Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
3Activity
0 of .
Results for:
No results containing your search query
P. 1
Kaitlyn Samuels v Department of Defense

Kaitlyn Samuels v Department of Defense

Ratings: (0)|Views: 2,473|Likes:
Published by Robert Wilonsky
A military family takes the government to court for refusing to pay for their daughter's physical therapy.
A military family takes the government to court for refusing to pay for their daughter's physical therapy.

More info:

Published by: Robert Wilonsky on Aug 16, 2014
Copyright:Traditional Copyright: All rights reserved

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

08/20/2014

pdf

text

original

 
 
IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF TEXAS DALLAS DIVISION
KAITLYN SAMUELS, and CAPTAIN MARK SAMUELS, USNR, and JENNIFER SAMUELS, as conservators and guardians of KAITLYN SAMUELS, Plaintiffs, v. U.S. DEPARTMENT OF DEFENSE 1400 Defense Pentagon Washington, DC 20301, DEFENSE HEALTH AGENCY 7700 Arlington Boulevard, Suite 5101 Falls Church, VA 22042 and CHUCK HAGEL United States Secretary of Defense 1000 Defense Pentagon, Room 3E880 Washington, DC 20301, Defendants. Case No. __________
COMPLAINT FOR DECLARATORY AND INJUNCTIVE RELIEF COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF
Plaintiffs Kaitlyn Samuels, and Captain Mark Samuels and Jennifer Samuels, as Kaitlyn’s conservators and guardians, file this Complaint for Injunctive and Declaratory Relief against Defendants the Defense Health Agency
1
 (DHA) and Chuck Hagel, United States Secretary of Defense, in his official capacity, alleging as follows:
1
 On October 1, 2013, the Department of Defense established the Defense Health Agency (DHA) to manage the activities of the Military Health System. These activities include those previously managed by TRICARE Management Activity (TMA), which was disestablished on the same date. Because TMA was administering the Military Health System when Kaitlyn’s benefits were denied, the Complaint will refer to TMA rather than DHA.
Case 3:14-cv-02948-K Document 1 Filed 08/15/14 Page 1 of 16 PageID 1
 
2
NATURE OF THE ACTION
1.
 
Mark Samuels, United States Navy Reserve, and Jennifer Samuels, on behalf of their daughter Kaitlyn Samuels, bring this action under the Administrative Procedure Act (“APA”), 5 U.S.C. § 702 (2006), challenging TRICARE Management Activity’s (TMA) denial of cost-sharing for necessary, life-saving physical therapy for Kaitlyn. Plaintiffs assert that TMA’s decision was arbitrary, capricious and unsupported by any substantial evidence. Plaintiffs request that this Court enjoin Defendants from denying coverage for Kaitlyn’s physical therapy and order Defendants to provide reimbursement for past physical therapy sessions, which were wrongfully denied. 2.
 
The TRICARE Basic Program is a supplemental program to the Uniformed Services direct medical care system. Beneficiaries receive coverage for necessary medical services and treatment strategies, including physical therapy.
2
 3.
 
Kaitlyn is a 17-year-old girl and TRICARE beneficiary who suffers from severe mental and physical impairments caused by agenesis of her corpus callosum. Due to Kaitlyn’s  brain disorders, her muscles do not function properly. She also suffers from neuromuscular scoliosis, a medical condition that causes her spine to curve from side to side. Jennifer Samuels has three simple wishes for her daughter, Kaitlyn: that she learn to say a few words, take a few steps unassisted, and curl the food from her plate onto her spoon.
2
 An “Authorized Individual Plan of Care” is the document that states a TMA patient’s health deficits that need treating, as well as the physical therapist’s doctor-prescribed, Current Procedural Terminology (CPT) coded “treatment strategy.” Kaitlyn’s treatment strategy calls for physical therapy. The two CPT codes Kaitlyn’s physical therapist uses for her treatment are billed under “97530 Therapeutic Activities” whereby the health care provider uses dynamic therapeutic activities designed to achieve improved functional performance (e.g., lifting, pulling,  bending), and “97110 Therapeutic Exercises” whereby the therapist and patient use a tool to perform therapeutic exercises to one or more body areas to develop strength, endurance, and flexibility. A Plan of Care determines treatment strategy, not the tools the therapist uses when executing the treatment strategy; indeed, there are no codes for tools.
Case 3:14-cv-02948-K Document 1 Filed 08/15/14 Page 2 of 16 PageID 2
 
3 4.
 
If untreated, Kaitlyn’s disorder will severely worsen the curvature of her spine, which will cause compression of her ribs into her internal organs and crush her organs. Kaitlyn’s  body will slowly shut down and she will die. 5.
 
Participation in effective physical therapy slows down and reverses negative effects of the curvature in Kaitlyn’s spine. Currently, Kaitlyn’s spine is straightening, and the surrounding muscles are growing stronger, because of the uniquely tailored physical therapy plan implemented by her physical therapist. Without specially tailored physical therapy, Kaitlyn’s only option would be an expensive and extremely risky surgery, which would involve fusing her  backbone from the neck to the lumbar region. As a result of this surgery, Kaitlyn would lose the  progress she’s made to-date, as well as what freedom she has to move freely: she would lose all flexibility from her torso and would require nonstop monitoring. Simple tasks such as assisted walking, unassisted sitting, and sleeping comfortably would be impossible. This life-threatening and costly surgery may need to be repeated throughout her lifetime and will likely result in constant muscle spasms and pain. Under Kaitlyn’s physical therapy regimen this surgery will not  be necessary. 6.
 
Kaitlyn’s doctors first prescribed physical therapy to Kaitlyn when she was an infant under one-year old. Since then, she and her parents have worked with a licensed physical therapist to treat and manage her condition through doctor-prescribed physical therapy. In her early childhood, Kaitlyn received physical therapy in a clinical setting using tools such as barrels and physioballs to engage her in various therapeutic activities. Eventually these tools proved ineffective because Kaitlyn—whose intellectual capacity is in the high infant-toddler-preschool range—lost interest and would no longer participate. Like many special-needs patients receiving
Case 3:14-cv-02948-K Document 1 Filed 08/15/14 Page 3 of 16 PageID 3

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->