Citation Nr: 18151991
Decision Date: 11/20/18	Archive Date: 11/20/18

DOCKET NO. 16-15 366A
DATE:	November 20, 2018
REMANDED
Payment or reimbursement for inpatient private medical care provided at a private hospital in Jacksonville, Florida from February 18, 2015 through March 7, 2015.
REASONS FOR REMAND
The Veteran served on active duty from September 1977 to August 1978.  He was hospitalized at a private medical facility in Jacksonville, Florida, from February 17, 2015 to March 7, 2015, but VA authorized payment for only February 17, 2015.  Payment for the remainder of his treatment was denied on the basis that his condition had stabilized as of February 18, 2015, and so he could have been transferred to a VA facility for further treatment.  
In the March 2016 statement of the case (SOC), Veterans Health Administration (VHA) personnel stated that a VA clinician reviewed available medical documentation and concluded the Veteran was stable to be transferred to a VA facility on February 17, 2015.  
However, the SOC did not identify the clinician who conducted the clinical review and, while the SOC reports some findings from available private treatment records and stated at what point the Veteran was considered stable, the exact basis for the clinician’s determination is unclear.  Moreover, the Board is unable to locate in the file the clinical review that served as the basis for the denials of the claims.
The matter is REMANDED for the following actions:
1. Associate any available documentation of the clinical review performed at the time of the original denials in November 2015 and prior to the March 2016 SOC, along with documentation of any other clinical reviews performed in this case and associate them with the claims file. 
2. If no such documentation is available, or if the previous reviews do not include a specific basis for their conclusions, a qualified medical professional should be asked to review the claims file and provide an opinion concerning whether the Veteran was stable for transfer from the Jacksonville hospital to a VA or other federal facility at any point from February 18, 2015 through March 7, 2015.  
The medical professional should specify when during this period the Veteran was stable for transfer and where he could have been transferred.  
The medical professional should also specifically explain why, according to his or her medical judgment, the Veteran was stable for transfer and should make appropriate reference to the records of the private hospitalization to support the conclusion. 
3. Then, readjudicate the issue on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, a supplemental statement of the case should 
 
be issued to the Veteran and his representative, and they should be afforded the requisite opportunity to respond.
 
L. HOWELL
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K. M. Schaefer, Counsel