Citation Nr: 1752968 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 13-33 917 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical Center in Nebraska-Western Iowa Healthcare System THE ISSUE Entitlement to payment or reimbursement of unauthorized medical expenses incurred at Good Samaritan Hospital from October 12, 2012 to October 14, 2012. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran served on active duty from August 1964 to August 1968. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2012 decision of the Department of Veterans Affairs (VA) Nebraska-Western Iowa Healthcare System. This matter was previously before the Board in June 2015 at which time the case was remanded for additional development. There has been substantial compliance with the Board's June 2015 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand.) This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing system as well as the Veteran's VA medical center paper claims file. FINDINGS OF FACT 1. The Veteran's initial treatment at Good Samaritan Hospital from October 10, 2010 to October 12, 2010, was for an emergency condition and was authorized pursuant to VA regulations. 2. The authorization for treatment at Good Samaritan Hospital did not extend beyond the point where the Veteran was stabilized. 3. The Veteran has been medically determined to have been stabilized and capable of being transferred to a VA facility by October 12, 2010. 4. The medical treatment provided at Good Samaritan Hospital from October 12, 2010 to October 14, 2010, was not authorized by VA and did not constitute emergency treatment. CONCLUSION OF LAW The criteria for payment or reimbursement of the medical expenses incurred at Good Samaritan Hospital from October 12, 2010 to October 14, 2010, are not met. 38 U.S.C. §§ 1703, 1725, 1728 (2012); 38 C.F.R. §§ 17.52 -17.54, 17.120-17.121 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran is seeking payment or reimbursement from VA concerning medical expenses incurred for services rendered at Good Samaritan Hospital from October 12, 2012 to October 14, 2012. He was transferred to that facility from the emergency room of another private facility on October 10, 2012, at which time he was experiencing chest pain and was diagnosed as having an acute inferior wall myocardial infarction. A cardiac catherization performed on October 10, 2012, revealed an acute lesion of the right coronary artery, and this was treated with a stent. He was also experiencing chronic diarrhea during his hospitalization and was diagnosed as having and treated for a clostridium difficile infection. He was discharged on October 14, 2012. The Veteran is service-connected for coronary artery disease status post myocardial infarction. In denying reimbursement for expenses from October 12, 2012 to October 14, 2012, the Agency of Original Jurisdiction (AOJ) determined, in part, that the Veteran's condition had stabilized as of October 12, 2012, that his medical emergency had ended as of that date, and that he could have been transferred to an available VA facility on that date. When a veteran receives treatment at a non-VA facility without prior authorization, a proper claimant may still be entitled to reimbursement for the cost of such care if certain requirements under 38 U.S.C.A. § 1728 or § 1725 are met. However, even when the requirements under these statues have been met, payment or reimbursement is only made for "emergency treatment," which only includes medical care provided until such time as the veteran can be transferred safely to a VA facility or other Federal facility and such facility is capable of accepting such transfer. 38 U.S.C.A. §§ 1728, 1725(f)(1). Likewise, VA regulations provide that an emergency shall be deemed to have ended at that point when a VA physician has determined that a veteran who received emergency hospital care or medical services could have been transferred from the non-VA facility to a VA medical center for continuation of treatment. 38 C.F.R. § 17.121. From that point on, no additional care in a non-VA facility will be approved for payment by VA unless the non-VA facility notified VA at the time the veteran could be safely transferred to a VA facility, and the transfer of the veteran was not accepted; and the non-VA facility made and documented reasonable attempts to request transfer of the veteran to a VA facility. Id. In the instant case, the Veteran's medical file contains a handwritten opinion from a physician that the Veteran "could have been transferred to VA by October 12." Due to the fact that this opinion was not accompanied by any specific explanation or rationale, it was considered inadequate for rating purposes and another opinion was obtained in March 2016. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The March 2016 opinion was rendered by the Chief of Medicine of the Nebraska-Western Iowa Healthcare System who opined that the Veteran's emergency had "clearly ended" by October 12, 2012. This VA clinician explained that the Veteran had undergone a cardiac procedure on October 10, 2012, and that documents from consultations on October 11, 2012, conducted by two separate physicians, indicate there were no abnormalities consistent with any continued emergency condition. The clinician said that the Veteran's vitals were "completely normal" and that the Veteran was noted during one of the consultations to be alert and comfortable with no acute distress. The clinician also pointed out that the consulting physician felt that the Veteran was stable enough to undergo elective endoscopy if necessary. He added that the Veteran had been moved out of the intensive care unit to a lower level of care. The Board finds that the March 2016 opinion above is adequate for rating purposes. In this regard, the opinion is based on the examiner's review of the October 2010 hospital records and contains an accurate report of the facts. It is also supported by sufficient reasoning and rationale and is based on sound medical judgment. There is no other medical opinion or medical evidence on file that contradicts this opinion. As noted, the ultimate determination as to whether the Veteran was undergoing continuing emergency care from October 12, 2012 to October 14, 2012, is a medical determination and the record supports the VA medical center clinical determination that he was no longer in an emergency condition on the dates in question. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991)(the Board is not permitted to base decisions on its own unsubstantiated medical conclusions). Moreover, there is no indication from the record that Good Samaritan Hospital notified VA that the Veteran was stabilized and ready for transfer to a VA facility and that the transfer was not accepted, or that any attempt to request transfer was made following the Veteran's stabilization. The Veteran's representative asserted in October 2017 that the Veteran was service connected for ischemic heart disease after suffering the myocardial infarction in October 2010, and that he was not in the position to know at the time that he transferred from a private medical facility to Good Samaritan Hospital on "October 12, 2010", that he should have gone to a VA medical facility. Contrary to this assertion, the facts show that Veteran was admitted to Good Samaritan Hospital on October 10 2010, not on October 12, 2010, and VA has already granted payment or reimbursement of medical costs for his initial hospitalization from October 10, 2010 to October 12, 2010, due to him receiving emergency treatment during that time. The issue as discussed above pertains to whether and at what point the emergency care ended thereby requiring transfer to a VA facility for continuation of medical care. This determination is pertinent to claims under 38 U.S.C. § 1728 which includes service-connected disability, as well as claims under 38 U.S.C.A. § 1725 pertaining nonservice connected disability. 38 C.F.R. § 17.121. Consideration has also been given to the Veteran's statement in April 2016 that he believes that given his age it was reasonable for the doctors to keep him a little longer at the local hospital rather than transport him, in "arguably a tenuous state," to the nearest VA hospital approximately "four light years away." However, as noted, the ultimate determination as to whether the Veteran was undergoing continuing emergency care from October 12, 2012 to October 14, 2012, is a medical determination to be made by a designated VA clinician at the VA facility. 38 C.F.R. § 17.121. Accordingly, as it has been medically determined that there was no emergency care being provided on the dates in question and the Veteran was capable of being transferred to a VA facility for continuing treatment, and as no prior authorization had been given for the services rendered, payment or reimbursement for medical costs incurred from October 12, 2012 to October 14, 2012, is not warranted. 38 U.S.C.A. §§ 5107, 1703, 1725, 1728; 17.52-17.54, 17.120-17.121. ORDER Payment or reimbursement for unauthorized medical expenses incurred at Good Samaritan Hospital from October 12, 2012 to October 14, 2012, is denied. ____________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs