Ministry of Social Development and Poverty Reduction

APPEAL NUMBER 2021-00044

PART C – DECISION UNDER APPEAL The decision under appeal is the Ministry of Social Development and Poverty Reduction (ministry) reconsideration decision dated February 19, 2021, which denied coverage for certain dental services. Specifically, in accordance with the definitions in Section 1 and 4.1 of Schedule C of the Employment and Assistance for Persons With Disabilities Regulation (EAPWDR), the appellant was not eligible for:  coverage of requested dental services that are not set out in the Schedule of Fee Allowances- Dentist, the Schedule of Fee Allowances-Emergency Dental-Dentist, or the Schedule of Fee Allowances- Crown and Bridgework;  coverage of fees in excess of the rates set out in the Schedule, for dental services included in the Schedule of Fee Allowances- Dentist; and,  coverage of requested dental services that were included in the Schedule of Fee Allowances- Crown and Bridgework as the requirements in Section 4.1(2) of Schedule C of the EAPWDR for the Crown and Bridgework supplement had not been met.

The ministry also determined that the requested dental services could not be provided under Section 57 of the EAPWDR [crisis supplements] or Section 69 of the EAPWDR [life-threatening health need].

PART D – RELEVANT LEGISLATION Employment and Assistance for Persons With Disabilities Regulation (EAPWDR), Sections 57, 63, 63.1, 64, and 69 and Schedule C, Sections 1, 4, 4.1 and 5.

Schedule of Fee Allowances- Dentist; Emergency Dental- Dentist; Crown and Bridgework.

APPEAL NUMBER 2021-00044

PART E – SUMMARY OF FACTS With the consent of both parties, the hearing was conducted as a written hearing, pursuant to section 22(3)(b) of the Employment and Assistance Act.

The evidence before the ministry at the time of the reconsideration decision consisted of: 1) Print out of X-rays showing a tooth missing on the jaw bone; 2) Standard Dental Claim Form dated August 18, 2020 in which the appellant made a claim for various dental services with the total fee submitted of $4,910.35; 3) Statement dated September 4, 2020 indicating a service description of “Retainers, Full, Cast Metal- 67301” for tooth 47, a total claimed amount of $1,250 and with an eligible amount of nil. The notes included instructions to provide:  A periaphical x-ray of tooth involved (must be within 1 year);  The date and condition of any existing prostheses and teeth involved. If no existing prostheses, indicate the length of time teeth have been missing.  Explanation as to the necessity for crown/bridge requests, why treatment requests cannot be met through the basic dental program.  Relevant information regarding the client’s medical condition that would support the need for crown or bridge. 4) Statement dated September 4, 2020 indicating a service description of “Pontics, Cast Metal- 62101” for tooth 46, a total claimed amount of $751 and with an eligible amount of nil. 5) Statement dated September 4, 2020 indicating a service description of “Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base- 67211” for tooth 45, a total claimed amount of $1,250 and with an eligible amount of nil. 6) Statement dated September 4, 2020 indicating a service description of “Periodontal, Maxillary Appliance- 14611,” a total claimed amount of $409.35 and with an eligible amount of $244.35. 7) Statement dated September 4, 2020 indicating a service description of “Crown, Porcelain/Ceramic/Polymer Glass- 27201” for tooth 26, a total claimed amount of $1,250 and with an eligible amount of nil. and, 8) Request for Reconsideration dated February 11, 2021.

In the Request for Reconsideration, the appellant’s information included the following:  The appellant has not been able to eat on the left side for over a year. It hurts with cold or, if the appellant tries to chew on that side, pain shoots through the appellant’s gums.  The appellant also has a tooth on the right side missing, which makes it hard to eat.  The appellant did not know that the dentist had not filled out the forms properly. The appellant would not use the same dentist if the services are approved since they have proven they do not follow through with things.

On August 26, 2020 PBC made a pre-determination of coverage for dental services summarized in the following table:

APPEAL NUMBER 2021-00044

Item Tooth Fee Description Dentist Approved # Code Fee 1 14611 Periodontal, Maxillary Appliance $409.35 $244.35 2 26 27201 Crown, Porcelain/Ceramic/Polymer Glass $1,250 0 3 45 67211 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to $1,250 0 Metal Base

4 46 62101 Pontics, Cast Metal $751 0 5 47 67301 Retainers, Full, Cast Metal $1,250 0 TOTAL $4,910.35 $244.35 Additional information In the Notice of Appeal dated February 23, 2021, the appellant expressed disagreement with the ministry decision and wrote that:  The appellant has a tooth that is broken off and nerve damage on the teeth around it. It is very painful and, with waiting, means that the tooth will become infected and will get worse over time. This will be very uncomfortable now and later on.  The teeth involved have been fixed as much as possible and now need a crown to fix them properly so the appellant is able to eat on both sides as opposed to just the one side.

Prior to the hearing, the appellant provided additional documents including: 1) An email dated March 2, 2021 in which the appellant attached a letter and pictures and X-rays from the dentist and the appellant wrote:  If the panel members were not able to eat on one side for over a year, they would likely want their teeth fixed.  If the appellant could afford the cost of the dental services, the appellant would have the work done but the appellant cannot afford $4,900 for dentist work. 2) Photo showing a tooth with a large piece of the tooth missing and another photo showing an area of the jaw with an entire tooth missing. 3) Two X-rays showing the missing tooth and one X-ray showing the tooth with a large piece of the tooth missing. 4) Letter in which the dentist wrote that the photograph and X-rays are of the area. The dentist also wrote:  The reason they would like to have a crown completed on the 26 is due to the size of the existing composite restoration and the existing fracture of the MB cusp. These carry a guarded prognosis for short to medium term restoration with direct composite or amalgam.  Having full coverage protection with a crown would help to protect the remaining tooth structure and allow confident function on the tooth.

APPEAL NUMBER 2021-00044

 The primary reason for a fixed bridge on the lower right quadrant is to replace the missing 46.

Prior to the hearing, the ministry provided a letter dated March 19, 2021 and wrote:  The requirement of Schedule C, Section 4.1(2)(a) of the EAPWDR may be met with the information from the dentist explaining the reason for a crown and the ‘guarded prognosis for short to medium term restoration’ and that the primary reason for a fixed bridge is to replace missing tooth #46.  However, the ministry is not satisfied that the dentist explains why a removable prosthetic could not be used for one of the permitted reasons under Schedule C, Section 4.1(2)(b) of the EAPWDR.  The ministry is only authorized to provide coverage for dental services set out in the Schedule of Fee Allowances- Dentist; Emergency Dental, and Crown and Bridgework and the appellant’s request for the crown (Fee Code 27201) is not set out on any of the Schedules.

Admissibility of Additional Information The ministry did not object to the admissibility of the additional documents provided by the appellant and referred to the information provided by the appellant in the ministry’s submission. The panel considered the additional documents provided by the appellant and admitted them in accordance with Section 22(4) of the Employment and Assistance Act on the basis that the information directly relates to the request for funding for specific dental services for the appellant and is, therefore, reasonably required for a full and fair disclosure of all matters related to the decision under appeal.

The panel considered the information in the ministry’s letter dated March 19, 2021 as part of the ministry’s arguments and will be addressed in Part F- Reasons for Panel Decision, below.

APPEAL NUMBER 2021-00044

PART F – REASONS FOR PANEL DECISION The issue on the appeal is whether the ministry's reconsideration decision in which the ministry determined that the appellant was not eligible for coverage of requested dental services or for coverage of fees in excess of the rates set out in the Schedule, and the requested dental services could not be provided under Section 57 of the EAPWDR or Section 69 of the EAPWDR, was reasonably supported by the evidence or a reasonable application of the applicable enactment in the appellant’s circumstances.

The applicable sections of the EAPWDR are set out in Appendix A and excerpts of the applicable Fee Schedules are set out in Appendix B at the end of these Reasons.

Ministry’s position The ministry’s position is that the legislation sets out limits regarding what dental services are funded and limits on the amount of funding. The ministry maintains that Crown, Porcelain/Ceramic/Polymer Glass, for tooth 26 (Fee Code 27201) is not funded and the maximum amount of funding for the Periodontal, Maxillary Appliance (Fee Code 14611), as set out in the Schedule of Fee Allowances- Dentist, has been approved and there is no ability to provide funding at the dentist’s higher rate. Regarding the crown and bridgework found on the Schedule of Fee Allowances- Crown and Bridgework, the ministry’s position is that the requirements of Section 4.1(2) of Schedule C of the EAPWDR have not been met.

Specifically, the ministry was not satisfied that the appellant has a dental condition that cannot be corrected through the provision of basic dental services because the dental condition precludes the provision of the restorative services set out under the Restorative Services section of the Schedule of Fee Allowances- Dentist. In the reconsideration decision, the ministry also wrote that the information provided by the appellant does not establish that the appellant is unable to use a removeable prosthetic (e.g. denture) for one of the listed reasons.

In the submission on appeal, the ministry wrote that the information provided by the dentist on appeal may meet the requirement of Section 4.1(2)(a) of Schedule C of the EAPWDR that the appellant has a dental condition that cannot be corrected through the provision of basic dental services because the dental condition precludes the provision of the restorative services set out under the Restorative Services section of the Schedule of Fee Allowances- Dentist. However, the ministry was still not satisfied that the dentist explains why the appellant could not use a removable prosthetic for one of the permitted reasons under Section 4.1(2)(b) of Schedule C of the EAPWDR.

The ministry also considered the appellant’s request under Section 57 of the EAPWDR [crisis supplements] and Section 69 of the EAPWDR [life-threatening health need] and found that neither section allowed for the provision of dental services.

APPEAL NUMBER 2021-00044

Appellant’s position

In the Notice of Appeal, the appellant wrote that the appellant has a tooth that is broken off and with nerve damage on the teeth around it. The appellant wrote that it is very painful and waiting means that the tooth will become infected and will get worse over time. The appellant wrote that the teeth involved have been fixed as much as possible and now need a crown to fix them properly so the appellant is able to eat on both sides as opposed to just the one side.

In the submission on appeal, the appellant wrote that If the panel members were not able to eat on one side for over a year, they would likely want their teeth fixed. In the Request for Reconsideration, the appellant wrote that the appellant has not been able to eat on the left side for over a year, that it hurts with cold or pain shoots through the appellant’s gums if the appellant tries to chew on that side. The appellant wrote that there is a tooth missing on the right side, which makes it hard to eat.

The appellant wrote in the submission that the appellant cannot afford $4,900 for dentist work. The appellant provided a letter in which the dentist explained that the reason they would like to have a crown completed on tooth 26 is “due to the size of the existing composite restoration and the existing fracture of the MB cusp.” The dentist wrote that “these carry a guarded prognosis for short to medium term restoration with direct composite or amalgam” and “having full coverage protection with a crown would help to protect the remaining tooth structure and allow confident function on the tooth.” The dentist wrote that “the primary reason for a fixed bridge on the lower right quadrant is to replace the missing tooth 46.”

Panel decision The ministry determined that the appellant is a Person With Disabilities (PWD) in receipt of disability assistance and, therefore, is eligible for coverage for basic dental services, emergency dental services, and crown & bridgework, in accordance with Sections 63, 63.1 and 64 of the EAPWDR and Schedule C, Sections 1, 4, 4.1 and 5. The ministry wrote that the appellant submitted a dental Claim Form dated August 18, 2020 in which the appellant made a claim for various dental services with the total dentist fee submitted of $4,910.35. The request was processed by Pacific Blue Cross (PBC), to which the ministry has delegated its powers, duties and functions respecting dental supplements in accordance with Section 25 of the Employment and Assistance for Persons With Disabilities Act (EAPWDA). In reviewing the eligibility for the particular dental services requested by the appellant, PBC approved the amount of $244.35 as eligible dental services and denied coverage of the balance of services and fees requested.

The panel reviewed the conclusion made by PBC for each requested dental service, as set out in the Table provided and set out in the Statement of Facts, to consider the ministry’s reasonableness in confirming these determinations and denying coverage for some of the requested costs and services.

APPEAL NUMBER 2021-00044

Item #1- Periodontal, Maxillary Appliance (Fee Code 14611)

For item #1, the appellant’s request was for coverage of dental services to be provided by a dentist and described as “Periodontal, Maxillary Appliance” with a Fee Code of 14611 and a total claimed amount of $409.35. The ministry considered the appellant’s eligibility for funding under Section 64 of the EAPWDR for emergency dental services and Section 1 of Schedule C of the EAPWDR defines "emergency dental service" to mean a dental service necessary for the immediate relief of pain that, if provided by a dentist, is set out in the Schedule of Fee Allowances- Emergency Dental- Dentist that is effective September 1, 2017 and is published on the website of the minister. After review of the Schedule, the panel concluded that the ministry reasonably determined that the Schedule does not list “Periodontal, Maxillary Appliance” with Fee Code 14611.

The ministry found that the appellant was eligible for funding for this dental service under Section 63 of the EAPWDR for basic dental services; however, even when someone is eligible to receive the dental service, there are limits to the amount of funding. Specifically, Section 1 of Schedule C of the EAPWDR defines "basic dental service" to mean a dental service that, if provided by a dentist, is set out in the Schedule of Fee Allowances- Dentist that is effective September 1, 2017 and is published on the website of the minister and is provided at the rate set out in that Schedule for the service and the category of person receiving the service [emphasis added]. In a review of the Schedule of Fee Allowances- Dentist, the panel finds that the ministry accurately identified the dental service and the category of person receiving the service to determine the adult fee of $244.35 and the panel notes the Schedule was last updated over 3 years ago, in 2017, and specifies that this fee is “inclusive of lab fees and the cost of study models.” Although the dentist’s fee for the “Periodontal, Maxillary Appliance” is $409.35, the Schedule of Fee Allowances- Dentist sets the maximum fee rate at $244.35. As the ministry has no discretion and must apply the legislation, the panel finds that the ministry was reasonable in determining that the funding for Item #1- Periodontal, Maxillary Appliance (Fee Code 14611) was limited to $244.35 and the appellant was not eligible for funding at the higher dentist’s rate.

Item #2- Crown, Porcelain/Ceramic/Polymer Glass, for tooth 26 (Fee Code 27201) For item #2, the appellant’s request was for coverage of dental services to be provided by a dentist and described as Crown, Porcelain/Ceramic/Polymer Glass, for tooth 26 with a Fee Code of 27201 and a dental fee of $1,250. In the Request for Reconsideration, the appellant wrote that the appellant has not been able to eat on the left side for over a year, that it hurts with cold or pain shoots through the appellant’s gums if the appellant tries to chew on that side. The dentist wrote in the letter provided on appeal that the reason they would like to have a crown completed on tooth 26 is “due to the size of the existing composite restoration and the existing fracture of the MB cusp.”

APPEAL NUMBER 2021-00044

The ministry considered the appellant’s eligibility for funding under Section 63 of the EAPWDR for basic dental services and Section 1 of Schedule C of the EAPWDR defines "basic dental service" to mean a dental service that, if provided by a dentist, 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. The ministry also considered the appellant’s eligibility for funding under Section 64 of the EAPWDR for emergency dental services and Section 1 of Schedule C defines "emergency dental service" to mean a dental service necessary for the immediate relief of pain that, if provided by a dentist, is set out in the Schedule of Fee Allowances- Emergency Dental- Dentist that is effective September 1, 2017 and is published on the website of the ministry of the minister. The ministry considered the appellant’s eligibility for funding under Section 63.1 of the EAPWDR for crown and bridgework and Section 4.1(1) of Schedule C of the EAPWDR defines "crown and bridgework" to mean a dental service that is provided by a dentist and that is set out in the Schedule of Fee Allowances- Crown and Bridgework, that is effective April 1, 2010 and is published on the website of the ministry. On appeal, the ministry reiterated the position that the ministry is only authorized to provide coverage for dental services set out in the Schedule of Fee Allowances- Dentist; Emergency Dental- Dentist, and Crown and Bridgework and the appellant’s request for the Crown (Fee Code 27201) is not set out on any of the Schedules.

Following review of the Schedule of Fee Allowances- Dentist and the Schedule of Fee Allowances- Emergency Dental- Dentist, the panel finds that the ministry reasonably determined that these Schedules do not list “Crown, Porcelain/Ceramic/Polymer Glass” with a Fee Code of 27201. On the Schedule of Fee Allowances- Crown and Bridgework, the panel notes that there is a fee description for “Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base” listed with Fee Code 27211 that provides the sum of $624.20 as a fee amount, including lab fee. As the fee description in the Schedule includes “fused to metal base” and a fee code of “27211” rather than the requested “27201,” the panel concluded that the ministry reasonably determined that the Schedule of Fee Allowances- Crown and Bridgework does not list “Crown, Porcelain/Ceramic/Polymer Glass” with a Fee Code 27201. Therefore, despite the need to have this dental service completed due to pain and the extent of damage to the tooth, as detailed by the appellant and the dentist, the ministry cannot provide coverage for the requested dentist fee of $1,250 for the crown as a basic dental, emergency dental, or crown and bridgework supplement.

Items #3, 4 and 5- Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, for tooth 45 (Fee Code 67211), Pontics, Cast Metal for tooth 46 (Fee Code 62101), and Retainers, Full, Cast Metal for tooth 47 (Fee Code 67301)

For items #3, 4 and 5, the appellant’s request was for coverage of dental services to be provided by a dentist and described as Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, for tooth 45 (Fee Code 67211), Pontics, Cast Metal for tooth 46 (Fee Code 62101), and Retainers, Full, Cast Metal for tooth 47 (Fee Code 67301). The ministry considered the appellant’s eligibility for funding under Section 63 of the EAPWDR for basic dental services and

APPEAL NUMBER 2021-00044

Section 1 of Schedule C of the EAPWDR defines "basic dental service" to mean a dental service that, if provided by a dentist, is set out in the Schedule of Fee Allowances- Dentist. The ministry also considered the appellant’s eligibility for funding under Section 64 of the EAPWDR for emergency dental services and Section 1 of Schedule C defines "emergency dental service" to mean a dental service necessary for the immediate relief of pain that, if provided by a dentist, is set out in the Schedule of Fee Allowances- Emergency Dental- Dentist. Following review of these Schedules, the panel concluded that the ministry reasonably determined that these Schedules do not list “Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base” with a Fee Code of 67211, “Pontics, Cast Metal” with a Fee Code of 62101, or “Retainers, Full, Cast Metal” with a Fee Code of 67301 and the panel finds that the ministry reasonably concluded that the appellant is not eligible for coverage of these dental services as a basic dental or emergency dental supplement.

The ministry also considered the appellant’s eligibility for funding under Section 63.1 of the EAPWDR for crown and bridgework and Section 4.1(1) of Schedule C of the EAPWDR defines "crown and bridgework" to mean a dental service that is provided by a dentist and that is set out in the Schedule of Fee Allowances- Crown and Bridgework, that is effective April 1, 2010 and is published on the website of the ministry. In the reconsideration decision, the ministry noted that the dentist originally requested a Porcelain Pontics on tooth 46 (Fee Code 62501) and a Porcelain Retainer (Fee Code 67211) on tooth 47 but since a note in the Schedule of Fee Allowances- Crown and Bridgework says that only full cast metal Pontics and Retainers will be provided for tooth numbers ending in 6, 7 and 8, PBC assessed the full cast metal option for these services. The Standard Dental Claim Form dated August 18, 2020, in which the appellant made a claim for various dental services, a fee code of “62501” is listed for tooth 46 and a fee code of “67211” for tooth 47 and, following a review of the Schedule of Fee Allowances- Crown and Bridgework, the panel finds that the Schedule includes a note pertaining to Bridges (both Retainers and Pontics) that “only full cast metal retainers and pontics will be considered on tooth numbers 6, 7, and 8.” As the Schedule precludes provision of a porcelain Pontics and a porcelain Retainer for these teeth, the panel finds that the ministry reasonably considered the full cast metal options for tooth 46 and tooth 47.