Citation Nr: 21011567
Decision Date: 03/02/21	Archive Date: 03/02/21

DOCKET NO. 17-04 900A
DATE: March 2, 2021

ORDER

Entitlement to payment or reimbursement for medical services received at St. Luke's Regional Medical Center and St. Luke's Clinic in Boise, Idaho on February 3, 2015 is granted.

FINDING OF FACT

The Veteran’s medical treatment at St. Luke's Regional Medical Center and St. Luke's Clinic in Boise, Idaho on February 3, 2015 was authorized in advance and was follow-up treatment for the December 2014 right shoulder surgery.

CONCLUSION OF LAW

The criteria for payment or reimbursement for medical services received at St. Luke's Regional Medical Center and St. Luke's Clinic in Boise, Idaho on February 3, 2015 have been met.  38 U.S.C. §§ 1703, 5107; 38 C.F.R. § 17.54 (2018).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from January 1967 to October 1970.

The Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing in December 2020.  A transcript is of record.

Entitlement to payment or reimbursement for medical services received at St. Luke's Regional Medical Center and St. Luke's Clinic in Boise, Idaho on February 3, 2015 

Under 38 U.S.C. § 1703, when VA facilities or other government facilities are not capable of furnishing economical hospital care or medical services because of geographic inaccessibility or are not capable of furnishing care or services required, VA may authorize or contract with non-VA facilities for care.  38 U.S.C. § 1703(a); 38 C.F.R. § 17.52(a).  

Under VA regulation in effect at the time of the claim, 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 (2018).  See Malone v. Gober, 10 Vet. App. 539, 541 (1997); see also VA O.G.C. Prec. Op. No. 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 June 2014 the Veteran was approved by VA for payment for private treatment of the right shoulder, including a pre-op evaluation, a surgical procedure if required, and follow-up treatment within the 90 days of surgery.  The Veteran underwent a right shoulder total arthroplasty at St. Luke’s Regional Medical Center in December 2014.  

On February 3, 2015 the Veteran had follow-up treatment with at St. Luke’s Clinic.  He reported that his shoulder had been doing well and that his physical therapy at VA was going well.  There were some intermittent muscle spasms over the right biceps that resolved quickly.  X-rays showed that the osteotomy site looked reasonable.  The overall impression was that there was a “nice result.”

The February 3, 2015 treatment at St. Luke’s was follow-up treatment for the December 2014 right shoulder total arthroplasty.  The Veteran was pre-authorized for follow-up treatment for 90 days after right shoulder surgery.  Furthermore, the surgery and February 3, 2015 follow-up treatment were with the same physician from St. Luke’s.  Giving the benefit of the doubt to the Veteran, the Board finds that the February 3, 2015 treatment at St. Luke’s, including x-rays, was part of the pre-authorized follow-up treatment for the December 2014 right shoulder surgery.  See 38 U.S.C. § 5107(b).  Therefore, the claim is granted.

 

 

P.M. DILORENZO

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Scott Shoreman, Counsel

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.