Citation Nr: 1301221 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 11-00 155A ) DATE ) ) On appeal from the Department of Veterans Affairs Nebraska-Western Iowa Health Care System THE ISSUE Entitlement to reimbursement of unauthorized medical care at a non-VA facility from May 13, 2010 to May 15, 2010. REPRESENTATION Appellant represented by: Nebraska Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Thomas H. O'Shay, Counsel INTRODUCTION The Veteran had active service from June 1972 to June 1976, and from October 1980 to April 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal of decisions by the Department of Veterans Affairs (VA) Nebraska-Western Iowa Health Care System (hereinafter, "VAMC"). The Veteran testified at a Board hearing held at the Lincoln, Nebraska Regional Office in November 2011. The appeal is REMANDED to the VAMC via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran contends that he is entitled to reimbursement of medical expenses incurred at a private facility while hospitalized in May 2010. Pursuant to 38 U.S.C.A. § 1728, VA may pay or reimburse Veterans for emergency medical care expenses incurred in non-VA facilities where such emergency treatment was rendered for, inter alia, an adjudicated service-connected disability. 38 U.S.C.A. § 1728. The term "emergency treatment" means medical care or services furnished when Department or other Federal facilities are not feasibly available and an attempt to use them beforehand would not be reasonable; when such care or services are rendered in a medical emergency of such nature that a prudent layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health; and until such time as the Veteran can be transferred safely to a Department facility or other Federal facility and such facility is capable of accepting such transfer. 38 U.S.C.A. § 1725(f)(1). The record shows that the Veteran was admitted to the St. Elizabeth Regional Medical Center on May 13, 2010, for symptoms associated with his service-connected diabetes. He was discharged from the facility two days later. VA has reimbursed him for the costs of emergency room services for May 13, 2010, and (according to him) his private insurance has absorbed a significant portion of the remaining medical expenses. The Veteran seeks reimbursement of the remaining medical expenses incurred from May 13, 2010 to May 15, 2010. The Veteran was brought to the private facility suffering from the effects of acute renal failure from low blood sugar, low blood pressure, and dehydration. The ambulance records document that he was alert and oriented, and admitted to taking double his normal dose of fast-acting insulin. The emergency room records show that his admission blood pressure was 72/40, with blood sugars of 68. He was alert and oriented, and again admitted to doubling his dose of a diabetes medication on his own initiative. The emergency room summary indicates that the Veteran's blood sugars rose to the 180's, and that his blood pressure was in the 120's. The plan was to admit him for aggressive intravenous fluids to improve renal function; to adjust his insulin, particularly in light of his overdose; and to check the electrocardiogram for hyperkalemia. The hospital report for the Veteran's admission indicated that he was admitted in a hypoglycemic state. The report notes that when the "squad" examined him, his blood sugar was in the 90's, and his systolic blood pressure readings were in the 70's. The report further noted that in the emergency room, the Veteran was found to have elevated creatinine levels, and he was given intravenous fluids and underwent vein mapping as well as adjustment of his medications. His blood sugars were noted to have remained somewhat labile during his stay, but that they generally ranged from 120 to 392. He was eventually discharged in stable condition. The final diagnoses noted in the hospital report included acute renal failure and hypotension secondary to volume depletion, and hypoglycemia. VA determined that the medical expenses for the emergency services rendered on May 13, 2010, were reimbursable by VA. VA determined, however, that the Veteran's condition became stable in the emergency room when his blood sugar reached 180, and his systolic blood pressure reached the 120's. VA concluded that, at that point, the Veteran's condition was such that he could be safely transferred to the VAMC in Omaha, Nebraska for any continued treatment. Thus, the Veteran's claim turns on when his condition stabilized during his May 2010 hospitalization. That determination is clearly one which requires medical opinion evidence. In reviewing the record, it appears that there is a medical opinion concerning when the Veteran's condition was stable enough to allow transfer, but it is unclear whether the physician was offering the opinion in the capacity of a physician, or in the capacity of an adjudicator. In a November 2010 handwritten note, the physician stated "Appeal denied. The admitting H & P documented medical stability that would have been sufficient to allow transfer to the Omaha VA." It appears from this that the physician was making the statement more as an adjudication than as a consulting medical opinion. In any event, the opinion does not offer any supporting rationale. Given the above, the Board finds that another VA medical opinion is necessary, to be provided by an individual other than the one who offered the November 10, 2010 "opinion." Accordingly, the case is REMANDED for the following actions: 1. The VAMC/AMC should forward the Veteran's claims file to a physician with appropriate expertise who has not previously reviewed the claims file in connection with the current appeal. The examiner is requested to review the claims file, and with respect to the private medical care received by the Veteran from May 13, 2010 through May 15, 2010, to provide an opinion as to when the Veteran's medical condition stabilized to the point where he could be transferred safely to the Omaha, Nebraska VAMC. The examiner must offer a detailed rationale for his or her opinion. 2. The VAMC/AMC should then readjudicate the issue on appeal. If the benefit sought on appeal is not granted in full the VAMC/AMC must issue a supplemental statement of the case, and provide the appellant and his representative an opportunity to respond. After the Veteran and his representative have been given an opportunity to respond to the supplemental statement of the case and the period for submission of additional information or evidence set forth in 38 U.S.C.A. § 5103(b) (West 2002) has expired, if applicable, the case should be returned to the Board for further appellate consideration, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is notified by the VAMC/AMC. The Veteran and his representative have the right to submit additional evidence and argument on the matter the Board has remanded to the VAMC/AMC. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).