Citation Nr: 1800178	
Decision Date: 01/03/18    Archive Date: 01/19/18

DOCKET NO.  16-586 57A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Medical Center in Fort Harrison, Montana



THE ISSUE

Entitlement to payment or reimbursement of medical expenses incurred at a private hospital on August 1, 2013.



ATTORNEY FOR THE BOARD

J. Connolly, Counsel



INTRODUCTION

The Veteran served on active duty from September 1962 to September 1964.

This case is before the Board of Veterans' Appeals (Board) on appeal from a decision by the Department of Veterans Affairs Medical Center (VAMC) in Fort Harrison, Montana. 

The issue of entitlement to payment or reimbursement of hotel expenses incurred on September 24, 2013 following private medical treatment on September 23, 2013 as a result of that treatment, has been raised by the record but has not been adjudicated by the Agency of Original Jurisdiction (AOJ).  See annotated August 4, 2016 letter of the VA Northern Arizona VA Health Care System.  It is noted in that letter that no claim had been filed, but the annotated version is accepted as a claim.  Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action.  38 C.F.R. § 19.9(b) (2017).


FINDING OF FACT

The Veteran's medical treatment provided by the Mayo Clinic in Scottsdale, Arizona, on August 13, 2013, was authorized in advance.


CONCLUSION OF LAW

The criteria for payment or reimbursement for medical services provided by the Mayo Clinic in Scottsdale, Arizona, on August 13, 2013, have been met.  38 U.S.C. §§ 1703, 5107 (2012); 38 C.F.R. § 17.54 (2017).



REASONS AND BASES FOR FINDING AND CONCLUSION

Veterans Claims Assistance Act of 2000 (VCAA)

With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions.  38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326.  Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim.  38 U.S.C.  5103 (a); 38 C.F.R. § 3.159 (b); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  However, because the claim in this case is governed by the provisions of Chapter 71 of Title 38 of the United States Code, the VCAA and its implementing regulations may not be applicable to such claims.  See Barger v. Principi, 16 Vet. App. 132, 138 (2002) and Lueras v. Principi, 18 Vet. App. 435 (2004). 

Reimbursement

Initially, the Board must make a factual determination as to whether VA gave prior authorization for the non-VA medical care provided during the hospitalization in question.  See 38 U.S.C. § 1703 (a); see also 38 C.F.R. § 17.54.  This is a factual, not a medical, determination.  See Similes v. Brown, 5 Vet. App. 555 (1994).  The law provides that, in connection with its statutory obligation to provide medical services to veterans, VA may contract for private care in certain limited circumstances.  Pursuant to 38 U.S.C.A. § 1703 (a), "When Department [of Veterans Affairs] facilities are not capable of furnishing . . . the care or services required, the Secretary, as authorized in [38 U.S.C. § 1710 or 1712], may contract with non-Department facilities in order to furnish certain care.  The admission of a veteran to a non-VA hospital at the expense of VA must be authorized in advance.  38 C.F.R. § 17.54.  See Opinion of the VA General Counsel, VAOPGCCONCL 
1-95, at 9 (Mar. 31, 1995) ("Authorization in advance is essential to any determination as to whether the Department is or is not going to furnish the contract care.").  In the case of an emergency that existed at the time of admission, an authorization may be deemed a prior authorization if an application is made to VA within 72 hours after the hour of admission.  38 C.F.R. § 17.54. 

The record shows that the Veteran was scheduled for urinary bladder surgery at the Mayo Clinic in Scottsdale, Arizona, on August 13, 2013.  During preoperative evaluation for that surgery, it was discovered that the Veteran had pneumonia via a chest x-rays so the Veteran was provided medication and discharged prior to the scheduled surgery to prepare him for the surgery.  The surgery was canceled until a later date, as indicated in an August 1, 2013 VA medical note which documents the event and circumstances.  The Board notes that the Veteran's claim was denied because the treatment was deemed not pre-authorized and was non-emergent in nature.  However, an August 4, 2013 letter of the VA Northern Arizona VA Health Care System reflects that the Veteran was approved by VA for non-VA care on that date for the bladder surgery.  The Board notes that the Veteran was scheduled for a surgical procedure and, as such, the preoperative care is part of that surgical process as the surgery does not commence until the preoperative assessment is complete and the Veteran is cleared for the procedure.  Once the Veteran was discovered to have pneumonia, he was discharged from preoperative care as the surgery could not be conducted until that was resolved.  The Board finds that the Veteran was preauthorized for medical treatment at the Mayo Clinic in Scottsdale, Arizona, on August 13, 2013, and that the preoperative assessment and treatment was contemplated as part of that medical treatment and was therefore also authorized in advance even though the surgery itself could not be conducted.  










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ORDER

Entitlement to payment or reimbursement of medical expenses incurred at a private hospital on August 1, 2013, is granted, subject to the laws and regulations governing the payment of monetary benefits.




S. L. Kennedy
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs