Disabled Girl's Treatment Coverage Depends on Definition of "Hippotherapy"

Categories: Legal Battles

horser.jpg
via Rocky Top
Horse or alternative therapy?
Mark Samuels, a captain in the Navy, and Jennifer, his wife, never imagined their first time in court would be fighting for healthcare benefits for their daughter Kaitlyn. The 15-year-old was born with an uncommon brain condition similar to cerebral palsy. She cannot communicate verbally and functions at the level of a toddler, but she can get out of bed, walk and eat with assistance.

The Keller family hopes she can maintain and improve her abilities, but they've come head-to-head with their military benefits provider, Tricare. The company refuses to cover Kaitlyn's physical therapy on a horse, or hippotherapy, which has been the only effective treatment.

Kaitlyn's condition affects the way her brain communicates with the rest of her body, resulting in severe scoliosis from her muscles tightening and contorting her back. Without physical therapy to prevent her condition from worsening, her neurologist and physical therapist agree, her condition would digress. Without treatment, the angle of her back could become acute enough to constrict her organs, eventually leading to death.

Surgery that would make her spine straight and rigid is also an option, but it comes with a litany of risks including a 50 percent chance that she would lose her ability to walk.

Kaitlyn understands none of this. As her parents see it, physical therapy is their best option, but there's a catch: Kaitlyn will not cooperate in a clinical setting. She becomes bored doing repetitive exercises on a balance ball or barrel and will not follow instructions. She shuts down, not dissimilar to the way she behaved when she was completely disinterested sitting in the courtroom earlier this month, slumped over in her wheelchair, resting her head on the attached counter.

Her parents have found one method of therapy that keeps Kaitlyn engaged -- physical therapy on a horse, commonly called hippotherapy. For the entire half hour she is completely alert and cooperates with her caregivers.

The Samuels's case against Tricare for the company's refusal to reimburse Kaitlyn's therapy on a horse -- or hippotherapy -- was heard by a Department of Defense judge at the Earle Cabell Federal Building a week ago. A lawyer for Tricare, Michael Bibbo, argued that hippotherapy is an "unproven treatment," and to be reimbursable, a method of care must be proven, as well as "safe and effective".

"Could Sea World hire a physical therapist [and charge Tricare]?" he asked. "Under Tricare, hippotherapy is not proven due to a lack of evidence. ... That really is the simple truth," he said in his opening argument via teleconference from Colorado. He said that while there's reason to believe the therapy works, Tricare's policies dictate that the company cannot cover it. "Congress can change the laws," he said, but he is tied to defending the policies that are already in place.

The Samuels's attorney, Colby Vokey, argued that the case is a "matter of semantics". The word "hippotherapy," he said, is also used to describe cognitive rehabilitative therapy on a horse, which he agreed that Tricare should not cover because of lack of research.

Rocky Top, the Keller facility where Kaitlyn received her therapy, recently received a $290,000 state grant to help veterans with psychological problems such as post-traumatic stress disorder and traumatic brain injury, as reported in The Dallas Morning News.

Kaitlyn is not using the horse to treat her brain condition, Vokey said, she's using the horse as a tool for traditional physical therapy. "The only option we have here is physical therapy using a different tool ... The other tools don't work; the horse does," he said.

Kaitlyn's physical therapist testified that the horse is merely a therapy tool that proves more effective in many cases because of the dynamic movement and warmth of the animal. "I am a physical therapist, not a hippotherapist," Suzanne Sessums said, adding that she is also not a ball or bench therapist.

Questioned by Bibbo, Sessums questioned him back, "You're telling me if I put Kaitlyn on a bench in a center you will pay for it?"

To which Bibbo said, "It's not the exact same thing if you're getting more" efficacy from a horse than a bench.

"It's still recoginized as a therapy tool, and that's what this is. ... I'm not understanding why I have to prove my use of a horse, but not my use of a ball," Sessums said.

Mark Samuels told the court that it "bothers" him that Medicaid will cover hippotherapy but his military benefits package will not. When Tricare refused to cover the therapy, the company also billed the Samuels for months of therapy that were held up in dispute. The amount totals less than $2,000, far less than the legal fees the Samuels incurred in pursuing the case.

Jennifer Samuels said she found that Kaitlyn does qualify for Medicaid coverage of her treatment, but that their family moves so frequently with the Navy that they cannot stay in one region long enough to ride out the waitlist and collect benefits. "If he was a deadbeat dad, we would not be here right now," she said.

"It is physical therapy. You put my child on a horse and somehow it's some alternative strange therapy," she said, telling the court that her greatest fear was that this point was not being understood.

"For the love of god, what we have is a bent spine and tight muscles," Vokey said in his closing argument. "It's not cognitive rehabilitative therapy, [the horse] is a tool -- only -- in physical therapy."

Bibbo bottom-lined his argument. "When a physical therapy uses a horse, that's hippotherapy."

The judge gave Bibbo two weeks to submit his closing argument, at which point he will make a decision on whether Kaitlyn's therapy is covered under the military benefits package or whether it's an unproven treatment that Kaitlyn should either give up or that her parents should bear financially.

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14 comments
lynnj0750
lynnj0750

This is MURDER! We have been subject to the same failed process! Why don't military members have the same protections under the PPACA act? Shame on our government and all those involved. Shame on those who reverse, deny and then arbitrarily and capriciously discriminate against sick beneficiaries like myself and Kaitlyn Samuels. My husband no longer proudly serves his country but counts the days until he may retire knowing that every day his family is being withheld proper medical treatment.I have been in contact with not only the reporters who have done an amazing job shedding light on these issues but also the Samuel family. I pray to god that not only does the care in question (that is, only questioned by Tricare/DoD lawyers) will finally be covered but that the person working on our DoD IG investigation will discover, that above and beyond specific care, (that Tricare makes it impossible to navigate or to be successful in arbitrating) that the DOD IG investigation will discover that Tricare (through contractor like Healthnet) is arbitrarily and capriciously delaying and/or denying all care/claims to beneficiaries who exercise their right to appeal. That this will shed light on the flawed appeals process, the flawed process in which lets Tricare contractors twist the words in federal regulations to defer and ultimately deny legitimate medical claims. A flawed process that lets Tricare decide the ultimate faith of life or death, regardless of an outcome of the appeal hearing.If this were any civilian insurance company this would not be tolerated or allowed. The PPACA act protects civilians but leaves our military families at the mercy of the flawed process. It lets them die. This is not about the specific appeal or the Samuel's need for physical therapy for their daughter. It's about flaws in the system. It’s about Tricare and their contractors making mistakes but nobody taking accountability.Fix the process that lets Tricare official's like Mr. O'Bar play GOD! Do you really think that the Samuels went through a three part appeal, which included spending more than $5,000 on legal representation over $1,300 worth of claims if it wasn't about what is morally and ethically wrongdoing? Please pray for the Samuels and families like ours, that the Armed Forces committee will get involved and will hold Tricare accountable for breech of contract. Hopefully they will amend legislation and/or will support new legislation that protects our beneficiaries. Legislation that doesn't allow Tricare and their contractor(s) (ie: health net) to twist and manipulate it to deny medically necessary care. Legislation that will give our military members the same rights and protections that give every other American under the PPACA act.

Casey06
Casey06

@lynnj0750

"It’s about Tricare and their contractors making mistakes but nobody taking accountability."  Lynnj0750

"Tricare is another governmental entity that lacks common sense in its dealings..." Chris  

I couldn't agree more. Tricare is excessively abusive and manipulaive to their beneficiaries. We were told at the begining of this year that they would not pay our medical bills because we had a "Vision Plan" that helps in buying eye glasses.

Last year we had a Catastrophic Medicare Supplement that would pay after Medicare and $5,500 of CoPays were paid by us and TRICARE. TRICARE refused to pay our bills and recouped (seized) funds that had gone to Hospitals, Doctors, Labs, and  Equipment providers for the past 4 years.

They had claimed that there had been duplicate payments to our providers over a 4 year period even though we never had copays that exceeded $2,500. After a year of harrassment, neither Tricare nor us or our providers have been able to find any duplicate payments.

Tricare recently paid the hospitals back, but have been dragging on paying the doctors, labs, and eqipment suppliers back. Tricare "lacks common sense in it dealings" and "It’s about Tricare and their contractors making mistakes but nobody taking accountability."  

I admire the Samuels for fighting for their earned benefits and for Kaitlyn's well being. It is frustrating to have served 34 years and have service connected disabilities, and then to have Tricare contractors deny your legitimate claims.       

Cm_rowley
Cm_rowley

If they get this passed, I will be the next one fighting to get it approved for my son. We had hippo therapy in AZ and it makes a high difference for my son with CP. He was walking with his gate trainer and more vocal. He has since regressed. I did however have the therapists doing his therapy bill for the PT potion and I payed for the use of the horse. It was very expensive. If tricare begins to pay, I will have my son back on a horse asap.

Russp
Russp

I guess what I'm missing from this article is what does the horse do to benefit the child? Shouldn't physical therapy be something the child is performing, where does the horse fit in? If it just functions as a bench or a ball (I'm sure at much greater expense), I can understand the argument against the payments. 

Jdsmws
Jdsmws

Costs are the same

Russp
Russp

If that's truly the case, I don't see the insurance companies complaint. Just as with any other procedure or treatment, there is usually an accepted cost that they will pay the provider. I am really surprised though that a horse can be provided at the same cost as treatment in an office on a therapy ball. I know what it costs to board and feed a horse

Russp
Russp

Then there should be absolutely no reason for Tricare not to pay the bill. Thanks for the explanation.

Jdsmws
Jdsmws

I should have explained better... Tricare is billed the same whether it's a ball or a horse. Rocky Top gets many donations that help cover their costs. Plus we were paying $100+ a month ourselves over and above what Tricare was billed. So, yes there are additional costs but Tricare was/is only being asked to cover the PT charges.

Jennifer Samuels
Jennifer Samuels

There is no additional expense using the horse the costs are the same as if she were using a therapy ball. And my daughter is working her weak muscles while on the horse ---the PT optimally positions her and then has the horse move as needed per Kaitlyn's PT goals. This IS physical therapy which Tricare agrees Kaitlyn is entitled to...they just refuse to understand that it is indeed PT.

Chris Danger
Chris Danger

I've said this for years, many people seek alternate methods of treatment and usually have more success in the process. Tricare is another governmental entity that lacks common sense in its dealings...

Guest
Guest

Why would anyone look at a hippopotamus and think it looked like a horse in the water?

Stupid Greeks.

Gabe
Gabe

Typo alert! "Could Sea World higher a physical therapist [and charge Tricare]?" he asked...

No malice intended, just want to make the world a more perfect place (including spelling). 

Great article by the way.

jfpo
jfpo

Looks like Bob's mailing it in as he leaves (I keed).

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