Story ID: 
AINsight: FAA Aeromedical Letters, Part 1
By: Robert Sancetta
Caption: Not all letters from the FAA are bad. Many of the medical-related ones the agency sends are approvals after a condition has been reviewed.
Word Count: 1561
Pilots receive medical-related letters from the FAA quite frequently. These typically come from the FAA Aerospace Medicine Certification division in Oklahoma City or the federal air surgeon office in Washington, D.C. Occasionally, letters will come from any one of a number of regional flight surgeon offices. 
This introductory discussion will give some background on why the FAA sends medical letters, and some of the good ones that pilots receive. Future discussions will explain the not-so-good letters (aka “nastygrams”) and how to deal with them effectively.
Why does the FAA send letters regarding a pilot’s medical status? Reasons include simply acknowledging the report of a new medical condition or after review of documentation that might have been sent to the FAA.
Approval letters are issued in various formats. In a future blog, I will discuss the various nastygrams, which can include anything from requests for additional data to denial letters.
Pilots should keep all FAA letters in a place where they can be found. Once the FAA has sent a pilot a letter, it becomes, in essence, the pilot’s medical “ops specs.” Do not lose these letters.
The simplest letter to receive would be an “eligibility” or “clearance” letter, which is usually brief, to the point, and easy to understand. It is sent when the FAA has evaluated a new medical condition that was simply reported on the most recent FAA examination form transmitted by the AME, or perhaps after review of some additional information that the AME requested the pilot to obtain before performing the medical examination.
These kinds of letters are actually very good to receive. While a pilot will always be alarmed when they receive a letter from the FAA, these ones are favorable and supportive. The FAA is acknowledging that the medical condition has been reviewed, that the pilot remains medically qualified, and usually such letters do not ask for additional documentation for that condition in the future.
Pilots should keep these letters. If the pilot needs to go to a new AME for a subsequent FAA examination, presenting this letter to the AME is basically the authorization to issue the medical certificate—as it pertains to the medical condition referred to in the clearance letter.
For even a seemingly minor medical condition, the FAA often sends letters stating that the pilot is cleared to continue flying. These letters are sent to both the pilot and the AME, but it is always wise to keep it on file.
A typical example of this kind of letter is after the FAA has reviewed data submitted in response to an unusual electrocardiogram (ECG). If there are significant changes to an ECG or if an initial screening ECG has a potentially abnormal variant, a cardiology evaluation will be required.
If the cardiology consultation and testing demonstrate that there is no concerning heart problem—either electrically or structurally—and that the ECG is simply a variant that portends no dire prognosis, then the pilot will be cleared by the FAA. Another cardiology evaluation will not be required for follow-up ECGs that appear similar. The pilot should keep that clearance letter and ask the AME for a copy of the ECG itself, in case the pilot needs to go to a different AME in the future.
One caveat with all letters that permit a pilot to continue to fly: there will always be a reference to FAR 61.53 (prohibition on operations during medical deficiency). While any approval letter from the FAA was issued in good faith based on the information the FAA was able to review, 61.53 covers every other moment until the next FAA examination and the pilot’s self-assessment as to whether they are fit to fly at any given time.
Under 61.53, if there is a new medical condition or medication that might be concerning to the FAA or the worsening of an existing medical condition (i.e. one that has been previously cleared by the FAA), the pilot should stop flying and work with their AME to see what could be done to get them back into the good graces of the FAA.
Another caveat: while I impress on all of my pilots to let me know if there have been any significant interim medical events between FAA examinations, I remind all pilots never to delay seeking urgent or emergent medical care waiting to hear from the AME. In those cases, seek the appropriate care, and the AME can interface later. A personal cliché that I still state quite frequently: “It is easier to keep you flying if you are still alive.”
So if it is an emergency, seek care immediately. Once that pilot has recovered sufficiently from whatever emergent care was needed, the AME can help guide the pilot on what documentation and/or additional testing data might be required at the time of the next FAA examination. The AME can also determine whether the pilot may or may not resume flying in the interim, before the FAA formally reviews the event in question.
Along those lines, in a clearly non-emergent setting, such as a decision to change blood pressure or other semi-routine medications, the pilot should indeed clear it with the AME.  There is nothing emergent about that situation, so in that case the pilot indeed should interface with the AME before changing course on treatment—primarily to ensure that the new medication and/or treatment will be FAA approved.
Some FAA clearance letters, while permitting the pilot to continue to fly, do require that the pilot submit additional documentation, either in advance or at the time of the next scheduled FAA medical examination.
A relatively new program that has streamlined issuance for many medical conditions that are somewhat complicated and need to be monitored routinely is the Conditions the AME Can Issue (CACI) program. CACI conditions include hypertension, ulcerative colitis, arthritis, asthma, hypothyroidism, and a growing host of cancers and other conditions that the FAA has determined can safely be monitored by the AME.
The beauty of the CACI program is that while the AME still often is required to review a lengthy set of documents, the AME can issue the medical certificate “on the spot” at the time of the next FAA examination. Better yet, the AME only must document that the required documents were reviewed and that the pilot is “CACI qualified” for the condition in question. The data itself does not have to be sent to the FAA but must be kept on file by the AME just in case the FAA does ask to see it.
To invoke the CACI provision, the AME simply makes the appropriate notation in the online FAA examination transmission. The pilot will later receive a clearance letter, permitting the pilot to continue to fly, which will also reminds the pilot to provide the appropriate CACI data to the AME at the time of the next scheduled examination or as per whatever timeline is appropriate for that CACI condition.
An important point to understand is that in any situation where the FAA requires follow-up documentation, it is not optional.  Even if the pilot’s “treating physician” does not believe the requested tests are of a “medical necessity” (meaning that the physician will order and the insurance company will pay for), they are mandatory for that pilot.
This can lead to some challenging logistical issues in trying to get the testing ordered and paid for, but that is a burden the pilot must suffer. Again, FAA testing requirements are not optional. There are, unfortunately, some occasions where pilots might have to pay for expensive tests out of pocket.
FAA testing requirements stated in any letter the pilot receives are minimum requirements. If the pilot’s treating physician deemed that any other testing was additionally warranted for that condition, those results must also be submitted to the FAA. The wording the FAA uses is that, after the basic requirements are stated, the pilot must also submit the results “of any other testing deemed necessary” or something along those lines.
And if there has been any new significant medical condition encountered since the last authorization or clearance letter was issued, that condition must be reported. There is then the possibility of yet additional data to be submitted.
In this kind of circumstance, I have had pilots complain to me that “the FAA didn’t ask for anything on that.” I remind them that, at the time of the last medical examination and issuance of a clearance or authorization letter, the FAA did not yet know about the new condition. That new condition must be dealt with as per the individual protocols that are applicable.
As cumbersome as I am making this sound, please remember that the vast majority of pilots do indeed receive a medical certificate after submitting the appropriate data. It may be a frustrating and challenging journey, but usually things work out.
I will discuss other versions of authorization letters and the dreaded nastygrams in a future blog.