor augmented insulin pump, 2) glucose sensor, and 3) mini-link transmitter. o The glucose sensor is a small electrode that is inserted into the subcutaneous adipose tissue using an automatic insertion device by the patient. Each sensor is worn for up to 6 days. • Continuous glucose monitoring requires the use of a mini-link transmitter and glucose sensors. • The sensor continuously measures glucose levels in the interstitial fluid and wirelessly relays these readings to the pump by means of a radiofrequency transmitter. • The pump displays the glucose readings every 5 minutes; the immediate glucose level as well as the direction of glucose transition is displayed. • The continuous glucose monitoring component of the insulin pump and the continuous glucose monitoring system monitors patients' glucose levels and provides regular updates of these readings up to 288 times per day, allowing patients and their physicians to evaluate the changes in interstitial glucose levels. • The insulin pump and continuous glucose monitoring system have several settings which can be used to help optimize glycemic control including upper and lower threshold limits set to define the target glucose range. When the sensor detects glucose values that exceed the preset limits, the pump will alert the patient. With the predictive alerts turned on, the pump will notify the patient of a potential pending hypo or hyper glycemic episode before it happens, therefore helping to keep the glucose level in the target range. • The 'low glucose suspend' functionality helps to prevent severe hypoglycemic episodes day or night by automatically suspending insulin delivery for up to 2 hours when the hypoglycemic threshold is crossed , and to avoid hypoglycemic rebound by enabling resumption of insulin delivery when glucose levels recover, or at the 2-hour interval. At the hearing, the ministry provided the following additional documents: 1) Ministry emails between departments on September 18, 2014; and, 2) Print out from the manufacturer's website with the cost of the sensors. At the hearing, the appellant and his advocates stated: • The lack of glucose sensors as part of the monitoring system poses a detrimental risk to his health. Without the sensors, there is a hiah oossibilitv of death.
• As has been set out in the d oc uments, he ha mid dle of the street because o f low blood sug o His s ituat i on is u nusua l s i nc e he goes from sup period of 40 m i nut e s. Th is is outside t he p arameters glucose sensor s are more than "something nice to have," the consi der an " ac cessory" to b e som e t hing li ke • N ormal b lood sug ar is in the r ange o f 3 .5 to 8 and anyth detr imental to a pe r son's health. Treatment would start a • His blood sugar levels can drop e xtr e m ely q uickly system will alert h im that his levels are dropping or going up at a • His e ndocrin ologist has trie d e v e rythin g el se and the continuous the only th ing th a t w i ll work. • The ap pellant cannot be discharged from the monitoring sy st em. No p hy sicia n w i ll sign his d the ap pellan t will have an e ven t a n d be b ac k into a • Dur ing h is time in the h o spita l, the appe ll a nt has bee (I CU) an d the HAU in order to sta biliz e h i m after prob • The h o spit al has start e d pr o viding the a ppe l lant with the continuous g system , incl udi n g the gluco se sen sors , be c au him a live. Th e h ospit a l ca nnot co ntin u e to pr discharge. • I f he l e ave s the hosp ital w i th o ut the c ontin uous e ven t. • If th e a ppe l lant is equ ippe d wit h the glucos e mo " the n e xt day." T h ere i s nothing els e k eep i ng • Th e app el lant wants to go h om e . H e ha s bee a ls o at risk o f contr acting other infec ti ons . • Th e ap pell a n t' s n ee d fo r the con tinuous glucose monitor r e s t of his li f e. There is a c ha nce that af ter a few not to need the co nti nuous monitoring. • While the c os t of 1 box o f s e nso rs, whi c h in cludes there are savings that can be realized by purch • The glucose sensor can only stay in a person's body for up to 6 days. 6 days, it will eithe r cause an i n f ect io n or the body will start to • The se nsors provide a gl u cose rea ding every 5 minute and sent to the pump. The sensor takes the cellular liquid from the body and determi blood sugar le vel and, through the transmitter, sends • Whe n the sensor is changed after 6 days, it takes the new sensor approximately 2 hours to become effe c tive and start providi ng readings. • In the appellant's situation, the problem with the hand prick blood glucose m conventional blood glucose meter is that the app reading of 25 to 3 in a period of 15 to 20 minutes. When it has reached that low level, the appellant would not be thinking clearly and would "not be in a mindset to do any self glucose monitoring." His levels drop and increase too quickly for him to react in time. • The higher levels are not as li fe-t hreatening as • The continuous glucose monitoring system identifies trends in blood sugar levels and provides alerts when there is a hioh rate of chanae. The record of trends provided also allows"_,t s been found unconscious, fac e down, in th e ar. er high level s to him be ing non-res ponsive in a of a normal di abetic. Fo r hi m, the y are essenti al. He would a ni ce case for t he pump. i ng in the 20' s is high and b elow 3 is t a read ing of 4. and t he continuo us glucose monitoring f ast r ate. gl uco s e m on itoring s ystem is h o spital unless he has the con t in uous glucose is c h a rg e papers w ith ou t this in place because c u t e ca r e . n in and out of th e in t e nsive care un it l e ms wit h his blo od glucose levels. l u c ose monitoring s e he is in acute c ar e and i t is requ i red to k e ep ovid e the g l ucose s ensors afte r t h e a ppe l lant's glucose monitoring s ystem, the re w i ll be a fata l ni to ri n g s y s t e m , t he h o spital w i ll d isch a r ge h i m h im in h os pital. n in hos pital for 8 months and, wh il e th er e , he is ing system is not n e ces sarily for the ye ars his c onditio n will sta b ilize s u ffi ciently 5 sen sors, is $32 5 and w il l last for 1 month, asing a 6 month's s up ply at one time. If it is left i n long e r th an reject it. s which is picked up by the transmitt er n es the th e r e adi ng to t h e pump. easurement a nd a ellant ' s blood sugar level can go from a th e low lev els of blood glucose. h e _ _J '""' -=-
e n d o c r i n o l o g i s t t o a d j u s t t h e a p p e l l a n t ' s m e d o T h e g l u c o s e s e n s o r i s " i n t e r n a l l y i m b e d d e d " c o n t i n u o u s g l u c o s e m o n i t o r i n g s y s t e m . T h e o f a n i n s t i t u t i o n . o T h e s y s t e m a l s o n e e d s t o b e c a l i b r a t e d t w i c e m e a s u r e m e n t . A n a l a r m g o e s o f f t o a l e r t t h e r e q u i r e d . • I n t h e a p p e l l a n t ' s s i t u a t i o n , h e h a s t o w e a r t w t h e o t h e r p r o v i d e s g l u c o s e . A d m i s s i b i l i t y o f N e w I n f o r m a t i o n T h e m i n i s t r y h a d n o t r e c e i v e d a c o p y o f t h e a p p e l l a r e c e s s e d t o a l l o w t h e m i n i s t r y t o r e v i e w t h e d o c u m e a p p e l l a n t o b j e c t e d t o t h e a d m i s s i b i l i t y o f t h e a d d i t i o n r e p r e s e n t a t i v e s f o r t h e a p p e l l a n t p r o v i d e d a d d i t i o n a a n d h i s n e e d f o r g l u c o s e s e n s o r s . T h e m i n i s t r y p r o v t h e g l u c o s e s e n s o r s . T h e p a n e l a d m i t t e d t h i s a d d i t i i n f o r m a t i o n a n d r e c o r d s t h a t w e r e b e f o r e t h e m i n i s t ry w i t h S e c t i o n 2 2 ( 4 ) ( b ) o f t h e E m p l o y m e n t a n d A s s i s t b e t w e e n d e p a rt m e n t s a n d t h e p a n e l c o n s i d e r e d t h i s e v i d e n c e . T h e m i n i s t r y r e l i e d o n i t s r e c o n s i d e r a t i o n d e c i s i o n , a c l a r i f i e d a t t h e h e a r i n g : • W i t h t h e c o n v e n t i o n a l g l u c o s e m e t e r s , a p e r s • T h e m i n i s t r y c o v e r s t h e c o s t o f t h e t e s t s t r i p s • T h e g l u c o s e s e n s o r s a r e n o t o n t h e m i n i s t r y ' s • T h e m i n i s t r y i s n o t a w a r e i f t h e g l u c o s e s e n s o i c a t i o n s . i n t h e b o d y a n d i s a r e q u i r e d p a r t o f t h e s y s t e m i s a n e c e s s i t y f o r h i m t o b e a b l e t o l i v e o u t a d a y t h r o u g h u s e o f a f i n g e r p r i c k a p p e l l a n t a n d t o i n d i c a t e t h a t t h e c a l i b r a t i o n i s o p u m p s . O n e p r o v i d e s h i s b o d y w i t h i n s u l i n a n d n t ' s a d d i t i o n a l d o c u m e n t s a n d t h e h e a r i n g n t s f o r a d m i s s i b i l i t y . N e i t h e r t h e m i n i s t r y n o r t h e a l i n f o r m a t i o n p r o v i d e d b y t h e o t h e r p a r t y . T h e l i n f o r m a t i o n r e g a r d i n g t h e a p p e l l a n t ' s d i a b e t e s i d e d a d d i t i o n a l i n f o r m a t i o n r e g a r d i n g t h e c o s t o f o n a l i n f o r m a t i o n a s b e i n g i n s u p p o r t o f a t t h e t i m e o f r e c o n s i d e r a t i o n , i n a c c o r d a n c e a n c e A c t . T h e m i n i s t r y a l s o p r o v i d e d e m a i l s a s p a r t o f t h e m i n i s t r y ' s a r g u m e n t a n d n o t s s u m m a r i z e d a t t h e h e a r i n g . T h e m i n i s t r y a l s o o n ' s b l o o d i s p l a c e d o n a t e s t s t r i p . a s t h e y a r e s e t o u t o n a l i s t o f e l i g i b l e i t e m s . l i s t o f e l i g i b l e i t e m s . r s a r e o n t h e m i n i s t r y ' s l i s t o f n o n e l i g i b l e i t e m s .
PART F -Reasons for Panel Decisi on The issue on the a ppeal is whether the m in is try's r econ appellant's request for a supplement to cover the cost of glucose sensors bec requirements of Sectio n s 2 or 3.1 2 of S chedule C of by the evidence or a r e asona bl e applic a ti o n o f the app ap pe llan t. P u rsuant t o Sectio n 62 of t he EAPWDR, t he a pplicant b e a dependent of a person in receipt of d isability assista cond ition is m et, Schedule C o f the EAPWDR specifies add qualify for a health supplement for various items. In this case, re q u irement o f Sec t ion 62 ha s been met in that the dis a b ility assis tan ce. S e ction 2(1 ) of Schedu l e C of th e EAP W D R provid e G e ner a l health su pple m e n ts 2 (1) T he fo llo wing are the h ea lth s u pp l e ments t hat may b e p aid elig ible unde r s ection 62 [gener al heal t h sup ple m e nts] of thi (a) me di c al or s urgi cal su ppl i es that ar e, at the mi n i s t e r's discretio s atis fied t hat all o f the f ollo wing requi re ments are met: ( i ) th e su p plies are require d f or o n e of the fol lo w ing (A) w o u nd ca re; (B) ong oing bo w el ca re r e quir e d d ue to loss o f mus (C ) cat het er izat i o n ; (D) i n con tine nc e; (E) skin parasite c a r e; (F ) limb c ircu l ation care; (i i) the su ppl i es ar e (A) prescribed by a medical practitioner or nurse practitioner, (B) the least expensive sup plies ap propriate for (C) necessary to avoid an imminent and substantial danger to health; (iii) there are no resources availab l e to the family unit to pay the cost of o (a .1) the following medical or surgical supplies th at are, at the m the minister is satisfied that all the requi r em ent s described in p the supplies: (i) lancets; (ii) needles and syringes; (iii) ventilator supplies required for the essential operation or sterilization of a ventilator; (iv) tracheostomy supplies; (a.2) consumable medical supplies, if the minister is satisfied that all of the following requirements are met: (i) the supplies are required to thicken food; (ii) all the requirements described in paragraph (a) (ii) and (iii) are met in relation to the supplies; . sideration d ec i sion, which denied the a u se n o t all o f th e the EA PWDR were m et, is rea so n ably supported li ca b le enactment in the ci r c umst ance s of the must be a recipient o f dis a b ility assist a nc e, or nce in a va riety of sce n arios. If that itional c riteria t h a t must b e m et in order to the ministry h as n o t di sp ut ed that the a ppellant has b e en approved a s a re cipient of s in part : for by the m inist e r if p rovid e d to a famil y unit that i s s r egu lation: n, eith e r d isp osab le or re usable, if t he m in ister is purposes: cle function; the p urpose, and r obtain t h e supplies; iniste r's discretion, ei ther di s posable or reusable, if a ragraph (a ) (ii ) and (iii) are met in relation to , .
S e c t i o n 3 . 1 2 o f S c h e d u l e C o f t h e E A P W D R p r o v i d e 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 n o n c o n v e n t i o n a l g l u c 3 . 1 2 ( 1 ) I n t h i s s e c t i o n , " n o n c o n v e n t i o n a l g l u c o s e m e t e r " i n c l ( a ) a c o n t i n u o u s g l u c o s e m o n i t o r i n g m e t e r , a n d ( b ) a t a l k i n g g l u c o s e m e t e r . ( 2 ) A n o n c o n v e n t i o n a l g l u c o s e m e t e r i s a h e a l t h s u p p l e m m i n i s t e r i s s a t i s f i e d t h a t ( a ) t h e g l u c o s e m e t e r i s m e d i c a l l y e s s e n t i a l t o t e s t b l o ( b ) t h e p e r s o n f o r w h o m t h e n o n c o n v e n t i o n a l g l u c o s e c o n v e n t i o n a l g l u c o s e m e t e r . ( 3 ) T h e p e r i o d o f t i m e r e f e r r e d t o i n s e c t i o n 3 ( 3 ) ( b ) o f t h c o n v e n t i o n a l g l u c o s e m e t e r i s 5 y e a r s f r o m t h e d a t e o r e p l a c e d . S e c t i o n 2 ( 1 ) o f S c h e d u l e C o f t h e E A P W D R 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 a p p e l l a n t i s e l i g i b l e o f t h e E A P W D R , b u t t h e a p p e l l a n t ' s r e q u e s t f o r a s u d o e s n o t m e e t t h e r e q u i r e m e n t s e t o u t i n S e c t i o n 2 ( m i n i s t r y a r g u e d t h a t t h e e v i d e n c e d o e s n o t e s t a b l i s h r e u s a b l e m e d i c a l o r s u r g i c a l s u p p l y r e q u i r e d f o r o n e w o u n d c a r e , o n g o i n g b o w e l c a r e r e q u i r e d d u e t o l o s i n c o n t i n e n c e , s k i n p a r a s i t e c a r e , o r l i m b c i r c u l a t i o n c T h e a p p e l l a n t d i d n o t d i r e c t l y a d v a n c e a p o s i t i o n t h a u n d e r S e c t i o n 2 ( 1 ) ( a ) ( i ) o f S c h e d u l e C o f t h e E A P W s e n s o r s m e e t t h e r e q u i r e m e n t i n S e c t i o n 2 ( 1 ) ( a ) ( i i ) ( C a n d s u b s t a n t i a l d a n g e r t o h i s h e a l t h . T h e a p p e l l a n t h y p o g l y c e m i c u n a w a r e n e s s a n d h a s f o u n d h i m s e l f u i n c r e a s i n g o v e r t h e y e a r s ; h e w a s o n c e u n c o n s c i o u s 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 s e n s o r s w i l l a l l o w h i m d o w n h i s p u m p , a l l o w i n g h i s b o d y t o r e c o u p h i s s u g a s e n s o r s , h e m a y n o t s u r v i v e t h e n e x t 5 y e a r s . A t t h e a r g u e d t h a t t h e a p p e l l a n t c a n n o t b e d i s c h a r g e d f r o m m o n i t o r i n g s y s t e m a u g m e n t e d b y a l a r m a m p l i f i c a t i o n s i g n h i s d i s c h a r g e p a p e r s w i t h o u t t h e s y s t e m i n p l a c a n e v e n t a n d e n d u p b a c k i n a c u t e c a r e . T h e a p p e l l a a b s o l u t e l y n e c e s s a r y t o a v o i d i m m i n e n t a n d s u b s t a n h y p o g l y c e m i a i n d u c e d s e i z u r e , c o m a a n d d e a t h . P a n e l d e c i s i o n T h e p a n e l f i n d s t h a t t h e e v i d e n c e d e m o n s t r a t e s t h a t m e a s u r e g l u c o s e l e v e l s i n t h e i n t e r s t i t i a l f l u i d a n d w i r g l u c o s e ) p u m p b y m e a n s o f a r a d i o f r e q u e n c y t r a n s m b l o o d g l u c o s e l e v e l s . T h e r e f o r e , t h e p a n e l f i n d s t h a t q l u c o s e s e n s o r s a r e n o t r e q u i r e d f o r o n e o f t h e p u r p o s : o s e m e t e r s u d e s e n t f o r t h e p u r p o s e s o f s e c t i o n 3 o f t h i s S c h e d u l e i f t h e o d g l u c o s e l e v e l s , a n d m e t e r h a s b e e n p r e s c r i b e d i s u n a b l e t o u s e a i s S c h e d u l e w i t h r e s p e c t t o r e p l a c e m e n t o f a n o n n w h i c h t h e m i n i s t e r p r o v i d e d t h e g l u c o s e m e t e r b e i n g t o r e c e i v e h e a l t h s u p p l e m e n t s u n d e r S e c t i o n 6 2 p p l e m e n t t o c o v e r t h e c o s t o f g l u c o s e s e n s o r s 1 ) ( a ) o f S c h e d u l e C o f t h e E A P W D R . T h e t h a t g l u c o s e s e n s o r s a r e a d i s p o s a b l e o r o f t h e p u r p o s e s s e t o u t i n t h e s e c t i o n , n a m e l y : s o f m u s c l e f u n c t i o n , c a t h e t e r i z a t i o n , a r e . t t h e g l u c o s e s e n s o r s a r e r e q u i r e d f o r a p u r p o s e D R , a l t h o u g h h e d i d a r g u e t h a t t h e g l u c o s e ) a s t h e y a r e n e c e s s a r y t o a v o i d a n i m m i n e n t a r g u e d t h a t h e i s a b r i t t l e T y p e I d i a b e t i c w i t h n c o n s c i o u s o u t i n p u b l i c a n d t h e s e e p i s o d e s a r e i n t h e m i d d l e o f a b u s y i n t e r s e c t i o n i n t h e c i t y . a n e a r l y w a r n i n g w i t h a n a l a r m a n d w i l l s h u t r l e v e l s . T h e a p p e l l a n t a r g u e d t h a t , w i t h o u t t h e h e a r i n g , t h e a p p e l l a n t a n d h i s r e p r e s e n t a t i v e s h o s p i t a l w i t h o u t t h e c o n t i n u o u s g l u c o s e . T h e a p p e l l a n t a r g u e d t h a t n o p h y s i c i a n w i l l e b e c a u s e i t i s u n s a f e a n d t h e a p p e l l a n t w i l l h a v e n t a r g u e d t h a t t h e g l u c o s e s e n s o r s a r e t i a l d a n g e r t o t h e a p p e l l a n t ' s h e a l t h b y w a y o f t h e g l u c o s e s e n s o r s f u n c t i o n t o c o n t i n u o u s l y e l e s s l y r e l a y t h e s e r e a d i n g s t o t h e ( i n s u l i n o r i t t e r . T h e p u r p o s e i s t o c o n t i n u o u s l y m e a s u r e t h e m i n i s t r y r e a s o n a b l y c o n c l u d e d t h a t t h e s e s o f w o u n d c a r e , o n q o i n a b o w e l c a r e ,
c a t h e t e r i z a t i o n , i n c o n t i n e n c e , s k i n p a r a s i t e c a r e o r l 2 ( 1 ) ( a ) ( i ) o f S c h e d u l e C o f t h e E A P W D R . T h e m i n i s t r y d i d n o t a d d r e s s t h e a p p e l l a n t ' s a r g u m e S e c t i o n 2 ( 1 ) ( a ) ( i i ) ( C ) o f S c h e d u l e C t h a t t h e g l u c o s e s u b s t a n t i a l d a n g e r t o h i s h e a l t h . I n h e r l e t t e r d a t e d a p p e l l a n t h a s b e e n u n d e r h e r c a r e o v e r t h e p a s t 1 8 w i t h r e c u r r e n t e p i s o d e s o f s e v e r e h y p o g l y c e m i a i n c a p p e l l a n t h a s b e e n h o s p i t a l i z e d o n m a n y o c c a s i o n s c o n t i n u o u s l y a n d a n y d i s c h a r g e p l a n h i n g e s o n a w a t h e a p p e l l a n t ' s i s " t r u l y a n e x c e p t i o n a l c a s e . " I n h e r w r o t e t h a t s h e a n d h e r c o l l e a g u e s f e e l t h a t i t w o u l d w i t h o u t c o n t i n u o u s g l u c o s e m o n i t o r i n g a u g m e n t e d b a b s o l u t e l y n e c e s s a r y t o a v o i d i m m i n e n t a n d s u b s t a n h y p o g l y c e m i a i n d u c e d s e i z u r e , c o m a a n d d e a t h . W s e n s o r s a r e n e c e s s a r y t o a v o i d a n i m m i n e n t a n d s u p a n e l f i n d s t h a t t h e m i n i s t r y r e a s o n a b l y c o n c l u d e d t S c h e d u l e C m u s t b e m e t i n o r d e r f o r t h e i t e m t o b e p s u p p l y . S e c t i o n 3 . 1 2 o f S c h e d u l e C o f t h e E A P W D R 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 a p p e l l a n t i s e l i g i b l e o f t h e E A P W D R , b u t t h e a p p e l l a n t ' s r e q u e s t f o r a s u d o e s n o t m e e t t h e r e q u i r e m e n t s s e t o u t i n S e c t i o n 3 a r g u e d t h a t w h i l e a l t e r n a t i v e g l u c o s e m o n i t o r s a r e p p r o v i s i o n f o r a c c e s s o r i e s s u c h a s s e n s o r s . 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 h i s s i t u a t i o n i s u n u s u t h a n " s o m e t h i n g n i c e t o h a v e , " l i k e a n a c c e s s o r y ; t h e t h a t h i s b l o o d s u g a r l e v e l s g o f r o m s u p e r h i g h l e v e l s m i n u t e s a n d t h a t t h i s i s o u t s i d e t h e p a r a m e t e r s o f a s i t u a t i o n , t h e p r o b l e m w i t h t h e h a n d p r i c k b l o o d g l u c g l u c o s e m e t e r i s t h a t h i s b l o o d s u g a r l e v e l c a n g o f r o 1 5 t o 2 0 m i n u t e s a n d , w h e n i t h a s r e a c h e d t h a t l o w l " n o t b e i n a m i n d s e t t o d o a n y s e l f g l u c o s e m o n i t o r i n i n c r e a s e t o o q u i c k l y f o r h i m t o r e a c t i n t i m e . I n h o s p g l u c o s e t e s t s p e r d a y w i t h o u t t h e g l u c o s e s e n s o r . P a n e l d e c i s i o n S e c t i o n 3 . 1 2 ( 2 ) o f S c h e d u l e C o f t h e E A P W D R s e t s h e a l t h s u p p l e m e n t f o r t h e p u r p o s e s o f S e c t i o n 3 o f t h g l u c o s e m e t e r i s m e d i c a l l y e s s e n t i a l t o t e s t b l o o d g l u c o n v e n t i o n a l g l u c o s e m e t e r h a s b e e n p r e s c r i b e d i s u 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 r e q u e s t f o r g l u c o s e s w i t h i n t h e d e f i n i t i o n o f a " n o n c o n v e n t i o n a l g l u c o s e m m e t e r . A d e f i n i t i o n o f a " n o n c o n v e n t i o n a l g l u c o s e m ' c o n t i n u o u s g l u c o s e m o n i t o r i n g m e t e r ' a n d a ' t a l k i n g a c l o s e d l i s t o f i t e m s t h a t f a l l w i t h i n t h e d e f i n i t i o n o f " n i m b c i r c u l a t i o n c a r e , a s s e t o u t i n S e c t i o n n t a t r e c o n s i d e r a t i o n r e g a r d i n g t h e r e q u i r e m e n t i n s e n s o r s a r e n e c e s s a r y t o a v o i d a n i m m i n e n t a n d J u n e 1 0 , 2 0 1 4 t h e e n d o c r i n o l o g i s t w r o t e t h a t t h e y e a r s a n d h e s u f f e r s h y p o g l y c e m i c u n a w a r e n e s s l u d i n g r e c u r r e n t n i g h t s e i z u r e s . S h e w r o t e t h a t t h e , i n c l u d i n g c u r r e n t l y s i n c e J a n u a r y 8 , 2 0 1 4 r n i n g s y s t e m . T h e e n d o c r i n o l o g i s t r e p o r t e d t h a t l e t t e r d a t e d J u l y 3 0 , 2 0 1 4 , t h e e n d o c r i n o l o g i s t b e u n s a f e t o d i s c h a r g e t h e a p p e l l a n t f r o m h o s p i t a l y a l a r m a m p l i f i c a t i o n a n d t h a t t h e s e n s o r s a r e t i a l d a n g e r t o t h e a p p e l l a n t ' s h e a l t h b y w a y o f h i l e t h e e v i d e n c e d e m o n s t r a t e s t h a t t h e g l u c o s e b s t a n t i a l d a n g e r t o t h e a p p e l l a n t ' s h e a l t h , t h e h a t a l l o f t h e r e q u i r e m e n t s i n S e c t i o n 2 ( 1 ) ( a ) o f r o v i d e d b y t h e m i n i s t r y a s a m e d i c a l o r s u r g i c a l t o r e c e i v e h e a l t h s u p p l e m e n t s u n d e r S e c t i o n 6 2 p p l e m e n t t o c o v e r t h e c o s t o f g l u c o s e s e n s o r s . 1 2 o f S c h e d u l e C o f t h e E A P W D R . T h e m i n i s t r y r o v i d e d a s a h e a l t h s u p p l e m e n t , t h e r e i s n o a l a n d , f o r h i m , t h e g l u c o s e s e n s o r s a r e m o r e y a r e e s s e n t i a l f o r h i m . T h e a p p e l l a n t a r g u e d t o h i m b e i n g n o n r e s p o n s i v e i n a p e r i o d o f 4 0 n o r m a l d i a b e t i c . T h e a p p e l l a n t a r g u e d t h a t , i n h i s o s e m e a s u r e m e n t a n d a c o n v e n t i o n a l b l o o d m a r e a d i n g o f 2 5 t o a r e a d i n g o f 3 i n a p e r i o d o f e v e l , h e w o u l d n o t b e t h i n k i n g c l e a r l y a n d w o u l d g . " T h e a p p e l l a n t a r g u e d t h a t h i s l e v e l s d r o p a n d i t a l , t h e a p p e l l a n t w a s l o g g i n g i n t h e r a n g e o f 3 0 o u t t h a t a n o n c o n v e n t i o n a l g l u c o s e m e t e r i s a e S c h e d u l e i f t h e m i n i s t r y i s s a t i s f i e d t h a t t h e c o s e l e v e l s a n d t h e p e r s o n f o r w h o m t h e n o n n a b l e t o u s e a c o n v e n t i o n a l g l u c o s e m e t e r . T h e e n s o r s o n t h e b a s i s t h a t t h e s e n s o r s d o n o t f i t e t e r ' ' b u t a r e , r a t h e r , a c c e s s o r i e s t o t h e g l u c o s e e t e r ' ' i s s e t o u t i n S e c t i o n 3 . 1 2 ( 1 ) a s i n c l u d i n g a g l u c o s e m e t e r ' . T h e p a n e l n o t e s t h a t t h i s i s n o t o n c o n v e n t i o n a l o l u c o s e m e t e r ' ' s i n c e t h e w o r d
" includes" was us ed r a ther tha n a word l ik e "m eans," the area of diabetes. In consi dering whether the glucose sensor falls within the definition of a 'continuous glucose monitori ng meter,' the pa nel considered t h e d ict iona measurin g , and sometimes r e cording, the am o unt or time description of the glucose sensor provide d by the m 2014, the glucose sensor is desc r i bed by the ma nu the subcutaneous adipose tissue u s ing an aut omatic i the se n sor contin uously mea su res glucose le vels in readings t o the p ump by m ean s o f a radiofrequenc y system' is stated to cons ist of: 1) a glucose sensor, an m ea s u re s the leve l of glu c ose and the transmi t ter relays of the insulin pump and t h e c o n t i nuou s g lucose monitoring sy t h e re are s e veral settings which c a n be u s ed to help lower t hre s hold lim i ts set to d e fine th e target glu cos e tha t exceed the prese t l im it s , the pump will alert the pump w i ll notify the p a ti ent of a p otenti al pend ing hypo th e refore hel pin g to kee p the glucos e le vel i n the targe T he m i n i s t ry di d not dispute e ither t he d escription or the by th e man u factur er; an uns u ccess fu l attempt ha d bee mo r e i n formation about the fu n c tion of a gl ucose s e t h e hearing. I n t h e let ter s from the ap pel lant's e n docri any di s c har ge pla n for the appel la nt hinges on a warnin case." She r e ported t hat it would be u nsafe to di s c har c o nti nuous g l u co se mo ni toring au gm e nt e d b y a larm neces sary to avoid imm inent an d substan tial dang er ind u ced seizure, coma an d death. C onsidering the dic tionary definition of the wo r d "meter'', the panel finds instrume n t for measuring the amo u n t of gl ucose le vels in the in along w ith the tra ns mitt er, are parts of a continuous glu hearing, the appellant stated that the glucose sensor is "internally imbedded" in the body and is a required part of the continuous glucose monitoring system, which is a nece live out of an institution . The appellant explained that the glucose sensor can only stay in a person's body for up to 6 days since, if it is left in longer than 6 days, it will either cause an in body will start to reject it. The ministry did not offer a reason that the glucos be an 'accessory', either in the reconsideration decision or at the hearing. fact that the glucose sensor must be replaced every 6 days does not, in itself, make the glucose sen so r a n 'access o ry. ' R a ther tha n being simply an 'accessory' to the continuous gluc system, the panel finds that the glucose sensor and the transmitter are both integral parts of the s ystem, which then works with the insuli n pump to keep glucose levels in the target range. The panel finds that the evidence demonstrates that the glucose sensors fall within the definition of a "continuous glucose monitoring meter'' and are, therefore, also a "non-conventional glucose meter" within Section 3.12 of Schedule C of the EAPWDR. reaso n able in co n clud i ng t hat t h e a ppellant's re q ue s t sensors does not meet the requirements set out in Section 3.12 of Schedule C of the EAPWDR. possibly to allow for technological advance s in ry definition of "meter'' as "an inst rument fo r of something" and appl ie d ii t o the anufacturer. In the Report dated September f acturer as a sm al l electrode that is inserted into nsertion devi c e an d, regar ding its func tion, that the interstitial f l uid and wireles sly relays t hes e transmit ter. T he ' con t in u ous glu c ose monitoring d 2} a mini-l i nk transmitter; i.e. the se n sor t hi s informat i o n . Describing the interaction stem, th e man uf a c t urer reported tha t optimiz e gly cemic contr ol i ncluding upp er a nd ran g e. Wh en the senso r detects g luc o se va lu es patient. With the pr ed ictive a l er ts tu rn ed on , th e or hype r glycem ic ep is ode before it ha p pens, t r ange. f u nc tion of t he gl ucose sensor as describe d n ma de, internally , for the min i s tr y to o b tain n sor, a s s e t out in t he cop y o f e mails pro v ided at n ol o gi st in Ju n e and Jul y 20 1 4 , she wrote t hat g s y s te m a nd that hi s is "truly a n e x c eptional ge the appel la nt from hosp ital w i tho ut a mpl ification an d that the s e nsor s are a b solutel y to the appellan t ' s health by way o f hypo glycemia that the glucose sensor is an terstitia l fluid a nd tha t the sensor , cose monitoring system, or meter. At the ssity for him to be able to f e ction or the e sensor is consider ed to The panel finds that the os e monit oring The panel finds that the ministry was not fo r a supplement t o cover the cost o f gl ucose
Conclusion In conclusion, the panel finds that the ministry's decision to deny the request for glucose sensors as not meeting all of the legislated criteria of Section 3.12 of Schedule C of the EAPWDR, was not a reasonable application of the applicable enactment in the appellant's circumstances and the panel rescinds the ministry's reconsideration decision. Therefore, the ministry's reconsideration decision is overturned in favour of the appellant.
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