Citation Nr: 18151852 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-13 683 DATE: November 20, 2018 REMANDED Entitlement to payment or reimbursement for medical expenses incurred at Jefferson Regional Medical Center from January 29, 2015 to January 31, 2015 is remanded. REFERRED The issue of entitlement to service connection for a kidney disorder, to include as due to exposure to herbicide agents, was raised in July and October 2015 statements, and is referred to the agency of original jurisdiction for adjudication. REASONS FOR REMAND The Veteran served on active duty from October 1968 to September 1971. The Veteran contends that payment is warranted for treatment of a kidney stone received at Jefferson Regional Medical Center from January 29-31, 2015. Private treatment records show that on January 29, 2015, the Veteran was admitted to Jefferson Regional Medical Center with complaints of stabbing right sided pain, nausea and vomiting. A CAT scan found a right-sided kidney stone with large amount of hydronephrosis. Payment or reimbursement for the treatment received at Jefferson Regional Medical Center was denied by VA on the basis that the Veteran had not received care under 38 U.S.C. Chapter 17 within the 24-month period prior to the treatment. The Veteran has written that he tried to receive medical care at the Pittsburgh Medical Center prior to his January 2015 treatment, but that medical care there was not available due to serious schedular appointment delays or problems. He wrote that on January 28 or 29, 2015, he called the Pittsburgh Medical Center and was told to go to his local emergency room. He wrote that he then called 911 and was told that the ambulance would only take him to the local emergency room, but not all the way to the Pittsburgh VA Medical Center. He also wrote that after he was admitted to the private facility, he was informed by a staff member there that VA had been contacted and had authorized this private care. Federal statutes and VA regulations offer several avenues by which a veteran can claim payment or reimbursement for emergency medical expenses incurred at non-VA medical facilities. Under 38 U.S.C. § 1703, medical services can be received at a private facility if they have been previously authorized by VA. 38 U.S.C. § 1703; 38 C.F.R. §§ 17.52, 17.53, 17.54. The Veteran has written that he did call the Pittsburgh VA Medical Center but they were unable to provide him with a ride, and the road to Pittsburgh was snowy and unsafe for travel. Consequently, he alleges that VA instructed him to go to the nearest emergency room. He has also asserted that staff at Jefferson Regional Medical Center contacted VA and that Jefferson received formal authorization from VA to provide treatment. The Board therefore requests that all records of contact between the Veteran and VA, as well as between Jefferson Regional Medical Center and VA from January 28, 2015 to January 31, 2015 be obtained and associated with the record, and a determination be made whether the Veteran received authorization from VA for private treatment in January 2015. Additionally, the Board also notes that the Veteran’s claim was initially denied by the agency of original jurisdiction on the basis that he had not received any treatment in the 24-month period prior to his treatment on January 29, 2015. The Veteran alleges that he was not informed that he had to undergo any treatment or evaluation prior to receiving private emergency care and that he had attempted to make an appointment at the Pittsburgh VA Medical Center, but was unable to do so due to scheduling delays at that facility. The Board requires that the agency of original jurisdiction obtain information documenting exactly when the Veteran enrolled for VA medical care and whether he received any kind of medical services after enrolling with VA and prior to his emergency treatment in January 2015. Under 38 U.S.C. § 1725; 38 C.F.R. § 17.1002, one of the criterion for reimbursement for emergency medical treatment is that the Veteran “received medical services” within the 24-month period preceding the emergency treatment. The term “medical services” is defined as including “the preventive health care services set forth in 38 U.S.C. § 1701(9).” Under 38 U.S.C. § 1701(9), “preventive health services” includes “patient health education (including nutrition education),” “maintenance of drug use profiles, patient drug monitoring, and drug utilization education,” “mental health preventive services,” and “substance abuse preventive measures.” The Veteran should be afforded an opportunity to provide any statements or evidence indicating whether he received any types of preventive health care services or health education prior to his treatment in January 2015. Further, the agency of original jurisdiction should review all interactions the Veteran had with VA between January 2013 and January 2015 to determine whether any such interaction could qualify as a “medical service.” The matter is REMANDED for the following action: 1. Associate all folders and all other paper files pertaining to the Veteran’s claim of entitlement to payment or reimbursement for medical care received at Jefferson Regional Medical Center with the current claims file. All relevant documents must be located and associated with the claims file. 2. The Veteran should be notified that he may submit lay statements or other evidence indicating whether he received any type of medical services from VA prior to his January 2015 emergency treatment, which could include “patient health education (including nutrition education),” “maintenance of drug use profiles, patient drug monitoring, and drug utilization education,” “mental health preventive services,” and “substance abuse preventive measures.” The Veteran should be provided an appropriate amount of time to submit this evidence. 3. Obtain all outstanding, pertinent VA treatment records. This includes all records of contact with the Veteran or staff members at Jefferson Regional Medical Center from January 28, 2015 to January 31, 2015. All records received should be associated with the claims file. If the agency of original jurisdiction cannot locate all Federal records requested herein, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. Then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The claimant must then be given an opportunity to respond. 4. Make a formal determination addressing whether any prior authorization was issued for the Veteran to receive private medical treatment at Jefferson Regional Medical Center either prior to his admission on January 29, 2015 or within 72 hours after admission. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mary E. Rude, Counsel