Citation Nr: 18160182 Decision Date: 12/26/18 Archive Date: 12/26/18 DOCKET NO. 16-17 727 DATE: December 26, 2018 REMANDED Entitlement to payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Carlinville Area Hospital on November 23, 2013, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty in the U.S. Marine Corps from June 1986 to May 1988. This matter is before the Board on appeal from an April 2015 Department of Veterans Affairs (VA) decision of the VA Illiana Health Care System (HCS) in Danville, Illinois. In August 2016, a Travel Board hearing was held before the undersigned; a transcript is associated with the claims file. This appeal was processed using both a paper-based claims file and an electronic Veterans Benefits Management System (VBMS). Regarding the remanded issue: On Saturday, November 23, 2013, at approximately 9:52pm, the Veteran arrived at the emergency department of Carlinville Area Hospital in Carlinville, Illinois. He arrived by private vehicle driven by his wife. He was 44 years of age at that time. Private emergency department records from Carlinville documented a four-day onset of worsening headaches and associated nausea. The Veteran reported severe pain from his headaches – 7/10 on the pain scale. A computed tomography (CT) scan of the head and neck revealed degenerative disc disease in the neck. The final diagnosis was headache and neck pain. He was treated with Tramadol, Dilaudid, and Zofran. He was discharged to his home a little over two hours later at 11:19pm (following an under two-hour stay). 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, the Veteran requests payment or reimbursement from VA for his unauthorized medical expenses on that evening. The Veteran asserts that 38 U.S.C. § 1728 for veterans with service-connected disability is for consideration here. See also 38 C.F.R. § 17.120(a)(1). He has no private health insurance. He asserts that the disability for which private hospital treatment was provided that evening (headaches), should be service-connected. He maintains that at the time he was taking Gabapentin to treat his service-connected lumbar spine and right lower extremity radiculopathy, and claims that the Gabapentin caused or aggravated the severe headaches treated at the private hospital that evening. He contends his headaches are secondary to the Gabapentin medication he was taking for his service-connected degenerative disc disease of the L5-S1 vertebrae and right lower extremity radiculopathy disabilities. He maintains that a medical emergency existed that evening and VA facilities were not feasibly available. See August 2016 travel board hearing testimony; May 2015 notice of disagreement (NOD); and April 2016 VA Form 9. In any event, a remand is required. The instant medical expense reimbursement issue is inextricably intertwined with a claim of service connection for migraine headaches as secondary to service-connected degenerative disc disease of the L5-S1 vertebrae. If secondary service connection for migraine headaches is granted, it would impact on the adjudication of the medical expense reimbursement claim (as requirements for substantiating the claim include that the emergency treatment be for a service-connected disability headaches). See 38 U.S.C. § 1728(a)(1); 38 C.F.R. § 17.120(a)(1). Accordingly, adjudication of the current medical expense reimbursement claim must be deferred pending resolution of the secondary service connection claim for migraine headaches. The secondary service connection for headaches issue was previously before the Board. An April 2018 decision by a Veterans Law Judge other than the undersigned, remanded the secondary service connection issue for a VA medical opinion addressing whether a headache disability was proximately due to, the result of, or aggravated by the Veteran’s service-connected lumbosacral spine disorder or its treatment. The agency of original jurisdiction (AOJ) secured a December 2018 VA medical opinion on this issue. However, it has not yet been readjudicated, or recertified to the Board (and remains pending). Notably, the Veteran’s vocational rehabilitation file (which was outstanding at the time of the Travel Board hearing in this matter) is now incorporated in the electronic part of the Veteran’s record. It appears from the record that the Veteran’s private hospitalization at Carlinville Area Hospital on November 23, 2013, may have been a medical emergency under the prudent layperson standard and that VA facilities may not have been feasibly available to the Veteran that evening. See 38 U.S.C. §§ 1725(f)(1), 1728(c); 38 C.F.R. § 17.120(b), (c). Hence, the outcome of this appeal may hinge on whether the Veteran’s headaches for which he was hospitalized that evening become a service-connected disability. The matter is REMANDED for the following: Upon resolution (at the AOJ) of the issue of service connection for migraine headaches as secondary to service-connected lumbosacral degenerative disc disease, readjudicate entitlement to payment or reimbursement of unauthorized medical expenses incurred during a non-VA hospitalization at Carlinville Area Hospital on November 23, 2013 considering the determination on the service connection matter. Please note that the two issues are inextricably intertwined. If secondary service connection for migraine headaches is granted, it would impact on the adjudication of the current medical expense reimbursement claim (as this claim requires that the emergency treatment be for service-connected headaches). See 38 U.S.C. § 1728(a)(1); 38 C.F.R. § 17.120(a)(1). It also appears from the record that the Veteran’s private hospitalization at Carlinville Area Hospital on November 23, 2013, may have been a medical emergency under the prudent layperson standard and that VA facilities may not have been feasibly available to the Veteran that evening. See 38 U.S.C. §§ 1725(f)(1), 1728(c); 38 C.F.R. § 17.120(b), (c). GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P.S. Rubin, Counsel