Sixteen-year-old Kaitlyn Samuels, diagnosed with cerebral palsy and scoliosis, no longer receives Tricare coverage for her horse therapy sessions. (Courtesy of Samuels family)
Like any teen, 16-year-old Kaitlyn Samuels has definite likes and dislikes. Disney movies and horses fall under “like”; waiting rooms and doctor's appointments, “strong dislike.”
And Kaitlyn, the daughter of Navy Capt. Mark and Jennifer Samuels, has had a lifetime of the latter. Diagnosed as an infant with cerebral palsy and scoliosis, she has the mental capacity of a toddler and requires multiple medical interventions to stay alive.
Among the treatments is physical therapy, which she needs to keep muscles toned and her spine from folding in on itself.
Still, three years ago, she began balking exercise, her parents said.
“If she's working on something … she doesn't want to do, she'll put her head down and ‘pretend' sleep,” Jennifer Samuels said, noting Kaitlyn can't comprehend the idea that she must do the physical work or she could die.
To work around her stubborn streak, her physical therapist came up with a plan: Because Kaitlyn enjoys horses and therapeutic riding, maybe she'd love doing her physical therapy sessions on horseback, a practice known as hippotherapy.
It worked. Since 2009, Kaitlyn has actively engaged in her PT regimen at Rocky Top Therapy Center in Keller, Texas.
But in mid-2010, Kaitlyn's parents said, Tricare stopped payments for the therapy.
They didn't know it, but Tricare considers hippotherapy an experimental treatment that “lacks reliable evidence establishing it as proven” for treating any medical conditions.
Tricare never issued a formal denial; it simply stopped paying. Tricare spokesman Austin Camacho said he couldn't specifically address the Samuels case but said that because of the volume of claims processed by Tricare, it's “inevitable that a small percentage will be improperly paid.”
The Samuelses appealed, arguing their daughter's treatment was not unique but a type of basic physical therapy using a horse as a tool, similar to a bench, stability ball or weights used by physical and occupational therapists.
In March 2012, the Samuelses won a small victory when a Tricare hearing officer agreed with them, calling Kaitlyn's treatment “physical therapy” and recommending Tricare pay the cost-share owed the Samuelses, $1,327.44.
“Should [Kaitlyn] fail to get proper PT, she will need surgery, a cost that would be incurred by the government … [without surgery] the curving can continue until her organs are crushed and she dies,” wrote Claude Heiny, a Tricare administrative judge.
But less than six months later, Tricare Appeals Director Mark Donahue issued a final decision: denied.
“I have determined that hippotherapy is not a covered medical benefit under the Tricare Basic Program because it is not medically or psychologically necessary,” Donahue wrote.
Although his decision is final within the Tricare system, the Samuelses are not through yet. Attorneys at the powerhouse law firm Akin Gump, Strauss, Hauer and Feld read about their case and decided to take it pro bono.
Their goal is to rewrite the law to broaden Tricare's definition of covered physical therapy services.
“If Kaitlyn were to use a ball or a bench or even a bench shaped like a horse, it would be covered. But you put skin and bones under the bench, suddenly it's experimental? We think that's a glaring mistake,” attorney Marcella Burke said.
Kaitlyn's therapy costs $160 a week, which the Samuelses now pay out of pocket, assisted by a grant from a Rocky Top benefactor.
Jennifer Samuels said the issue is not one of money, but of benefits for special needs children in military families. To her, Tricare's “whole argument makes no sense.”
But Tricare is hardly alone in labeling hippotherapy as experimental. Many larger insurers, including UnitedHealth, Aetna and Wellcare, do not reimburse for hippotherapy.
Yet Rocky Top often receives payments from insurers of clients who are receiving physical therapy on horseback — an accepted billable treatment.
The center also receives payments from Medicaid, which covers children with special needs regardless of income. Kaitlyn Samuels would qualify for the Medicaid provision, but since she is a military child and moves often, she ends up at the bottom of wait lists for the state-administered program each time the Samuelses relocate.
The case has drawn attention from special needs groups and military advocates who think the law should be changed.
“How can [Tricare] do this when a licensed professional has determined it works?” said Sharon Gilbert, a program director with the American Hippotherapy Association. “Insurance companies don't revoke payment if PT is conducted in a pool or at therapy room. Why should a horse be any different?”