A creative therapy was working on a severely disabled young woman. Yet the Pentagon decided it would no longer be covered by military insurance.
This story was updated on 12/21 (see bottom of page).
The story of Kaitlyn N. Samuels is an infuriating one. It blends together the senselessness of our military bureaucracy with the powerlessness of individual veterans and their families. It mocks the professed patriotism of our politicians, who pledge endlessly that they will do all they can to make life easier for our military families. It favors insurance policy at the expense of medicine. It's an instance where the Obama Administration turned a smart solution into a problem. And it is a case where the Pentagon has said no to a severely disabled teenage girl.
When Kaitlyn Samuels was 4 months old, her parents, Mark and Jennifer, worried that she couldn't reach for her toys. Doctors initially assured them that it was probably normal, but after two months brought little improvement they ordered a battery of neurological tests that revealed Kaitlyn had a very rare and very serious brain malfunction.
The years since then have been a struggle, as Kaitlyn has suffered the effects of epilepsy, cerebral palsy and all sorts of related complications. She can't speak or walk by herself. Her food has to be blended into liquid form because she can't chew. Her brain is frozen in perpetual toddlerhood.
Kaitlyn also suffers from severe scoliosis. Left unchecked, the condition would get progressively worse, with the increasing curvature of the spine diminishing lung capacity, popping joints out of socket and eventually killing her by crushing her internal organs. It can be treated with physical therapy, but traditional methods didn't work for Kaitlyn; she would grow bored and shut down, rendering the session worthless.
By 2009, the family and its doctors had come up with an excellent solution. Twice a week, for 30 minutes at a time, Kaitlyn would ride atop a horse, around and around in a circle, in an exercise that stretched her muscles, worked her back and legs, and kept her focused on sitting upright. To the family, the sound exercise is a creative and successful form of physical therapy. To the government, the exercise is called "hippotherapy"-- a controversial designation that has allowed the feds to malign its usefulness.
At first, Kaitlyn's therapy was paid by her father's military health insurance, TRICARE, which calls itself "the health care program for Uniformed Service members, retirees and their families worldwide." But then, in 2010, TRICARE suddenly refused to pay for the girl's therapy -- and unconscionably demanded as well that the Samuels, with Mark on active duty, reimburse the Pentagon for therapy payments made -- totaling $1,327.44 -- from September 2009 until the end of March 2010. Why? Here's how the feds explain it in the "Final Decision" in the case:
The original TMA denial of cost-sharing is based on findings that: 1) the Beneficiary received hippotherapy; (2) hippotherapy is not medically necessary and appropriate for treatment of the Beneficiary's medical condition; (3) hippotherapy for the treatment of the Beneficiary's medical condition has not been proven safe and effective by reliable evidence; and (4) hippotherapy for treatment of the Beneficiary's medical condition is an unproven treatment.
The government declared, in other words, that Kaitlyn's physical therapy was "unproven" even though it had long been proven to be working on her. That it was not yet "proven safe and effective by reliable evidence" even though it was safe and reliable enough for Kaitlyn and her family. That it was "not medically necessary and appropriate" for Kaitlyn even though her doctor and therapist had deemed it to be entirely "necessary and appropriate." Anyone who has ever had to fight with an insurance company over health coverage knows this awful drill.
And so did the Samuels. With their doctors at their side, and with the therapy's success visibly evident to them, they appealed the denial of Kaitlyn's medical benefits through the briar patch of federal statutes and Pentagon regulations. What follows is the way Congress and the Department of Defense have designed these sorts of cases to be resolved-- every government functionary playing his own little role in justifying the deprivation of benefits to people like Kaitlyn. It took the Samuels nearly two years to have their case and their cause heard.
The first "hearing officer" who heard the case agreed with the family. Claude R. Heiny, a longtime administrative law judge, was a voice of sanity and reason. "It is more beneficial to use the horse as a tool," Heiny wrote, "because [Kaitlyn] engages in her physical therapy on the horse and fails to cooperate with her treatment in a clinical setting." Judge Heiny added: "It would be a waste of the Government's money to pay for therapy in a traditional setting for it would provide no benefit." He told TRICARE to pay for the horse therapy.
But then the case went up the ladder until TRICARE got the result it wanted. Functioning as the final arbiter of Kaitlyn's fate was a man named Michael W. O'Bar, whose official title is "Deputy Chief, TRICARE Policy and Operations." TRICARE itself, an arm of the Defense Department, was represented in the case by a lawyer named Michael Bibbo, who during the course of the hearing in February actually said aloud the following words: "Could Sea World hire a physical therapist" and then charge the federal government?