Citation Nr: 18141978 Decision Date: 10/12/18 Archive Date: 10/12/18 DOCKET NO. 16-27 498A DATE: October 12, 2018 ORDER Payment or reimbursement of medical expenses incurred for treatment at a private hospital from December 2, 2014 to December 5, 2014 is denied. FINDINGS OF FACT 1. The Veteran served on active duty from March 1958 to March 1964. 2. Service connection is not in effect for any disabilities. 3. The Veteran received non-emergent care for a heart disorder at a private hospital from December 2, 2014 to December 5, 2014 that was not authorized by VA. CONCLUSION OF LAW The criteria for payment or reimbursement of unauthorized medical expenses incurred for treatment at a private hospital from December 2, 2014 to December 5, 2014 are not met. 38 U.S.C. §§ 1703, 1728, 1725, 5107 (2012); 38 C.F.R. §§ 17.53, 17.54, 17.55, 17.120, 17.130, 17.1002(a)-(c) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran seeks payment or reimbursement for medical expenses incurred at a private hospital from December 2, 2014 to December 5, 2014 for care surrounding and including aortic valve replacement surgery. The claim was denied by the agency of original jurisdiction (AOJ) on the basis that the care was not pre-authorized by VA. He does not assert, nor does the evidence reflect, that the care was provided on an emergent basis. 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); 38 C.F.R. § 17.52(a). Further, in general, if VA is to provide payment or reimbursement of medical expenses incurred in connection with a veteran’s care at a non-VA hospital, the care must be authorized in advance. See 38 U.S.C. § 1703; 38 C.F.R. § 17.54. In the case of an emergency that existed at the time of admission, an authorization may be deemed a prior authorization if an application is made to VA within 72 hours after the hour of admission. 38 C.F.R. § 17.54. Whether treatment was authorized is a factual, not a medical, determination. Similes v. Brown, 5 Vet. App. 555 (1994). 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. 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. The Veteran contends that he sought care at a VA clinic for chest pain and was advised that he was having an active heart issue and should seek treatment at a private hospital because the VA clinic was not able to handle his current condition. He further indicates that he was advised to seek treatment at a local hospital and not go to the Seattle VA Medical Center (VAMC). He then sought treatment at a local hospital which transferred him to another private hospital as the first hospital also did not have the means of treating his condition. The record includes VA intake notes for the two private facilities that provided treatment from November 12, 2014 to November 15, 2014. The Veteran argues that the care he received at that time resulted in treatment and testing from November 12, 2014 through December 5, 2014 that was all related to his emergent heart issue, culminating in the heart surgery performed on December 5, 2014. Thus, the Veteran argues that the initial authorization by VA to seek care at a private hospital on November 12, 2014 was for all care related to that issue, through December 5, 2014. He does not argue that he received separate authorization for the care received in December 2014. However, as previously stated, authorization for treatment at a private hospital will only be authorized if VA facilities are not feasibly available, and only for the period of time required to improve or stabilize a veteran’s condition. In this case, when the Veteran sought VA care in November 2014, it was determined that the VA clinic did not have the means to treat his condition and that the VAMC was too far away given the emergent nature of the condition. However, once the Veteran was discharged on November 15, 2014, the period of private care authorized by VA ended as his condition had stabilized and further care was no longer required to satisfy the purpose for which it was initiated, which was to treat his emergent condition of an active heart issue. Therefore, he was required to obtain new authorization from VA for the care he received from December 2, 2014 to December 5, 2014. For the reasons discussed above, the preponderance of the evidence is against the claim and the appeal is denied. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. M. Schaefer, Counsel