PART C – Decision under Appeal
Under appeal is the Minis
try of Social Development and Social Innovation's (“the ministry”) July 24,
2015 reconsideration decision denying the appellant coverage for a crown and bridgework on the
basis she does not meet the eligibility requirements set out in the Employment and Assistance for
Persons with Disabilities Regulation (EAPWDR), Schedule C, section 4.1(2), and that the ministry is
not authorized to provide coverage in excess of the rates in the Schedule of Fee Allowances –
Crown
and Bridgework. The ministry also determined the appellant is not eligible under section 69 of the
EAPWDR as it was not established she faced a direct and imminent life-threatening need for the
services requested, and the remedy under section 69 applies only to medical supplies, medical
transportation, and medical equipment and devices, not to dental and denture supplements.
PART D – Relevant Legislation
EAPWDR
Employment and Assistance for Persons with Disabilities Regulation, s
ections 63.1 and
69, and Schedule C, section 4.1(2)
Schedule of Fee Allowances – Crown and Bridgework Eff
ective April 1, 2010
PART E – Summary of Facts
The evidence before the ministry at reconsideration was
-
As a Person with Disabilities transitioned to medical services only, the appellant is eligible for
crowns and bridgework under section 63.1 and Schedule C section 4.1 of the EAPWDR.
–
April 1, 2015 Standard Dental Claim form with ancillary documentation submitted by the
appellant's dentist
to Pacific Blue Cross (PBC), with a note explaining the necessity for
crown/bridge, saying the 46 cusp fracture needed full coverage to prevent tooth loss, tooth will
not hold simple restoration, and a prescription note from her physician stating she has a
medical condition that requires her to have a non-removable upper plate.
–
April 1, 2015 estimat
e from dentist totalling $4116.30.
–
April 13, 2015 letter from PBC to dentist requesting further information.
–
April 27, 2015 letter from PBC rejecting the requested treatment.
–
April 30, 2015 letter from the family physician stating the appellant had bilateral mastectomy,
osteoporosis and COPD which caused increasing difficulty as her phlegm is getting caught in
her upper removable dental partial plate, that she needs a fixed partial plate from her dentist to
prevent her choking spells and s
peech disturbances, which will also help her in mastication to
ensure her nutrition for her conditions.
–
May 11, 2015 letter from PBC rejecting the requested treatment.
–
May 12, 2015 letter from PBC headed Dental Predetermination Summary showing total
amount submitted $4116.30, amount approved by PBC $0.00.
–
J
une 3, 2015 letter from the appellant stating she has COPD and is prone to coughing up
mucus which catches on the upper plate causing her to gag and throw up, that this is a serious
problem when she is driving, and she has to decline social events involving eating. She says
both her family doctor and her den
tist support the option of a permanent bridge that would
eliminate the obstructive part of the removable partial plate and el
iminate the problem. She
s
ays her dentist advised her that the lower tooth cannot be filled and requires a crown as the
only option for fixing that tooth. She says the ministry pointed out to her the statement
Persons with Disabilities and Persons with Persistent Multiple Barriers who have a dental
condition that cannot be corrected through basic dental services and have a medical condition
that prevents the use of a removable denture are also eligible for funding for crown and
bridgework.
–
Employment and Assistance Request for Reconsideration form signed by ministry wor
ker June
23, 2015.
–
June 25, 2015 letter from the appellant requesting additional time to submit her Request for
Reconsideration.
–
June 25, 2015 Request for Reconsideration form signed by the appellant reiterating her
reasons for requesting a reconsideration and requesting an extension of time to obtain
advocacy services.
–
An extension to July 24, 2015 was granted.
–
On July 3, 2015 the appellant's advocate requested an extension of time. The further
extension was declined, as under the EAPWDR section 72 the ministry was authorized to
grant only an extension of twenty business days.
With the reconsideration decision the ministry attached a chart showing the dentist's fees for services
and the ministry rates, illustrating how the dentist's fees exceeded the ministry rates.
Upon appeal the appellant submitted a letter stating that choking is life-threatening, can result in
blockage of the airway, and without oxygen permanent brain damage can occur in as little as 4-6
minutes. In many cases when phlegm cau
ses her to cough, her eyes water, she starts to choke and
begin to throw up. This is a danger to her and others when it happens while she is driving, and she
has choked while eating and it is a concern that food can enter the lungs. The tooth on the lower
right has caused difficulty when she was eating, she began choking, and a piece of the tooth
dislodged and went down her throat.
PART F – Reasons for Panel Decision
The issue is the reasonableness of the minis
try's reconsideration decision denying the appellant
coverage for a crown and bridgework on the basis she does not meet the eligibility requirements set
out in the EAPWDR, Schedule C, section 4.1(2), that the ministry is not authorized to provide
coverage in excess of the rates in the Schedule of Fee Allowances – Crown and Bridgework, nor was
the appellant eligible under section 69 of the EAPWDR as it was not es
tablished she faced a direct
and imminent life-threatening need for the services requested, and the remedy under section 69
applies only to medical supplies, medical transportation, and medical equipment and devices, not to
dental and denture supplements.
Relevant Legislation
EMPLOYMENT AND ASSISTANCE FOR PERSONS WITH DISABILITIES REGULATION
63.1 (1) Subject to subsections (1.1) and (1.2), the minister may provide a crown and bridgework
supplement under section 4.1 of Schedule C to any of the following persons:
(a) a recipient of disability assistance;
(b) a person with disabilities who has not reached 65 years of age and who has ceased to be eligible for
disability assistance because of
(i)
employment income earned by the person or the person's spouse, if either the person or the person's
spouse
(A) is under age 65 and the family unit is receiving premium assistance under the Medicare Protection Act,
or
(B) is aged 65 or more and a person in the family unit is receiving the federal spouse's allowance or the
federal guaranteed income supplement,
(ii)
a pension or other payment under the Canada Pension Plan (Canada), or
(iii)
money or value received by the person or the person's spouse that is maintenance under a
maintenance order, maintenance agreement or other agreement, if either the person or the person's
spouse
(A) is under age 65 and the family unit is receiving premium assistance under the Medicare Protection
Act, or
(B) is aged 65 or more and any person in the family unit is receiving the federal spouse's allowance or
the federal guaranteed income supplement;
(c) a person with disabilities who was a recipient of disability assistance on the day he or she became
65 years of age;
(d) a person referred to in section 62 (1) (f), if
(i)
the person is under age 65 and the family unit is receiving premium assistance under the Medicare
Protection Act, or
(ii)
the person is aged 65 or more and any person in the family unit is receiving the federal spouse's
allowance or the federal guaranteed income supplement, or
(e) a person whose family unit ceases to be eligible for disability assistance because of financial assistance
provided through an agreement under section 12.3 of the Child, Family and Community Service Act,
during the term of the agreement.
(1.1) A person eligible to receive a crown and bridgework supplement under subsection (1) (b) (ii) may
receive the supplement
(a) while any person in the family unit is
(i)
under age 65 and receiving a pension or other payment under the Canada Pension Plan, or
(ii) aged 65 or more and receiving the federal spouse's allowance or the federal guaranteed income
supplement, and
(b) for a maximum of one year from the date on which the family unit ceased to be eligible for medical
services only.
(1.2) A person eligible to receive a crown and bridgework supplement under subsection (1) (c) may
receive the supplement
(a) while any person in the family unit is receiving the federal spouse's allowance or the federal
guaranteed income supplement, and
(b) for a maximum of one year from the date on which the family unit ceased to be eligible for medical
services only.
(1.3) A person who was eligible to receive a crown and bridgework supplement under subsection (1) (b)
(i) or (iii) or (d) but ceases to be eligible for medical services only may continue to receive the
supplement for a maximum of one year from the date on which the family unit ceased to be eligible for
medical services only.
(2) Repealed. [B.C. Reg. 67/2010, Sch. 2, s. 5 (f).]
[en. B.C. Reg. 430/2003, s. 3; am. B.C. Regs. 170/2008, App. 2, s. 5; 67/2010, Sch. 2, s. 5; 114/2010,
Sch. 2, s. 6; 27/2014, s. 7.]
Health supplement for persons facing direct and imminent life threatening health need
69
The minister may provide to a family unit any health supplement set out in sections 2 (1) (a) and
(f) [general health supplements] and 3 [medical equipment and devices] of Schedule C, if the health
supplement is provided to or for a person in the family unit who is otherwise not eligible for t
he
health supplement under this regulation, and if the minister is satisfied that
(a) the person faces a direct and imminent life threatening need and there are no resources available
to the person's family unit with which to meet that need,
(b) the health supplement is necessary to meet that need,
(c) the person's family unit is receiving premium assistance under the Medicare Protection Act
, and
(d) the requirements specified in the following provisions of Schedule C, as applicable, are met:
(i)
paragraph (a) or (f) of section (2) (1);
(ii)
sections 3 to 3.12, other than paragraph (a) of section 3 (1).
[en. B.C. Reg. 61/2010, s. 4; am. B.C. Reg. 197/2012, Sch. 2, s. 8.]
S
CHEDULE C Health Supplements
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.
Appellant's Position
The appellant argues she is supported by her doctor and dentist for the requested dental work she
needs because her COPD causes her to cough up mucus, which catches on her existing upper
removable partial plate causing her to gag and throw up and her eyes to water. She says that is
dangerous when she is driving, that she has to decline social events involving eating, and resulting
c
hoking can be a life-threatening risk.
The appellant also argues her dentist advised the damaged lower tooth cannot be filled, that the only
repair option is a crown.
Ministry'sP
osition
The ministry argues with respect to the requested bridgework no evidence was provided that remedial
measures to the upper partial denture have been taken, (i.e. adjustment, reline or rebase), or that any
of the circumstances in the applicable legislation exist for the bridgework and therefore the request
does not meet the legislated eligibility criteria set out in Schedule C section 4.1(2)(b) of the EAPWDR.
With respect to the requested crown, the minis
try argues the dental practitioner did not establish the
dental condition precluded the provision of res
torative services set out under the Restorative Services
s
ection of the Schedule of Fee Allowances – Dentist, in particular the use of stainless steel crowns,
nor was there evidence res
toration was performed but failed, therefore the requirements of Schedule
C s
ection 4.1(2)(a) were not met, and evidence was not provided that the circumstances set out in
Schedule C section 4.1(2)(b) exist.
The ministry also says it is not authorized to provide coverage for fees in excess of the rates set out
in the Schedule of Fee Allowances – Crown and Bridgework.
The ministry considered the eligibility for coverage for a life-threatening health need provided by
EAPWDR section 69, and argues the information provided did not establish the appellant faced a
direct and imminent life-threatening need for the services requested, and that the remedy provided by
section 69 applies only to medical supplies, medical transportation and medical equipment, not to
dental and denture supplements.
Panel's Decision
The appellant requests bridgework to replace her upper removable denture partial plate that is
causing her to choke because of her medical condition. She describes the choking as a life-
threatening risk. The cost quoted for the crown and bridgework is $3192.10. She also requests a
c
rown for tooth number 46, as her dentist reported the tooth was fractured and would not hold simple
restoration. The dentist quoted $924.20 for a full cast metal crown for the tooth, for a total of
$4116.30 for the two procedures.
Eligibility for bridgework
In determining the appellant's eligibility for bridgework, the ministry accepted her dental condition
precludes the provision of restorative services under the Restorative Services section of the
Schedule of Fee Allowances, but noted there was no evidence presented that the partial plate had
been adjusted or altered to try to resolve the problem.
EAPWDR Schedule C section 4.1(1) provides a supplement may be paid for crown and bridgework
under the terms of the Schedule of Fee Allowances – Crown and Bridgework if pre-authorized by the
minis
ter. Section 4.1(2) requires the supplement may be paid only if the minister is of the opinion the
dental condition cannot be corrected by the provision of basic dental services set out in the
Restorative Services section of the Schedule of Fee Allowances – Dentist and one of four listed
circumstances exists: the dental condition precludes the use of a removable prosthetic, the person
has a physical impairment making it impossible to place a removable prosthetic, an allergic reaction
or other intolerance to the composition or materials in a removable prosthetic,
or a mental condition
preventing the assumption of responsibility for a removable prosthetic. The information did not
indicate any of these conditions apply to the appellant. The panel finds the minis
try's determination
that the appellant does not meet the eligibility requirements of EAPWDR Schedule C section 4.1(2) to
be a reasonable application of the legislation in the circumstances of the appellant.
Eligibility for crown
The appellant's dentist stated a crown was needed because the fractured tooth would not hold a
s
imple restoration, and quoted a fee of $539.90 for a full cast metal crown. The ministry's says the
information provided by the appellant's dentist does not establish the dental condition precluded the
provision of restorative services set out under the Restorative Services section of the Schedule of
Fee Allowances – Dentist, in particular the use of a stainless
steel crown.
For that reason, the panel
finds the ministry's den
ial of coverage for the requested crown for failing to meet the requirement of
Schedule C 4.1(2)(a) to be a reasonable application of the legislation.
The ministry's observation there was no evidence the conditions in EAPWDR Schedule C section
4.1(2)(b) exist is inapplicable to the requested crown as the conditions deal with a removable
prosthetic.
Eligibility for coverage at requested fees
If the coverage had been authorized by the ministry, it would be subject to the Schedule of Fee
Allowances – Crown and Bridgework, for a total of $2471.51. The quote submitted by the appellant's
dentist totalled $4116.30. The panel finds as reasonable the ministry's determination that the ministry
is not authorized to provide coverage for fees in excess of the rates in the Schedule of Fee
Allowances.
Eligibility for coverage as a life-threatening health need
EAPWDR section 69 provides for any health supplement set out in Schedule C for a person who is
otherwise not eligible if the person faces a direct and imminent life-threatening health need.
The
panel finds the ministry's conclusion that there was no information the appellant was facing a direct
and imminent life-threatening condition, and in any event the remedy in the legislation does not
include dental and denture supplements, to be a reasonable application of the legislation in the
circumstances of the appellant.
The panel finds the reconsideration decision to be a reasonable application of the applicable
enactment in the circumstances of the appellant, and confirms the 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.