Ministry of Social Development and Poverty Reduction

Appeal Number 2022-0240 Part C – Decision Under Appeal The decision under appeal is the Reconsideration Decision (RD) of the Ministry of Social Development and Poverty Reduction (the Ministry), dated October 11, 2022, which denied the Appellant’s request for an exam, a cone-beam computed tomography (CBCT) scan, and a crown on teeth #44 and #16 (collectively, the Dental Work).

Specifically, the Ministry determined that the Appellant is not eligible for coverage of the Dental Work as a basic dental service under the Schedule of Fee Allowances – Dentist, Emergency Dental – Dentist, effective September 1, 2017 (the Fee Schedule), as an emergency dental service, as a crown and bridge supplement, as a crisis supplement, or because it represented a direct and imminent life threatening health need.

Part D – Relevant Legislation Employment and Assistance Act (EAA), Sections 22(4) and 24(1) 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 The Fee Schedule

The relevant legislation is provided in the Appendix

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Appeal Number 2022-0240 Part E – Summary of Facts The Appellant is a recipient of disability assistance. According to information included in the Ministry’s RD: • On September 15, 2022, the Appellant submitted a Predetermination Explanation of Benefits form (the PEB Form) from Pacific Blue Cross (PBC) indicating that PBC had denied the Appellant’s request for the cost of a consultation (exam) and a CBCT scan because they are not a covered benefit under the Appellant’s plan;

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On September 27, 2022, the Appellant submitted a request for reconsideration (RFR);

PBC denied the Appellant’s request for coverage of the cost of a Crown on two of her teeth on October 3, 2022. Details of the Appellant’s request and the reasons for PBC’s decision are provided in the summary of the information in the PBC Claim Assessment evidence summary below; and

On October 6, 2022, the Ministry asked PBC to provide the documentation provided by the Appellant’s dentist (the Dentist) concerning her request for coverage. Details of the information contained in the documentation provided are detailed in the summary of the information in the Standard Dental Claim Form and the X-Rays evidence summaries below.

The evidence before the Ministry at reconsideration included the Appellant’s RFR, dated September 27, 2022, which included:

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The Appellant’s reasons for the RFR, which were she wrote were as follows: “I have been having chronic infections on three of my teeth that have had root canal done many years ago. The chronic infections caused a lot of pain and discomfort and I have endured it for many years due to lack of funds for proper treatments. Because my body absorbed the reinfections and redistributed and circulated it to other areas of the body, I have been very ill chronically for many years that sent me to the hospital ER department a few times. My dentist (has) also advised me that if I don’t seek help from (an endodontist) immediately, I may lose those teeth. Once I am assessed by the endodontist he will advise on a treatment plan. The treatment plan may include retreatment of the root canal. Then a crown on top of each affected tooth, or if the damage of the infection is too severe that the teeth are no longer salvageable, he may need to extract the teeth and do implants on it at a later date. I … ask the Ministry to … allow funding for any treatment plans the endodontist may have after consultation. I am currently not working due to illness and I have no financial means to pay for the consultation nor the treatment … I am in constant pain and discomfort …”;

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Appeal Number 2022-0240 A one-page letter, dated September 15, 2022 and addressed “To Whom it May Concern”, referring to the Appellant and signed by a mental health and poverty law advocate representing a community social services agency. The letter says, in part, that the advocate was hoping that the Ministry could assist the Appellant in “obtaining (the) … funding to complete the dental work deemed necessary for her health by the Dentist and Orthodontist … I believe that (the Appellant) would benefit greatly from securing this funding as it would allow her to access additional health benefits as well as giving her a strong foundation to focus on attending to her emotional and physical health needs”;

A two-page predetermination explanation of benefits (PEB) form in the name of the Appellant with a submission date of August 29, 2022 (the PEB Form). The PEB Form lists two procedures: a consultation and a CBT scan, with charges of $140 and $150 respectively, for a total charge of $290;

A two-page PBC document titled “AUTHORIZED PRODUCTS AND SERVICES”, dated October 3, 2022 (the PBC Claim Assessment), which provides the results of PBC’s assessment of a claim for dental service coverage made by the Appellant on September 21, 2022. The PBC Claim Assessment indicates that three dental services included in the Appellant’s September 21, 2022 claim were not approved for funding, as follows:

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A claim for one crown, fused to metal base, showing an amount submitted of $1,194.00 and an amount approved of $0.00. The reasons given for denial of coverage are that “(t)he documentation provided does not indicate that the dental condition precludes the provision of restorative services set out under the restorative services section the Ministry Fee Schedule, the clinical explanation submitted does not confirm that (the Appellant) needs cannot be met through the Ministry basic dental program, and the information provided does not confirm that one of the (four) circumstances listed (in EAPWDR Schedule C, Section 4.1(2) applies);

A claim for one full cast metal crown, showing an amount submitted of $1,194.00 and an amount approved of $0.00. The reasons given for denial of coverage are the same as listed under the previous bullet; and

A claim for an examination and a CBCT scan, showing amounts submitted of $140.00 and $150.00 respectively, and an amount approved of $0.00. The reasons given for denial of coverage are that neither dental service is a covered benefit under the Appellant’s plan;

A one-page document titled “PREDETERMINATION – STANDARD DENTAL CLAIM FORM” (the Standard Dental Claim Form), prepared by the Appellant’s Dentist on behalf of the Appellant and dated September 2, 2022. The Standard Dental Claim

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Appeal Number 2022-0240 Form lists dental services for two of the Appellant’s teeth, both identifying procedure code 27201, and each showing a total charge of $1,194.00, for a combined total claim in the amount of $2,388.00. In response to the question “Are any dental benefits or services provided under any other group insurance or dental plan, W.C.B. or gov’t plan?” on the Standard Dental Claim Form, the Appellant has ticked “yes” and provided the name of the other insuring agency (Manulife Financial) and the policy number; and

• Two pages comprising eight X-Ray images of the Appellant’s teeth. Additional Information In the Notice of Appeal (NOA), dated October 13, 2022, the Appellant wrote “I have had chronic infections on my teeth for many years. It affected all aspects of my life especially my health. I desperately need help. Please help”.

On December 14, 2022, the Appellant submitted a five-page document containing additional evidence (the Appellant Submission). In addition to a cover e-mail, the Appellant submission comprised:

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A two-page document titled “Pre Treatment Estimate” identifying the Appellant as “Patient” and dated November 24, 2022 (the Estimate). The Estimate lists nine treatments on three of the Appellant’s teeth (#36, #37, and #12). The Estimate was provided by an endodontist on November 24, 2022, with estimates for the services totalling $7,150, deductibles totalling $0, amount covered by insurance of $0, and a total estimated charge due to the Appellant of $7,150;

A one-page consultation report from an endodontist and addressed to the Dentist, dated November 20, 2022, regarding the results of an examination of two of the Appellant’s teeth (the Consultation Report). The Consultation report says, in part:

“Patient complains of periodic pain and gingival swelling near #36, #37 and near #12 for over 10 years. Patient also reported fever and stuffy nose that were often associated with gingival swelling … cone-beam computed tomography scan revealed large size radiolucencies associated with #36 and #37 root apexes, both lesion(s) are close to the inferior alveolar nerve. #37 had more percussion pain than #36. #12 also has small apical radiolucency but with noticeable apical palpation pain. I have recommended endodontic Retreatment on #37, #36 and #12. I am uncertain that the fever and stuffy nose symptoms are indeed related to root canal infections, and have recommended patient to see a Rheumatologist”. The Consultation Report also includes eight x-Rays and photographic images of the Appellant’s teeth;

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A one-page letter from the Dentist addressed “To Whom it May Concern” and dated December 13, 2022 (the Dentist’s Letter). The Dentist’s Letter refers to their patient

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Appeal Number 2022-0240 (the Appellant) and her recent consultati on with the endodontist “to diagnose the suspected ongoing infections and irritation that (the Appellant) has been experiencing”. The Dentist’s Letter also says:

“I performed a root canal on (two of the Appellant’s other teeth) … in the past. I strongly advised (the Appellant) to have 2 crowns completed to help protect the integrity of the root canals to prevent potential future damage or infections of those 2 teeth. I am supportive in the fact that I believe this is necessary for (the Appellant) to have these dental procedures and that they will benefit the health and life of (the Appellant). The infections have brought (the Appellant) pain, and I believe to have led to overall health issues, but this is something I cannot state for certain”.

Evidence Presented at the Hearing The Appellant was also represented at the hearing by an advocate (the Advocate). At the hearing, speaking on behalf of the Appellant, the Advocate said that the Appellant was challenging the Ministry’s RD because “Ministry policy” allows the Ministry to provide a dental supplement if there is a “direct and imminent health need”. The Advocate argued that the additional evidence contained in the Appellant Submission confirms that not providing a dental supplement for the Dental Work would have a severe impact on the Appellant’s health.

The Appellant said that her body has been fighting an infection for 10 to 15 years, and that blood tests have shown that her white blood cell count is two to three times higher than normal. She said that medical professionals have been unable to identify the cause of her abnormally high white bold cell counts, and that she takes anti-inflammatory medication to address the chronic fevers and gum-swelling she experiences as a result of the infection. In response to a question from the Panel, the Appellant confirmed that the periodic pain and gum swelling she is experiencing is present near teeth #36, #37 and #12, as stated in the Consultation Report. She said that because of the pain she experiences as a result of the chronic infection she chews on the other side of her mouth, and has done so constantly for many years. She said that her body “metastasizes and temporarily relocates the infection to other parts of (her) body”. She also said that she has also developed ulcers from anti-inflammatory drugs and that she is unable to take Naproxen. She said that medical professionals have told her “(t)he active infection won’t go away on its own. Taking medications are not a preventative action … (my impairments) affect all aspects of my life”.

Regarding a conclusive diagnosis of the cause of her chronic infection, the Appellant said that medical professionals have told her that it is difficult to make a connection between her high white blood cell count and her “tooth problems”, adding “(t)he doctor and the dentist can’t converse – it’s hard to make that happen. Everyone is inconclusive and uncertain.

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Appeal Number 2022-0240 I can’t get anyone to say (that there is a direct link between the high white blood cell count and the problems with my teeth).”

In response to a question from the Ministry, the Appellant said that she has not been prescribed antibiotics for her infection because her doctor isn’t sure of the cause of her infection. In response to another question from the Ministry, the Appellant said that the Dentist had referred her to an endodontist because the Dentist was not confident that he could treat her for the required additional crowns for teeth #36, #37 and #12 as the Dentist “doesn’t have knowledge in a situation where there is an infection and doesn’t have the (necessary dental equipment)”.

In response to a question from the Panel about whether her doctor had referred the Appellant to a rheumatologist as recommended by the endodontist in the Consultation Report, the Appellant said that she has not yet seen a rheumatologist but will be asking her doctor to make a referral.

In response to another question from the Panel about whether the Appellant had considered applying for coverage from Manulife Financial under the policy identified in the Standard Dental Claim Form, the Appellant said that that insurance was no longer in effect because it had been provided by a previous employer for whom she no longer worked.

The Ministry relied on the RD, emphasizing that the legislation does not permit coverage for any of the Dental Work in the Appellant’s circumstances because the fee codes relating to the Dental Work do not appear in the Fee Schedule and the Ministry does not have the discretion that would allow it to make any exceptions to the types of dental services it’s permitted to provide under the legislation.

When asked by the Appellant to explain in more detail the circumstances under which a crown and bridge supplement could be provided under EAPWDR Schedule C, Section 4.1, the Ministry said that eligibility depends on some very specific criteria. The criteria are that the problem can’t be corrected through the basic dental services (because the dental condition can’t be addressed by a “restorative service”), and because one of the other specified circumstances exists. The circumstance listed in the legislation are:

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The dental condition won’t permit the use of a “removable prosthetic”; The person has a physical impairment that makes it impossible for them to use a removable prosthetic;

The person has an allergic reaction or other intolerance to the materials used in a removable prosthetic; or,

The Person has a mental condition that makes it impossible for them to assume responsibility for a removable prosthetic.

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Appeal Number 2022-0240 In response to a question from the Panel, the M inistry said that a removable prosthetic would include both partial and full dentures.

In response to a question from the Appellant about what kind of physical or mental conditions might make it impossible for a person to use a removeable prosthetic, the Ministry said this would include any physical condition under which the person has no way of putting in or taking out dentures on their own, or was mentally incapable of putting in or taking out the dentures. The Appellant said that her disabilities were both physical and mental, and resulted from multiple concussions she suffered as a result of a car accident.

The Advocate asked the Ministry whether the Appellant might qualify for root canals because they appear in the Fee Schedule under “periapical services” as service codes 34111 through 34264. The Ministry said that the Appellant might qualify for partial coverage under this provision. In response to a related question from the Appellant, the Ministry said yes, the Appellant would have to fill out a new application for coverage for root canals. There followed a discussion about whether the new application would have to be completed by the Dentist or an endodontist in the Appellant’s circumstances. In the end, the Appellant was advised to contact the Ministry by phone to ensure that an application was properly completed if she wished to proceed with one.

Admissibility of New Evidence Section 22(4) of the Employment and Assistance Act (EAA) says that a panel may consider evidence that is not part of the record that the panel considers to be reasonably required for a full and fair disclosure of all matters related to the decision under appeal. Once a panel has determined which additional evidence, if any, is admitted under EAA Section 22(4), instead of asking whether the decision under appeal was reasonable at the time it was made, a panel must determine whether the decision under appeal was reasonable based the requirements set out in the legislation and on all admissible evidence.

New evidence that the Ministry didn’t have when it made its RD comprises: • In the NOA, the Appellant’s assertion that: o Her body “absorbed the reinfections and redistributed and circulated it to other areas of (her) body” and caused her to have to visit the hospital ER department a few times;

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Her dentist told her she might lose some of her teeth if she didn’t immediately seek help from an endodontist. Once she has been assessed by an endodontist she will have a treatment plan; and,

The treatment plan that the endodontist recommends might include retreatment of one or more of the root canals, a crown on top of each affected

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Appeal Number 2022-0240 tooth, or if any of her teeth are not sa lvageable, tooth extractions followed by implants on a later date.

In the Estimate (forming part of the Appellant Submission), the estimated cost of treatments to three of the Appellant’s teeth (#36, #37 and #12);

In the Consultation Report (also forming part of the Appellant Submission), the endodontist’s explanation of the results of the examination of teeth #36, #37 and #12, the endodontist’s recommendation for endodontic retreatment of those teeth, and the statement “I am uncertain that the fever and stuffy nose symptoms are indeed related to root canal infections, and have recommended patient to see a Rheumatologist”;

In the Dentist’s Letter (also forming part of the Appellant Submission), the Dentist’s statement that the Dentist:

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Performed root canals on the Appellant’s two teeth that are the subject of this appeal;

“(S)trongly advises” the Appellant to have these two crowns retreated by an endodontist to “help protect the integrity of the root canals to prevent potential future damage or infections”;

Believes it is necessary for the Appellant to have the recommended dental procedures done as they will benefit her “health and life”, and the Appellant’s infections have led to overall health issues, but “this is something (the Dentist) cannot state for certain”.

At the hearing, the Appellant’s assertion that her white blood cell count is two to three times higher than normal, that medical professionals have told her that it is difficult to make a connection between her high white blood cell count and her tooth problems, the fact that the Manulife Financial dental plan insurance was no longer in effect, and the nature and circumstances of the accident that led to the Appellant being designated as a person with severe physical and mental impairments.

In deciding whether to admit any new evidence, a panel must first consider the Ministry decision under appeal, and then assess whether the new information is reasonably required for a full and fair disclosure of all matters relating to that decision. If the new information is reasonably required to assess the reasonableness of the decision in hand, a panel must admit it and assign it weight.

The decision under appeal in this case is the Ministry’s decision to deny the Appellant’s request for an exam, a CBCT scan, and a Crown on her teeth #44 and #16. Much of the information contained in the Appellant Submission and provided at the hearing concerns

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Appeal Number 2022-0240 the Appellant’s need to have teeth #44 and #16 retreated by an endodontist and her need to have dental treatments (root canals and crowns) on teeth #36, #37 and #12. As these dental treatments were not part of the Appellant’s original request for dental treatments and were therefore not addressed by the Ministry in the RD, the Panel has no basis upon which to admit any of this new evidence.

The Panel admits the new evidence presented by the Appellant at the hearing about her high white blood cell count and about her infections being redistributed and circulated to other areas of her body. The Panel also admits the Appellant’s evidence that medical professionals have not been able to firmly establish that her infections relate to the problems she is having with her teeth and that the problems might have led to broader health problems. However, the Panel notes that the Dentist is not able to confirm that the Appellant’s broader health problems are a result of her need for the Dental Work or any of the other dental treatments referred to in the new evidence.

In addition, no new evidence has been provided by any medical professionals (either medical or dental practitioners) resulting in a diagnosis that connects the pain and swelling in the Appellant’s gums to her broader health problems. Neither have any test results been provided to confirm that the Appellant’s white blood cell count is high, how high it is, or what the implications might be. The Panel further notes that the recommended consultation with a rheumatologist, which might provide additional evidence, has not yet taken place.

Because the information provided by the Appellant about her high white blood cell counts and their impact on her health, and any possible links between her dental problems and her overall health has not been confirmed by any medical professionals, the Panel assigns little weight to this new information. It is unclear whether medical opinions regarding the Appellant's white blood cell counts would have affected the Ministry's RD.

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Appeal Number 2022-0240 Part F – Reasons for Panel Decision EAA Section 24(1) limits a panel’s authority to render a decision as the result of an appeal to determining whether the decision being appealed is reasonably supported by the evidence or is a reasonable application of the applicable enactment in the circumstances of the Appellant. With respect to this appeal, the Panel must determine whether the Ministry’s RD dated October 11, 2022, which denied the Appellant’s request for the Dental Work, was reasonable based on the legislation and the available evidence.