Part C – Decision Under Appeal
Appeal Number 2022-0015
Under appeal is the reconsideration decision of the Ministry of Social Development and Poverty Reduction (the ministry) dated January 13, 2022, denying funding for dental services for tooth 46 under the Employment and Assistance for Persons with Disabilities Regulation (EAPWDR). The ministry concluded that the appellant: is not eligible for coverage for a porcelain/ceramic crown (fee code 27211) or, alternatively, a full cast metal crown (27301), in conjunction with a composite core (27211, 27301 and 23602) as a basic dental or emergency dental service because it is not included in the Dental Supplement section of the Schedule of Fee Allowances; is not eligible for coverage for a porcelain/ceramic crown (27211) or, alternatively, a full cast metal crown (27301), in conjunction with a composite core (27211, 27301 and 23602) as a Crown and Bridge Supplement. While the ministry was satisfied that the appellant’s dental condition cannot be corrected by restorative services, it has not been established that the appellant is unable to use a removable prosthetic; is not eligible for a crown and composite core as a life-threatening health need because dental supplements are not set out in section 69 (life-threatening health need); and, is not eligible for a crown and composite core under section 57 (crisis supplement) because the ministry may not provide a supplement described in Schedule C or any other health care goods or services under this section.
Part D – Relevant Legislation
Employment and Assistance for Persons with Disabilities Regulation (EAPWDR) sections 57, 63, 63.1, 64, and 69
EAPWDR Schedule C, sections 1, 4, 4.1, and 5 Schedule of Fee Allowances (Dental Supplements, Emergency Dental Supplements, Crown and Bridgework Supplements)
Part E – Summary of Facts
Appeal Number 2022-0015
The appellant has PWD designation and is a recipient of disability assistance. The ministry has delegated its powers, duties and functions respecting dental supplements to Pacific Blue Cross (PBC) in accordance with section 34 of the Employment and Assistance Act.
The appellant’s dentist provided a proposed course of treatment for tooth 46 dated September 24, 2021: “27211 Porce/Ceram/Fused to Met” - fee: $939 “99111 Lab PFM Crown” - fee: $350 “23602 Etch/Bnd, W Crown” - fee: $90.56. Total fee: $1379.56 “Multiple cracklines & large filling. Needs crown.” The panel notes that all lab fees are included in the cost of crown and bridgework set out in the Schedule of Fee Allowance - Dentist; consequently, the proposed crown fee for 27211 is $1289.00 ($939+$350).
A predetermination of benefits by PBC dated October 6, 2021 indicates that the appellant is not covered for procedures 23602 and 27211.
Information from ministry files on the dental service codes and dentist’s fees at issue:
Tooth Fee No. Code
46
46
23602
27211
Description
Bonded Composite Core, in Conjunction with Crown
Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base TOTAL:
Dentist Fees
$90.56
$1289.00 $1379.56
Amount Approved by PBC
$0
$0 $0
Information provided on appeal In her Notice of Appeal dated January 18, 2022, the appellant writes that she has no other resources available to pay for her crown. She has no master card or visa card and no family who can help. The tooth in question is important for chewing as part of digestion. She has only 8 lower teeth. She does not receive enough money monthly to save up for dentistry, and the dentist does not offer monthly payments. If her tooth keeps hurting she will have to get it extracted which would be bad for her digestion.
Admissibility of New Information The panel finds that the information provided by the appellant in her Notice of Appeal is reasonably required for a full and fair disclosure of all matters related to the decision under appeal, as it contributes to the panel’s understanding of the circumstances surrounding the appellant’s dental claim. The panel therefore admits this information as evidence pursuant to section 22(4) of the Employment and Assistance Act.
Part F – Reasons for Panel Decision
Appeal Number 2022-0015
Issue on Appeal The issue on appeal is whether the ministry’s decision to deny the appellant the requested funding for a crown and composite core was reasonably supported by the evidence or was a reasonable application of the legislation in the circumstances of the appellant.
Positions of the Parties The appellant’s position is that funds should be made available to her to pay for a crown as she has no resources of her own. She argues that the tooth in question plays an important part in her digestion and an extraction would worsen it.
The ministry’s position is that the appellant is not eligible to receive funding for a crown and composite core because
she is not eligible for coverage of a Crown, Porcelain/Ceramic Fused to Metal Base (or alternatively a Full Cast Metal Crown) and Composite Core (fee codes 27211, 27301 and 23602) as a Basic Dental Service or Emergency Dental Service because the requested dental treatment is not set out in the Schedules of Fee Allowances - Dentist and Emergency Dental - Dentist.
She is not eligible for coverage as a Crown and Bridgework Supplement because only full cast metal crowns can be provided for tooth 46 which means the crown (fee code 27211) originally requested by the dentist cannot be considered. In addition, neither she nor her dentist has indicated that her dental condition precludes the use of a removable prosthetic.
She is not eligible for coverage of a Crown and Composite Core as a life-threatening health need. Section 69 only applies to medical transportation, medical equipment / devices, and some types of medical supplies. Dental and denture supplements are not set out in these sections.
Section 57(3) of the EAPWDR says that 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. As a result, the appellant is not eligible to receive a crisis supplement to cover a dental service - Crown and Composite Core.
Panel’s Analysis The EAPWDR addresses dental services as follows: Section 1 of Schedule C defines “basic dental service” and “emergency dental service”, and section 4.1(1) of Schedule C defines “crown and bridgework” as a dental service set out in the applicable section of Schedule of Fee Allowances
For crown and bridgework dental services, section 4.1(2) of Schedule C of the Regulation imposes the additional requirements that: (a) the dental condition precludes the provision of the restorative services set out in the Schedule of Fee Allowances – Dentist; and (b) use of a removable prosthetic is precluded for one of the listed reasons.
Additional requirements for specific dental services are also set out in the Schedule of Fee Allowances.
Appeal Number 2022-0015
The appellant’s dentist requested coverage of a Bonded Composite Core and Crown (fee code 23602) and a Porcelain/Ceramic Fused to Metal Base (fee code 27211) for tooth 46. A note in the Schedule of Fee Allowance says the ministry is not permitted to provide coverage for this type of crown on tooth 46 and therefore the ministry has also addressed the alternative service (Full Cast Metal Crown 27301) as suggested by PBC.
In the appellant’s case, the panel finds that the ministry reasonably determined that, based on the definition of basic dental service, the appellant is not eligible for coverage of a Crown, Porcelain/Ceramic Fused to Metal Base (or alternatively a Full Cast Metal Crown) and Composite Core (fee codes 27211, 27301 and 23602) as a Basic Dental Service or Emergency Dental Service because the requested dental treatment is not set out in the Schedules of Fee Allowances - Dentist and Emergency Dental - Dentist.
The Crown and Bridgework section of the Schedule of Fee Allowances only allows for a full cast metal crown (fee code 27301) for tooth 46. Consequently, the panel finds that the ministry was reasonable to conclude that the appellant was not eligible under this section because the originally requested crown (fee code 27211) cannot be considered. Furthermore, the appellant’s dentist has not indicated that her dental condition precludes the use of a removable prosthetic and as such the appellant has not met this eligibility requirement.
The panel finds further that the ministry reasonably determined that the appellant is not eligible for coverage of a crown and composite core as a life-threatening health need. The ministry stated correctly that section 69 only applies to medical transportation, medical equipment / devices, and some types of medical supplies; dental and denture supplements are not set out in these sections. While the appellant reports that loss of her tooth would have a negative impact on her digestion the panel finds that there is no evidence that the appellant needs a crown and composite core in order to avoid a life-threatening situation.
The panel also finds that the ministry was reasonable when it denied coverage for a crown and composite core as a crisis supplement. The ministry correctly quoted and interpreted section 57(3) which says that the ministry may not provide a crisis supplement to obtain a supplement described in Schedule C (where dental supplements are listed) or for any other health care goods or services.
Conclusion The panel acknowledges that the appellant may benefit from the crown proposed by her dentist and that the loss of tooth 46 may have a negative impact on her digestion. However, based on the coverage requirements set out in the EAPWDR and the Schedule of Fee Allowances, the panel concludes that the ministry’s reconsideration decision denying the requested coverage for the dental services was a reasonable application of the legislation in the circumstances of the appellant. The panel therefore confirms the reconsideration decision and the appellant is not successful on appeal.
Appeal Number 2022-0015
Employment and Assistance for Persons with Disabilities Regulation
Crisis supplement 57 (3)A crisis supplement may not be provided for the purpose of obtaining (a)a supplement described in Schedule C, or (b)any other health care goods or services.
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
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 family unit in receipt of disability assistance
Health supplement for persons facing direct and imminent life threatening health need 69 (1)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, (c)the adjusted net income of any person in the family unit, other than a dependent child, does not exceed the amount set out in section 11 (3) of the Medical and Health Care Services Regulation, and (d)the requirements specified in the following provisions of Schedule C, as applicable, are met: …
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….
Appeal Number 2022-0015
"emergency dental service" means a dental service necessary for the immediate relief of pain that (a) if provided by a dentist, (i) 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, and (ii) is provided at the rate set out in that Schedule for the service and the category of person receiving the service….
Dental supplements 4 (1.1) The health supplements that may be paid under section 63 [dental supplements] are basic dental services……
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 published on the website of the minister, (c) that is provided at the rate set out for the service in that Schedule……
Emergency dental supplements 5 The health supplements that may be paid for under section 64 [emergency dental and denture supplements] of this regulation are emergency dental services.
Schedule of Fee Allowances - Crown and Bridgework Effective April 1, 2010
FEE NO. FEE DESCRIPTION FEE AMOUNT ($) CROWNS Note: Limited to one per tooth in a five-year period. Only full cast metal crowns will be considered on tooth numbers 6, 7 and 8. 27301 Crown, Full Cast Metal *539.90 27211 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base *624.20 CORES Note: Limited to one per tooth in a five-year period. 23602 Bonded Composite Core, in Conjunction with Crown 90.56 *Denotes Lab fee(s) included
Part G – Order The panel decision is: (Check one)
APPEAL NUMBER 2022-0015
☒Unanimous
☐By Majority
The Panel ☒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)☐ or Section 24(1)(b) ☒ Section 24(2)(a)☒ or Section 24(2)(b) ☐
Part H – Signatures Print Name Inge Morrissey
Signature of Chair
Date (Year/Month/Day) 2022/02/16
Print Name Robert Kelly
Signature of Member
Date (Year/Month/Day) 2022/02/16
Print Name Effie Simpson
Signature of Member
Date (Year 2022/02/16