Citation Nr: 22012018 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 19-13 263 DATE: March 2, 2022 REMANDED Reimbursement of medical expenses associated with a condition requiring treatment at a non-VA facility in January 2019 is remanded. REASONS FOR REMAND The Veteran had active duty from August 1966 to August 1970. Documentation pertinent to the appeal is not in the electronic record. Initially, the original claim submission(s) is/are missing. Available documents for review show February 2019 and March 2019 denial letters from the Agency of Original Jurisdiction (AOJ), Loma Linda VA Medical Center (VAMC) for an ambulance ride that began on December 31, 2018 and ended with hospital admittance on January 1, 2019, medical treatment starting on January 1, 2019 at San Antonio Regional Hospital, and medical treatment starting on January 4, 2019 under Dr. C. S. The AOJ found the claims were incomplete submissions as medical records were not attached with the claim and therefore, denied the claims. In his March 2019 notice of disagreement (NOD), the Veteran stated that the AOJ erred in adjudicating his claim as he had already submitted the necessary medical evidence for a complete claim and the AOJ had not attempted to obtain billing information from the ambulance service as it was supposed to. He re-attached the medical evidence and billing information from the ambulance. Medical information currently available for review are the first two pages out of 19 pages, as listed at the bottom, of his discharge instructions, the ambulance report by the EMT, CT scan taken at the hospital, a receipt for prescriptions from Walgreens in the amount of $366.98 and a receipt from Dr. C. S. dated January 9, 2019 in the amount of $100. On March 14, 2019, the AOJ sent the Veteran a letter explaining that the Loma Linda VAMC would reimburse the Veteran for his pharmacy expenditures in the amount of $466.89. The Veteran was instructed to fill out an attached VA Form 10091 as he needed to be "Vendorized in the VA system." It is unclear whether the VA Form 10091 was ever attached to the letter and/or whether the Veteran filled the form out and submitted it to the AOJ. On March 20, 2019, the Veteran was sent a statement of the case (SOC). Under "Timeline of Events" the March 14, 2019 letter confirming payment for prescriptions does not appear. After initial review, the AOJ continued to deny the Veteran's episode of care as it was not pre-authorized and did not meet the requirements under 38 U.S.C. § 1703. The Veteran sent a subsequent letter on March 21, 2019 to the AOJ. He acknowledged the March 14, 2019 letter approving reimbursement for pharmaceutical expenditures but noted the AOJ's explanation that the follow-up examination with Dr. C. S. had never been addressed in a decision or SOC. Therefore, the Veteran wished to receive a proper denial on the claim regarding Dr. C. S. so that the appeal process could continue. The claim must be remanded in order for the AOJ to reconstruct the record and upload all missing documentation related to the appeal to the electronic claims file. If such records, including the initial claim submissions, the last 17 pages of discharge instructions, emergency room records, and VA Form 10091 (blank or completed/signed), are unable to be located, the AOJ should make a formal finding of unavailability. The matters are REMANDED for the following action: 1. Reconstruct the record and upload all documentation related to the claim for payment or reimbursement for medical costs associated with the Veteran's condition which caused his visit to the emergency room in January 2019, to the electronic claims file that has not already been uploaded. Missing documentation includes but is not limited to the initial claims submitted by the Veteran, hospital, or ambulance service, the last 17 pages of discharge instructions, emergency room records, and VA Form 10091 (blank or completed/signed). 2. If any records are unable to be associated with the record, make a formal finding of unavailability. 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.