Citation Nr: 18142871 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 15-35 416A DATE: October 17, 2018 ORDER Entitlement to payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Washington Hospital from November 30, 2014, through December 8, 2014, is granted. FINDINGS OF FACT 1. On Saturday, November 29, 2014, the Veteran was hospitalized at a private facility, Washington Hospital in Washington, Pennsylvania. He was 62 years old at the time. The diagnosis was a myocardial infarction. He was also diagnosed with “severe” three-vessel coronary artery disease, unstable angina, and hypertension. He underwent several cardiovascular surgeries during his hospital stay. His cardiovascular disabilities are nonservice-connected. He remained hospitalized at the private facility for 10 days from November 29, 2014, through December 8, 2014. 2. VA already approved payment for the costs of the first day of private hospitalization at Washington Hospital on November 29, 2014. However, VA did not approve payment for the remaining nine days of his private hospitalization – that is, from November 30, 2014, to December 8, 2014. 3. Under the prudent layperson standard, the totality of the circumstances demonstrates that although the Veteran refused transfer to a VA medical facility from November 30, 2014 to December 8, 2014, he was not “stabilized” for transfer to a VA facility during that period of time, within the meaning of the applicable VA regulation. Material deterioration of the Veteran’s emergency medical condition would likely have occurred if the Veteran had been transferred to a VA facility during that timeframe. CONCLUSION OF LAW The criteria are met for payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Washington Hospital from November 30, 2014 through December 8, 2014. 38 U.S.C. § 1725, 5107 (2012); 38 C.F.R. §§ 17.130, 17.1001, 17.1002, 17.1005 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active duty from January 1971 to July 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 decision by the Department of Veterans Affairs (VA) Health Care System (HCS) in Pittsburgh, Pennsylvania. Jurisdiction of case has since been transferred to the VA Medical Center (VAMC) in Clarksburg, West Virginia. That VAMC forwarded this appeal to the Board. In March 2017, the Veteran presented testimony at a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the Veteran’s claims file. In 2017, the Veteran has submitted and VA has secured additional VA and private treatment records, after certification of the appeal. However, in a March 2017 statement from the representative, the Veteran waived his right to have the VAMC initially consider this evidence. Therefore, the Board accepts that additional evidence for inclusion in the record and consideration by the Board. 38 C.F.R. §§ 20.800, 20.1304(c) (2017). Medical Expense Reimbursement On Saturday, November 29, 2014, the Veteran was hospitalized at a private facility, Washington Hospital in Washington, Pennsylvania. He remained hospitalized through December 8, 2014. He was 62 years old at the time. He was hospitalized for complaints of worsening chest discomfort and burning for two days prior, and for the recent onset of shortness of breath. He had been taking nitroglycerin. The diagnosis was a myocardial infarction. He was also diagnosed with “severe” three-vessel coronary artery disease, unstable angina, and hypertension. He underwent extensive cardiovascular testing for several days. A left heart catherization was performed at the private facility on Monday, December 1, 2014. The next day, on Tuesday, December 2, 2014, coronary artery bypass grafting (CABG) of three coronary arteries with revascularization was performed. The Veteran remained hospitalized until December 8, 2014. He was then discharged and instructed to follow up with VA and private outpatient providers, which he did. The Veteran is not service-connected for any cardiovascular condition. He also has no health insurance. Thus, there is no dispute that his private hospitalization from November 29, 2014 through December 8, 2014 was for a nonservice-connected cardiovascular disorder. In any event, the VAMC already approved payment for the costs of the first day of his private hospitalization at Washington Hospital on November 29, 2014. Therefore, the costs for that day of hospitalization are not in dispute here. However, the VAMC did not approve payment for the remaining nine days of his private hospitalization from November 30, 2014, to December 8, 2014. The Veteran testified that his private hospital costs for that time period to include the surgeries and treatment totaled approximately $70,000. He has paid approximately $7,000 of the costs thus far, leaving $63,000 due and unpaid according to his hearing testimony. The VAMC determined that by November 30, 2014, the Veteran’s condition had stabilized such that he could have been transferred to a VA facility for the continuation of treatment and for the performance of heart surgeries. 38 C.F.R. § 17.1001(d). The VAMC in Clarksburg, West Virginia was feasibly available to perform those surgeries and to continue the Veteran’s treatment. But instead, the Veteran, despite being stabilized, “refused” to be transferred to the available VAMC facility in Clarksburg, West Virginia. 38 C.F.R. § 17.1005(d). Rather, the VAMC’s position is that the Veteran procured the private treatment from November 30, 2014, to December 8, 2014, at Washington Hospital, in preference to available VA facilities, such that it should not be covered by VA. 38 C.F.R. § 17.130. In summary, the VAMC would not cover the Veteran’s medical expenses accrued from November 30, 2014 to December 8, 2014, due to his stabilized condition and refusal to be transferred. He chose to stay at the private facility beyond the point of stabilization, and with VA facilities readily available. Thus, VA concluded the Veteran did not meet the criteria for payment or reimbursement of non-VA medical treatment. The Veteran appealed that 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 Washington Hospital to provide the Veteran with no cost private care from November 30, 2014, to December 8, 2014. The Veteran has never contended that. The issue of prior authorization, as delineated by VA statute and regulation, is thus not applicable here. When a veteran receives treatment at a non-VA 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. Since the Veteran’s private hospitalization was for a nonservice-connected cardiovascular disorder, the Veteran is not eligible for payment or reimbursement of unauthorized medical expenses incurred at a non-VA facility for a service-connected disability under 38 U.S.C. § 1728(a). In fact, the Veteran has not established service connection for any disabilities. There is also no evidence or allegation he is participating in a vocational rehabilitation program under 38 U.S.C. Chapter 31, or that he had a total disability permanent in nature resulting from service-connected disabilities, or that nonservice-connected problems were associated with and aggravating service-connected disabilities, which in certain instances might have qualified him under 38 U.S.C. § 1728. 38 C.F.R. § 17.120(a). Consequently, the only possible route to entitlement to unreimbursed medical expenses in this case stems from 38 U.S.C. § 1725, the Veterans Millennium Health Care and Benefits Act. Pursuant to the Veterans Millennium Health Care and Benefits Act, payment or reimbursement of non-VA emergency medical services for nonservice-connected disorders for veterans without insurance is available if certain conditions are met. 38 U.S.C. § 1725; 38 C.F.R. §§ 17.1000-17.1008. Effective October 10, 2008, the provisions of 38 U.S.C. § 1725 and § 1728 were amended. 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 November 2014 and December 2014, subsequent to the October 2008 effective date of the amendments. With regard to stabilization, the amended statutes expand the meaning of “emergency treatment” under § 1725(f)(1) and § 1728(c) by stating that emergency treatment means 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. 38 U.S.C. §§ 1725, 1728 (2012). All the above elements must be satisfied for a claimant to qualify for payment or reimbursement. Zimick v. West, 11 Vet. App. 45 (1998); Malone v. Gober, 10 Vet. App. 539 (1997). The criteria under 38 U.S.C. § 1725 and 38 C.F.R. § 17.1002(a) (h) are conjunctive, not disjunctive; thus, all criteria must be met. Melson v. Derwinski, 1 Vet. App. 334 (1991). In addition, effective January 20, 2012, VA regulations implementing the statutes were amended to conform to the statutory changes. 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. 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 (2009). In determining the claim at issue, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran has already met nearly all of the substantive and administrative prerequisites for payment or reimbursement of nonservice-connected medical care listed under 38 C.F.R. § 17.1002(a)-(h). That is, the VAMC already determined that the initial hospitalization at the private facility on November 29, 2014 was for a “medical emergency;” VA facilities were not feasibly available to the Veteran on November 29, 2014, due to geographical distance and the severity of his condition; the services in question were provided in a hospital emergency department; the claim for reimbursement was timely filed by the private provider in December 2014; the Veteran is financially liable to the private provider for treatment; the Veteran has no health insurance to cover his hospitalization expenses; the Veteran was enrolled in the VA health care system and had received medical services under authority of 38 U.S.C. Chapter 17 within the 24-month period preceding the furnishing of the emergency treatment; the cardiovascular disability for which he was hospitalized was not caused by an accident or work-related injury for purposes of third-party liability; and the Veteran is not eligible for reimbursement under 38 U.S.C. § 1728 for a service-connected disability for the emergency treatment provided. 38 C.F.R. § 17.1002(a)-(h). It follows that the sole remaining issue in the present case centers around stabilization. What must be determined is when precisely, during the course of his private hospitalization, the Veteran “stable” for transfer to a VA facility for further treatment. VA regulation defines “stabilized” to mean that no material deterioration of the emergency medical condition is likely, within reasonable medical probability, to occur if the veteran is discharged or transferred to a VA or other Federal facility. 38 C.F.R. § 17.1001(d). Generally, VA will not approve claims for payment or reimbursement of the costs of emergency treatment not previously authorized for any period beyond the date on which the medical emergency ended, or beyond the point of stabilization. For this purpose, VA considers that an emergency ends when the designated VA clinician at the VA facility has determined that, based on sound medical judgment, a veteran who received emergency treatment: (1) could have been transferred from the non-VA facility to a VAMC (or other appropriate Federal facility) for continuation of treatment, OR (2) could have reported to a VAMC (or other appropriate Federal facility) for continuation of treatment. 38 C.F.R. § 17.1005(b). However, claims for payment or reimbursement of the costs of emergency treatment not previously authorized may be approved for continued, non-emergent treatment (that is, treatment after the veteran’s condition has stabilized), only if: (1) The non-VA facility notified VA at the time the veteran could be safely transferred to a VA facility (or other appropriate Federal facility), but the transfer of the veteran was not accepted, and (2) The non-VA facility made and documented reasonable attempts to request transfer of the veteran to a VA facility or other appropriate Federal facility. That means the non-VA facility contacted the VA Transfer Coordinator, Administrative Officer of the Day, or designated staff responsible for accepting transfer of patients to VA (or other appropriate Federal facility) and documented that contact in the veteran's progress/physicians’ notes, discharge summary, or other applicable medical record. 38 C.F.R. § 17.1005(c). But if a stabilized veteran who requires continued non-emergency treatment refuses to be transferred to an available VA facility or other Federal facility, VA will make payment or reimbursement only for the expenses related to the initial evaluation and the emergency treatment furnished to the veteran up to the point of refusal of transfer by the veteran. 38 C.F.R. § 17.1005(d). Similarly, no reimbursement or payment of services not previously authorized will be made when such treatment was procured through private sources in preference to available VA or government facilities. 38 C.F.R. § 17.130. In short, under the new version of 38 U.S.C. § 1725, effective October 10, 2008, and its implementing regulation, 38 C.F.R. § 17.1005, VA is authorized to make payment beyond the point of stabilization, but only if certain criteria are met. The public policy behind the change in law is that if VA fails to promptly accept transfer of a veteran to a VA facility upon request once that veteran has stabilized, it is unjust to make the veteran liable for additional expense at the non-VA facility due to no fault of the veteran. Upon review of the evidence, the Board finds that the requirements for payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Washington Hospital from November 30, 2014 to December 8, 2014, under 38 U.S.C. § 1725, are met. The totality of the circumstances demonstrates that although the Veteran refused transfer to a VA medical facility from November 30, 2014, to December 8, 2014, he was not “stabilized” for transfer to a VA facility during that period of time, within the meaning of the applicable VA regulation. 38 C.F.R. § 17.1001(d). Under the prudent layperson standard, the medical and lay evidence of record establishes that material deterioration of the Veteran’s emergency medical condition was likely to occur within reasonable medical probability, if the Veteran had been transferred to a VA or other Federal facility during the timeframe in question. The Board finds that the Veteran was not stable for transfer to a VA facility. In making this favorable determination, the Board acknowledges that both the VAMC and the private hospital documented several discussions of a possible transfer of the Veteran to the VAMC in Clarksburg, West Virginia. 38 C.F.R. § 17.1005(c). That fact is not in dispute. On this issue, a non-VA care hospital notification note dated on November 30, 2014, and a December 1, 2014 addendum note from a VA nurse indicates that the Veteran had been considering transfer to the VAMC for surgery, but instead decided to remain at Washington Hospital. But interestingly, it was also noted that Washington Hospital itself was not requesting a transfer of the Veteran to the VAMC. A December 1, 2014 private social worker/case manager progress note from Washington Hospital documented that the Veteran himself chose to stay at the private facility for his surgery and care, after representatives from both the private facility and the VAMC had discussed the possibility of transfer. The Veteran stated that he probably signed a consent form indicating that he wished to remain at the private hospital, although any such form is not located in the claims file. Payment “beyond the point of stabilization” would not be permitted for this Veteran, because he knowingly refused transfer to a VA facility. 38 C.F.R. §§ 17.130, 17.1005. But the central question here is whether the Veteran was actually “stabilized” beginning on November 30, 2014, and continuing through December 8, 2014. 38 C.F.R. § 17.1001(d). If the Board determines that the Veteran’s medical condition was not stable for transfer during this time period, then the Veteran is entitled to payment or reimbursement for his unauthorized medical expenses. 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. Struck v. Brown, 9 Vet. App. 145 (1996); Caluza v. Brown, 7 Vet. App. 498 (1995); Gabrielson v. Brown, 7 Vet. App. 36 (1994); Abernathy v. Principi, 3 Vet. App. 461 (1992); Simon v. Derwinski, 2 Vet. App. 621 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). The Veteran’s credibility affects the weight to be given to his testimony and lay statements, and it is the Board’s responsibility to determine the appropriate weight. Washington v. Nicholson, 19 Vet. App. 362 (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 (1995). In particular, personal interest may affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24 (1991). With regard to favorable lay evidence on whether the Veteran was stable, the Veteran has stated and testified that his survival and well-being depended on receiving immediate emergent care, including the 3 vessel CABG surgery, at the Washington Hospital rather than being transferred to a VA facility. The Veteran stated that prior to his private hospitalization, he was seen by his VA primary care doctor at the VA Community Based Outpatient Clinic (CBOC) in Morgantown, West Virginia, in early November 2014. He stated that his VA primary care physician was insufficiently concerned about his increasingly frequent and severe chest pains. He indicates that VA wait-listed him for a follow-up appointment a month later, for December 8, 2014, and a stress test for December 24, 2014. His VA provider told the Veteran that his heart condition might be treatable with a prescription drug. But the VA provider ended the appointment without actually writing the prescription. The Veteran maintains that VA doctors ignored his symptoms or did not realize their significance. VA treatment records on VBMS dated on November 10, 2014, confirm some elements of the Veteran’s lay description of that appointment. Thus, in that context, when considering a potential transfer to the VAMC, the Veteran was hesitant to have the VA medical personnel at the VAMC perform the essential heart surgeries. He was also concerned that in the news VA had long waiting lists for veterans awaiting their surgeries. He was frightened that a delay would occur if he was transferred to the VAMC, putting his life in jeopardy. With regard to favorable lay evidence on whether the Veteran was stable, the Veteran has indicated his condition worsened over several weeks, and he was hospitalized at Washington Hospital on November 29, 2014. The Veteran reports that the medical staff at Washington Hospital emphasized there was an “urgent” need to perform the CABG surgery. He has stated that they were “adamant” the surgery be performed immediately at the private facility. In addition, the Veteran did not have a family member or friend there to discuss the situation with him, or to question the private doctor, or to help him decide whether he was sufficiently stable to be transferred to the VAMC, before CABG bypass surgery was performed. He was under extreme pressure in a hospital bed, and wanted to make the choice that best guaranteed his survival. In that respect, the standard is that of what a reasonably prudent person would do in the same circumstances. The Veteran contends that he reasonably believed he was not stable and did not want to risk an ambulance trip to the VAMC in Clarksburg, West Virginia, which would take at least an hour and a half. The Board finds that the Veteran is competent and credible as a layperson in describing why he believed he was not stable for transfer to the VAMC in Clarksburg, West Virginia from November 30, 2014, through December 8, 2014. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran’s lay statements and hearing testimony are consistent with the clinical findings in the private hospital and surgical records from Washington Hospital dated in November and December of 2014, as discussed below. With regard to favorable medical evidence on whether the Veteran was stable, private hospital and surgical records from Washington Hospital dated in November and December of 2014 frequently describe the Veteran’s cardiovascular condition as “severe.” Several of those medical records remark that the Veteran was in “a great amount of pain.” He had continuing “unstable” angina. The Board emphasizes that the strong language used by private hospital personnel to describe the Veteran’s cardiovascular condition as “severe” and “unstable” are a factor in favor of whether the Veteran was stable for transfer from November 30, 2014, through December 8, 2014. Swinney v. Shinseki, 23 Vet. App. 257 (2009). After the CABG surgery was performed on December 2, 2014, the Veteran remained at the private hospital until December 8, 2014, to be closely monitored. He was placed in the “intensive care unit.” A December 2, 2014, physicians progress note from Washington Hospital advised the Veteran if he went home without the necessary heart surgery he may have a heart attack and die. It was also noted that if he went home at that juncture, he would not be able to make it back to the hospital alive. His heart condition was again assessed as “severe.” He was also advised that during this CABG surgery there was a chance of death, debility, and a long recovery. All of that clinical evidence provides strong support for the Veteran not being stable for transfer to a VA facility from November 30, 2014 through December 8, 2014. It would have been a risky proposition. The Veteran was advised that he would be in jeopardy of dying if her returned home, which was much closer than the nearest VAMC. With regard to favorable medical evidence on whether the Veteran was stable, the Board has carefully reviewed a February 2015 private cardiologist letter from the surgeon who performed the Veteran’s heart surgeries at Washington Hospital on December 1, 2014, and December 2, of 2014. That letter was written in support of the “urgent” need of coronary revascularization surgery for the Veteran in early December 2014. The Veteran was admitted to Washington Hospital for a myocardial infarction. Due to his history and presentation and coronary anatomy with significant disease involving the proximal left anterior descending (LAD) artery, proximal ramus, and also distal circumflex, the Veteran required “urgent” coronary artery bypass grafting. The private surgeon further opined that the Veteran had to be kept in the private hospital for significant findings and was “best served” during his stay to have the operation provided for him at the private hospital, to do ultimately better with his operation. As a result of that choice, the Veteran did very well with the operation. When considering the probative value of that significant private medical opinion, the VA benefits system does not favor the opinion of a VA examiner over a private examiner. White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001). A report of a medical examination administered by a private physician may be accepted without a requirement for confirmation by an examination by a physician employed by the Veterans Health Administration (VHA), if the private report is sufficiently complete to be adequate for the purpose of adjudicating such claim. 38 U.S.C. § 5125. From the conclusions of the probative private medical opinion above, the Board infers that although the Veteran himself refused transfer to the VAMC, based on sound medical judgment the Veteran still could not have been safely transferred from the private facility to the VAMC for continuation of treatment, due to the delicate state of his heart condition at that time. 38 C.F.R. § 17.1005(b). The Board, and its reviewing Courts, may take judicial notice of facts, as compared to evidence, which are not subject to interpretation. Yeoman v. West, 140 F.3d 1443 (Fed. Cir. 1998); Dedicatoria v. Brown, 8 Vet. App. 441 (1995). The Board takes judicial notice that the VAMC in Clarksburg, West Virginia, is approximately 83.7 miles away from Washington Hospital, which is at least a 1.5 hour drive. Because of the Veteran’s apparent level of distress, and the severity of his heart condition from November 30, 2014, through December 8, 2014, a prudent layperson would not endure a long drive in order to undergo surgery and treatment that he could undergo at the private facility. That would simply be unreasonable and unwise because of the severity of the heart disability. There was a potential for a delay. The Veteran’s life was in jeopardy, and his choice to remain at the private hospital was understandable, because he was not stable for transfer based on the clinical evidence discussed above. To the extent that the Board has made inferences and considered circumstantial evidence in its analysis of the evidence, this type of reasoning is well within the discretion of a fact finder. Although another fact finder may have declined to make the same inference, that does not mean that the Board in the present case is clearly erroneous. Bastien v. Shinseki, 599 F.3d 1301 (Fed. Cir. 2010). With regard to other favorable medical evidence on whether the Veteran was stable, a VA physician in a February 2015 VA primary care note remarked that the Veteran’s hospitalization and treatment at Washington Hospital in early December 2014 “could not have been delayed.” With regard to other favorable medical evidence on whether the Veteran was stable, the Board has also reviewed a December 30, 2014, VA authorization for request for outpatient services on VBMS. Subsequent to the Veteran’s hospitalization at Washington Hospital from November 29, 2014 to December 8, 2014, VA authorized continuing coronary artery bypass treatment at the same private facility, Washington Hospital, from December 16, 2014 to June 1, 2015. That continuing “outpatient hospital and professional outpatient medical services” at the same facility was for purposes of “cardiology rehabilitation.” The number of visits covered by VA was 36. It was noted that VA payment to the private provider would be payment in full for the medical services provided to the Veteran. The “type of service” was described as evaluation and treatment subsequent to the earlier 3 vessel CABG surgery on December 2, 2014. That particular authorization for VA payment was issued under 38 U.S.C. § 1703. The December 30, 2014 VA authorization form provided that the justification for the 36 visits of non-VA care was the following: “the VA facility does not provide the required service.” By analogy, the Board has considered it relevant that if the VAMC in Clarksburg, West Virginia could not provide the Veteran with adequate and safe outpatient care for his heart condition following the heart surgeries in question, then it is unclear how safe and prudent would it have been for the Veteran to undergo the critical left heart catherization and CABC surgeries and follow up care at the VAMC during the period in question from November 30, 2014 to December 8, 2014. The logical implication is that the VAMC in Clarksburg, West Virginia was not feasibly available to the Veteran from November 30, 2014, to December 8, 2014, due to the relative distance involved, the urgency of his heart condition, and the complicated nature of the heart surgery required. 38 C.F.R. §§ 17.53, 17.1002(c). In summary, all of the above evidence, medical and lay, supports a finding that the Veteran’s medical condition was not “stabilized” beginning on November 30, 2014, and continuing through December 8, 2014. 38 C.F.R. § 17.1001(d). Any attempt to transfer the Veteran from the private hospital to the VAMC by a 1.5 hour trip by ambulance would not been have prudent at that time. The Board acknowledges that a short medical opinion from a VHA clinician dated in January 2015 assessed that the Veteran was stable but nonetheless refused to transfer to a VA facility on November 30, 2014. In any event, the Board finds that this VHA clinician opinion is outweighed by all of the medical and lay evidence discussed in detail above. Accordingly, the Board finds that payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Washington Hospital from November 30, 2014 to December 8, 2014, is granted. 38 U.S.C. §§ 1725, 5107. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P.S. Rubin, Counsel