Navy Family in Battle with TRICARE to Treat Special Needs Child

Posted by Jason Van Steenwyk

TRICARE won't pay for child's therapy with a horseKaitlyn N. Samuels, the 16-year-old daughter of a Navy officer, was born with a variety of congenital disabilities, including cerebral palsy, severe life-threatening progressive scoliosis, and developmental retardation – her brain functions at the toddler level.

Kaitlyn needs ongoing physical therapy to help her exercise the muscles that allow her to sit upright and stabilize herself. Otherwise the curvature of her spine will eventually cause bones to leave their sockets and crush her lungs. She doesn’t respond to physical therapy in a hospital or clinic setting, though. So her therapists hit on the idea – get her on the back of a horse.

The response was positive. While Kaitlyn would shut down and not cooperate with her therapy sessions in a clinical setting, she loves riding the horse. And it accomplishes many of the physical therapy treatment objectives – she has to concentrate on sitting upright and using her thigh, back and abdominal muscles to stabilize herself and compensate for the movement of the horse.

And what American girl doesn’t love horses?

Naturally, TRICARE, being a government bureaucracy, can’t figure that out. They issued a final decision denying coverage for her physical therapy.

While TRICARE does normally provide coverage for physical therapy in general, it won’t cover Kaitlyn’s, because Kaitlyn doesn’t do her therapy in a clinical setting with a ball and bench and other traditional clinical tools.

Hippotherapy – that is, doing physical therapy on horseback, rather than with the usual set of balls, benches and weights in a clinical setting – does not qualify for TRICARE funding, the government asserted – and so when they realized that the therapist was using a horse to get positive results rather than a ball to get no results, they stopped funding the treatment.

They even sent Kaitlyn’s father a bill – $1,324 – to reimburse them for treatment they had already funded.

The Samuels family went to appeal TRICARE’s decision. And won, initially. The hearing officer sided with Kaitlyn’s family. He held that physical therapy was physical therapy, regardless of whether it took place on horseback or in a clinic with benches, weights and braces. If physical therapy was a covered benefit, and hippotherapy was an effective form of it, it didn’t matter whether the tool was a horse or a large plastic ball.

 “It cannot be forgotten that even though [Kaitlyn] is 15 years old, she has the mental capacity of a toddler-preschool child,” he wrote in his recommendation. “It would be a waste of the Government’s money to pay for therapy in a traditional setting for it would provide no benefit.”

TRICARE’s Deputy Chief of Policy and Operations, Michael O’Bar, even went against the recommendations of his own hearing officer in the case, stating that he believed the hearing officer misapplied the statutes that govern the nature of medical documentation and peer-reviewed studies required to prove the efficacy of hippotherapy for the medical condition. As of this writing, Kaitlyn’s hippotherapy is not covered under TRICARE, period. They would fund it if she were not cooperating with her therapy in a hospital and getting no results. But TRICARE refuses to fund a treatment that has actually proven to be effective, in Kaitlyn’s case.

TRICARE officials, for their part, argue that they cannot responsibly fund experimental therapies, nor can they fund therapies that do not have a body of peer-reviewed work demonstrating effectiveness.

Kaitlyn’s family, her therapist and their lawyers, meanwhile, argue that the treatment is the same – the fact that hippotherapy takes place on a horse instead of on a ball is incidental. And given that the treatment modality, other than the context and the specific tool used, is identical, it doesn’t make sense for the government to fund one but not the other.

The government lawyer assigned to argue the case, however, argued that if one treatment that they didn’t fund worked, and the treatment that they were willing to cover was useless, then they couldn’t be the same treatment.

The government still maintains that they will fund the useless therapy in the hospital or clinic setting – but they will not fund the therapy that actually works.

O’Bar’s finding is the final authority within the TRICARE appeals process. The next step, should the Samuels family decide to pursue it, is a lawsuit in federal court – an expensive and time-consuming process.

Medicaid Doesn’t Work for Military Families

Most families with severely disabled children can apply for Medicaid benefits in the states in which they live. But for military families, Medicaid isn’t so simple: While Medicaid dollars are largely federal, each state runs its own Medicaid program – and waiting lists for Medicaid benefits are routine. In some cases, families can be on the waiting list for years before becoming eligible for benefits. But military families move every three years – usually out of state – and have to start at the bottom of the waiting list each time. That’s what’s happening here, according to Kaitlyn’s mother. Her daughter does qualify for Medicaid, but the family doesn’t stay in one state long enough for that to matter, because of the waiting list requirements. If Kaitlyn’s daughter were a deadbeat dad, she says, “We wouldn’t be here right now.”

Hippotherapy and the Romney Family

Hippotherapy came to public attention earlier this year, when it became public that Ann Romney, wife of former Republican presidential candidate Mitt Romney, credited horseback therapy with saving her life. Ann Romney was diagnosed with multiple sclerosis in 1998. The Romneys – being a family of substantial means – own a partnership in a competitive horse breeding operation, and have ready access to horses.

Ann Romney’s use of horse therapy actually became a campaign issue, briefly, and MSNBC television personality Lawrence O’Donnell actually mocked for her use of hippotherapy to treat her MS symptoms.

A number of studies have, indeed, supported the clinical benefits of hippotherapy for a variety of conditions. TRICARE, however, continues to deny treatment for the Kaitlyn Samuels.

 


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