P A R T C D E C I S I O N U N D E R A P P E A L T h e d e c i s i o n u n d e r a p p e a l i s t h e M i n i s t r y o f S o c i a l r e c o n s i d e r a t i o n d e c i s i o n d a t e d A p r i l 1 0 , 2 0 1 9 , w h i c s e d a t i o n [ f e e c o d e 9 2 4 4 2 -2 u n i t s ] p r o v i d e d o n S e p i n t h e m i n i s t r y ' s S c h e d u l e o f F e e A l l o w a n c e s D e n P A R T D R E L E V A N T L E G I S L A T I O N E m p l o y m e n t a n d A s s i s t a n c e f o r P e r s o n s w i t h D i s a b a n d S c h e d u l e C , s e c t i o n s 1 , 4 a n d 5 . S c h e d u l e s o f F e e A l l o w a n c e s D e n t i s t a n d E m e r g I D e v e l o p m e n t a n d P o v e rt y R e d u c t i o n ( t h e m i n i s t r y ) h 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 c o v e r a g e o f I V t e m b e r 2 6 , 2 0 1 8 , b e c a u s e t h i s s e rv i c e i s n o t s e t o u t t i s t o r E m e r g e n c y D e n t a l D e n t i s t . i l i t i e s R e g u l a t i o n ( EA P W D R ) s e c t i o n s 6 3 a n d 6 4 , e n c y D e n t a l D e n t i s t
P A R T E S U M M A R Y O F F A C T S O n S e p t e m b e r 2 6 , 2 0 1 8 t h e a p p e l l a n t h a d s e v e r a l t T h e d e n t i s t s u b m i t t e d a c l a i m f o r t h e e x t r a c t i o n s t o w a s p a i d o n O c t o b e r 1 7 , 2 0 1 8 . H e d i d n o t s u b m i t a P a r e n t e r a l C o n s c i o u s S e d a t i o n T w o U n i t s ] r e c e i v e a m o u n t c h a r g e d f o r t h a t s e r v i c e w a s $ 2 7 5 . T h e c l a i u n d e r t h e a p p e l l a n t ' s p l a n . O n S e p t e m b e r 2 8 , 2 0 1 8 t h e m i n i s t r y r e c e i v e d a d o c a p p e l l a n t . I t s e t o u t t h e d a t e o f t h e s u r g e r y a s S e p t e $ 2 7 5 , a n d i n s t r u c t i o n s t o t h e a p p e l l a n t o n h o w t o p r " m i n i s t r y d o e s n ' t c o v e r t h e I V s e d a t i o n o f $ 2 7 5 . 0 0 " O n S e p t e m b e r 2 8 , 2 0 1 8 a m i n i s t r y w o r k e r w r o t e a n d e n i e d c o v e r a g e f o r I V S e d a t i o n f o r d e n t a l w o r k . O n O c t o b e r 1 , 2 0 1 8 P B C r e s p o n d e d , n o t i n g t h a t t h c l a i m t o P B C , a n d i f d e n i e d , t h e a p p e l l a n t c o u l d p r o O n O c t o b e r 2 , 2 0 1 8 t h e m i n i s t r y w o r k e r e n t e r e d a n t h a t s h e c a l l e d h e r a n d r e c o m m e n d e d s h e a s k h e r a n d , i f d e n i e d , s h e c o u l d p r o c e e d t o r e c o n s i d e r a t i o n O n O c t o b e r 1 1 , 2 0 1 8 t h e a p p e l l a n t c o n t a c t e d t h e m p r o v i d e a l e t t e r . T h e d e n t a l o f f i c e i n f o r m e d h e r t h e y n o t b e e l i g i b l e . S h e w a s a d v i s e d t h a t t h e m i n i s t ry w r e c o n s i d e r a t i o n t o p r o c e e d . O n O c t o b e r 1 9 , 2 0 1 8 t h e a p p e l l a n t s u b m i t t e d a l e tt e t h r o u g h b e c a u s e s h e d i d n o t q u a l i f y . T h i s d o c u m e n M a n a g e m e n t s y s t e m . O n M a r c h 2 6 2 0 1 9 t h e a p p e l l a n t s u b m i t t e d a n i n v o i n o t p r o v i d e c o v e r a g e fo r t h e s e d a t i o n p r o v i d e d d u r i a d o c u m e n t r e c e i v e d b y t h e a p p e l l a n t ' s d e n t a l o ff i c S e p t e m b e r 2 6 , 2 0 1 8 , t h e f e e c o d e w a s 9 2 4 4 2 , a n d c o v e r a g e , s t a t i n g : " W e a r e u n a b l e t o p r o v i d e r e i m b u n d e r y o u r p l a n . " O n M a r c h 2 8 , 2 0 1 9 t h e m i n i s t r y p r e p a r e d a r e c o n s i c o m p l e t e 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 o n t h e s a m e i n f o r m a t i o n i n s e c t i o n 3 o f t h e R e q u e s t fo r R e c o n s i d " I n e e d t h i s m o n e y . I h a v e t h r e e c h i l d r e n . T h i s c o s t s e n t d i r e c t l y t o t h e h o m e o w n e r . W i t h t h e r i s i n g c o s t w i t h t h e t i n y a m o u n t p r o v i d e d . W h e n I h a d t o p a y I I A P P E A L N U M B E R e e t h o n h e r l o w e r a r c h r e m o v e d b y a d e n t i s t . P a c i f i c B l u e C r o s s ( P B C ) o n O c t o b e r 2 , 2 0 1 8 , w h i c h c l a i m f o r t h e I V S e d a t i o n [ fe e c o d e 9 2 4 4 2 d d u r i n g t h e e x t r a c t i o n s u n t i l F e b r u a r y 1 2 , 2 0 1 9 . T h e m w a s r e j e c t e d b e c a u s e i t w a s n o t a c o v e r e d b e n e f i t u m e n t f r o m t h e d e n t i s t o ff i c e , s u b m i t t e d b y t h e m b e r 2 6 , 2 0 1 8 , t h e e s t i m a t e d c o s t o f t h e s u r g e r y a s e p a r e fo r t h e s u r g e r y . S o m e o n e w r o t e b y h a n d o n t h i s d o c u m e n t . e m a i l t o P B C n o t i n g t h a t t h e a p p e l l a n t h a d b e e n e r e w a s n o r e c o r d o f a c l a i m o r p r e a u t h o r i z a t i o n c e e d t o r e c o n s i d e r a t i o n i f s h e w i s h e d . o t e i n t h e a p p e l l a n t ' s e l e c t r o n i c r e c o r d s i n d i c a t i n g d e n t i s t t o s u b m i t a p r e a u t h o r i z a t i o n c l a i m t o P B C , i f s h e w i s h e d . i n i s t r y t o r e p o rt t h a t t h e d e n t i s t w a s n o t a b l e t o d i d n o t p u t a c l a i m t h r o u g h a s t h e y k n e w s h e w o u l d o u l d r e q u i r e a d e n i a l l e tt e r i n o r d e r fo r a r f r o m h e r d e n t i s t s t a t i n g t h a t t h e c l a i m w a s n o t p u t t w a s n o t s c a n n e d i n t o t h e I n t e g r a t e d C a s e c e f r o m h e r d e n t a l o ff i c e i n d i c a t i n g t h a t P B C w o u l d n g t h e e x t r a c t i o n s t o h e r l o w e r a r c h . A n e x c e r p t f r o m e i n d i c a t e d t h a t t h e s e r v i c e w a s p r o v i d e d o n t h e a m o u n t c h a r g e d w a s $ 2 7 5 . P B C d e n i e d u r s e m e n t f o r t h i s e x p e n s e . I t i s n o t a c o v e r e d b e n e f i t d e r a t i o n p a c k a g e f o r t h e a p p e l l a n t . S h e r e t u r n e d t h e d a y . T h e a p p e l l a n t p r o v i d e d t h e f o l l o w i n g e r a t i o n f o r m : c u t i n t o m y g r o c e r y , b i l l s , p o r t i o n . F o r m y r e n t g e t s s o f r e n t a l a n d f o o d . I t ' s r e a l l y h a r d t o e v e n b u d g e t w e n t t o f o o d b a n k s a n d a n y o t h e r a v a i l a b l e h e l p . "
I APPEAL NUMBER • With her request for reconsideration the appellant submitted an Account Statement dated September 26, 2018 completed by the dental office. The statement indicates that the appellant paid $275 by debit card for a code 92442 IV sedation on September 26, 2018. • She attached documents previously submitted including the pre-surgery instructions by the dental office and PBC's denial of coverage of sedation. In her Notice of Appeal dated April 16, 2019 the appellant wrote: "I was denied IV sedation for multiple teeth extractions which were covered for a person with disability status." Upon confirming that the appellant had been notified within the prescribed time line the hearing pro ceeded in her absence in accordance with section 86(b) of the Employment and Assistance Regulation. At the hearing the ministry submitted an extract of the applicable legislation: Schedule C section 1 definitions of "basic dental service", section 4, and section 5. The ministry clarified that at reconsideration it had used an outdated template and as a result had written "April 1, 2010 " instead of "September 1, 2017" as effective date for the Schedule of Fee Allowances -Dentist as well as the Schedule Fee Allowances Emergency Dental -Dentist. The ministry commented that the wording of the applicable sections of the Schedules effective April 1, 2010 was identical with the ones effective September 1, 2017. The reconsideration officer had given her assurance that the template would be updated i mmediately. The ministry noted that the reference to eligibility to receive a dental supplement should read "section 63 and 64" instead of "section 64 and 65" -it was a typo. After these explanations the ministry presented the reconsideration decision and added that the appellant is over 19 years of age.
I APPEAL NUMBER PART F -REASONS FOR PANEL DECISION The issue in this appeal is whether the ministry reconsideration decision which denied the appellant's request for coverage of IV sedation [fee code 92442 -2 units] provided on September 26, 2018 because this service is not set out in the ministry's Schedule of Fee Allowances -Dentist or Emergency Dental Dentist was a reasonable application of the legislation or reasonably supported by the evidence. 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, Emergency dental and denture supplement 64 The minister may provide any health supplement set out in section 5 [emergency dental supplements] of Schedule C to or for (a)a family unit in receipt of disability assistance, Schedule C Health Supplements Definitions 1 In this Schedule: "basic dental service" means a dental service that (a)if provided by a dentist, (i)is set out in the Schedule of Fee Allowances -Dentist that is effective September 1, 2017 and is published on the website of the ministry of the minister, and (ii)is provided at the rate set out in that Schedule for the service and the category of person receiving the service, "dentist" means a dentist registered with the College of Dental Surgeons of British Columbia continued under the Health Professions Act; "emergency dental service" means a dental service necessary for the immediate
r e l i e f o f p a i n t h a t , ( a ) i f p r o v i d e d b y a d e n ( i ) i s s e t o u t i n t h D e n t i s t , t h a t t h e w e b s i t e o f t h ( i i ) i s p r o v i d e d a t a n d t h e c a t e g o ry D e n t a l s u p p l e m e n t s 4 ( l ) I n t h i s s e c t i o n , " p e r i o d " m ( a ) i n r e s p e c t o f a p e r s o o n J a n u a r y 1 , 2 0 1 7 , a n n u m b e r e d y e a r , a n d ( b ) i n r e s p e c t o f a p e r s o b e g i n n i n g o n J a n u a r y 1 o d d n u m b e r e d y e a r . ( 1 . l ) T h e h e a l t h s u p p l e m e n t s t h a t m a y b e p a i d u n r e g u l a t i o n a r e b a s i c d e n t a l s e r v i c e s t o a m a x i m u m ( a ) $ 2 0 0 0 e a c h p e r i o d , ( b ) $ 1 0 0 0 e a c h p e r i o d , ( a ) . . . E m e r g e n c y d e n t a l s u p p l e m e n t s 5 T h e h e a l t h s u p p l e m e n t s t h a t m a y b e p a i d f o r u s u p p l e m e n t s ] o f t h i s r e g u l a t i o n a r e e m e r g e n c y d e S c h e d u l e o f F e e A l l o w a n c e s D e n t i s t / S c h D e A n e s t h e s i a N o t e : W h e n d e l i v e r i n g s e d a t i o n a n d g e n e r a l a n a e R e q u i r e m e n t s s e t o u t b y t h e C o l l e g e o f D e n G e n e r a l A n a e s t h e t i c a n d I n t r a v e n o u s s e d a t i o n ( i n F E E N O . F E E D E S C R I P T I O N 9 2 2 1 5 p e r h o u r o r p o t i o n t h e r e o f A P P E A L N U M B E R t i s t , e S c h e d u l e o f F e e A l l o w a n c e s E m e r g e n c y D e n t a l i s e ff e c t i v e S e p t e m b e r 1 , 2 0 1 7 a n d i s p u b l i s h e d o n e m i n i s t r y o f t h e m i n i s t e r , a n d t h e r a t e s e t o u t i n t h a t S c h e d u l e f o r t h e s e r v i c e o f t h e p e r s o n r e c e i v i n g t h e s e r v i c e , . . . e a n s n u n d e r 1 9 y e a r s o f a g e , a 2 y e a r p e r i o d b e g i n n i n g d o n e a c h s u b s e q u e n t J a n u a r y 1 i n a n o d d n n o t r e f e r r e d t o i n p a r a g r a p h ( a ) , a 2 y e a r p e r i o d , 2 0 0 3 a n d o n e a c h s u b s e q u e n t J a n u a r y 1 i n a n d e r s e c t i o n 6 3 [ d e n t a l s u p p l e m e n t s ] o f t h i s o f i f p r o v i d e d t o a p e r s o n u n d e r 1 9 y e a r s o f a g e , a n d i f p r o v i d e d t o a p e r s o n n o t r e f e r r e d t o i n p a r a g r a p h n d e r s e c t i o n 6 4 [ e m e r g e n c y d e n t a l a n d d e n t u r e n t a l s e r v i c e s . e d u l e o f F e e A l l o w a n c e s E m e r g e n c y D e n t a l n t i s t s t h e t i c , d e n t i s t s m u s t m e e t t h e r e g u l a t o r y t a l S u r g e o n s o f B C . o f f i c e ) F E E A M O U N T ( $ ) A D U L T 5 0 . 5 7
APPEAL NUMBER Note: GA or IV sedation (in office) will only be considered f o r coverage f o r children under 19 years of age where necessary for the safe performance of dental treatment; and children and adults with a severe mental or physical disability that prevents a dentist from providing necessary treatment without the administration of a GA or sedation. New Conscious sedation Note: Conscious sedation is only covered for children under 19 years of age, and only when necessary for the safe performance of dental treatment or when the dentist is prevented from providing necessary treatment without the administration of a GA or sedation. Fee items 92411 to 92418 and 92431 to 92438 ... Appellant's position The appellant argues that as Person with Disability she is eligible for coverage for IV sedation. The expense of paying for the sedation left her with insufficient funds to pay for groceries and bills. Ministry's position The ministry determined that eligibility for basic dental services is set out under the EAPWDR, Schedule C, sections 1 and 4. Sedation is a basic dental service. Schedule C, section 1 defines a basic dental service as a dental service that (a) if provided by a dentist, (i)is set out in the Schedule of Fee Allowances -Dentist that is effective April 1, 201 O and is on file with the office of the deputy minister, and (B.C. Reg. 65/2010) (ii) is provided at th e rate set out for the service in that Schedule. Fee Code 92442 is not set out in the ministry's Schedule of Fee Allowances-Dentist and the ministry is not authorized to provide coverage for services that are not set out in that Schedule. The ministry determined further that appellant is also eligible to receive Emergency Dental Services under the EAPWDR. Section 64 and Schedule C, sections 1 and 5. Schedule C section 1 defines an emergency dental service as one that is necessary for the immediate relief of pain and (a) if provided by a dentist, (i) is set out in the Schedule of Fee-Allowances-Emergency Dental-Dentist, that is effective April 1, 2010 and is on file with the office of the deputy minister, and (B.C. Re. 65/2010) (ii) is provided at the rate set out in that Schedule ... Fee Code 92442 is not set out in the ministry's Schedule of Fee Allowances-Emergency Dental-Dentist and the ministry is not authorized to provide coverage for services that are not set out in that Schedule. The ministry noted that the parameters for the provision of sedation are set out in the Schedule of Fee Allowances-Dentist. Coverage for Intravenous Sedation (in office) is provided under fee code 92215 which is described in the BC Dental Fee Guide as general anaesthesia involving loss of consciousness. Eligibility requirements for funding for this service are defined in the ministry's Schedule of Fee Allowances as follows: "GA or IV sedation (in office) will only be considered for coverage for children
APPEAL NUMBER under 19 years of age where necessary for the safe performance of dental treatment, and children and adults with a severe mental or physical disability that prevents a dentist from providing necessary treatment without the administration of a GA or sedation." The ministry noted that evidence was not provided to establish or suggest that the appellant has a severe mental or physical disability that prevents a dentist from providing necessary dental treatment without the administration of a GA or IV sedation. The ministr y noted that even if this were the case, the appellant did not receive sedation on September 26, 2018 under fee code 92215. The ministry noted that while the Schedule of Fee Allowances-Dentist includes coverage for conscious sedation (fee codes 92411 to 92418 and 92431 to 92438) this type of sedation is only covered for children under 19 years of age. Panel Decision While the appellant argues that she should be eligible for coverage for IV sedation due to her PWD designation the panel finds that even though the appellant is eligible for basic dental services and emergency dental services pursuant to section 63 and 64 and Schedule C sections 1, 4 and 5, the service provided (fee code 92442) is not listed among the services covered in the Schedule of Fee Allowances Dentist or the Schedule of Fee Allowances Emergency Dental -Dentist. The panel finds that the ministry reasonably concluded that the appellant was not eligible for Parenteral Conscious Sedation -2 Units (Fee Code 92442) under sections 63 and 64 and Schedule C sections 1, 4 and 5 of the EAPWDR. The panel notes that the ministry was correct in their analysis that coverage for GA and Intravenous Sedation (in office) under fee code 92215 is only considered for coverage for children under 19 years of age where necessary for the safe performance of dental treatment, and children and adults with a severe mental or physical disability that prevents a dentist from providing necessary treatment without the administration of a GA or sedation. As the appellant is over 19 years old, and as there is no evidence that she has a severe mental or physical disability that prevents a dentist from providing necessary dental treatment without the administration of a GA or IV sedation, the appellant is not eligible to receive sedation under fee code 92215. Even if she were eligible to receive sedation under this code she received sedation under code 92442 which is not set out in the ministry's fee allowance schedules. The panel notes further that the ministry was correct when it noted that conscious sedation under fee codes 92411 to 92418 and 92431 to 92438 is only covered for children under 19 years of age where necessary for the safe performance of dental treatment or when the dentist is prevented from providing necessary treatment without the administration of a GA or sedation. Even if the appellant were under 19 years of age she could not have been considered eligible as she did not receive sedation under fee codes 92411 to 92418 and 92431 to 92438. Conclusion The panel finds that the ministry's determination that the appellant is not eligible for coverage of dental fees for Parenteral Conscious Sedation -2 Units [Fee Code 92442] 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.
PARTG-ORDER THE PANELDECISIONIS:(Check one) IZ]UNANIMOUS □BY MAJORITY THE PANEL IZ]CONFIRMS THE MINISTRY DECISION □RESCINDS THE MINISTRY DECISION If the ministry decision is rescinded, is the panel decision referred back to the Minister for a decision as to amount? □Yes □No LEGISLATIVE AUTHORITY FOR THE DECISION: Employment and Assistance Act Section 24(1)(a) D or Section 24(1 )(b) IZl and Section 24(2){a) IZl or Section 24{2)(b) D PART H-SIGNATURES PRINTNAME Inge Morrissey DATE(YEAR/MONTH/DAY ) 2019/05/08 PRINTNAME R obert Fenske SIGNATURE O F MEMBER DATE(YEAR/MONTHIDA Y) 2019/05/08 PRINTNAME Charles Schellink SIGNATURE OF MEMBER DATE(YEAR/MONTH/DAY) 2019/05/10
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.