Ministry of Social Development and Poverty Reduction

APPEAL NUMBER 2021-0168 Part C – Decision Under Appeal The decision under appeal is the Ministry of Social Development and Poverty Reduction (ministry) reconsideration decision dated August 10, 2021, which determined that the appellant was not eligible for coverage of surgical treatment for dental implants as per the Employment and Assistance for Persons with Disabilities Regulation, sections 57, 63, 63.1, 64 and 69. Specifically, the ministry determined that the appellant was not eligible for coverage of dental implants as a crisis supplement, or health supplement (dental supplement, crown and bridgework supplement, emergency dental and denture supplement or a health supplement for persons facing a direct and imminent life-threatening health need). In addition, the ministry determined it was unable to conduct a reconsideration of the exam and diagnosis, panoramic film, personal protective equipment surcharge consult, completed on June 2, 2021, as per section 16 of the Employment and Assistance for Persons with Disabilities Act.

Part D – Relevant Legislation

Employment and Assistance for Persons with Disabilities Act (EAPWDA), section16 Employment and Assistance for Persons with Disabilities Regulation (EAPWDR), sections 57, 63, 63.1, 64, 69 and Schedule C, sections 1, 4, 4.1, and 5

APPEAL NUMBER 2021-0168 Part E – Summary of Facts Relevant Evidence Before the Minister at Reconsideration

Ministry records show: ▪ The appellant is a recipient of disability assistance. ▪ On July 20, 2021 the appellant’s mother contacted the ministry to request reconsideration of Pacific Blue Cross’s decision to deny coverage of dental implants. ▪ The ministry reviewed the appellant’s preauthorization history with Pacific Blue Cross (PBC) and noted the appellant’s dentist requested coverage on July 9 and 19, which PBC denied because these items are not covered under the appellant’s plan. Payment Receipt from Dr. C (June 2, 2021) - exam & diagnostic surgical, general - panoramic film - personal protective equipment (PPE) surcharge consult - payment $160 Letter to Whom It May Concern, from Dr. C (June 3, 2021) Dr. C saw the appellant on June 2, 2021 for a consultation regarding dental implants to support both upper and lower overdentures. The appellant had all of his teeth removed approximately three years ago by Dr. B. He had both upper and lower dentures made a few months later but the appellant has been unable to wear his dentures for the past five years due to a lack of suction and retention, which limits what he can eat. This affects his overall ability to get proper nutrition. The appellant has an extreme case of dry mouth and has virtually no vestibule in the maxillary posterior arch which makes it almost impossible to have an upper denture stay in place as there is no suction to help retain it. On his mandibular arch, the ridge has become very reserved and therefore there is also no retention to keep his lower denture in place. Without implants the appellant will not be able to wear dentures at all due to the lack of salivary production and severe resorption of both his maxilla and mandibular. The doctor recommended bilateral sinus augmentation with six maxillary implants as well as four mandibular implants with locator attachments to help create a stable platform to retain both upper and lower dentures. Having dental implants will dramatically increase the appellant’s ability to eat, chew, speak and maintain proper nutrition, which will benefit his overall health and well-being long term. Letter to Ministry, from a Registered Denturist (June 10, 2021) c/o Pacific Blue Cross Re: appellant The denturist wrote on behalf of the appellant regarding his oral state for new dentures. The appellant attended the denture clinic on May 18, 2021 for consultation and the denturist observed severely resorbed alveolar ridges on the maxillary and mandibular arches (i.e. a lack of adequate form to support conventional upper and lower dentures). In addition, the gingiva was very highly attached to the height of bone (i.e. the gingiva will work to destabilize and unseat conventional upper and lower dentures). The denturist stated it is rare to see a case of such extreme resorption combined with such highly attached gingiva. Due to the combination of these two conditions there is no point in the appellant proceeding with conventional upper and lower dentures - they simply would not function or have any chance of retention on his lower ridge and he would have substantial and ongoing problems with denture fit and function on his upper ridge. The appellant told the denturist that he had a set of conventional dentures made by another denturist approximately two years ago but lost them. He also stated that he never wore them much and had lots of

APPEAL NUMBER 2021-0168 trouble with them. Based on the denturist’s clinical findings of severely resorbed alveolar ridges and highly attached gingiva, the denturist was not surprised that the appellant was unable to tolerate those dentures. The only treatment for tooth replacement that will have any reasonable outcome for the appellant is to have implants placed on both arches and either bridges or dentures affixed to those implants. The denturist referred the appellant to Dr. C for consultation to discuss dental implants. Treatment Plan Proposal from Dr. C (June 21, 2021) 1. Cost of upper implants 2. Cost of lower implant Code Description Tooth Dr. Fee Total Insurance Patient Sequence Charge Charge Charge ($s) ($s) ($s) 79933 Denture 16 2000 2000 0 2,000 1 Implant 79933 Denture 14 2000 2000 0 2,000 1 Implant 79933 Denture 12 2000 2000 0 2,000 1 Implant 79933 Denture 26 2000 2000 0 2,000 1 Implant 79352 Sinus Graft 2000 2000 0 2,000 1 79352 Sinus Graft 2000 2000 0 2,000 1 79933 Denture 24 2000 2000 0 2,000 1 Implant 79933 Denture 22 2000 2000 0 2,000 1 Implant Sub- 16,000 16,000 0 16,000 Total 79933 Denture 32 2000 2000 0 2,000 2 Implant 79933 Denture 34 2000 2000 0 2,000 2 Implant 79933 Denture 42 2000 2000 0 2,000 2 Implant 79933 Denture 44 2000 2000 0 2,000 2 Implant 99902 PPE surcharge 30 30 0 30 2 surgery Sub- 8,030 8,030 0 8,030 Total Total 24,030 24,030 0 24,030 Letter to Whom It May Concern – from Dr. F (June 24, 2021) Re: appellant’s oral state for new dentures The appellant has a history of chronic pain and opiate use. Unfortunately, some opiates like the oxycodone he was taking can increase the risk for tolerance, dental caries, gingivitis and other oral conditions. He has lost all of his teeth and is unable to tolerate conventional dentures. He was recently

APPEAL NUMBER 2021-0168 seen by his dentist and was found to have severely resorbed alveolar ridges on the maxillary and mandibular arches. Due to lack of adequate bone needed to support conventional upper and lower dentures he was unable to tolerate dentures, as expected. Complicating matters further the gingiva is very highly attached to the height of the bone, which is likely contributing to the destabilization and unseating of conventional dentures. His dentist does not feel that proceeding with conventional dentures would be appropriate or effective and reports that the only treatment for tooth placement that will have any reasonable outcome for the appellant is to have implants placed on both arches and either bridges or dentures affixed to those implants. The appellant has been referred to Dr. C for consultation to discuss dental implants. Pre-determination letter from Pacific Blue Cross (PBC) (July 9, 2021) Patient Name – Appellant Tooth Submitted Eligible Deductible % Plan Approved No Amount Amount Covered Procedure Amount $s $0 Procedure Amount Message $s $s Code 79352 2000 0 0 0% 79352 0 C4708 79352 2000 0 0 0% 79352 0 C050L 12 79933 2000 0 0 0% 79933 0 C4708 14 70933 2000 0 0 0% 79933 0 C4708 16 70933 2000 0 0 0% 79933 0 C4708 22 70933 2000 0 0 0% 79933 0 C4708 24 70933 2000 0 0 0% 79933 0 C4708 26 70933 2000 0 0 0% 79933 0 C4708 32 70933 2000 0 0 0% 79933 0 C4708 34 70933 2000 0 0 0% 79933 0 C4708 42 70933 2000 0 0 0% 79933 0 C4708 44 70933 2000 0 0 0% 79933 0 C4708 99902 30 0 0 0% 99902 0 C4708 $24,030 0 C050L – This is a duplicate claim C4708 – We are unable to provide reimbursement for this expense. It is not a covered benefit under your plan. Request for Re-consideration (July 28, 2021) The appellant outlined the following reasons for needing his teeth: 1. First, he needs his teeth to eat. He can only eat soft food because he is unable to chew. Solid food causes him pain when he tries to eat and swallow. The appellant no longer accepts invitations to go anywhere for meals because he feels uncomfortable asking to cool a separate meal. 2. Secondly, the appellant needs teeth for his appearance. He is very self-conscious of the way people look at him. They treat him differently than when he had his own teeth. This makes him very uncomfortable so consequently he no longer goes out in public unless it's absolutely necessary. The only people he visits are members of his family. His mental health has deteriorated, and he finds himself contemplating ending his life. 3. Thirdly, the appellant needs teeth to talk. He slurs his words, which is affecting his mental health. Repeating sentences makes him uncomfortable talking to people directly or on the phone.

APPEAL NUMBER 2021-0168 Additional Information Appellant Notice of Appeal – August 26, 2021 The appellant provided the following submissions: Letter to Whom It May Concern – from Dr. AB (no date) Re: appellant The doctor states the appellant has been in dentures for several years. Unfortunately, he has not adapted well to them and consequently has been unable to eat a well-rounded diet. It has been shown time and time again what a life changer implant supported dentures can be for some people who are unable to tolerate traditional dentures. It would be a significant step up in health for the appellant to have his dentures supported by implants. Submission – by Appellant’s Mother to Appeal Tribunal (September 23, 2021) The request is for all or partial payment for the appellant’s implants and dentures. The appellant can’t possibly afford to pay for the implants and dentures as he is on PWD and his parents are pensioners. Physical Health: Before the appellant lost his teeth, he weighed around 120lbs. Now he weighs over 200 lbs with a small frame (5ft 5in). He can’t eat meat and vegetables unless they are chopped up finely or pureed. He can only eat carbohydrates such as mashed potatoes, rice or pasta, which has caused the weight gain. He has trouble walking, climbing stairs and has shortness of breath. Diabetes is a huge worry. The appellant is on disability because of many back issues and the weight gain just adds to the problem. Mental Health: Before the appellant lost his teeth, he had a great sense of humor and was easy to be around. Now, he only eats alone or with his partner as he does not want anyone to see his mouth, especially when eating. The appellant is depressed to the point of seeking a psychiatrist. He can't sleep and doesn't leave the house unless it's absolutely necessary. His friends react to his appearance. He has trouble speaking and has to repeat himself several times, especially on the phone. The appellant lost his teeth due to two back surgeries and a car accident - his physician prescribed opiates for pain. The opiates caused all of his teeth to rot and consequently were all removed in 2017. This situation has been really hard on his parents - watching the appellant deteriorate mentally and physically. He never smiles and seldom leaves the house to visit. Previously the appellant was a chef, a really good cook. The appellant lost a volunteer position with the local hockey team he had for years. He is allowed to do a small amount of work on disability but because of his appearance is unable to get even small jobs. At the hearing, the appellant provided some background information on his prior life (e.g. had his own business) and how his life completely changed with the opiates (lost his business, ended up on permanent disability). The appellant stated he was unaware of the side effects of taking the opiates. He lost his teeth and the dentures he was provided never fit. In attempting to find financial assistance for his dental implant surgery, the appellant considered several other options such as discussing payment plans, accessing community resources and accessing

APPEAL NUMBER 2021-0168 services offered at universities (students studying dentistry). However, none of these options were available. Ministry At the hearing, the ministry relied on the information in its record and added that it considered various pieces of legislation in making the decision. However, none of the legislation allows coverage for dental implants.

The panel determined that the additional information is reasonably required for a full and fair disclosure of all matters related to the decision under appeal and therefore is admissible under section 22(4) of the Employment and Assistance Act.

APPEAL NUMBER 2021-0168 Part F – Reasons for Panel Decision The issue on appeal is whether the ministry’s reconsideration decision, which determined that the appellant was not eligible for coverage of surgical treatment for dental implants as per the EAPWDR, sections 57, 63, 63.1, 64, and 69 was reasonably supported by the evidence or was a reasonable application of the legislation in the circumstances of the appellant. Specifically, did the ministry reasonably determine that the appellant was not eligible for coverage for dental implants as a crisis supplement, or health supplement (dental supplement, crown and bridgework supplement, emergency dental and denture supplement or a health supplement for persons facing a direct and imminent life-threatening health need)? In addition, did the ministry reasonably determine it was unable to conduct a reconsideration for the exam and diagnosis, panoramic film, PPE surcharge consult completed on June 2, 2021, as per section 16 of the EAPWDA?

Relevant sections of the legislation can be found in the Schedule of Legislation.

Ministry Argument Eligibility for coverage of dental services as a crisis supplement The ministry argues that the appellant is not eligible to receive a crisis supplement to cover dental implants as section 57(3) of the EAPWDR states the ministry may not provide a crisis supplement to obtain a supplement described in Schedule C or for any other health care goods or services and the dental services requested are a health care service, described in Schedule C. Basic Eligibility The ministry states although the appellant may be considered for coverage of basic dental services, emergency dental services, and crown/bridgework under sections 63, 63.1, and 64 (EAPWDR), the ministry is only authorized to provide coverage for dental services set out in the Schedule of Fee Allowances – Dentist. The ministry argues that although the appellant is a recipient of disability assistance, the requested dental treatment (surgical installation of implants, sinus osseous augmentation and aerosol generating procedures - fee codes 79933, 79352 and 99902) are not included in the Schedules of Fee Allowances - Dentist. Therefore, the appellant is not eligible for coverage of these items. Eligibility for Coverage as a life-threatening health need The ministry argues that the appellant is not eligible for coverage of dental services as a life-threatening health need as dental and denture supplements are not included in these sections. Reconsideration The ministry also argues a reconsideration cannot be made regarding the exam and diagnosis, panoramic film and PPE surcharge consult as the appellant’s dentist has not requested coverage for

APPEAL NUMBER 2021-0168 these items. As there is no pre-authorization or claim for these items on the appellant’s PBC file, no ministry decision or PBC decision was made. Therefore, a reconsideration decision was not completed. Appellant Argument The appellant argues that he needs his teeth to eat. He can only eat soft food because he is unable to chew. Solid food causes him pain when he tries to eat and swallow. He no longer accepts invitations to go anywhere for meals because he feels uncomfortable asking to cook a separate meal. The appellant argues further that he needs teeth for his appearance. He is very self-conscious of the way people look at him. They treat him differently than when he had his own teeth. This makes him very uncomfortable so consequently he no longer goes out in public unless it's absolutely necessary. The only people he visits are members of his family. His mental health has deteriorated, and he finds himself contemplating ending his life. In addition, the appellant argues he needs teeth to talk. He slurs his words, which is affecting his mental health. Repeating sentences makes him uncomfortable talking to people directly or on the phone. Analysis Section 16, EAPWDA – reconsideration and appeal rights Section 16 states that a person may request the minister to reconsider a decision that results in a refusal to provide a supplement for someone in the family unit and that a person who is dissatisfied with the outcome of a request for a reconsideration may appeal the decision that is the outcome of the request to the tribunal. The ministry argues a reconsideration cannot be made regarding the exam and diagnosis, panoramic film and PPE surcharge consult as the appellant’s dentist has not requested coverage for these items. As there is no pre-authorization or claim for these items on the appellant’s PBC file, no ministry decision or PBC decision was made. Therefore, a reconsideration decision was not completed. The panel notes a receipt for $160 (for exam and diagnosis, panoramic film and PPE surcharge consult) was submitted as evidence. The expenses are dental-related. However, as there are no fee codes associated with them, neither the ministry nor the tribunal is able to determine whether or not these items may be covered under the Schedule of Fee Allowances — Dentist. Therefore, the panel finds the ministry reasonably concluded it could not reconsider a decision for these items as per section 16 of the EAPWDR. However, the panel notes the ministry stated that because no decision regarding the eligibility for exam and diagnosis, panoramic film, PPE surcharge consult was made, the appellant’s dentist may submit the information to PBC at any time. PBC will then determine the appellant’s eligibility and if the appellant disagrees with the decision, he may request a reconsideration. Section 57 (EAPWDR) - crisis supplement Section 57(3) states, a “crisis supplement may not be provided for the purpose of obtaining…a supplement described in Schedule C, or…any other health care goods or services”. The panel notes the appellant has provided evidence (letters from dentists, denturist and doctor) that all demonstrate the need for him to have the surgical treatment needed for dental implants. The panel acknowledges that the appellant has great difficulty eating, talking and participating in social events, but as the appellant is requesting a supplement which is included in Schedule C, the panel finds the ministry reasonably determined that the appellant was not eligible for coverage for surgical installation of

APPEAL NUMBER 2021-0168 implants, sinus osseous augmentation and aerosol generating procedures as a crisis supplement under section 57(3) of the EAPWDR. Sections 63, 63.1 and 64 (EAPWDR) – dental, crown and bridgework, and emergency dental and denture supplements Sections 63, 63.1 and 64 all state that the minister may provide dental, crown and bridgework and emergency dental supplements (in Schedule C) for a recipient of disability assistance. The panel notes, ministry records show the appellant is a recipient of disability assistance. Schedule C defines: - "basic dental service" as a dental service that, if provided by a dentist, is set out in the Schedule of Fee Allowances — Dentist - “crown and bridgework” as a dental service that is provided by a dentist that is set out in the Schedule of Fee Allowances – Crown and Bridgework, and - “emergency dental” as a dental service necessary for the immediate relief of pain if provided by a dentist, is set out in the Schedule of Fee Allowances — Dentist. The panel notes the services are being requested by a dentist. However, the panel also notes that codes 79933, 79352 and 99902 are not found in the fee allowance schedules in the Dental Supplement—Dentist. basic dental service Therefore, the panel finds as “basic dental service” is defined in Schedule C as “a dental service…if provided by a dentist,…is set out in the Schedule of Fee Allowances – Dentist”, and as the above codes are not found in this Schedule, the ministry reasonably determined it was unable to provide coverage for dental implants under section 63 for basic dental service. crown and bridgework The panel also finds as “crown and bridgework” is defined, in Schedule C, as a dental service that is provided by a dentist that is set out in the Schedule of Fee Allowances – Crown and Bridgework (effective April 1, 2010) - in Dental Supplement – Dentist, and as the above codes are not found in this Schedule, the ministry reasonably determined it was unable to provide coverage for a dental implants under section 63.1 for crown and bridgework. emergency dental service In addition the panel finds as “emergency dental service” is defined, in Schedule C, as a dental service necessary for the immediate relief of pain…if provided by a dentist, is set out in the Schedule of Fee Allowances — Emergency Dental — Dentist, and as the above codes are not found in this Schedule, the ministry reasonably determined it was unable to provide coverage for a dental implants under section 64 for emergency dental service. Section 69 (EAPWDR) – health supplement for persons facing direct and imminent life-threatening health need Section 69 states 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…” The ministry argues the appellant is not eligible for coverage of dental services as a life-threatening health need as dental and denture supplements are not included under this legislation.

APPEAL NUMBER 2021-0168 The panel notes that section 2(1)(a) pertains to medical or surgical supplies, section (f) pertains to transportation and section 3 pertains to medical equipment and devices. Dental services are not included in this section. Therefore, the panel finds the ministry reasonably determined that the appellant was not eligible for coverage under section 69.

The panel acknowledges the appellant’s challenges. However, the role of the panel is to determine if the ministry reasonably applied its legislation.