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 June 18, 2016 which denied the appellant’s request for coverage for restoration (fee code 23315 – tooth coloured restoration, bonded – bicuspids, five surfaces) for tooth number 15. Pursuant to sections 1 and 4 of the of Schedule C of the Employment and Assistance for Persons with Disabilities Regulation (EAPWDR) and the Schedule of Fee Allowances - Dentist, the requested coverage would exceed the maximum fee allowance for tooth coloured restorations for a single tooth in a two-year period. The ministry also determined that the appellant was not eligible for the requested service under section 69 of the EAPWDR [life-threatening health need] because dental health supplements are not included in this section. PART D – Relevant Legislation EAPWDR, section 69 and sections 1 and 4 of Schedule C Schedule of Fee Allowances - Dentist
PART E – Summary of Facts The appellant is a recipient of disability assistance. Her dentist submitted a request for coverage for tooth restoration for tooth number 15. The restoration is fee code 23315 in the Schedule of Fee Allowances – Dentist and has a fee amount of $203.58. The appellant’s dental claims history indicates that the appellant previously received coverage of $203.58 for this same service on the same tooth on April 28, 2015. The appellant also received coverage for additional services on tooth number 15 between April 28 th and September 2 nd 2015. In her request for reconsideration, the appellant stated that past treatment has not worked and that a full coverage crown is required to enable long term functionality. At the hearing, the appellant stated that she and the ministry have both spent a big amount of money on her tooth, money which will have been wasted if she loses this tooth. She does not want to lose this tooth, which is in her smile line, even if the treatment is a metal cap. At the hearing, the ministry confirmed that the service the appellant’s dentist requested coverage for was tooth restoration 23315, not a cap or crown.
PART F – Reasons for Panel Decision Issue under appeal The issue under appeal is whether the ministry decision, which held that the appellant is not eligible for coverage for restoration on tooth number 15 because it would exceed the maximum amount for tooth coloured restorations on a single tooth in a two year period under sections 1 and 4 of Schedule C of the EAPWDR and the Schedule of Fee Allowances – Dentist, is reasonably supported by the evidence or a reasonable application of the legislation in the circumstances of the appellant. Relevant Legislation – EAPWDR and Schedule of Fee Allowances - Denturist Schedule C Definitions 1 In this Schedule……. "basic dental service" means a dental service that………. (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances — Denturist that is effective April 1, 2010 and is on file with the office of the deputy minister, and (ii) is provided at the rate set out for the service in that Schedule, and Dental supplements 4 (1) In this section, "period" means (a) in respect of a dependent child, a 2 year period beginning on January 1, 2009, and on each subsequent January 1 in an odd numbered year, and (b) in respect of a person not referred to in paragraph (a), a 2 year period beginning on January 1, 2003 and on each subsequent January 1 in an odd numbered year. (1.1) The health supplements that may be paid under section 63 [dental supplements] of this regulation are basic dental services to a maximum of (a) $1 400 each period, if provided to a dependent child, and
(b) $1 000 each period, if provided to a person not referred to in paragraph (a). (c) Repealed. [B.C. Reg. 163/2005, s. (b).] (2) Dentures may be provided as a basic dental service only to a person (a) who has never worn dentures, or (b) whose dentures are more than 5 years old. (3) The limits under subsection (1.1) may be exceeded by an amount necessary to provide dentures, taking into account the amount remaining to the person under those limits at the time the dentures are to be provided, if (a) a person requires a full upper denture, a full lower denture or both because of extractions made in the previous 6 months to relieve pain, (b) a person requires a partial denture to replace at least 3 contiguous missing teeth on the same arch, at least one of which was extracted in the previous 6 months to relieve pain, or (c) a person who has been a recipient of disability assistance or income assistance for at least 2 years or a dependant of that person requires replacement dentures. Schedule of Fee Allowances – Dentist, Effective April 1, 2010 FEE NO. FEE DESCRIPTION FEE AMOUNT ($) TOOTH COLOURED RESTORATIONS Note: Maximum fee allowance is five surfaces or the dollar equivalent per tooth in a two-year period. Tooth numbers are required. Tooth Coloured – Permanent Teeth Bonded - Bicuspids 23315 Five surfaces (maximum) 203.58
Appellant’s position The appellant argues that it would be a waste of the money she and the ministry have already paid for the tooth in question if she now loses the tooth. She requires a full coverage crown for which she should be eligible. The appellant also argued that the Schedule of Fee Allowances – Dentist does not reflect current dental rates. Ministry’s position The ministry’s position is that the appellant has received the maximum amount of coverage for the requested restoration for tooth number 15 that is allowed over a two-year period under Schedule C of the EAPWDR and the Schedule of Fee Allowances – Dentist. Section 4(1.1) of Schedule C specifies that the health supplements that may be provided under section 63 are “basic dental services” which are defined in section 1 of Schedule C as services set out in the Schedule of Fee Allowances – Dentist, at the rate set out for the service in that Schedule. Parameters for the provision of these services are found in the Schedule of Fee Allowances – Dentist, including the Notes. In accordance with the Note respecting the basic dental services classified as tooth coloured restorations, the maximum fee allowance is five surfaces or the equivalent per tooth in a two-year period, which is $203.58. As the appellant received this amount of coverage for same coloured tooth restoration on tooth number 15 on April 28, 2015, she is not eligible for coverage for restoration 23315 until April 29, 2017. The ministry also determined that the appellant is not eligible for the requested dental service under section 69 of the EAPWDR, which provides certain health supplements to meet a life-threatening need, because section 69 does not include dental supplements. Panel Decision The appellant’s dentist submitted a request for coverage of the cost of restoration of tooth number 15 (fee no. 23315) which was denied by Pacific Blue Cross, on behalf of the ministry, on March 29, 2016. In the Schedule of Fee Allowances - Dentist, this service has a fee amount of $203.58. Previously, the ministry provided coverage in the amount of $203.58 for the same dental service on the same tooth performed on April 28, 2015. Section 1 of Schedule C of the EAPWDR defines basic dental services as services provided by a dentist that are set out in the Schedule of Fee Allowances – Dentist that are provided at the rate set out in that Schedule. Sections 4(1) and (1.1) of Schedule C limit the total amount of coverage for basic dental services provided over a 2 year period, beginning on January 1 st , 2009, and on each subsequent January 1 st in an odd numbered year. Additional parameters, or limitations, of the basic dental services that may be covered are set out in the Schedule of Fee Allowances – Dentist. In the appellant’s circumstances, the service requested (fee no. 23315) is subject to the limitation set out in the Note respecting tooth coloured restorations. The Note states that the “Maximum fee allowance is five surfaces or the dollar equivalent per tooth in a two-year period.”
As the appellant received coverage for five surfaces for tooth number 15 on April 28, 2015, in the amount of $203.58, the maximum fee allowance of $203.58 within a two-year period has been reached. Accordingly, the panel finds that the ministry reasonably determined that the appellant is not eligible for coverage for the requested restoration (fee no. 23315) because it would exceed the limits of coverage set out under sections 1 and 4 of Schedule C of the EAPWDR and the Schedule of Fee Allowances – Dentist. The panel also finds that the ministry reasonably determined that the appellant is not eligible for coverage for the requested service under section 69 of the EAPWDR. Section 69 allows for the provision of certain health supplements set out under Schedule C if the supplement is required to meet a life-threatening health need. The health supplements included in section 69 are those set out in Sections 2(1)(a) or (f) and section 3 of Schedule C. Dental supplements, which are set out in section 4 of Schedule C, are not included in section 69. Conclusion The panel finds that the ministry’s determination that the appellant is not eligible for coverage for restoration (fee no. 23315) for tooth number 15 is a reasonable application of the legislation in the appellant’s circumstances. The ministry’s reconsideration decision is confirmed and the appellant is not successful on appeal.
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