PART C – Decision under Appeal The decision under appeal is the Ministry of Social Development and Social Innovation (the ministry) reconsideration decision dated June 1, 2017 which denied the appellant’s request for coverage for crowns for teeth number 15 (Porcelain/Ceramic/Polymer Glass) and 26 (Full Cast Metal) because she does not meet the eligibility requirements set out in the EAPWDR Schedule C 4.1(2)(a) and (b); the information submitted by the appellant does not establish that the appellant’s dental condition precludes restorative services such as pre-fabricated crowns as set out in section 4.1(2)(a), and furthermore, in accordance with section 4.1(2)(b) the information does not establish that the appellant’s medical condition precludes the use of a removable prosthetic, or that the appellant has a physical impairment that makes it impossible for her to place a removable prosthetic, or that she has an allergic reaction or intolerance to the composition or materials used in a removable prosthetic, or that she has a mental condition that makes it impossible for her to assume responsibility for a removable prosthetic. In addition, the ministry 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 set out in this section. PART D – Relevant Legislation EAPWDR, section 63, 63(1), 69 and sections 1 and 4 of Schedule C Schedule of Fee Allowances - Dentist
PART E – Summary of Facts The information before the ministry at reconsideration included the following: The appellant is a recipient of disability assistance. Coverage for the following services was requested on January 10, 2017 for tooth 15: Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base: Fee Code 27211 tooth 15: Bonded Composite Core, in Conjunction with Crown: Fee Code 23602 tooth 26: Crown, Full Cast Metal: Fee Code 27301 tooth 26: Bonded Composite Core, in Conjunction with Crown: Fee Code 23602. In a dental claim form for tooth # 26, dated May 11, 2017 the dentist states that tooth #26 is cracked and sore when biting hard foods and requires a crown for support. The patient is anxious and does not wish to lose this tooth. On January 1, 2017 a dental claim form for tooth #26 had been submitted containing the same information as the May 11 form with the exception of an error in the fee amount, and with the addition of reporting missing teeth. In a dental claim form for tooth #15, dated May 11, 2017 the dentist states that tooth #15 has been treated with a root canal and requires a crown to support the tooth from fracture. The patient is anxious of possibly losing the tooth. On January 1, 2017 a dental claim form for tooth #15 had been submitted containing the same information as the May 11 form, with the addition of reporting missing teeth. 6 dental X-Rays In a letter to the dentist dated January 31, 2017, Pacific Blue Cross stated that before they can proceed with the application they ask for the following supporting documentation/information: a list of all teeth missing; the date and condition of any existing prosthesis and teeth involved; if no existing prosthesis, length of time teeth have been missing; an explanation as to why treatment needs cannot be met through the Basic Dental Program (ie: conventional restorations, stainless steel crowns, extractions, partial denture, plastic crown etc.); and relevant information regarding the client’s medical condition(s) that would support the need for a crown or bridge. In a letter to the dentist dated February 14, 2017, Pacific Blue Cross cites the legislative criteria that have to be met for a crown or bridge to be paid, and requests that the dentist “submit a treatment plan, current radiographs, a list of the patient’s missing dentition, a clinical explanation as to necessity: i.e. why the patient’s needs cannot be met through basic dental treatment and relevant information regarding the client’s medical condition(s) that would support the need for a crown or bridge.” On appeal and at the hearing neither the ministry nor the appellant provided new evidence; the appellant provided additional argument which is recorded in Part F of the decision; the ministry presented their reconsideration decision.
PART F – Reasons for Panel Decision Issue under appeal The issue under appeal is whether the ministry reasonably determined that the appellant was not eligible for coverage for crowns for teeth number 15 (Porcelain/Ceramic/Polymer Glass) and 26 (Full Cast Metal) because she does not meet the eligibility requirements set out in the EAPWDR Schedule C, sections 4.1(2)(a) and 4.1(2)(b); specifically, did the ministry reasonably conclude that the information submitted by the appellant does not establish that (a) the appellant’s dental condition precludes restorative services such as pre-fabricated crowns, and that (b) the information does not establish that (b) the appellant’s medical condition precludes the use of a removable prosthetic, or that the appellant has a physical impairment that makes it impossible for her to place a removable prosthetic, or that she has an allergic reaction or intolerance to the composition or materials used in a removable prosthetic, or that she has a mental condition that makes it impossible for her to assume responsibility for a removable prosthetic? In addition, did the ministry reasonably determine 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 set out in this section? Relevant Legislation – EAPWDR and Schedule of Fee Allowances – Dentist Dental supplements 63 The minister may provide any health supplement set out in section 4 [dental supplements] of Schedule C to or for (a) a family unit in receipt of disability assistance, Crown and bridgework supplement 63.1 The minister may provide a crown and bridgework supplement under section 4.1 of Schedule C to or for (a) a family unit in receipt of disability assistance, if the supplement is provided to or for a person in the family unit who is a person with disabilities, … 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 the 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, … Schedule C 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.
Schedule of Fee Allowances – Dentist, effective April 1, 2010 FULL COVERAGE PRE-FABRICATED RESTORATIONS … FEE NO. FEE DESCRIPTION FEE AMOUNT ($) 22201 Stainless steel crown (primary anterior) 119.10 22211 Stainless steel crown (primary posterior) 119.10 22301 Stainless steel crown (permanent anterior) 119.10 22311 Stainless steel crown (permanent posterior) 119.10 22401 Plastic pre-fabricated crown (primary anterior) 119.10 22501 Plastic pre-fabricated crown (permanent anterior) 135.52 Schedule of Fee Allowances - Crown and Bridgework, effective April 1, 2010 27211 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base *624.20 27301 Crown, Full Cast Metal *539.90 *Denotes Lab fee(s) included Appellant’s position The appellant argues that to ignore her dentist’s recommendation for a crown would be neglectful because her dental condition cannot be corrected through the provision of basic dental services such as restorations or removable prosthetics. Her dentist described the medical necessity of crowns to support her cracked and deteriorating teeth - these are not radical procedures. The appellant argues further that prefabricated crowns are not suitable for adults and not recommended by her dentist - they are used for children’s primary teeth. Removable prosthetics are not an option for her at this time of her life because she does not want to lose any more teeth; the affected teeth have functional occlusion with a good long-term prognosis; furthermore, she has a smaller than average mouth with crooked and already missing teeth, which precludes the use of removable prosthetics. Ministry’s position The ministry’s position is that the appellant is ineligible for coverage for crowns for teeth no.15 (Porcelain/Ceramic/Polymer Glass) and no. 26 (Full Cast Metal) because she does not meet the eligibility requirements set out in the EAPWDR Schedule C, section 4.1.(2)(a) and 4.1(2)(b). The ministry argues that the information submitted by the appellant and her dentist does not establish that the dental condition precludes the provision of prefabricated plastic crowns and/or stainless steel crowns as set out in section 4.1(2)(a) and in the Schedule of Fee Allowances-Dentist - Full Coverage Pre-fabricated Restorations. Further, the information submitted by the appellant does not establish that one of the 4 circumstances under EAPWDR Schedule C s. 4.1(2)(b) exists: 1. The dental condition precludes the use of a removable prosthetic; 2. The person has a physical impairment that makes it impossible for her to place a removable prosthetic; 3. The person has an allergic reaction or
other intolerance to the composition or materials used in a removable prosthetic; 4. The person has a mental condition that makes it impossible for her to assume responsibility for a removable prosthetic. Even though the ministry wrote 2 letters to the appellant’s dentist requesting additional information there was no response forthcoming. The onus is on the dentist to provide this information. 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 set out in this section. “The remedy provided under section 69 only applies to medical supplies, medical transportation and medical equipment and devices as noted above. Dental and denture supplements are not set out in these sections.” Panel Decision Section 4.1(2) of Schedule C of the EAPWDR sets out criteria the appellant has to meet in order to be considered for coverage of crown and bridgework by the ministry: The person must have a dental condition that cannot be corrected through the provision of basic dental services such as restoration through prefabricated crowns or removable prosthetics because (a) the dental condition precludes the provision of the restorative services, and (b), the appellant’s medical condition precludes the use of a removable prosthetic, or a physical impairment makes it impossible for her to place a removable prosthetic, or the appellant has an allergic reaction or intolerance to the composition or materials used in a removable prosthetic, or a mental condition makes it impossible for the appellant to assume responsibility for a removable prosthetic. The panel finds that there is insufficient evidence that the appellant meets any of the conditions/pre-requirements set out in section 4.1.(2) that would justify coverage for a crown as set out in the Schedule of Fee Allowances – Crown and Bridgework; while the appellant’s dentist reports that the appellant is missing teeth already and tooth #15 and 26 require crowns for support and to prevent fracture he does provide no information why the appellant’s condition precludes the use of restorative services or removable prosthetics as highlighted in section 4.1.(2), or how a possible loss of teeth #15 and 26 justifies coverage for crowns in accordance with the above mentioned legislation. While the appellant mentioned that prefabricated crowns are only used for children there is no supporting evidence for this claim from the dentist. Accordingly, the panel finds that the ministry reasonably determined that the appellant is not eligible for coverage for the requested crowns for teeth 15 and 26. The panel further finds that the ministry reasonably 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. Conclusion The panel finds that the ministry’s determination that the appellant is not eligible for coverage for crowns for tooth number 15 (Porcelain/Ceramic/Polymer Glass) and 26 (Full Cast Metal) 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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