Citation Nr: A24065166 Decision Date: 10/10/24 Archive Date: 10/10/24 DOCKET NO. 210304-254647 DATE: October 10, 2024 ORDER The issue of whether the payment for the cost of non-Department of Veterans Affairs (VA) medical services provided in a nursing facility on November 3, 2019, is granted, subject to laws and regulations regarding payment. The issue of whether the payment for the cost of non-Department of Veterans Affairs (VA) medical services provided in a nursing facility on November 13, 2019, is granted, subject to laws and regulations regarding payment. The issue of whether the payment for the cost of non-Department of Veterans Affairs (VA) medical services provided in a nursing facility on November 20, 2019, is granted, subject to laws and regulations regarding payment. FINDING OF FACT The Department of Veterans Affairs (VA) authorized the medical services provided by Fall Prevention Stroke Rehab, LLC on September 13, 2019. CONCLUSIONS OF LAW 1. The criteria for payment or reimbursement of medical expenses incurred by Fall Prevention Stroke Rehab, LLC on November 3, 2019, are met. 38 U.S.C. §§ 1703, 5107; 38 C.F.R. §§ 17.52, 17.1500-17.1540. 2. The criteria for payment or reimbursement of medical expenses incurred by Fall Prevention Stroke Rehab, LLC on November 13, 2019, are met. 38 U.S.C. §§ 1703, 5107; 38 C.F.R. §§ 17.52, 17.1500-17.1540. 3. The criteria for payment or reimbursement of medical expenses incurred by Fall Prevention Stroke Rehab, LLC on November 20, 2019, are met. 38 U.S.C. §§ 1703, 5107; 38 C.F.R. §§ 17.52, 17.1500-17.1540. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from September 1952 to August 1954. Regrettably, the Veteran died in April 2020. The appellant rendered medical services in a nursing facility to the Veteran. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a determination made by the Department of Veterans Affairs (VA) Veterans Health Administration (VHA). The Veteran seeks reimbursement for treatment provided by Fall Prevention Stroke Rehab, LLC on November 3, 2019, November 13, 2019, and November 20, 2019. Fall Prevention Stroke Rehab, LLC is a non-VA medical provider who rendered services to the Veteran, on behalf of VA, furnished through a Veterans Care Agreement (VCA). See generally 38 C.F.R. § 17.4110. In the March 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review option; therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. The appellant asserts that they should be paid in full for the episodes of care that were furnished to the Veteran pursuant to the VCA because the nurses at the facility would have received prior authorization. The evidence shows that the appellant provided medical service to the Veteran on November 3, 2019, November 13, 2019, and November 20, 2019. Of note, the Board notes that upon review, the AOJ determined the appellant received authorization via TriWest for the services rendered. See Report of Contact, July 14, 2022. Pursuant to 38 U.S.C. § 1703, as it pertains to treatment prior June 6, 2019, 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 contract with non-VA facilities for care in accordance with the provisions of the relevant regulations. When demand is only for infrequent use, individual authorization may be used. 38 U.S.C. § 1703 (2018); 38 C.F.R. § 17.52 (a)(3); see also Veterans Community Care Program, 84 Fed. Reg. 26278, 26306 (June 5, 2019). VA regulations in effect at the time of the treatment in question further provide provisions in 38 C.F.R. §§ 17.1500 through 17.1540 implementing the Veterans Choice Program, which authorizes VA to furnish hospital care and medical services to certain eligible Veterans though agreements with eligible entities of providers. 38 C.F.R. § 17.1500 (2017). Eligible Veterans include those enrolled in the VA healthcare system who meet certain criteria, including where VA is unable to provide clinically necessary services within an appropriate period of time. 38 C.F.R. § 17.1510 (2017). A Veteran eligible for the Veterans Choice Program may have VA authorize the Veteran to receive an episode of care for medical services from an eligible provider. 38 C.F.R. § 17.1515 (a) (2017). Whether treatment was authorized is a factual, not a medical, determination. Similes v. Brown, 5 Vet. App. 555 (1994). VA internal administrative notes from July 2022 state that there was a Veterans Choice consult approving the treatments by the appellant from September 13, 2019, for 180 days. In this case, there is no dispute that the Veteran obtained VA authorization for his care by the Veteran on November 3, 2019, November 13, 2019, and November 20, 2019, which is documented in VA records. Considering the above, the Board finds that the care provided by Fall Prevention Stroke Rehab, LLC on November 3, 2019, November 13, 2019, and November 20, 2019, was pre-authorized, and the treatment rendered fell under the scope of the pre-authorization. (Continued on the next page) ? Given the above, the Board finds that the evidence as to whether VA, through its actions in total, provided authorization of the treatment by Fall Prevention Stroke Rehab, LLC on November 3, 2019, November 13, 2019, and November 20, 2019, is in approximate balance. Affording the Veteran the benefit of the doubt, the Board finds that VA authorized such services. Accordingly, payment or reimbursement of medical expenses incurred by Fall Prevention Stroke Rehab, LLC on November 3, 2019, November 13, 2019, and November 20, 2019, must be granted. See 38 U.S.C. § 5107. Colleen M. Glaser-Allen Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.