ASSISTANT SECRETARY OF DEFENSE WASHINGTON D C. ,',)io!

Transcription

1 ASSISTANT SECRETARY OF DEFENSE WASHINGTON D C,',)iO! health AFFAIRS FINAL DECISION: OASD(HA) Case File No I_r E ~-. =. ~...,.--, App e a1 *..-.,. -.. # 3 i The Hearing File of Reord, the tape of oral testimony presented at the hearing, the RECOMMENDED DECISION of the Hearing Offier, and the Memorandum of Nononurrene from the Diretor, ochampus, on OASD(HA) Appeal Case 02-80, have been reviewed. CHAMPUS extended benefits in the amount of $1, for the first twenty-! one (21) days of a thirty-five (35) day hospital onfinemento partiipate in an alohol rehabilitation program. The amount in dispute for the last fourteen (14) days of the hospital onfinement (as laimed by the appealing party) is $ Beause OCHAMPUS also questioned payment of benefits for the entire stay, inluding the first twenty-one (21) days, the total amount atually in dispute is $2, The Hearing Offier reommended affirming the C'HAMPUS Fisal Intermediary's initial determination to deny benefits for the last fourteen (14) days of the thirty-five (35) day hospital onfinement for aloholism. He did not, however, make a reommendation relative to the first twenty-one (21) days of the onfinement, even though finding that the admission did not meet CHAMPUS riteria. This omission was apparently due to a misunderstanding that the first twenty-one (21) days ould not be an issue in the appeal. This was an inorret assumption inasmuh as any aspet.of a ase submitted to appeal is subjet to review during the appeal proess. The Diretor, OCHAMPUS, onurred with the Hearing Offier's RECOMMENDED DECISION relative to the last fourteen (14) days of the onfinement, but did not agree that the first twenty-one (21) days should not be onsidered in this appeal. He reommended either remanding the appeal to the Hearing Offier for a revised RECOMMENDED DECISION or that the Offie of the Assistant Seretary of Defense issue a revised deision denying benefits for the entire onfinement. After due onsideration and areful review of the evidene presented, the Prinipal Deputy Seretary of Defense (Health Affairs), _- ating as the authorized designee for the Assistant Seretary, does not aept the Hearing Offier's RECOMMENDED DECISION on the basis it is defiient in that it did not address all issues in the ase. This FINAL DECISION is therefore based on the L' evidene ontained in the Hearing File of Reord. It is the finding of the Prinipal Deputy Seretary of Defense (Health Affairs) that the entire thirty-five (35) day onfinement, from

2 1 FINAL DECISION: OASD(HA) June to 26 July 1978, failed to meet CHAMPUS riteria for extending benefits for an inpatient aloholi rehabilitation stay and that the entire- stay should have been denied. I The PRIMARY ISSuE(S) The primary matter at issue in this appeal is whether the inpatient environment was neessary in order for the appealing party to partiipate in an alohol rehabilitation program. If it had been found that the inpatient setting was neessary, a related issue would be the number of inpatient days required. The appliable Regulation defines "medially neessary" [in part) as "...the level of servies and supplies (i.e., frequeny, extent and kinds) adequate for the diagnosis and treatment of illness and injury... It (Referene: CHAMPUS DoD R, CHAPTER 11, Subsetion B ) The Regulation further defines "appropriate- level of are" [in part] as I f...the medial environment in whih the medial servies are performed is at a level adequate to provide the required medial are. If (Referene: CHAMPUS Regulation DoD R, CHAPTER 11, Setion B., Paragraph 14..) Authorized benefits for treatment of aloholism is also speifially addressed in the Regulation, stating... "Inpatient hospital stays may be required for detoxifiation servies during aute stages of aloholism when the patient is suffering from delirium, onfusion, trauma, unonsiousness, and severe malnutrition, and is no longer able to funtion. During suh aute periods of detoxifiation and physial stabilization (i.e., 'drying out') of the aloholi patient, it is generally aepted that there an be a need for medial management of the patient; i-e-, there is a probability that medial ompliations will =ur during alohol withdrawal, neessitating the onstant availability of physiians and/or omplex medial equipment found only in the hospital setting. Therefore, inpatient hospital are, durinq suh aute periods and under suh onditions, is onsidered reasonable and medially neessary for the treatment of the aloholi patient and thus overed under CHAMPUS. Ative medial treatment of the aute phase of aloholi withdrawal and the stabilization period usually takes from three (3) to seven (7) days. It [Emphasis added] IReferene: CHAMPUS Regulation DOD 6010,8-R, CHAPTER IV, Subsetion E.4.) Regulation also states... "An inpatient stay for aloholism. (either in a hospital or through transfer to another type of authorized institution) may ontinue beyond the three (3) to seven (7) day period, movinq into the rehabilitative proqram phase. Eah suh ase will be reviewed on its own merits to determine

3 p FINAL DECISION: t OASD(HA) whether an inpatient setting ontinues to be required." [Emphasis added] (Referene: CHAMPUS Regulation DOD R, CHAPTER IV, Setion E..,...Paragraph 4. a. ) There are also speifi regulatory exlusions whih affet this ase. That setion dealing with exlusions and limitations states... "[Exluded are] Servies and supplies whih are not medially neessary for the diagnosis and/or treatment of a overed illness or injury." (Referene: CHAMPUS Regulation DOD R, CHAPTER IV, Subsetion G.l.) Also listed as exluded are... I'Senries and supplies related to inpatient stays in hospitals or other authorized institutions above the appropriate level required.to provide neessary medial are." [Emphasis added] (Referene: CHAMPUS Regulation DoD R, CHAPTER IV, Setion G.3. ) ai 0 The appealing party, his wife, the attending physiian, and the hospital's business offie manager, submitted written statements and/or'presented oral testimony detailing those fators whih they believed supported the position that the hospital inpatient setting was neessary in the ase under appeal, inluding the last fourteen (14) days of the onfinement. Nonetheless it.is the position of the Prinipal Deputy Assistant Seretary of Defense (Health Affairs) that the entire inpatient stay (not only the final fourteen (14) days) was unneessary; that while hroni aloholism may well have been present, aute aloholism was not established and that the rehabilitative program ould have been aomplished on an outpatient basis. To be sure the appealing party fully understands the bases upon whih the. finding that the entire -inpatient stay was unneessary and did not qualify for benefits under CHAMPUS (thus also onfirming the initial denial of the last fourteen (14) days), eah point raised by the appealing party, his wife, and those appearing or submitting evidene in his behalf, is addressed in this FINAL DECISION. 1. Presene of Aloholism: Aute vs. Chroni. The appealing party asserted be had been drinking every day for many years and that at the time of the disputed hospital stay was suffering from both aute and hroni aloholism. This assertion inluded the impliation that this history should automatially -qualify his inpatient stay for CHAMPUS benefits. The Hearing File of Reord does not support a finding of aute aloholism and this assertion, is disputed. At no time, however, did CHAMPUS dispute the diagnosis of hroni aloholism despite the lak of linial doumentation as to

4 FINAL DECISION: OASD(HA) the extent it was present and the degree of dysfuntion it produed in the appealing party s life. The matter at issue in this- ase is not whether hroni aloholism was 5 - present; rather it is the bnditim-.of the appealing party 9 at the time of admission and during the ontinued hospital stay, and whether his ase meets the CKAMPUS riteria for extending benefits for inpatient alohol detoxifiation and rehabilitation. (Referene: CHAMPUS Regulation DoD R, CHAPTER IV, Subsetion E.4 and Setion E, Paragraph 4.a.) 2. Inpatient Admission for Aloholi Rehabilitation: Medial Neessity. A review of the evidene made available in the Hearina File of Reord indiates the first issue in this appealdis not whether the last fourteen (14) days of the inpatient stay qualify for benefits but whether any part of the stay qualifies. In order for CHAMPUS benefits to be extended for an inpatient aloholi rehabilitation stay requires that the patient in be a state of aute aloholism and that the rehabilitative stay be immediately preeded by an admission for detoxifiation where the patient is suffering from severe medial effets of alohol--i.e., delerium tremens trauma, unonsiousness and malnutrition, and is essentially unable to funtion. Inpatient stays for detoxifiation of patient with lessevere symptoms may be onsidered for benefits but would not qualify the rehabilitation phase to be onduted on an inpatient basis. Additionally, the rehabilitation stay must Immediately follow detoxifiation (i.e., be ontinuous), although the patient an transfer from an aute hospital to an aloholi faility for the rehabilitation phase. 0 Medial Condition on Admission. Aording to his own testimony the appealing party was sober on admission and had disontinued use of alohol at least two days before. Physial examination on admission showed him to be well-nourished, oriented, ambulatory, alert, and suffering no adverse reation from disontinuinq alohol intake prior to admission. He was sober and physially and mentally in a non-aute state. There was no evidene of heart trouble, high blood pressure or trauma. Clinial doumentation did not present any evidene of debilitation or malnutrition. The mental status and neurologial examinations were reported to be normal. No aute ondition, either medial and/or alohol-relaked, was reported and there was no indiation of shaking or onvulsive episodes due to alohol intake

5 FINAL DECISION: OASD(HA) being disontinued. The physial examination revealed no hroni or aute onditions or disabilities other than some liver enlargement and possible hroni pulmonary disease. The hospital staff apparently did 4 not-onsider these latter two findings of major onern 0 beause no diagnosti tests were ordered or performed related to them nor was any'speifi treatment for these onditions initiated. There was no evidene presented to indiate the onfinement was needed for any medial or psyhiatri ondition other than hroni aloholism. There were apparently no antiipated medial ompliations. The only hroni ondition addressed in the Hearing File of Reord was glauoma, diagnosed in 1965 and treated with ophthalmi solution eyedrops whih the appealing party had been self administering prior to his admission (and whih he ontinued to do in the hospital). 0 No Prior Treatment: Degree of Dysfuntion..The lin- - ial reords show (and the appealing party onfirmed) that prior to the inpatient stay in dispute in this appeal, he had never sought any treatment and/or assistane of any kind related to his use of alohol-- either inpatient or outpatient. He also denied any alohol-related medial-problems whih had required treatment or any emergeny room are related to aloholi behavior. There is little information in the Hearhg File of Reord whih would support a finding of a signifiant degree of dysfuntion due to drinking. The appealing party apparently was employed only parttime at periodi jobs but there was nothing to indiate that this was due to drinking problems as opposed to his normal retirement work pattern. Also, the appealing party denied any problems with the polie due to aloholi behavior or that he had ever been ited for driving while intoxiated (DWI), despite the fat he had ontinuous.ly operated a vehile over the years. Although his spouse laimed to be fearful of his temper if she tried to withhold alohol from him, the appealing party denied any abusive behavior and the linial reord is silent on any history of violent or aggressive behavior. There is some indiation, however, of at least pereived dysfuntion within the family sine his spouse and daughter had exerted pressure on him to seek help for his drinking. But here again the reord

6 FINAL DECISION: OASD(HA) is extremely limited as to the kind and extent of family problems. The reord does,indiate the family - # was intat, however.. In view-.of-.the. absene of a... -_ 3 history of prior 'treatmentforaloholism,theabsene f of aute aloholism, the appealing party's general good ondition, both mental and physial, and the he fat was a part of a supportive family struture, it must be our finding that the initial rehabilitation efforts for hroni aloholism ould have been undertaken in an outpatient setting. If the outpatient program proved unsuessful, it would then be appropriate to onsider the more strutured inpatient setting. \ 0 Detoxifiation. The Hearing File of Reord supports the onlusion thathe appealing party was plaed in detoxifiation upon admission as-a matter of standard routine pratie--i.e., pro forma--as opposed to medial need. While the Progress Notes are silent as - to speifis of the appealing party's ondition while in the hospital's detoxifiation unit neither do they report any adverse reations to disontinuing alohol. The hospital reords do not indiate any mediations were administered during the first of day onfinement to assist the appealing party through detoxifiation or, for that matter, that sedatives or tranquilizing mediations were administered at any time during his entire inpatient stay. A general diet was presribed on the first day of onfinement, indiating the patient was able to eat normally. General hospital proedure was to plae those patients in the detox unit on a liquid diet. That this was not required for the 'appealing party further supports the position that the inpatient environment was not neessary. The hospital reords do not indiate how long the appealing party stayed in the detoxifiation unit, but in his oral testimony he stated.he stayed only one day--again indiating the appealing party was not suffering from aute aloholism upon admission. 0 Compliations Assoiated with Alohol Withdrawal. No medial ompliations assoiated with alohol withdrawal were reported. Progress Notes do not indiate any adverse reations, episodes of disorientation, onfusion, shaking, onvulsions, insomnia or physial reations. No hypertension or ardiovasular disease was suspeted or onfirmed that required lose'observation. No ompliations were reported and the reords do not indiate that any were antiipated. Although the reords show a diagnosis of hroni aloholism,

7 p- FINAL DECISION: OASD( HA) the reord is generally silent as to the degree of physial or mental dependene on alohol atually experiened by the appealing party or.the extent ' to whih i.t -interfered with his life. 0 Mediations. The only mediation presribed was a vitamin preparation, administered orally on a daily basis for the first fourteen (14) days of the stay--a routine proedure. The ophthalmi solution required for the appealing party's glauoma treatment ontinued to be self-administered, as he had done before entering the hospital. This indiated the hospital staff believed the appealing party to be suffiiently stable to handle self-mediation. Neither the oral vitamins nor the eyedrops. require an inpatient hospital setting for- their administration, however. 0 Diagnosti Tests. After admission, routine blood studies, urinalysis, hest X-ray, and an EKG were ordered. The EKG was repeated one, and urine for drug analysis was requested. The results of these tests were not reported in the hearing file of reord exept that the EKG results were within normal limits. Some liver enlargement was disovered on the admission physial, but no liver funtion tests Or other speifi diagnosti tests were requested or performed to determine the speifi ause or extent of the ondition. A hroni respiratory ondition was also noted in the report of the admitting history and physial, but again, no tests were onduted to verify the presene of the suspeted ondition or its extent. Psyhologial tests were onduted twie as part of the routine program but speifi results were not made available --only vague summaries were noted by the psyhologists. No other tests were reorded. The tests that were performed were of a type whih ould have been, and routinely are, onduted on an outpatient basis and would not require an inpatient setting for their performane. 0 Consultations. The Hearing File of Reord does not indiate any medial onsultations were obtained relative to the liver enlargement noted on initial examination nor to establish whether a suspeted hroni respiratory ondition was, in fat, present. And while routine psyhologial tests were administered, no psyhiatri evaluation was obtained. This would further support the finding that the appealing

8 FINAL DECI SI ON : f"- OASD(HA) A -' party's medial and emotional health were onsidered good and stable, and no ompliations were present or antiipated. $ *? 0 Reason for Confinement. The appealing party indiated he had never before been admitted to a hospital for aloholism nor had he ever undergone outpatient therapy or partiipated in an outpatient.rehab program for this purpose. The appealing party laimed that the onfinement urrently in dispute was preipitated solely by ations initiated by family members who were otherwise seeking ways to have him "ommitted." This statement was substantiated by the appealing party's wife, who stated that she and her daughter(s) were in ontat with the authorities about involuntary ommitment beause they did not approve of his drinking and felt it was out of ontrol. There was no evidene submitted to the Hearing File of Reord as to whih "authorities" had been ontated or what basis would be used for foring an involuntary ommitment. From the linial doumentation provided for the Hearing ' File of reord, it is extremely doubtful this ould have been aomplished through legal means even assuming hroni aloholism was present. Nonetheless, the appealing party laimed be submitted to a stay in an aloholi faility rather than fae possible ommitment efforts. We find this to be a somewhat startling hypotheses, but ertainly not a ompelling argument for the neessity of onduting the alohol rehab program in an inpatient setting. The CHAMPUS benefit available for inpatient are related to aloholism; partiularly the rehabilitative phase, is not unlimited. In order for suh a stay to be overed first requires that the rehabilitative stay be immediately preeeded by an admission for detoxifiation where the patient is suffering from aute aloholism and where his/her medial ondition due to alohol abuse has resulted in signifiant medial symptomotology. It is our finding that not only was there no indiation of aute aloholism at the time of admission, it appears symptoms were almost totally laking and detoxifiation was a pro forma proedure only. Further, even if.the detoxifiation requirement had been met, in order for a ontinued inpatient stay for the rehabilitative phase to be overed (whether in the same faility or upon. immediate transfer to a speial aloholi faility) requires a determination that the ondition of the patient and the 8

9 FINAL DECISION: OASD(HA) , -does rehabilitative program itself requires a ontinued inpatient setting. As desribed, above, the Hearing File of Reord not support a finding..tha.t.the.app.ealing party's treatment.history or physial or mental.ondition required a ontinuation of the inpatient setting or that the type of rehabilitative program offered was suh that it ould only be provided to a hospital inpatient. Therefore, despite the assertions made by the appealing party and others, it is our finding that the irumstanes of the appealing party's entire inpatient admission for aloholism failed to meet the CHAMPUS riteria for benefits and that the CHAMPUS Fisal Intermediary was in error in extending benefits for the first twenty-one (21) days of the stay. (Referenes: CHAMPUS Regulation DoD R, CHAPTER 11, Subsetion B.104 and Setion B., Paragraph 14.C.; CHAPTER IV, Subsetion E.4; Setion E., Paragraph 4.a.; Subsetion G.l and Subsetion G.3.) 3. Medial Neessity: Last (14) Days of Stay. The appealing party and the physiian laimed that the hospital onfinement for the last 14 days was neessary for the patient to omplete the alohol program. The Business Offie Manager of the Hospital laimed the full 35-day onfinement was medially neessary to stabilize the patient's disease, for "apprehensive diet eduation, '' and for "sedative use. 'I With the finding that the initial admission and the entire stay did not qualify for benefits, the issue of the last fourteen (14) days is moot. It had been found that benefits had been extended for the first twenty (21) the final fourteen'(l4) days still would not have qualified for benefits. o. Mediations. The only mediation speifially presribed was a vitamin preparation, administered daily for the first fourteen (14) days of the onfinement. There was no evidene submitted that sedatives or any other mediations presribed by dotors in the faility were administered during the entire stay, inluding last fourteen (14) days. Only an ophthalmi solution is mentioned in the reords and this was required by the appealing party for his glauoma (diagnosed in 1965), was brought into the hospital by him and was self-administered. 0 Rehabilitation Program. Hospital reords show the appealing party partiipated in a standard, organized alohol rehabilitation program onsisting of letures

10 FINAL DECISION: f7.l % OASD(HA) i.. 10 and disussions; visits with ounselors, lergy, and volunteers; films; group meetings; and reading. The appealing party began.this phase of the program the -day..after his. admission and ontinued it until -disharge. None of these ativities automatially requires an inpatient setting. The faility's inpatient program is similar to those available through other out-of-hospital treatment programs. The reords give no indiation that the strutured hospital environment, or use of omplex medial equipment or speially trained or skilled medial personnel available only in a hospital inpatient setting, were required. 0 Consultations: Speial Treatments. The reords inlude no reports of onsultations or speial medial examinations during the last fourteen (14) days of the onfinement. Neither is there evidene of surgery, speial medial treatments,: or other speial therapy requiring use of hospital inpatient failities. 0 Group Therapy. The speifi number and types of group. therapy sessions and professional status of the therapist, were not indiated in the Hearing File of Reord. The patient's ondition, however, would have permitted use of group therapy on an outpatient basis without adverse affet. Even in a ase where the initial phase of an inpatient rehabilitation stay for aloholism qualifies for,benefits in order for suh benefits to ontinue beyond twenty-one (21) days there must be a determination of a medial need for the stay to ontinue. In this ase it has been learly established that the hospital inpatient setting was not medially neessary for any part of the treatment plan during the last fourteen (14) days of the onfinement. The patient's ondition did not require an inpatient setting and the level and types of are the appealing party reeived ould have been, and routinely are, provided on an outpatient basis, (Referenes: CHAMPUS Regulation DoD R, CHAPTER 11, Subsetion B.104; and Setion B., Paragraph 14..; CHAPTER IV, Setion E., Paragraph 4.a; Subsetions G.l and Subsetion G.3,) 4. Speial Review: Change in Proqram Poliy on Inpatient Aloholi Rehabilitative Stays. In May 1981, subsequent to -. the inpatient stay in dispute in this appeal, the Department of Defense revised its poliy relative to extending CHAMPUS benefits for inpatient rehabilitative stays for aloholism. Under the revised poliy it is no longer required that a

11 z FINAL DECISION: '\ OASD(HA) 2 0 MAY 1~ rehabilitative stay be a ontinuation of an inpatient detoxifieati.on stay for severe physial effets of aute aloholism. The.revised poliy permits the.extension of benefits for diret admission to inpatient rehabi1.itation units, provided the irumstanes of the ase require the inpatient environment in order for the rehabilitative servies to be provided. Sine this hange in poliy was made retroative to 1 June 1977, this appeal was again reviewed under the revised poliy--i.e., without the requirement for immediately preeding detoxifiation for aute aloholism. It is the finding of the Prinipal Deputy Assistant Seretary that this hange in poliy does not affet the deision in this appeal. The need the for inpatient setting to provide the rehabilitative are in this ase was not established. (Refer to Item 2. above, "Inpatient Admission for Alholi Rehabilitation: Medial Neessity") z SECONI%Y ISSUES Several seondary issues were raised whih the appealing party or his spouse laimed supported the extension of benefits and whih, in their view, should reeive speial onsideration in sthis appeal. 1. Cause of Aloholism. The appealing party related his drinking problem to Military servie, partiularly his last assignment to an isolated post of duty during 1965 and The Hearing File of Reord arries only his personal assertion on this matter. No evidene was presented to show that drinking was evex an issue in his servie reord. Even if suh evidene had been presented, however, it would have no bearing on whether or CHAMPUS not benefits are payable for the disputed onfinement. CHAMPUS benefits and limitations related to aloholism are speifially set forth in the appliable regulation and not are influened by any alledged ausal relationship to the drinking problem, whether Servie-related or not. 2. Physiians and Hospital Staff Control Hospital Admission and Disharge. The appealing party strongly maintained that only the attending physiian and hospital staff an deide when a onfinement is medially neessary and when a patient has suffiiently reovered to be disharged. He also implied that the patient an leave a hospital only when permitted to do so by hospital staff. (This latter statement is not true insofar as voluntary admissions are onerned but is irrelevant to the ase issues.) The staff at the faility where the appealing party was admitted is.

12 FINAL DECISION: OASD(HA) ommitted to a standard inpatient program of twenty-eight (28) to fifth-six (56) day.s. This pre-set alohol rehabilitative regime does not, however, obligate CHAMPUS to automatially provide benefits.. for,any part- of a hospital onfine&.---. e.. - ment or.for the speifi program itself. The advie of a physiian and the deision to admit and retain a patient as an inpatient is, we onur, solely between the physiian and patient. To this extent the appealing party is orret. On the other hand, the deision on whether CHAMPUS benefits are payable in a given ase is a Program deision, to be based on provisions of the appliable regulation. While an attending, physiian's statements are always given areful onsideration in any ase review, again, the irumstanes under whih CHAMPUS benefits may be provided for aloholism are speifially set forth in the appliable regulation. 4. Inpatient Alohol Rehabilitation: Available in Military Failities. The appealing party laimed that inasmuh as inpatient alohol rehabilitation is available through at 'least some Military hospitals, that where it is not available the retiree is guaranteed CHAMPUS benefits for similar ivilian are at 75% of the ost. The appealing party is orret that aloholi rehabilitation is available at ertain Uniformed Servies failities--both inpatient and outpatient programs. Sine the Military-hospital where the appealing party obtained the Nonavailability Statement did not have alohol rehabilitation failities, there is no way of knowing whether-the appealing party would have been aepted as either.an inpatient or outpatient, or at all, due to the limitations of spae available, sine most suh programs are primarily for ative duty members. These questions are moot, however, inasmuh as the determination of CHAMPUS benefits is totally separate and apart from the availability and extent of are in the diret are system. CHAMPUS benefits are determined on the fats in the ase, based on of law and appliable regulations. In order for benefits to be provided for any ivilian are requires that overed servies and supplies must be provided under the irumstanes set forth by the Program. In this ase, regardless of all other onsiderations, it was determined that the hospital stay in dispute did not meet the requirements for inpatient alohol rehabilitation speifially, and use of the inpatient setting generally, and therefore, it has been determined that not only the last fourteen (14) days of the inpatient stay were orretly denied, but also that the entire inpatient period was inappropriate and represented are that ould have been provided on an outpatient basis. (Referenes: CHAMPUS Regulation DoD R, CHAPTER IV, Subsetion E.4,; CHAPTER IV, Setion E, Paragraph -4. a. ; and CHAPTER. IV, Subsetion G. 1. and G. 3. )

13 \ 6. FINAL DECISION: OASD(HA) Care Available Through Veterans Administration: Disrimina -tion. The appealing party also laimed disrimination on the basis that aloholi rehabilitation was available through -+ the Veterans Administration without limit. He further stated a - 3 he~had an aquaintane who had reeived similar are at a Veterans Administration Hospital and no question was raised as to length of stay. The programs administered by the Veterans Administration are not under the purvue of the Department of Defense. We annot, therefore, speak to the onditions under whih the appealing party's aquaintane was omfined--i.e., whether alohol-related medial ompliations were present, whether the aquaintane had had prior treatment episodes for aloholism, et. Further, despite - his ldm that his drinking-problem was servie-onneted, there is!nothing in the Hearing File of Reord that indiates the appealing party made any effort to obtain alohol rehabilitati,on servies through the Veterans Administration. Again, the questions onerning the availability of VA alohol.rehab programs is moot. As stated previously, CHAMPUS benefits must be determined on the fats in the ase, based on the law and appliable regulations. What might be available through another Federal ageny's program is not pertinent a to deision under CHAMPUS. Issuane of CertLfiate of Nonavailability (CNA): Authori zation of CHAMPUS Benefits. The appealing-party also strongly implied that issuane of a Nonavailability Statement entitled him to are--in a ivilian faility, with CHAMPUS paying seventy-five (75%) perent-of the ost. A Nonavailability Statement -was. issued to the appealing party by the loal Military hospital indiating that "neuropsyhiatri serviestt were not available at that faility. (The Statement made no mention of aloholism.) The CNA was issued retroatively to 22 June 1978, the date of the appealing party's admission to the ivilian hosital whih indiates he did not seek are his from the Military hospital before seeking admission the to ivilian hospital. Although it is aknowledged that the appealing party may have believed that obtaining a Certifiate of Nonavailability automatially entitled him to CHANPUS benefits, it represents a misunderstanding of the purpose for issuing the CNA. The Nonavailability Statement only represents evidene that the type of inpatient are the patient seeks is not available at that issuing Uniformed Servies faility at the time the request was made. It is not a ertifiation of the patient's ondition or his need for are. Neither is it an authorization or a guarantee that CHAMPUS benefits will be available. Corret information onerning the

14 -. r _- FINAL DECISION: OASD(HA) ' THIS Certifiate of Nonavailability is learly stated in the setion of Chat doument under the heading, "ISSUANCE OF... STATEMENT MEANS... It.~., Misinformation: Retirement Soures. The appealing party also asserted that on retirement and sine retirement, he had been informed verbally and through retirement bulletins, and other media that he is entitled to medial are from the Government. His statements were of suh ambiguity, however, that it annot be asertained whether he was referring to his former Servie or some retiree organization as the soure of his information--or both. Nothing was inluded in the Hearing File of Reord to support this laim so it ould not be verified. -If a soure of retiree information did, in fat, guarantee that any and all medial are would either be provided by Servie failities or paid for by CHAIVTPUS, suh information soures were in error. Every effort is made to assure orret general information about the Department of Defense medial programs is available to those who interat diretly with ative duty personnel, retirees and their dependents, beause it is reognized that suh soures an serve a useful purpose. Determination of whether spae and/or professional apability will he available for retirees in a speifi Uniformed Servie faility or whether CHAMPUS benefits an be extended for speifi ivilian medial are, is the prerogative of the faility ommander and the Program, respetively. When suh "retirement soures" do disseminate inaurate or inomplete information,-it is truly unforunate. Suh soures, however, have no legal status or authority. 8. Cinial Do'mentation. Burden of Evidene. The linial doumentation submitted to the Hearing File of Reord in this ase is very skimpy. In reviewing the ase it appears that efforts were made by both OCHAMPUS and the appealing party to obtain omplete medial reords from the hospital where the desputed inpatient stay ourred. We must therefore assume that the medial evidene submitted onstitutes the omplete medial reord available at the faility. If this assumption is orret, the reords are woefully inadequate for a thirty-five (35) day inpatient stay. Very little ritial information was made available and many assumptions and findings had to be based on the fat the Hearing File of Reord was silent. If omplete medial reords were not provided in this ase, it is possible the lak of information worked to the detriment of the appealing party. This is beause the burden of proof rests with the appealing party to present whatsoever evidene is. - 1 \

15 r- FINAL DECISION: OASD(HA) neessary to overome an initial adverse determination. In this ase suffiient evidene to overturn the initial denial. was aot. forthoming. In fati- the-pauity of doumentat-ion-- rela2ive to a need for the rehab program to be aomplished'.. -in t5e inpatient environment, ontributed to the finding that the entire inpatient stay should have been denied. (Referene: CHAMPUS Regulation DoD R, Chapter X, Se~on F, Paragraph 16.i). SUMMARY This FINAL DECISION in no way implies that the appealing party did not suffer from some degree of aloholism, that his partiipation in an alohol rehabilitation program was inappropriate or that is wzs not benefiial. It only onfirms that the irumstanes of the inpatient onfinement for alohol rehabilitation in dispute in this appeal do not qualify for benefits under CHAMPUS for any part of the stay. Under usual irumstanes, reoupment ation would be initiated to reover the amount of the CHAMPUS benefits paid in error for the first twenty-one (21) days of the disputed stay ($1,271.59). In view of the length of time sine the admission ourred, suh reoupment is hereby waived as authorized under the provisions of the Claims Colletion At of * * * * * Our review indiates the appealing party has reeived full due proess in his appeal. Issuane of this FINAL DECISION is the onluding step in the CHAMPUS appeals proess. No further administrative appeal is available. dm 8&1_ Vernon MKenzie 1 Prinipal Deputy Assistane Seretary of Defense (Health Affairs) b