Citation Nr: 22014992 Decision Date: 03/15/22 Archive Date: 03/15/22 DOCKET NO. 19-15 865A DATE: March 15, 2022 REMANDED Entitlement to payment or reimbursement for the cost of medical services received at Orthopaedics of Jackson Hole on August 30, 2017, September 29, 2017, November 9, 2017, and December 11, 2017, is remanded. REASONS FOR REMAND The Veteran had active service from February 1971 to November 1973. This claim was previously before the Board in February 2020, at which time the Board remanded it for additional development. Additional development is needed before the claim is decided on the merits. Entitlement to payment or reimbursement for the cost of medical services received at Orthopaedics of Jackson Hole on August 30, 2017, September 29, 2017, November 9, 2017, and December 11, 2017, is remanded. The Veteran is seeking reimbursement for the cost of treatment at Orthopaedics of Jackson Hole, a private facility, on August 30, 2017, September 29, 2017, November 9, 2017, and December 11, 2017. As noted in the February 2020 Board remand, the claims forms show that the treatment on the first three dates was follow-up treatment for a displaced fracture of the lateral malleolus of the left fibula. The December 11, 2017, treatment was coded as being for left foot metatarsalgia. The Veteran wrote in January 2018 and June 2019 that he believed that since payment or reimbursement for the private emergent care after the Veteran broke his leg was approved, payment or reimbursement for the follow-up care was also approved. The record did not include documentation related to the approval of payment or reimbursement for the emergent treatment from when the Veteran broke his leg. Therefore, the Board is unable to fully evaluate the Veteran's contentions. On remand, the approval notice and other documentation sent to the Veteran related to the approval of payment or reimbursement for the emergent care from when he broke his leg should be associated with the claims file. The treatment records related to the left leg should also be obtained. It was further noted that although a summary of the Veteran's January 2018 notice of disagreement was in the claims file, the notice of disagreement itself was not. On remand, the notice of disagreement was to be obtained. In addition, the February 2020 Board remand states that there is a report of contact in the claims file stating that the January 2018 denial letter, which is the decision on appeal, could not be printed. The February 2020 Board remand states that the notice of approval and other related documents sent to the Veteran for payment or reimbursement of the emergent care when he broke his left leg, the January 2018 decision in the present case, and the January 2018 notice of disagreement were to be associated with the claims file. Furthermore, the Veteran was to be sent a release form to allow VA to obtain the private treatment records from Orthopaedics of Jackson Hole on August 30, 2017, September 29, 2017, November 9, 2017, and December 11, 2017. The electronic record does not contain the file for this claim, including the documents that were of record at the time of the February 2020 Board remand. Therefore, the claim must be remanded in order for the agency of original jurisdiction (AOJ) to reconstruct the record and upload all documentation related to the appeal to the electronic claims file. This includes the documents requested in the February 2020 Board remand. If any such records 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 entitlement to payment or reimbursement of the cost of medical services received at Orthopaedics of Jackson Hole on August 30, 2017, September 29, 2017, November 9, 2017, and December 11, 2017. 2. Associate with the claims file the notice of approval and other related documents sent to the Veteran for payment or reimbursement of the emergent care when he broke his left leg, the January 2018 decision in the present case, and the January 2018 notice of disagreement, 3. Send the Veteran a release form in order to allow VA to obtain the private treatment records from when he broke his left leg, and the treatment from Orthopaedics of Jackson Hole on August 30, 2017, September 29, 2017, November 9, 2017, and December 11, 2017, and invite him to submit treatment records in his possession. He should be provided an appropriate amount of time to submit this evidence or return the release form. There must be two attempts made to request private treatment records for which the Veteran returns a release form, and all attempts must be documented in the claims file. If the notice of approval and other related documents sent to the Veteran for payment or reimbursement of the emergent care when he broke his left leg, the January 2018 decision in the present case, the January 2018 notice of disagreement cannot be obtained and associated with the claims file, and other documents from the claims file for this case are unavailable and further attempts to obtain these records would be futile, note such unavailability in a Memorandum of Unavailability and associate it with the claims file. Michael J. Skaltsounis 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.