Citation Nr: 18146975
Decision Date: 11/05/18	Archive Date: 11/02/18

DOCKET NO. 16-15 210A
DATE:	November 5, 2018
REMANDED
The issue of entitlement to payment or reimbursement of medical expenses incurred at a private hospital on June 27, 2014 is remanded.
The Veteran sought emergency care on June 24, 2014 for right leg symptoms, diagnosed as cellulitis, and was hospitalized until June 28, 2014.  The claim was denied by the agency of original jurisdiction (AOJ) on the basis that a VA clinician had determined that the Veteran had stabilized on June 26, 2014 and could have been transferred to a VA facility for continued care.  
However, there is no documentation of communication between the VA Medical Center (VAMC) and the private hospital regarding the Veteran’s treatment and need for transfer.  Further, the rationale for the opinion by the VA clinician is not of record.  Therefore, the appeal must be remanded for further development. 
The matter is REMANDED for the following actions:
1.  Associate with the claims file all VAMC administrative, telephone, and treated notes related to the Veteran’s treatment at the private hospital from June 24, 2014 to June 27, 2014. 
2.  Return the case to the VA clinician who made the determination that the Veteran’s condition had stabilized on June 26, 2014, such that he could continue his treatment at a VA facility so that the individual may review the prior decision and provide a complete rationale for that determination. 
If further examination is in order, that examination must be conducted.  If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 
The clinician must cite the medical facts in the record which led to the June 2014 conclusion that the Veteran’s condition had stabilized, that is, what evidence in the record allowed the conclusion (with a reasonable degree of medical certainty) that no deterioration in the emergency medical condition was likely to occur if the Veteran was transferred for continuation of his treatment to a VA facility.  
The clinician must also report the date the Veteran’s condition had stabilized, as well as his or her name, credentials, and official position/title.
If the VA clinician who reviewed the case in June 2014 is unavailable, forward the record to an appropriate VA clinician for their review and opinion.
3. Then, readjudicate the issue on appeal.  If the benefits sought on appeal are not granted to the Veteran’s satisfaction, a supplemental statement of the case should be issued to the Veteran and his representative and they should be afforded the requisite opportunity to respond.
 
L. HOWELL
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K. M. Schaefer, Counsel