Citation Nr: A21020063 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 210114-186640 DATE: December 15, 2021 ORDER Entitlement to payment or reimbursement for cost of non-VA medical care provided by Henry Ford Health System (HFHS) on November 8, 2019 is denied. FINDING OF FACT On November 8, 2019, the Veteran was provided non-VA medical care by HFHS; the medical services had not been pre-authorized by VA nor were they of such a nature that a reasonably prudent person would expect that delay in seeking immediate medical attention would be hazardous to life or health. CONCLUSION OF LAW The criteria for payment or reimbursement for cost of non-VA medical care provided by HFHS on November 8, 2019 have not been met. 38 U.S.C. §§ 1703, 1725, 1728; 38 C.F.R. §§ 17.52, 17.53, 17.1000-17.1008, 17.4020. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the Navy from December 1960 to December 1964. According to a January 2021 Report of Contact from Louis Stokes VA Medical Center (VAMC), the Veteran is deceased. The appellant is Henry Ford Health System. The appellant is claiming entitlement to payment or reimbursement of the costs for unauthorized non-VA treatment provided to the Veteran on November 8, 2019 at HFHS for treatment of a non-service connected condition. The claims file includes an August 2021 Memorandum for Record Missing Documents stating that the Explanation of Payment is missing. The remainder of the procedural evidence, notably a December 2020 Authorization Reconsideration submitted by the appellant, shows that a February 2020 denial is on appeal. The denial was issued by VA because prior authorization had not been received for treatment. Treatment provided on November 8, 2019 by HFHS was for psychiatric diagnostic evaluation and medical services. Initially, the Board of Veterans' Appeals (Board) notes that prior to his death, the Veteran was not service-connected for any disabilities. Generally, the treatment of a Veteran at a non-VA hospital at VA expense must be authorized in advance. See 38 C.F.R. § 17.55. VA may only authorize emergency treatment under 38 C.F.R. § 17.4020(c) if the covered veteran, someone acting on the covered veteran's behalf, or the eligible entity or provider notifies VA within 72 hours of such care or services being furnished and VA approves the furnishing of such care or services under 38 C.F.R. § 17.4020(c)(3). VA may approve emergency treatment of a covered veteran only if (i) the veteran is receiving emergency treatment from an eligible entity or provider; (ii) the notice to VA complies with the provisions of 38 C.F.R. § 17.4020(c)(4) and is submitted within 72 hours of the beginning of such treatment; and (iii) the emergency treatment only includes services covered by VA's medical benefits package in § 17.38. 38 C.F.R. § 17.4020(c)(3). Notice to VA must (i) be made to the appropriate VA official at the nearest VA facility; (ii) identify the covered veteran; and (iii) identify the eligible entity or provider. 38 C.F.R. § 17.4020(c)(4). In this case, there is no indication in the record that VA authorization in accordance with 38 C.F.R. § 17.4020(c) was given for the Veteran's treatment on November 8, 2019. The evidence does not indicate nor does the appellant contend that it had received any proper VA authorization for treatment provided by HFHS on November 8, 2019. Hence, the Board finds that VA did not give authorization for this non-VA treatment. In the absence of prior authorization for medical services, there is no factual or legal basis for payment or reimbursement by VA under 38 U.S.C. § 1703 and 38 C.F.R. §§ 17.52, and 17.53 for medical services provided at HFHS on November 8, 2019. Additionally, VA law provides for payment or reimbursement or unauthorized medical expenses incurred at a non-VA facility under 38 U.S.C.§ 1728 and 38 U.S.C. § 1725. In addition to other necessary criteria, both statutes require that the medical expenses to potentially be reimbursed be for "emergency treatment." Emergency treatment is defined as medical care or services furnished when Department or other federal facilities are not feasibly available and an attempt to use them beforehand would not be reasonable and when such care or services are rendered in a medical emergency of such a nature that a prudent layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health. See 38 U.S.C. §§ 1725(f), 1728(c). The November 8, 2019 admitting evaluation states that the Veteran was admitted for dementia with worsening physical aggressiveness. During his time at HFHS, he was found wandering around the unit, which was not a locked unit, and was irritable when staff redirected him. The Veteran spent time one-on-one with a male nurse prior to discharge. The Veteran described his mood as "all right, but [he] wanted to go home," and reported sleeping well and having a good appetite. The Veteran denied any paranoia, delusions, hallucinations, suicidal ideation, homicidal ideation, excessive worry, anxiety, panic attacks, or depressed mood. The evaluator noted that the Veteran was a poor historian and medical records indicated that he had one prior psychiatric hospitalization at HFHS for dementia with behaviors. The medical evidence, including the November 8, 2019 admitting evaluation, does not indicate that the need for his treatment at HFHS on November 8, 2019 arose suddenly or that a prudent layperson would reasonably expect that delay in seeking such immediate medical care, rather than delaying for the time needed to obtain pre-authorization for treatment by VA, would be hazardous to life or health. In sum, payment or reimbursement for private medical expenses incurred for non-VA medical services on November 8, 2019 by HFHS is not warranted as the VA did not pre-authorize such care and such care was not rendered for a medical emergency. Therefore, the claim must be denied. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Lee The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.