Defense Department (DOD) officials decided to stop covering a certain form of physical therapy for the disable children of military members, despite an administrative judge’s ruling that the treatment is covered under the law.
“For my daughter, this therapy means life, death or some horrible surgery, but she’s not alone — there are 27 other military families who use the center where Kaitlyn goes,” Jennifer Samuels told Military Times.
DOD decided not to pay for a physical therapy program for Kaitlyn Samuels, a 15-year-old girl with severe neuromuscular scoliosis – a spinal curvature caused by her brain’s inability to send the signals needed to keep her spine in proper alignment. Initially, DOD’s Tricare paid for the therapy sessions. The government eventually revoked coverage on the theory that the therapy, because it took place while Kaitlyn sat on a horse, is an experimental “hippotherapy” not covered by law.
“[T]he therapy is still considered unproven under the Basic Program,” Michael W. O’Bar, deputy chief of of Tricare Policy and Operations replied on October 24, 2012 when he rejected an administrative judge’s ruling that the therapy is covered under current law.
“[T]he horse is used as a dynamic surface, a therapeutic tool for physical therapy,” Claude R. Heiny, a Tricare hearing office, wrote in his March 30, 2012, ruling. “The physical therapy [Samuels] receives on the horse is the same physical therapy she would receive using a therapy ball or bolster ‘if’ she engaged when the other tools were employed.”
The judge noted that Samuels, who has the mental capacity of a toddler, gets bored and refuses to participate in therapy sessions that take place in traditional clinical settings. “On a horse, [Samuels] enjoys the therapy and allows the therapist to do all the things necessary to address [Samuels] physical condition,” Heiny wrote.
Under the current ruling, DOD is willing to pay for a more expensive treatment that is not effective, rather than cover the cheaper, more effective physical therapy on horseback ($80 per 30 minute session).
“The same physical therapist providing physical therapy services in a clinical setting charges $300 per 30 minute session,” the administrative judge pointed out. “It would be a waste of the Government’s money to pay for therapy in a traditional setting for it would provide no benefit to [Samuels].”
The judge also noted that Medicaid covers such treatment, provided the patient receives a waiver, but that Kaitlyn Samuels cannot receive the Medicaid waiver because her father is an active duty member of the U.S. Navy; every time he transfers to a new location, “she went to the bottom of the [waiver waiting] list,” the judge observed.
Kaitlyn Samuels’ mother wrote President Obama asking that he intervene on her behalf. “We followed the appeals process that was required of us and Tricare needs to accept the ruling of the judge they hired and provide coverage for the therapy that Kaitlyn is entitled [to receive],” Jennifer Samuels wrote.
That request was denied. “Thank you for your recent letter to President Barack Obama concerning TRICARE’s denial of hippotherapy services provided to your daughter, Kaitlyn,” U.S. Army Brigadier General W. Bryan Gamble replied. “[T]he TRICARE contractor . . . determined Kaitlyn was receiving hippotherapy (a form of exercise or therapeutic horseback riding), as opposed to physical therapy.” Gamble, like O’Bar before him, also said that the administrative judge misapplied relevant laws and regulations to the case, resulting in an errant ruling.
In any case, “the hearing officer does not have authority to make a final decision in a hearing case but may only issue a recommended decision,” Gamble also pointed out.
The Samuels family hopes that Congress will pass “Kaitlyn’s Law” clarifying that current law covers her physical therapy, even if it does take place while she sits on a horse. Over 120 advocacy groups support the bill, including the American Association on Health and Disability, the American Physical Therapy Association, and the Children’s Hospital Association.