Citation Nr: 18141442 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 16-00 279A DATE: October 10, 2018 ORDER Entitlement to payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Marshall Medical Center on March 25, 2015, is GRANTED. FINDINGS OF FACT 1. On the afternoon of Wednesday, March 25, 2015 at around 2:39 pm, the Veteran was hospitalized at the Marshall Medical Center in Lewisburg, Tennessee. This is a private facility. He was driven to the hospital by his spouse. His chief complaint was “severe” headaches after sustaining a fall. He was treated with various pain medications, administered by IV. The final diagnoses were “acute” headaches and a concussion. His migraine headaches are a nonservice-connected disability. 2. The Veteran has a 100 percent permanent and total (P&T) rating due to his adjudicated service-connected disabilities. 3. This private hospitalization was rendered in a medical emergency of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. 4. During this private hospitalization on March 25, 2015, VA facilities were not feasibly available and an attempt to use them beforehand would not have been considered reasonable by a prudent layperson. 5. There is no stabilization issue – in other words, on March 25, 2015, the Veteran did not remain at Marshall Medical Center beyond the point of stabilization. He only remained at the private facility for a little over three hours. CONCLUSION OF LAW Resolving all reasonable doubt in his favor, the criteria are met for payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Marshall Medical Center on March 25, 2015. 38 U.S.C. §§ 1728, 5107 (2012); 38 C.F.R. §§ 17.53, 17.120, 17.1002 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active duty in the U.S Army from August 1966 to April 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 decision by the Department of Veterans Affairs (VA) Tennessee Valley Health Care System (HCS) in Murfreesboro, Tennessee. This appeal was processed using both a paper-based claims file and an electronic Veterans Benefits Management System (VBMS). VA’s Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA’s duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In Beverly v. Nicholson, 19 Vet. App. 394, 403-04 (2005), although not explicitly stated, the U.S. Court of Appeals for Veterans Claims (Court) implied the VCAA is applicable to a Chapter 17 claim, but then held that the failure to comply with the VCAA notice requirements in that case constituted non-prejudicial error. To the extent the VCAA is applicable to the instant medical expenses reimbursement claim, the Board has considered its provisions. In any event, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Also, the Veteran has articulated why he considered his non-VA hospitalization to be emergent on March 25, 2015, and also why he considered it infeasible to visit a VA facility that afternoon. Medical Expense Reimbursement On the afternoon of Wednesday, March 25, 2015 at around 2:39 pm, the Veteran was hospitalized at the Marshall Medical Center in Lewisburg, Tennessee. This is a private facility. He was 67 years old at the time. He was driven to the hospital by his spouse. His chief complaint was “severe” headaches. Three weeks earlier he reported a fall in which he struck his head. He had experienced intermittent headaches since that time. However, two hours prior to his private hospitalization that day, his headaches significantly worsened to a level of 10/10. At the private hospital, a computed tomography (CT) scan of the head revealed atrophy and background chronic white matter changes. The final diagnoses were “acute” headaches and a concussion. He was treated with Tramadol, Benadryl, Toradol, Compazine, all administered by IV. He remained at the private hospital for over three hours. His headaches are a nonservice-connected disability. He has partial health insurance through Medicare Part A. The Veteran did not receive written authorization from VA prior to this private hospitalization. It also appears from outstanding invoices that he owes the private hospital at least $2,956 for its services that afternoon. The Veteran has requested reimbursement for his unauthorized medical expenses, contending that the private hospitalization at Marshall Medical Center on the afternoon of March 25, 2015, was rendered in a “medical emergency” of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. He maintains that his headaches were “severe.” He says he could not think clearly and needed the assistance of his wife. He reports his wife called his VA primary care provider (B.V.H., a registered nurse) at the VA Medical Center (VAMC) in Nashville on the phone that afternoon. She advised the Veteran to seek immediate treatment at the nearest ER. He also asserts that the nearest VAMC in Nashville, Tennessee was not feasibly available at the time of the private hospitalization - due to the severity or urgency of his medical condition and the relative distance of the travel involved to the VAMC facility vs. the private facility. The nearest VAMC was close to an hour’s drive away, whereas Marshall Medical Center was only six minutes away. See January 2016 VA Form 9. In the May 2015 administrative decision on appeal and in the December 2015 Statement of the Case (SOC), VA denied the Veteran’s unauthorized medical expenses claim. VA determined that his private hospitalization at Marshall Medical Center on the afternoon of March 25, 2015, was non-emergent. In addition, the VA determined that VA facilities were feasibly available to the Veteran on the afternoon of March 25, 2015, because an ambulance could have been called to drive the Veteran for treatment at the VAMC in Nashville, Tennessee. VA adjudicators noted that the Veteran was seen for a separate emergency only several days earlier on March 22nd and 23rd, 2015, at the VAMC in Nashville. Moreover, on the day in question – March 25, 2015, the Veteran was seen that morning at the VAMC in Nashville for a dental appointment. In short, the VAMC concluded the Veteran did not meet the criteria for payment or reimbursement of non-VA medical treatment. The Veteran appealed this denial to the Board. Initially, under 38 U.S.C. § 1703, 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 authorize or contract with non-VA facilities for care. 38 U.S.C. § 1703(a) (2012); 38 C.F.R. § 17.52(a) (2017). However, in this case, VA did not authorize or contract for Marshall Medical Center to provide the Veteran with no cost private care on the afternoon of March 25, 2015. In this regard, although a VA nurse told the Veteran to visit the nearest emergency room, the U.S. Court of Appeals for Veterans Claims (Court) has held that the oral advice of a VA clinician to a claimant to seek treatment at a private hospital is not the type of specific authorization contemplated by § 17.54(a). Smith v. Derwinski, 2 Vet. App. 378, 379 (1992). Thus, the issue of prior authorization, as delineated by VA statute and regulation, is not applicable here. Regardless, when a veteran receives treatment at a private facility without prior authorization, such as the case here, there are two statutes that allow for claimants to be paid or reimbursed for the medical expenses incurred for that treatment - specifically 38 U.S.C. § 1728 and 38 U.S.C. § 1725. Application of either statute is generally dependent on whether the Veteran has an adjudicated service-connected disability. In the present case, in adjudicating the “unauthorized” medical expenses claim, the Board concludes that 38 U.S.C. § 1728 for veterans with service-connected disability is for consideration. The Board acknowledges that the Veteran’s headaches for which he was treated are not a service-connected disability. See 38 C.F.R. § 17.120(a)(1). That notwithstanding, the Veteran has a 100 percent permanent and total (P&T) rating due to his adjudicated service-connected disabilities. See 38 C.F.R. § 17.120(a)(3). Therefore, the Veteran meets this initial criterion of 38 U.S.C. § 1728(a), in that he has a P&T service-connected disability. Effective October 10, 2008, the provisions of 38 U.S.C. § 1725 and § 1728 were amended. See Veterans’ Mental Health and Other Care Improvements Act of 2008, Pub. L. No. 110-387, § 402, 122 Stat. 4110 (2008). The changes are liberalizing in that they make reimbursement for medical expenses mandatory instead of discretionary, as well as expand the definition of “emergency treatment” beyond the point of stabilization. In addition, the changes apply the more liberal prudent layperson standard for determining whether an actual medical emergency existed under either 38 U.S.C. § 1725 and § 1728. The Board will apply the more liberal amended law in this case because the Veteran’s private hospitalization occurred in March 2015, subsequent to the October 2008 effective date of the amendments. Specifically, the amended statutes expand the meaning of “emergency treatment” under section 1725(f)(1) and section 1728(c) by defining emergency treatment as medical care or services furnished, in the judgment of VA: (A) when Department or other Federal facilities are not feasibly available and an attempt to use them beforehand would not be reasonable; (B) 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 (C) until such time (i) as the veteran can be transferred safely to a Department facility or other Federal facility and such facility is capable of accepting such transfer; or (ii) as a Department facility or other Federal facility accepts such transfer if at the time the veteran could have been transferred safely to a Department facility or other Federal facility, no Department facility or other Federal facility agreed to accept such transfer; and the non-Department facility in which such medical care or services was furnished made and documented reasonable attempts to transfer the veteran to a Department facility or other Federal facility. See 38 U.S.C. §§ 1725, 1728 (2012). In addition, effective January 20, 2012, VA regulations implementing 38 U.S.C. § 1725 and § 1728 were amended to conform to the statutory changes. See 76 Fed. Reg. 79,067-79,072 (December 21, 2011). The amendments affected the following Title 38 regulations: 38 C.F.R. §§ 17.120, 17.121, 17.1001, 17.1002, 17.1005, 17.1006, and 17.1008. All of the above elements must be satisfied for a claimant to qualify for payment or reimbursement. Zimick v. West, 11 Vet. App. 45, 49 (1998); Malone v. Gober, 10 Vet. App. 539, 544 (1997). That is, these criteria under 38 U.S.C. § 1728 and 38 C.F.R. §§ 17.120 -17.121 are conjunctive, not disjunctive; thus, all criteria must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (noting that use of the conjunctive “and” in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (providing that only one disjunctive “or” requirement must be met in order for an increased rating to be assigned). Both medical and lay evidence may be considered in a prudent layperson evaluation for determining what constitutes a medical emergency. That is, VA should weigh the totality of the circumstances to determine whether a prudent layperson would consider the situation emergent. Swinney v. Shinseki, 23 Vet. App. 257, 264-266 (2009) (emphasis added). In determining the claim at issue, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The central issues in the present case are the following: (1) whether the private hospitalization at Marshall Medical Center on March 25, 2015, was of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health - i.e., was the situation an emergency; (2) and whether a VA or other Federal facility / provider was not feasibly available to the Veteran on the afternoon of March 25, 2015, and an attempt to use them beforehand would not have been considered reasonable by a prudent layperson. See 38 U.S.C. §§ 1725(f)(1), 1728(c); 38 C.F.R. § 17.120(b), (c). (Incidentally, VA’s authorization to make payment beyond the point of stabilization is not at issue here because the Veteran was only hospitalized for a little over three hours at the Marshall Medical Center on March 25, 2015, and was discharged from the private facility with his spouse accompanying him. See 38 C.F.R. §§ 17.53, 17.121). Upon review of the evidence, the Board finds that the requirements under 38 U.S.C. § 1728 for payment or reimbursement for unauthorized emergency medical treatment at Marshall Medical Center, on March 25, 2015, are met. In this regard, the totality of the circumstances demonstrates that this private hospitalization on March 25, 2015, was for a “medical emergency,” and that VA facilities at the nearest VAMCs in Nashville and Murfreesboro were not feasibly available. In making this determination, the Board has considered whether “emergency treatment” was furnished that afternoon under the prudent layperson standard. The Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). The Veteran’s credibility affects the weight to be given to his or her testimony and lay statements, and it is the Board’s responsibility to determine the appropriate weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, the demeanor of the witness, the facial plausibility of the testimony, the internal consistency of the testimony, impairment in memory, or, to a certain extent, bad character, among other factors. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In particular, personal interest may affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). First, the Board will address whether a medical emergency existed on the afternoon of March 25, 2015. Second, the Board will address whether a VA facility was feasibly available on the afternoon of March 25, 2015. Under the applicable VA regulation, with regard to what constitutes a “medical emergency,” under the prudent layperson standard, emergency treatment not previously authorized including medical services, professional services, ambulance services, ancillary care and medication (including a short course of medication related to and necessary for the treatment of the emergency condition that is provided directly to the patient for use after the emergency condition is stabilized and the patient is discharged) must be rendered in a “medical emergency” of such nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. This standard is met by an emergency medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. 38 C.F.R. § 17.120(b). The Board finds the totality of the evidence (both medical and lay evidence of record) establishes that a medical emergency existed for the Veteran under the prudent layperson standard on the afternoon of March 25, 2015. That is, it is shown that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Id. With regard to favorable medical evidence on whether a medical emergency existed, the Board has considered private ER records from Marshall Medical Center dated on March 25, 2015. These records include physician and nursing assessments. These hospital records document that on the afternoon of Wednesday, March 25, 2015 at around 2:39 pm, the Veteran was hospitalized at the Marshall Medical Center in Lewisburg, Tennessee. He was driven to the hospital by his spouse. His chief complaint was “severe” headaches with pain radiating down the jaw on his left side. The pain was described as “acute” and “throbbing” and “constant.” He was observed to be in “severe” distress. He was drowsy. Three weeks earlier he reported a fall in which he struck his head. He had experienced intermittent headaches since that time. However, two hours prior to his private hospitalization that day, his headaches significantly worsened to a level of 10/10. At the private hospital, a CT scan of the head revealed atrophy and background chronic white matter changes. The final diagnoses were “acute” headaches and a concussion. His condition steadily improved after the administering of various medications and hydration fluids by way of - Tramadol, Morphine Sulfate, Benadryl, Toradol, and Compazine. He was discharged home that evening at around 5:58pm. He was driven home by his wife. With regard to favorable medical evidence on whether a medical emergency existed, a March 25, 2015 VA nursing note at 2:29pm (only 10 minutes prior to his private hospitalization), confirmed that the Veteran’s wife called his VA primary care nurse, B.V.H., reporting the Veteran has an “extreme” headache from a fall. The Veteran was described as “moaning loudly all day” and this is not like him. His wife was instructed by the VA nurse to call 911 for the Veteran to go to the ER for immediate evaluation. His wife agreed, informing the VA nurse the Veteran will be brought to the ER. This VA nursing note was signed by his VA primary care nurse (B.V.H.), and acknowledged by a VA attending physician (G.G., MD.). The fact that the Veteran was instructed by VA medical personnel to seek emergency room treatment is a factor in favor of whether a medical emergency existed on the afternoon of March 25, 2015. See again Swinney, 23 Vet. App. at 264-266. Also, the Board emphasizes that the strong language utilized by private and VA hospital personnel to describe the Veteran’s headaches as “severe” and “extreme” and “acute” and “throbbing” and “constant” is a factor in favor of whether a medical emergency existed on the afternoon of March 25, 2015. See id. With regard to favorable medical evidence on whether a medical emergency existed, the Board has also considered the Emergency Severity Index (ESI) assessment by private medical personnel at Marshall Medical Center on the afternoon of March 25, 2015. The ESI is a tool for use in emergency department (ED) triage. The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs. The triage acuity scales have five levels (1- resuscitation, 2- emergent, 3- urgent, 4- less urgent, and 5- nonurgent). The ER personnel at Marshall Medical Center on the afternoon of March 25, 2015 assigned a triage level of three (3) for the Veteran. A level three (3) patient is considered a stable but urgent patient, who should be seen urgently by a physician (within 30 minutes), often requiring laboratory and radiology testing and medication for investigation or treatment, but are most often then discharged. See (ESI): A Triage Tool for Emergency Departments Version 4, available at http://www.esitriage.org. An example provided is a patient with abdominal pain or a patient with a high fever and a cough. In any event, the level 3 urgency triage assigned to the current Veteran provides some evidence in support of his claim, because it was urgent for him to see a physician within 30 minutes. With regard to favorable lay evidence of whether a medical emergency existed, the Veteran’s lay description (see January 2016 VA Form 9) of the circumstances surrounding his headaches that quickly worsened on the afternoon of March 25, 2015, has for the most part been corroborated by the clinical evidence discussed in detail above. He could not focus. His pain was 10/10. He was driven to the private hospital by his wife. He believes it was clearly an emergency. To determine whether a medical emergency existed, the Board must consider the claimant’s state of mind at the time he or she sought private treatment and evaluate the claimant’s actions in light of what a prudent layperson would do under the same circumstances. Swinney, 23 Vet. App. at 266. In fact, it is noted that his specific lay assertion that a VA nurse advised his wife by telephone to seek immediate treatment at the nearest ER was confirmed by the March 25, 2015 VA nursing note discussed above. Therefore, the Veteran’s lay assertions are competent and credible in describing the severity of his symptomatology on the afternoon of March 25, 2015. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). As mentioned, the Veteran’s lay statements are consistent with the clinical findings in the ER records from Marshall Medical Center and in VA treatment records as well. In summary, all of the above evidence (medical and lay) clearly demonstrates that a medical emergency existed for the Veteran on the afternoon of March 25, 2015. The Board now turns to the issue of feasible availability. With regard to feasible availability, the admission of any patient to a private or public hospital at VA expense will only be authorized if a VA or other federal facility to which the patient would otherwise be eligible for admission is not feasibly available. 38 C.F.R. § 17.53 (2017). A VA facility may be considered as not feasibly available when the urgency of the medical condition, the relative distance of the travel involved, or the nature of the treatment required makes it necessary or economically advisable to use public or private facilities. When non-VA care is authorized in such circumstances, the authorization will be continued after admission only for the period of time required to stabilize or improve the patient’s condition to the extent that further care is no longer required to satisfy the purpose for which it was initiated. Id. With regard to feasible availability, payment or reimbursement of the expenses of emergency treatment, not previously authorized, can be made when VA or other Federal facilities that VA has an agreement with to furnish health care services for Veterans were not feasibly available, and an attempt to use them beforehand or obtain prior VA authorization for the services required would not have been reasonable, sound, wise, or practicable, or treatment had been or would have been refused. 38 C.F.R. § 17.120(c). With regard to feasible availability, under the regulation pertaining to emergency treatment for nonservice-connected disabilities, payment or reimbursement of the expenses of emergency treatment, not previously authorized, can be made when VA or other Federal facility/provider that VA has an agreement with to furnish health care services for Veterans was not feasibly available and an attempt to use them beforehand would not have been considered reasonable by a prudent layperson. (As an example, these conditions would be met by evidence establishing that a Veteran was brought to a hospital in an ambulance and the ambulance personnel determined the nearest available appropriate level of care was at a non–VA medical center.) 38 C.F.R. § 17.1002(c). No reimbursement or payment of services not previously authorized will be made when such treatment was procured through private sources in preference to available Government facilities. 38 C.F.R. § 17.130. The term VA medical facility of jurisdiction means the nearest VA medical facility to where the emergency service was provided. 38 C.F.R. § 17.1001(e). With regard to the feasibility availability of a VA facility, the Board concludes on the afternoon of March 25, 2015, the nearest VAMCs in Nashville and Murfreesboro, were not feasibly available to the Veteran. See 38 U.S.C. § 1728(c); 38 C.F.R. §§ 17.53, 17.120(c), 38 C.F.R. § 17.1002(c). The factors that are relevant to this favorable finding in the present case are the following: the urgency of the Veteran’s medical condition such that an attempt to go to the VAMCs in Nashville and Murfreesboro would not have been reasonable, sound, wise, or practicable, and not considered prudent by a reasonable layperson; the relative distance of the travel involved from the Veteran’s home to the VAMCs vs. the shorter distance to the private hospital in question; and the urgency / severity of the Veteran’s medical condition that afternoon. The existence of a VA facility does not in and of itself mean that the VA facility was feasibly available. Cotton v. Brown, 7 Vet. App 325, 327 (1995). The fact that a VA medical center was located in the same city as the private facility does not provide an adequate basis for the Board’s findings that a VA facility was “available”; rather, the determination of whether a VA facility was “feasibly available” must be made after consideration of such factors as the urgent nature of the veteran’s medical condition and the length of any delay that would have been required to obtain treatment from a VA facility. Id. at 327-28. Respecting the relative distance of the travel involved, the Board may take judicial notice of facts, as compared to evidence, which are not subject to interpretation. See Yeoman v. West, 140 F.3d 1443 (Fed. Cir. 1998); Dedicatoria v. Brown, 8 Vet. App. 441 (1995). As to the geographical distance, this factor clearly weighs in the Veteran’s favor. Specifically, according to Google Maps, the distance from the Veteran’s home to the VAMC in Nashville, Tennessee is a 57-minute drive (50.9 miles). (The VAMC in Murfreesboro is a similar one-hour drive). But in contrast, the private hospital (Marshall Medical Center) is located in the Veteran’s home town of Lewisburg, Tennessee, only a short distance from his home --- a six-minute drive (2.1 miles). Thus, the drive to the private hospital would have been much quicker. It was clearly the more prudent path to take that evening, as “severe” headaches rated at a 10/10 pain level would have been intolerable. If the Veteran had waited for an ambulance, this would have added to the travel time. Also, as noted above, his spouse was instructed by a VA nurse to go to the nearest ER. As to the urgency of the Veteran’s headaches on the afternoon of March 25, 2015, when considering feasible availability, as discussed in great detail above, it is undisputed that “immediate” medical attention was required as the Veteran’s headaches were hazardous to his life and health. The pain from his headaches were assessed as “acute” and “severe” and “constant.” In addition, the Veteran could not have gone to a VA outpatient or VA community based clinic, because his condition was emergent, and these particular VA facilities are not equipped to handle such emergencies. With regard to the feasibility availability of a VA facility, the Board acknowledges that a VHA clinician provided an opinion dated in November 2015 concluding that the VAMC’s were feasibly available to the Veteran and his condition was “non-emergent.” However, the Board's conclusions must be based on evidence in the record and "must be justified by a clear statement of reasons or bases and not by the equivalent of 'because I say so.'" Hood v. Brown, 4 Vet. App. 301, 303 (1993). In short, a VHA clinician or administrator must provide a rationale for any opinion provided. The Court has stated that an examination or opinion is adequate when it sufficiently informs the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). As such, the probative value of this VHA clinician opinion is limited. Therefore, at least two factors for feasible availability as listed under the applicable VA regulations weigh in the Veteran’s favor. In light of the above analysis, an attempt to drive to the VAMCs in Nashville or Murfreesboro on the afternoon of March 25, 2015, would not have been reasonable, sound, wise, or practicable, given the confluence of circumstances in the present case. See 38 C.F.R. §§ 17.53, 17.120(c), 17.1002(c). A reasonable, prudent layperson could easily be seen to have chosen the private hospital in question for emergency treatment that afternoon. Accordingly, the Board finds that payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Marshall Medical   Center on the afternoon of March 25, 2015, is warranted. 38 U.S.C. §§ 1728, 5107. The claim is granted. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P.S. Rubin, Counsel