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

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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