APPEAL # PART C – Decision under Appeal The decision under appeal is the reconsideration decision of the Ministry of Social Development and Social Innovation (the ministry) dated 14 July 2015 that determined that the appellant was not eligible for a crown and bridge work supplement for tooth #16 because her dental condition does not preclude the provision of services set out under the Restorative Services section of the Schedule of Fee Allowances – Dentist as required under section 4.1(2)(c) of Schedule C of the Employment and Assistance for Persons with Disabilities Regulation, and none of the circumstances listed in section 4.1(2)(d) of Schedule C exist. The ministry did not provide a reconsideration for the appellant’s request for a crown for tooth #17 as a request for pre-authorization was not submitted to Pacific Blue Cross (PBC) in accordance with the Schedule of Fee Allowances – Dentist (schedule of fees), Preamble to Part E, Crown and Bridgework Supplement and a complete decision concerning eligibility was therefore not made. The ministry further held that the appellant was not eligible for coverage for these crowns as a life-threatening health need under section 69 of the Regulation as this remedy does not apply to dental supplements. PART D – Relevant Legislation Employment and Assistance for Persons with Disabilities Regulation (EAPWDR), section 63.1, section 69 and Schedule C, section 4.1.
APPEAL # PART E – Summary of Facts The evidence before the ministry at reconsideration consisted of the following: 1. The appellant is a recipient of disability assistance. 2. The appellant's Request for Reconsideration dated 29 June 2015. Under reasons, the appellant writes: “..since my 1 st molar broke, while waiting to find out about getting it fixed the next molar broke. Now I have two molars that require crowns. Being diabetic it seems now I have 6 tiny cavities and these two broken teeth to be repaired. In my 20’s I had a 7 tooth bridge put in my front 7 teeth from an earlier accident. I do not have any other molars but the two broken ones. These teeth cannot give any support to the bridge and it is getting loose since my broken molars cannot give added support to my front teeth. Living on disability does not allow me to save up or get my dental work paid for by myself. Before I have any more trouble I need help to do this now.” The appellant attaches a letter dated 19 June 2015 further elaborating on her dental history and her understanding of her dental clinic’s efforts to obtain Pacific Blue Cross (PCB) approval for the requested crowns. 3. Information provided to the reconsideration officer by PBC dated 13 July 2015: • Pre-authorization claim forms submitted to PBC dated 07 October 2014: One, marked Option #1, states “Pt in pain. Tooth needs to be restored!” and “Tooth is suffering active decay, broken down beside a bridge.” The form shows the following proposed procedures for tooth #16: 27301 [crown, full metal cast] 99111 [a procedure not found in the fee schedule] 23601 [non-bonded composite core, in conjunction with crown] The second, marked Option 2, shows the following proposed procedure 23325 [tooth-coloured restoration, non-bonded, molar, five surfaces (maximum)] Also included is a claim form of the same date for pre-approval for one canal root canal therapy for teeth #22, 23 and 24. Also included are 2 X-ray images dated 07 October 2014, of the appellant’s teeth, one showing tooth #16 supporting a bridge and the other that indicates it is of teeth #18-45. Another claim dated 29 October 2014 appears to be a duplicate of the first, without the notations. • A form letter from PBC to the appellant's dentist dated 21 October 2014 asking for further supporting documentation. On the form in response, the dentist lists all of the missing teeth: 18, 28, 38, 48, 12, 34, and 44. In answer to a request to provide an explanation as to the necessity for the crown, in the context of the intent of the supplement as set out in the preamble to the crown and bridgework section of the fee schedule, the dentist answered: “Pt. in pain, teeth are abscessed.” Asked to provide relevant information
APPEAL # regarding any medical conditions that would support the need for crown or bridge, the dentist replied: “Active decay occurring.” • A letter dated 06 November 2014 from PBC to the appellant's dentist advising that the requested treatment has been rejected, indicating that a) the documentation provided does not indicate that the dental condition precludes the provision of restorative services, b) the clinical explanation submitted does not confirm that the patient's needs cannot be met through the ministry’s basic dental program and c) that the information provided does not confirm that one of the circumstances listed under section 4.1(2)(b) exists. • A reply to the reconsideration officer dated 13 July 2013 seeking clarification from PBC: “We show [the dentist] has submitted 3 pre-authorizations to PBC. In October 2014, they submitted for tooth number 16; we rejected and requested more information. They resubmitted the pre-authorization for tooth number 16 in November 2014 and we rejected it as it did not meet criteria. The most recent submission in April 2015 was submitted electronically so it was denied.” The appellant's Notice of Appeal is dated 23 July 2015. The appellant attaches a 6 page letter commenting on various passages in the reconsideration decision and expressing frustration with the process (see Part F, reasons for Panel Decision, below). At the hearing, the appellant stated that, though she had been a recipient of disability assistance for around eight years, nobody had ever advised her that the ministry provided a dental program – she had paid for dental work before out of her own pocket. It was only when she found she needed dental crowns that she learned of the program and has since found it frustrating to obtain the necessary approvals. She stated that she suffers from seven serious medical conditions in addition to her dental problems and has found dealing with her current dental situation has caused a great deal of stress and anxiety. She stated that her dentist has said that he has submitted everything required regarding her need for the two crowns – he made another submission two weeks ago. The appellant argued that her disability assistance does not provide enough money left over to save for dental work and took repeated issue with various aspects of how the disability assistance program works and the impact on her past and current finances. The balance of her presentation went to argument (see Part F, Reasons for Panel Decision, below). The ministry stood by its position at reconsideration. The ministry representative reviewed the ministry’s basic dental program, noting that the maximum payable in the appellant's circumstances is $1000 for a two-year period beginning January 1 of each odd-numbered year and that pre-authorization for basic dental services is not required, though eligibility must be confirmed for all clients prior to proceeding with any treatment. (Thus pre-authorizations for the fillings for teeth #22, #23 and #24 were not required.) Coverage for crown and bridgework, however, is managed separately as an exception: pre-authorization is required and the ministry will pay the amounts set out for each procedure listed in the crown and bridgework fee schedule – the two-year $1000 limit does not apply. The panel finds that neither the appellant nor the ministry presented any new information requiring a determination as to admissibility.
APPEAL # PART F – Reasons for Panel Decision The issue in this appeal is whether any of the following determinations by the ministry are reasonably supported by the evidence or a reasonable application of the legislation in the circumstances of the appellant: • The appellant was not eligible for a crown and bridge work supplement for tooth #16 because her dental condition does not preclude the provision of services set out under the Restorative Services section of the Schedule of Fee Allowances – Dentist as required under section 4.1(2)(c) of Schedule C of the Employment and Assistance for Persons with Disabilities Regulation, and none of the circumstances listed in section 4.1(2)(d) of Schedule C exist. • A reconsideration was not granted for the appellant’s request for a crown for tooth #17 as a request for pre-authorization was not submitted to Pacific Blue Cross (PBC) in accordance with the Preamble to the Schedule of Fee Allowances – Crown and Bridgework and a complete decision concerning eligibility was therefore not made. • The appellant was not eligible for coverage for these crowns as a life-threatening health need under section 69 of the Regulation as this remedy does not apply to dental supplements. The relevant legislation is from the EAPWDR: Crown and bridgework supplement 4.1 (1) In this section, "crown and bridgework" means a dental service (a) that is provided by a dentist, (b) that is set out in the Schedule of Fee Allowances — Crown and Bridgework, that is effective April 1, 2010 and is on file with the office of the deputy minister, (c) that is provided at the rate set out for the service in that Schedule, and (d) for which a person has received the pre-authorization of the minister. (2) A health supplement may be paid under section 63.1 of this regulation for crown and bridgework but only if the minister is of the opinion that the person has a dental condition that cannot be corrected through the provision of basic dental services because (a) the dental condition precludes the provision of the restorative services set out under the Restorative Services section of the Schedule of Fee Allowances — Dentist, and (b) one of the following circumstances exists: (i) the dental condition precludes the use of a removable prosthetic; (ii) the person has a physical impairment that makes it impossible for him or her to place a removable prosthetic; (iii) the person has an allergic reaction or other intolerance to the composition or materials used in a removable prosthetic; (iv) the person has a mental condition that makes it impossible for him or her to assume responsibility for a removable prosthetic. (3) The minister must also be satisfied that a health supplement for crown and bridgework will be adequate to correct the dental condition. (4) A health supplement for crown and bridgework may not be provided in respect of the same tooth more than once in any period of 60 calendar months. Also relevant:
APPEAL # From the Preamble to Part E of the Schedule of Fee Allowances – Dentist – Crown and Bridgework Supplement: It is important to note that when a case presents an option of effective remedial treatment by the use of either: an amalgam, composite or prefabricated restoration or a removable prosthetic, or a crown or bridgework, the restoration or removable prosthetic must be used. In all instances the affected tooth or teeth must have functional occlusion and must be periodontally sound with a good, long-term prognosis. General Information: Porcelain-Fused-to-Metal (PFM) crowns/bridges will not be approved for tooth numbers 6, 7 and 8. Only full cast metal (gold) crowns/bridges will be covered for molar teeth. It is important to note that if a PFM crown or bridge is placed on molar teeth, the ministry will not pay the equivalent fee to a gold crown or bridge. All crown and bridgework services (crowns, fixed bridge restoration and buildups/cores) are limited to once every five years from the original insertion date. Procedures for Requesting Preauthorization: A request for preauthorization for a crown or bridge must be submitted in writing to Pacific Blue Cross (PBC) outlining the proposed treatment plan on a standard dental claim form marked “FOR PREAUTHORIZATION.” When submitting a request, it is essential that PBC be provided with all relevant information to support the request. Applications for this type of work must include the following: crown and/or bridge treatment plan including tooth number(s) and fee codes; current, mounted periapical radiograph(s) of the tooth or teeth involved and bitewing or panorex radiograph(s) showing the remaining dentition;* a list of client’s missing dentition and existing removal prostheses; a clinical explanation as to necessity; (i.e., why the client’s needs cannot be met under the Restorative Services section in the Schedule of Fee Allowances - Dentist); and relevant information regarding the client’s medical condition(s) that would support the need for a crown or bridge. *When the patient cannot tolerate a radiograph, a photograph and full explanation is required. Failure to provide any of the above-noted information will result in the treatment plan being returned and unnecessary delays in the adjudication of the request. Position of the Parties In the reconsideration decision the ministry notes that the appellant's dentist reports that tooth #16 is beside a bridge, is suffering active decay and is broken down. In addition the dentist reports that the appellant is in pain and the tooth needs to be restored. The dentist provided treatment options as follows: full metal crown with core or tooth-colored restoration (five surfaces). The position of the ministry, as set out in the reconsideration decision, is that upon review of the information provided by the appellant's dentist, the ministry determined that her dental condition does not preclude the
APPEAL # provision of restorative services set out under the restorative services section of the fee schedule. In addition information is not provided to establish that the request meet any of the criteria set out in section 4.1(2)(d)(i-iv) of Schedule C of the EAPWDR. Therefore the request does not meet the legislative eligibility requirements. With respect to the crown for tooth #17, the ministry found that there is no evidence that the appellant's dentist submitted pre-authorizations by following the process set out in the preamble to the crown and bridgework section of the fee schedule. Therefore, information correlating with the eligibility requirements set out in legislation was not received by PBC and therefore a complete decision concerning her eligibility for crown for this tooth was not made; accordingly the ministry is not able to grant reconsideration of this matter. With regard to eligibility for the crowns under section 69 of the EAPWDR has a life-threatening health need, the position of the ministry is that as section 69 only applies to medical supplies, medical transportation and medical equipment and devices, this remedy is not applicable to dental and denture supplements. The position of the appellant is that her need for the requested crowns is urgent: she has been going through this whole process with her dentist, PBC and the ministry for almost 10 months, with no results. Her dentist tells her that he has submitted all the necessary paperwork. She cannot understand the ministry’s denial: Tooth #16 is so damaged that a restorative procedure no longer an option. The same applies to tooth #17. With all her missing teeth, a removable prosthesis is not possible, as there are no teeth for one to be attached to. She argues that the reasons given for non-approval are aimed at denying her the help she is entitled to as a person with disabilities – they amount to “a kick in the pants” and are unfair. Panel decision On 17 June 2015, the appellant was advised of a Predetermination from PBC denying coverage for porcelain crowns for teeth #16 and #17 and requested a reconsideration. The Predetermination denial was based on the fee schedule stipulating that porcelain crowns are not covered for molars (only a full metal crown is covered for teeth the numbers of which end in 6,7 or 8) and on the pre-authorization being submitted electronically without supporting paper documentation. Pre-authorization for a procedure not found in the fee schedule was also denied. The reconsideration decision took a much broader view of the outcome of the Predetermination decision and has addressed the full history of the denial of the crown for tooth #16. Tooth #16: Section 4.1 of Schedule C of the EAPWDR states that the ministry may provide coverage for crown and bridgework only if the minister is of the opinion that the person has a dental condition that precludes the provision of the restorative services as set out in the fee schedule and the dental condition precludes the use of a removable prosthetic. The pre-authorization forms submitted by the appellant's dentist on 07 October 2014 provide two options – full metal crown with core or a tooth colored restoration (five surfaces). On 21 October 2014 PBC requested the dentist to provide further information. The dentist listed all teeth missing (seven, three of which upper). In answer to a request to provide an explanation as to the necessity for the crown, in the context of the intent of the supplement as set out in the preamble to the crown and bridgework section of the fee schedule, the
APPEAL # dentist answered: “Pt. in pain, teeth are abscessed.” As to providing relevant information regarding any medical conditions that would support the need for crown or bridge, the dentist replied: “Active decay occurring.” The appellant argues that, while her dentist was waiting for a response from PBC, a filling in the adjoining molar, tooth #17, fell out and that tooth broke as well. She states that as a result, there was further damage to tooth #16, to the point where the restorative option could no longer be considered. She also submits that, given how many of her teeth are missing, a removable prosthetic would not work because she does not have enough teeth left in her mouth for a prosthetic to attached to. The panel considers it reasonable that the ministry would rely on the information provided by, and the opinion of, a dentist in making a determination regarding the requested supplement. The panel finds that, given that the restorative option was presented to PBC in October 2014 by the appellant’s dentist, and with no further information provided by the dentist that such an option might no longer workable, and considering the information provided by PBC to the ministry that does not contain any explanation by the dentist that the appellant's dental condition cannot be corrected through the provision of basic dental services, such as restorative procedures, or through a removable prosthetic, the panel finds that the ministry was reasonable in denying coverage for the crown under section 4.1 of Schedule C of the EAPWDR. Tooth #17: As the pre-authorization for a crown for tooth #17 was submitted electronically, showing only the procedure numbers, and not in paper form with the information required as described in the preamble to the crown and bridgework section of the fee schedule, the panel finds that the ministry was reasonable in determining that the determination regarding the denial for a crown for this tooth only constitutes a decision regarding the type of crown that will be considered and does not constitute a denial of eligibility for a crown. As a reconsideration can only be made of a decision already taken, the panel finds that the ministry was reasonable in not granting a reconsideration. Section 69 – life-threatening health need As this remedy only applies to medical supplies, medical transportation and medical equipment and devices as set out in sections 2(1)(a) and (f) and 3 of Schedule C of the EAPWDR and does not apply to crown and bridgework procedures set out in section 4.1 of Schedule C, the panel finds that the ministry reason ably determined that the appellant was not eligible for the requested dental crowns under this section. Based on the foregoing, the panel finds that the ministry’s decision to deny the appellant’s request for coverage for a crown for tooth #17 and to not grant a reconsideration regarding a crown for tooth #17 was reasonably supported by the evidence and a reasonable application of the legislation in the circumstances of the appellant. The panel therefore confirms the ministry’s decision.
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