Citation Nr: 21015380 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-31 204A DATE: March 17, 2021 ORDER Payment or reimbursement for unauthorized expenses incurred by the Veteran for care at Sanpete Valley Hospital, Mount Pleasant, Utah on February 4, 2014 is denied. FINDING OF FACT On February 4, 2014, the Veteran was seen at Sanpete Valley Hospital, Mount Pleasant, Utah for scheduled MRI studies of the cervical, thoracic, and lumbar spine segments. There is no evidence of pre-authorization or of any emergent medical condition. See February 2014 Private Treatment Record; October 2014 Notice of Disagreement; September 2015 Appeal to the Board. CONCLUSION OF LAW The criteria for payment or reimbursement for unauthorized expenses incurred by the Veteran for care at Sanpete Valley Hospital, Mount Pleasant, Utah on February 4, 2014 are not met. 38 U.S.C. §§ 1703, 1725, 5107; 38 C.F.R. §§ 17.52, 17.53, 17.54, 17.120, 17.121, 17.1002. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in Army National Guard from June 1980 to November 1980 and from December 1980 to October 1981. This case comes before the Board on appeal from a September 2014 decision of a VA Medical Center in Fort Harrison, Montana. The Veteran is seeking payment or reimbursement for medical expenses he incurred for scheduled MRI studies at Sanpete Valley Hospital, Mount Pleasant, Utah on February 4, 2014. VA will pay for or reimburse veterans for the cost of unauthorized care at non-VA facilities under the following conditions: (a) The care and services rendered were either: (1) for an adjudicated service-connected disability, or (2) for a nonservice-connected disability associated with and held to be aggravating an adjudicated service-connected disability, or (3) for any disability of a veteran who has a total disability, permanent in nature, resulting from a service-connected disability, or (4) for any injury, illness, or dental condition in the case of a veteran who is participating in a rehabilitation program and who is medically determined to be in need of hospital care or medical services for reasons set forth in 38 C.F.R. § 17.47(i) (formerly § 17.48(j)); and, (b) The services were rendered in a medical emergency of such nature that delay would have been hazardous to life or health; and, (c) No VA or other Federal facilities were feasibly available and an attempt to use them beforehand would not have been reasonable. 38 U.S.C. § 1728; 38 C.F.R. § 17.120. Moreover, VA will pay for or reimburse the cost of unauthorized care at non-VA facilities for veterans who are personally liable for non-VA treatment costs, regardless of whether the treated condition is a service-connected condition or related thereto, provided the veterans are enrolled in the VA health care system and have received VA care within the last twenty-four months, and under the following conditions: (a) The emergency services were provided in a hospital emergency department or a similar facility held out as providing emergency care to the public; (b) The claim for payment or reimbursement for the initial evaluation and treatment is for a condition of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health; (c) A VA or other Federal facility/provider that VA has an agreement with to furnish health care services for veterans was not feasibly available and an attempt to use them beforehand would not have been considered reasonable by a prudent layperson; (d) At the time the emergency treatment was furnished, the veteran was enrolled in the VA health care system and had received medical services under authority of 38 U.S.C. chapter 17 within the 24-month period preceding the furnishing of such emergency treatment; (e) The veteran is financially liable to the provider of emergency treatment for that treatment; (f) The veteran does not have coverage under a health-plan contract that would fully extinguish the medical liability for the emergency treatment; (g) If the condition for which the emergency treatment was furnished was caused by an accident or work-related injury, the claimant has exhausted without success all claims and remedies reasonably available to the veteran or provider against a third party for payment of such treatment; and the veteran has no contractual or legal recourse against a third party that could reasonably be pursued for the purpose of extinguishing, in whole, the veteran’s liability to the provider; and (h) The veteran is not eligible for reimbursement under 38 U.S.C. § 1728 for the emergency treatment provided. 38 U.S.C. § 1725; 38 C.F.R. § 17.1002. The Veteran is service connected for a low back disability and associated right lower extremity radiculopathy, a left knee disability, and a right foot disability. As noted above, the treatment in question consists of MRI studies of the Veteran’s cervical, thoracic, and lumbar spine. However, the Board finds that payment or reimbursement for the cost of this treatment is not warranted under either 38 U.S.C. § 1728 or § 1725, because the treatment provided was not for an emergency medical condition. A “medical emergency” under both 38 U.S.C. § 1728 and § 1725 means a condition of such nature that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. 38 C.F.R. § 17.1002(b). In this case, the treatment in question is not, strictly speaking, treatment at all, but a scheduled diagnostic imaging study. See February 2014 PTR (record of MRI studies, noting history of pain, but no indication of emergency or any acute distress). Moreover, the Veteran himself reported that he scheduled the studies not in light of a medical emergency requiring immediate treatment, but in order to provide reliable medical evidence to the Board in connection with his appeal of compensation claims. See October 2014 Notice of Disagreement. The Veteran also stated that he “got previous approval/verification for services outside the VA 10 months before” he obtained these MRIs, but he has not asserted that he obtained authorization for the MRIs themselves. See September 2015 Appeal to the Board. Nor is there any evidence of pre-authorization. The Veteran argues that these services constituted emergency treatment because delay would have led to “further injury and/or penalties.” See October 2014 Notice of Disagreement. He also reported that he feared for his life and safety, and that therefore his situation constituted an emergency to him, “which is all that’s required under the statute.” See September 2015 Appeal to the Board. The Board acknowledges the extreme frustration the Veteran has experienced in his dealings with VA, as expressed in his Notice of Disagreement and Appeal to the Board. However, the relevant law, as noted above, requires not only that the Veteran consider the situation to be an emergency, but that “a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.” In this case, the Board finds that there is no evidence that the Veteran himself expected that the absence of immediate medical attention would result in placing his health in serious jeopardy. Rather, the evidence indicates that the Veteran waited to procure the relevant MRI study until he felt it was necessary to support his compensation appeal. Therefore, because there is no evidence of a medical emergency, the Board finds that payment or reimbursement for unauthorized expenses incurred by the Veteran for care at Sanpete Valley Hospital, Mount Pleasant, Utah on February 4, 2014 is not warranted. S.C. KREMBS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Timmerman, Associate 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.