VA Final Service Dog Rules Still Nix Psych Dogs, Hold to Foreign Outsourcing

Reference Note: An article appearing in the Quinnipiac Health Law Journal contains an incisive analysis of the VA's failure to provide service dogs for veterans with mental disabilities.  Alma Nunley (July 2014). Service Dogs for (Some) Veterans: Inequality in the Treatment of Disabilities by the Department of Veterans Affairs. Quinnipiac Health Law Journal, 17(2), 261-291. 

The Department of Veterans Affairs has finalized rules proposed in 2011 on service dogs. The VA says that its proposal was not intended to provide guidance concerning what service dogs could have access to VA facilities, only on what types of service dogs would be funded.  Dogs for veterans with mental health disabilities will still not be funded, unless a dog also has a function relating to a veteran’s sight, hearing, or mobility impairment.  The requirement that dogs be certified by one of two foreign-controlled umbrella associations is retained, and indeed reinforced because the VA now states that an organization must be a full member, not merely a candidate member of either association. 

In the end, the proposed rules have been adopted with only minor alterations, and the VA still expects only to fund expenses related to 100 new dogs a year, two-thirds of which will be guide dogs.   The VA received 98 comments on the rules proposal it issued in June 2011.  The rules as modified become effective on October 5, 2012.  The final rule is reproduced in full at the end of this piece.

VA Defines Service Dog for Funding Purposes Only

The final rules define service dogs as “guide or service dogs prescribed for a disabled veteran….”  Commenters had noted the circularity of the definition and had recommended that the VA adopt the definition given by the Department of Justice under the Americans with Disabilities Act.  The VA acknowledges that the definition is circular, but finds it adequate for its purposes and declines to change it, declaring that “the ADA and its implementing regulations are neither controlling nor informative with regard to the administration of benefits to veterans with service dogs.”  The circularity means that the VA has effectively avoided providing a useful definition. 

The VA says that its rules are designed for an entirely different purpose from the ADA:

“The ADA and its implementing regulations exclusively address the issue of access to public facilities by individuals with disabilities, whereas the purpose of [the VA’s] rule is to authorize benefits to a veteran with a service dog.  Access is not discussed in [the VA’s rules].”

This restricted objective of the VA rules is emphasized throughout the release accompanying the VA’s final rules. They are funding rules, not access rules. 

“We reiterate that this rulemaking does not address the issue of access to VA health care facilities by individuals accompanied by service dogs, and will not be used to determine whether a particular service dog will be allowed to enter a VA facility…. A certificate is required … only to enable the veteran to receive service dog benefits, but is not required to gain entry to VA facilities.  This rulemaking does not permit or prohibit the access of service dogs to VA health care facilities.” 

VA Drafting New Access Rule

The preamble notes that 40 U.S.C. 3103(a) states: “Guide dogs or other service animals accompanying individuals with disabilities and especially trained and educated for that purpose shall be admitted to any building or other property owned or controlled by the Federal Government on the same terms and conditions, and subject to the same regulations, as generally govern the admission of the public to the property.” 

The VA’s current access regulation, 38 CFR 1.212(a)(11), is much narrower: “Dogs and other animals, except seeing-eye dogs, shall not be brought upon property except as authorized by the head of the facility or designee.”

The VA release states that “we are in the process of amending § 1.218(a)(11) to be fully compliant with 40 U.S.C. 3103(a).” 

No Mention of Honoring America’s Veterans Act

The regulatory release makes no mention of the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, P.L. 112-154, which contains a section entitled: Use of Service Dogs on Property of the Department of Veterans Affairs.  That section of the Act revises the security and law enforcement section that applies to property under the jurisdiction of the Department of Veterans Affairs, 38 U.S.C. 901, to include a new subsection stating:

“(f)(1) The Secretary may not prohibit the use of a covered service dog in any facility or on any property of the Department or in any facility or on any property that receives funding from the Secretary.

(2) For purposes of this subsection, a covered service dog is a service dog that has been trained by an entity that is accredited by an appropriate accrediting body that evaluates and accredits organizations which train guide or service dogs.”

This certainly looks like an access rule, though it only requires that access be provided to dogs that meet the criteria that are now being used for a funding rule.  It does not specify animals that are to be denied access.  In theory, then, the Department could expand its access rule to permit “the use of” a non-covered service dog as well. 

The fact that this section (38 U.S.C. 901) was not mentioned in the preamble to the regulations would suggest that the regulation writers were not aware of it when they completed writing the preamble.  Nevertheless, the Act was signed by President Obama on August 6 and there should have been time to add a reference to a release published in the Federal Register on September 5.  Whether the reg writers were sloppy or disingenuous is not clear. 

Service Dogs for Visual, Hearing, or Substantial Mobility Impairments

The final rules provide funding for dogs for veterans “diagnosed as having a visual, hearing, or substantial mobility impairment.” Benefits will not be provided “for a dog to mitigate the effects of a mental illness that are not related to visual, hearing or mobility impairments.”  The preamble clarifies that veterans “diagnosed with a hearing or visual impairment will certainly not be deemed ineligible for service dog benefits because they also have a mental health impairment.” 

As to mobility impairments, the VA states that “if a veteran’s mental impairment manifests in symptoms that meet the definition of ‘chronic impairment that substantially limits mobility’ … and a service dog is clinically determined to be the optimal device to manage that mobility impairment, then such a veteran will be awarded service dog benefits.”  The dog must, however, “mitigate the effects of a visual, hearing, or mobility impairment.”  Thus, a dog that mitigates the effect of a mental illness of someone who has a hearing impairment, but which does not mitigate the effects of the hearing impairment (i.e., is not a hearing or signal dog) would not be funded by the VA.  If the dog alerted to an anxiety attack that produced a temporary deafness, but had no standard hearing dog functions, it would presumably also not be covered, unless this could be called a seizure disorder. Seizure disorders are specifically covered if the disorder “causes a veteran to become immobile during and after a seizure event,” so seizure alert dogs may be funded.  

Rationale for Not Covering Dogs for Mental Disabilities

The VA says that the reason it is not covering dogs for mental health conditions is “based on a lack of evidence to support a finding of mental health service dog efficacy.”  Citing “widely accepted training protocols” for guide, hearing, and mobility impairment dogs, the VA states:

“We are unaware of similarly vetted and accepted training protocols for mental health service dogs, or how assistance from such dogs could be consistently helpful for veterans to mitigate mental health impairments.” 

The VA does not dispute that many veterans have argued that mental health service dogs have improved the quality of their lives, but the agency insists that it “has not yet been able to determine that these dogs provide a medical benefit to veterans with mental illness.  Until such a determination can be made, VA cannot justify providing benefits for mental health service dogs.” 

This opens up the question of how a medical benefit from a mental health service dog (the release generally avoids using the term “psychiatric service dogs”) would be determined.  If a benefit is only demonstrated by a statistical improvement in generally accepted psychological measures in a clinical study of a sufficiently large sample of individuals using such dogs, then the VA can find some support for its position.  As described in a prior blog, the evidence from refereed psychiatric and psychological publications is inconsistent, with some studies finding improved psychological conditions and others not. If, on the other hand, a dog sits behind a veteran with PTSD in a movie line to give him some distance from those behind him while guarding his back, this may provide some temporary relief in a stressful situation and make it possible for the veteran to go to the movie in the first place. That is certainly a measurable benefit.  Guide dogs do not cure blindness, but they allow a blind person to function in ways that might otherwise be impossible.  It must be questioned whether the VA has posed the question of a mental health benefits from a service dog appropriately. 

Regardless of the ultimate criteria for determining effectiveness, more studies are in progress and the field of the psychological benefits of service dogs is not static.  The VA mentions a study in progress in Tampa, Florida.  A similar study was mentioned in a recent issue of the Army Medical Journal, as described in a prior blog.  It will be important to verify whether veterans and soldiers with service dogs reduce use of medications after getting dogs. 

The VA says here, as it had previously stated in its 2011 proposal, that although Congress has given it the authority to provide “service dogs trained for the aid of persons with mental illnesses, including post-traumatic stress disorder, to veterans with such illnesses” who are eligible for VA benefits, the statute, 38 U.S.C. 1714(c)(3), does not require it to do so.  The VA states that “if we ultimately determine that mental health dogs are appropriate treatment tools for mental health impairments, we will amend our regulations to authorize benefits for such dogs.” 

Requirement of Certification by Members of Foreign-Controlled Organizations  

Numerous commenters had criticized the VA’s outsourcing of service dog qualification to the International Guide Dog Federation (IGDF) and Assistance Dogs International (ADI) but the VA is holding fast to this approach. 

“There are no Federal standards for service dog training that we can apply, and VA does not have the expertise to design its own accreditation program or standards.  ADI and IGDF are national, industry-recognized organizations with established and proven training criteria.” 

The word “national” is not correct, unless it is meant to indicate that these organizations operate in the United States.  IGDF is headquartered in England, its director is Canadian, and only one of its seven directors is located in the U.S.  ADI gives contact information for a Santa Rosa address, but its president, vice-president, and four of its seven board members are not in the U.S. 

The VA notes that, for other accreditation purposes, it relies on a number of organizations, including (1) Centers for Medicare and Medicaid Services, (2) the National Fire Protection Association, and (3) State licensing organizations for health care professionals.  This is undoubtedly true, but all of these instances of accreditation outsourcing involve organizations based in the United States.  With IGDF and ADI, the VA is allowing policy decisions to be made overseas. 

Effect of Limiting Dogs to ADI and IGDF Organizations

The VA acknowledges that “not all States have registered ADI-accredited or IGDF-accredited organizations, but argues that its final rules “provide for the reimbursement of travel expenses associated with the training a veteran must complete as offered by an ADI-accredited or IGDF-accredited organization.”  Because the VA will pick up the travel expenses, “we do not believe the absence of ADI-accredited or IGDF-accredited organizations in a particular State will serve as a barrier to obtaining a service dog.”

Traveling to obtain a dog is a severe problem for active duty military personnel, who are not (yet) veterans covered by the VA’s rules, but who must now operate under rules that the Army has adopted that use the same organizational approach as used by the VA.  That is not the VA’s problem, however.

Full Membership in ADI and IGDF Required

In commenting on the VA proposal in August 2011, I had asked: “Are candidate organizations of the umbrella groups to be authorized to certify service dogs for veterans, given that their candidacies may not ultimately result in full membership?”  To me or someone who asked the same thing, the VA states:

“We clarify for one commenter that VA only intends to recognize those service dog organizations that have full membership in ADI or IGDF, or that are fully ADI or IGDF accredited, versus those organizations in the process of becoming ADI or IGDF accredited.” 

This substantially cuts the potential supply of service dogs, since there are many organizations in candidate status with ADI.  The VA also noted that commenters had argued for “owner training,” but the agency declined to fund dogs trained in this manner, or trained in any manner by an organization not a full member of ADI or IGDF. 

The VA specifies that it “will not formally refer veterans to specific ADI-accredited or IGDF-accredited organizations, or initiate a process whereby a veteran may consent to have the VA act as an intermediary between the veteran and the service dog organization.”  Clinical staff will be able to give patients website information where they may find the nearest ADI- or IGDF-accredited organization, but the VA clearly wants to keep its distance from the process of actually getting the veteran a dog.  One senses a certain concern about liability here.  If the veteran provides a poorly functioning dog, the VA can insist that it only made a recommendation, not that it approved a specific organization or a specific dog. 

Service Dog Must Be an Optimal Device

Many commenters were surprised that the VA anticipated funding only about 100 dogs per year to veterans.  How that number was calculated will be discussed below, but the way that the VA may assure not having to fund more is the principle that it incorporates into the rule that a service dog must be “the ‘optimal’ device for the veteran to manage his or her impairment and live independently.”  The VA elaborates:  “[S]ervice dog benefits will not be provided if other assistive means or devices would provide the same level of independence as a service dog.” 

The VA acknowledges that “an eligible veteran may be prescribed both a service dog and another assistive device, as long as each provides a distinct type of assistance, or if, without each of the devices, the veteran would be unable to complete tasks independently.”  Thus, a veteran might be prescribed both a balance cane and a service dog, where the balance cane is optimal for walking, but the service dog is the best way to “regain a standing position and stabilize after a fall.” 

The VA states its reason for treating service dogs as secondary to other assistive devices:

“A service dog is a long term commitment that requires tremendous dedication and effort on the part of the veteran, as well as significant costs—only part of which would be paid for by VA…. A service dog must be fed, exercised, groomed, nursed when ill, and integrated into the veteran’s family as a necessary partner in the veteran’s daily life. If the extent of the veteran’s mobility impairment is such that the only tasks requiring assistance are picking up or reaching items, then a device that is not a service dog that fully accomplishes these tasks is not only sufficient, but also is not unduly burdensome for the veteran.”

Thus, if a cane works as well as a dog, the cane will be prescribed, the dog will not.  The fact that the dog adds emotional support to physical support will not be taken into account.  “Congress authorized VA to provide service dogs to veterans with disabilities as a means of mitigating the effects of a disability—and not for the purpose of companionship or emotional support.”  The VA also says that cost will not enter into its decision as to what devices to supply to a veteran. 

Expanding the example of the last paragraph, it is also apparent that if the dog is not optimal, not only will the cane be prescribed, but any mental illness that the veteran has on top of the mobility impairment will be treated by means other than a dog.  So if the soldier could use a dog just as well as a cane, and would not have to take as many psychotropic medications if he had a dog, the dog will still not be prescribed because it is not optimal for the mobility impairment.  As stated previously, the “service dog benefits will not be provided if other assistive means or devices would provide the same level of independence as a service dog.”  

Would a VA treatment team be able to argue that a service dog provides greater independence because the psychotropic medications have side effects that reduce the patient’s ability to function independently?  Perhaps, but this would seem to stretch the wording of the release well beyond what the reg writers intended. 

Who Determines What is Optimal?

The proposed rules specified that a VA clinician using medical judgment was to determine if a service dog was optimal.  The VA agreed with commenters who suggested that other professionals might appropriately be involved, including prosthetic staff and rehabilitative therapy staff who are members of an interdisciplinary team.  The VA clinical team will thus include “the veteran’s primary healthcare provider, and any other relevant specialty care providers and professional staff, to include prosthetic, and rehabilitative therapy staff.” 

What VA Will Pay For

The final rules follow the concept of the proposed rules in specifying that the VA will not buy service dogs for veterans.  Of course many organizations do not sell service dogs to end-users because they want to retain the ability to take the dog back if it is not being properly cared for or not being used for its intended service.  In any case, the VA is correct that “a majority of service dogs are acquired by veterans with little or no out of pocket cost.” 

The VA will pay for “repairing and or replacing harnesses or other hardware, providing annual and emergent veterinary care, providing prescription medications, or paying for other services when prescribed by a veterinarian.” 

The VA will not pay for grooming, nail trimming, non-sedated teeth cleaning, nonprescription medications, and nonprescription food and dietary supplements.  The VA will also not pay for standard nonspecialized leashes and collars and dog licenses.

Benefits will generally not be provided for more than one service dog at a time.  Thus, the VA will not pay expenses for a service dog that has been retired.  The final rule adds a provision that is a limited exception to the one-dog rule:

“VA will provide payment for travel expenses related to obtaining a replacement service dog, even if the veteran is receiving other benefits under this section for the service dog that the veteran needs to replace.”

Service Dogs Obtained before October 2012

The VA states that “we accept a certificate from a non-ADI or non-IGDF organization that existed before the effective date of the final rule as proof that the veteran’s service dog has successfully completed an adequate training program, and that a veteran who otherwise meets the criteria in the rule may receive applicable benefits.”  The VA says that it is essentially grandfathering service dogs acquired before the effective date of the final rule by not requiring these dogs to have ADI or IGDF certification. 

There appears to be a logical inconsistency here.  An organization that is a candidate member of IGDF or ADI cannot certify a dog either before or after the effective date of the final rules, i.e., October 5, 2012.  An organization that never applied for ADI membership can do so up to that date.  

The preamble adds one curious sentence:

“In response to commenters’ concerns that ADI-accredited organizations will not certify service dogs that were not also initially trained there, VA will ensure through continued workings with ADI-accredited and IGDF-accredited organizations that there exists a mechanism to provide such certification.” 

What “continued workings?”  In a 2010 audit of the VA’s Service Dog Program (10-01714-188), the VA Inspector General mentions that the VA signed a Memorandum of Understanding with Assistance Dogs International “to gain their assistance in preparing educational materials for providers and veterans.”  This MOU would not seem to cover the continued workings discussed here.  In any case, the VA apparently anticipates the possibility of having to pressure an accredited organization to work with a veteran who has a dog but no certification from a non-accredited organization.  Presumably ADI will have to contact member organizations and inform them of the advisability of cooperating with the VA on providing a certification for a previously trained dog.  It will be very interesting to see how all this works in practice, and I encourage anyone who gets into this situation to publish or post their experience.

In the few hours since this blog was first posted, I have been advised that at least one ADI member organization believes it will not be able to provide any certification for dogs it has not trained because its insurance policy would not cover such an activity.  Insurers in this business are likely to follow suit in interpreting policy provisions. It will be interesting to see if the VA comes up with a Plan B.  The easiest solution for many organizations will simply be to deny any applicant seeking a secondary certification, regardless of the quality of the dog and despite the language in the release.  

Service Dog Insurance Policies

The VA says that it “has researched the commercial market and anticipates that VA will be able to contract” that will mean that veterans will not have to pay any out of pocket costs for covered veterinary care and treatment costs.”  Because of concerns expressed by commenters, the final rule bars the billing of veterans for covered costs.  The VA says it “will consult with ADI, IGDF, and the American Veterinary Medical Association to ensure that the most comprehensive policy, specific to the needs of service dogs, is chosen.”    

Presumably, despite the foreign control of two out of three of the organization with which the agency will consult, the insurer will be U.S. based. Presumably also, due diligence should assure that the insurer has no direct or indirect connection with the designated umbrella organizations or members of those organizations.  

Number of Dogs VA Expects to Fund

The 2011 proposed rules estimated that 100 new service dogs would be provided to veterans annually.  Commenters objected that this was too low an estimate.  The preamble says that “100 is not an estimate of the number of veterans who may need a service dog.”  Rather, the number “was based on the number of veterans who sought to receive new guide dog benefits in fiscal year 2010 … which was 66, plus an additional number of veterans we estimated who would seek to receive new … service dog benefits for hearing and mobility impairments.”  Thus, the VA estimated that only 34 hearing and mobility impairment dogs would be needed to satisfy the demand created by VA system recommendations for such dogs as an “optimal device.” 

This highly questionable arithmetic will produce a very small number of dogs needed and one wonders what will happen if more recommendations than are being budgeted for start to come in.  A Republican administration, perhaps even a Democratic administration, may not be terribly flexible about making an adjustment to a figure that appears to have been calculated through use of a dart board.  Nevertheless, the VA insists that it has “no financial motive to underreport the estimated number of respondents.” 

Conclusion

It is unfortunate that the VA has chosen to ignore those veterans who have obtained service dogs for mental disabilities, but it is my opinion that this is not at present a litigable issue.  The VA is awaiting research results and has closed the door only for the present. 

The fact that the VA does not see its rules as defining service dog access would be a great relief to many veterans were it not that the Honoring America’s Veterans Act seems to include contrary language.  Also, the Army has been adopting access policies based on the same sort of foreign outsourcing approach that appears to have been blessed by Congress in the Act, so no one with a non-ADI or –IGDF service dog should rest easy until a final rule gives them access rights. 

The VA’s determination to give control of service dog qualification to two foreign-controlled organizations is tantamount to providing government contracts to a very limited number of bidders, and may have a significant impact on the economics of the service dog industry.  This is something that has happened in military contracts for working dogs, which I discussed in a blog two years ago.  There is a major difference, however.  With contract working dogs for military operations, the Department of Defense is paying for the services provided by the contractors, including the use of dogs over their useful lives, and due diligence is required for the spending of federal tax dollars on such contracts.  Awards are subject to review and can be overturned by the Government Accountability Office or by the courts, as happened with multi-million dollar contract I described in that blog. 

With service dogs, the veterans may have to pay for the dogs themselves and if a veteran can find a dog with the necessary skills by going to an individual trainer or small business that trains service dogs at a lower cost than an established charity, he or she should not be precluded from using such a resource.  By excluding funding for dogs trained outside of approved channels, the VA is essentially supporting a segment of the industry based not on the quality of its product but rather on the source of its product. The VA was able to do this without holding a public hearing on its proposed rulemaking, or by giving any consideration to approaches used by other federal agencies, including the Departments of Justice, Transportation, and Housing and Urban Development, all of which developed the sort of expertise the VA and the Army seem to find unattainable.  By insisting that its lack of expertise with service dogs excuses it from developing its own criteria for evaluating them, the VA has just awarded a very large government contract without any due diligence whatsoever.   

The final rule is reproduced below.

Thanks to Joan Esnayra, Debbie Kandoll, Leigh Anne Novak, Hilary Phillips, and Dailyah Rudek for comments and corrections, though I must acknowledge that I have not always followed their sound advice. I am solely responsible for all errors in fact or judgment.   

38 CFR 17.148 Service Dogs

(a) Definitions. For the purposes of this section: Service dogs are guide or service dogs prescribed for a disabled veteran under this section.

(b) Clinical requirements. VA will provide benefits under this section to a veteran with a service dog only if:

(1) The veteran is diagnosed as having a visual, hearing, or substantial mobility impairment; and

(2) The VA clinical team that is treating the veteran for such impairment determines based upon medical judgment that it is optimal for the veteran to manage the impairment and live independently through the assistance of a trained service dog. Note: If other means (such as technological devices or rehabilitative therapy) will provide the same level of independence, then VA will not authorize benefits under this section.

(3) For the purposes of this section, substantial mobility impairment means a spinal cord injury or dysfunction or other chronic impairment thatsubstantially limits mobility. A chronic impairment that substantially limits mobility includes but is not limited to a traumatic brain injury that compromises a veteran’s ability to make appropriate decisions based on environmental cues (i.e., traffic lights or dangerous obstacles) or a seizure disorder that causes a veteran to become immobile during and after a seizure event.

(c) Recognized service dogs. VA will recognize, for the purpose of paying benefits under this section, the following service dogs:

(1) The dog and veteran must have successfully completed a training program offered by an organization accredited by Assistance Dogs International or the International Guide Dog Federation, or both (for dogs that perform both service- and guide-dog assistance). The veteran must provide to VA a certificate showing successful completion issued by the accredited organization that provided such program.

(2) Dogs obtained before September 5, 2012 will be recognized if a guide or service dog training organization in existence before September 5, 2012 certifies that the veteran and dog, as a team, successfully completed, no later than September 5, 2013, a training program offered by that training organization. The veteran must provide to VA a certificate showing successful completion issued by the organization that provided such program. Alternatively, the veteran and dog will be recognized if they comply with paragraph (c)(1) of this section.

(d) Authorized benefits. Except as noted in paragraph (d)(3) of this section, VA will provide to a veteran enrolled under 38 U.S.C. 1705 only the following benefits for one service dog at any given time in accordance with this section:

(1) A commercially available insurance policy, to the extent commercially practicable, that meets the following minimum requirements:

(i) VA, and not the veteran, will be billed for any premiums, copayments, or deductibles associated with the policy; however, the veteran will be responsible for any cost of care that exceeds the maximum amount authorized by the policy for a particular procedure, course of treatment, or policy year. If a dog requires care that may exceed the policy’s limit, the insurer will, whenever reasonably possible under the circumstances, provide advance notice to the veteran.

(ii) The policy will guarantee coverage for all treatment (and associated prescription medications), subject to premiums, copayments, deductibles or annual caps, determined to be medically necessary, including euthanasia, by any veterinarian who meets the requirements of the insurer. The veteran will not be billed for these covered costs, and the insurer will directly reimburse the provider.

(iii) The policy will not exclude dogs with preexisting conditions that do not prevent the dog from being a service dog.

(2) Hardware, or repairs or replacements for hardware, that are clinically determined to be required by the dog to perform the tasks necessary to assist the veteran with his or her impairment. To obtain such devices, the veteran must contact the Prosthetic and Sensory Aids Service at his or her local VA medical facility and request the items needed.

(3) Payments for travel expenses associated with obtaining a dog under paragraph (c)(1) of this section. Travel costs will be provided only to a veteran who has been prescribed a service dog by a VA clinical team under paragraph (b) of this section. Payments will be made as if the veteran is an eligible beneficiary under 38 U.S.C. 111 and 38 CFR part 70, without regard to whether the veteran meets the eligibility criteria as set forth in 38 CFR part 70. Note: VA will provide payment for travel expenses related to obtaining a replacement service dog, even if the veteran is receiving other benefits under this section for the service dog that the veteran needs to replace.

(4) The veteran is responsible for procuring and paying for any items or expenses not authorized by this section. This means that VA will not pay for items such as license tags, nonprescription food, grooming, insurance for personal injury, nonsedated dental cleanings, nail trimming, boarding, pet-sitting or dog-walking services, over-the-counter medications, or other goods and services not covered by the policy. The dog is not the property of VA; VA will never assume responsibility for, or take possession of, any service dog.

(e) Dog must maintain ability to function as a service dog. To continue to receive benefits under this section, the service dog must maintain its ability to function as a service dog. If at any time VA learns from any source that the dog is medically unable to maintain that role, or VA makes a clinical determination that the veteran no longer requires the dog, VA will provide at least 30 days notice to the veteran before benefits will no longer be authorized.