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AINsight: FAA Aeromedical Letters, Part 3
By: Robert Sancetta
Caption: In the third of a three-part blog series, AME Dr. Robert Sancetta discusses various types of FAA aeromedical approval letters.
Word Count: 2013
As noted in my prior blogs on this subject, the FAA, at its discretion, sometimes sends letters to pilots in reference to their aeromedical eligibility. Most of these letters are sent from the Aerospace Medical Certification Division (AMCD) in Oklahoma City. However, some such letters may be sent directly from the Federal Air Surgeon office in Washington, D.C., or from any number of the FAA regional offices.
I have discussed some of the reasons why such letters are sent to pilots, including the FAA’s request to have additional documentation on a reported medical condition. When arriving unexpectedly, and sometimes seemingly unnecessarily at first glance, this can be disconcerting to pilots, as well as their aviation medical examiners (AMEs). These letters are often referred to colloquially as “nastygrams,” which I previously discussed in detail. In reality, most of the time these letters are sent, the request by the FAA is not entirely unreasonable.
Sometimes, however, things do go awry in the review process at the AMCD. Amusingly, as I write this, I just received my copy of an entirely unnecessary nastygram that the FAA sent to one of my pilot patients, who is on a special issuance authorization for a medical condition and has been in complete compliance, and stability, for many years.
This letter was entirely inappropriate and unnecessary. It is never amusing for a pilot to find out that there is a certified letter from the FAA awaiting them at the local post office.
Fortunately, with one quick call to the FAA I was able to get the issue resolved, and the pilot should eventually receive his “oops” correction letter in the mail. If the pilot and/or AME demonstrates some patience and tact when dealing with the FAA, often things can be corrected sooner rather than later. 
If a reasonable request for additional medical information is received, I also discussed the rationale for getting “on it” sooner rather than later. This is to proactively prevent the receipt of a far more disconcerting letter, the “failure to provide” (FTP) denial letter—sent because the FAA did not receive the requested data in the time allotted in the first letter.
Before I discuss the various types of approval letters, please let me soften the impact of a pilot’s concern about receiving unexpected letters from the FAA. In reality, if a pilot plays the proverbial game correctly, over 99.9 percent of the time the pilot will ultimately receive a medical certificate.
Less than one in one thousand pilot applicants are ultimately denied—even if the process drives that pilot batty along the way. And of those rare denials, more of them are from pilots simply giving up and receiving the FTP denial letter than from the aspects and merits of the medical condition itself.
As long as we’re on the subject of denial letters, sadly they are sometimes unavoidable. Many such denial letters result from a student pilot’s first medical application. If they have a history of epilepsy (that wasn’t just a childhood condition that the pilot grew out of) or bipolar disorder (or any form of psychosis), that pilot will receive a denial letter and likely will never fly.
Some of the initial denial letters result from a reported history of diabetes, cardiac disease, or substance abuse, among other conditions. Even though a denial letter is initially received, many conditions, through the special issuance process, may ultimately lead to medical approval of that pilot, if ongoing stability can be demonstrated to the satisfaction of the FAA.
If a previously approved pilot has a new condition, such as head trauma (with significant cognitive impairments) or any number of other aeromedically significant diagnoses that arise which are likely to be of a permanent nature, then that pilot may also receive a denial letter. It is very sad when a professional pilot gets well into a career and then can no longer pursue their chosen vocation.
Once a medical condition is approved by the FAA, there are many types of letters and protocols that may follow.
I have already discussed the “letter of eligibility” or “clearance letter.” This is typically a brief letter, in which the FAA acknowledges the medical condition, but does not require further follow-up.
As with all approval letters, however, there will be a reference to FAR 61.53 (prohibition on operations during medical deficiency). Basically, this FAR states that if there is a new condition or exacerbation or worsening of a known condition, the pilot should not fly until the situation is revisited formally.
In point of fact, regardless of references to FAR 61.53 in FAA letters, the ethics of its intent are in effect at all times that a pilot exercises the privileges of a medical certificate.
A letter of eligibility is often sent after a pilot passes a medical flight test to remove a color vision restriction from the medical certificate. In the old days, the pilot was issued a statement of demonstrated ability—one of the forms of a “waiver”—for color vision.
Now that the FAA more typically issues a letter of eligibility instead for this condition, one advantage is that the pilot does not have to answer “yes” when an employment application asks if the pilot has any waivers on the medical certificate.
Other approval letters from the FAA do not place the pilot on a formal special-issuance authorization, but they do state that a pilot needs to provide additional data at “the next medical application.” This means that whenever the pilot is next due for the formal FAA examination, certain data needs to be presented to the AME.
Usually, the AME can issue the subsequent medical certificate “on the spot” if the appropriate data is provided and is favorable.
I have also previously referred to the Conditions the AME Can Issue (CACI) program. This program is great—it permits the AME to issue medical certificates, without any delay awaiting FAA pre-approval, for certain conditions that are of interest enough to the FAA to warrant additional information, but are not so complicated that an internal FAA review is mandated beforehand.
CACI conditions include hypothyroidism, asthma, glaucoma, hypertension, pre-diabetes, and a host of other conditions wherein ongoing stability can be demonstrated with typically just a few medical documents.
Added to the CACI protocols in recent years are somewhat more concerning diagnoses, but under certain conditions, the AME can still issue the medical certificate.  These include prostate, testicular, renal, colon, and breast cancers. These cancers must be in an early stage without metastasis (spread).
More and more conditions are being added to the CACI program. Obviously, in cancer diagnoses, more than “a few” pages of data will be required. But if the AME is willing to review all of them, that pilot will not face any undue delay awaiting an FAA review.
Another beauty of the CACI program is that the AME simply must certify that the required documentation has been reviewed. The data does not have to be sent to the FAA.
This theoretically saves delays caused by unwieldy documents adding to the enormous workload already at the AMCD—but don’t ask how well that theory is working for any pilot who has been waiting months for their individual review. The documents must be retained by the AME, of course, should the FAA decide after reviewing the AMEs comment that it later wants to see the data.
The most formal version of approvals are special-issuance authorizations (SIA). SIAs are issued for medical conditions that would otherwise be disqualifying.
However, based on a review of comprehensive medical documentation that confirms that the pilot is stable and at low risk for “sudden incapacitation” in flight (and, in fact, is also at low risk for a gradual but significant deterioration medically during the interim between FAA medical examinations), that pilot may be granted an SIA. The difference between SIAs and the other waivers or letters of eligibility—such as for color vision deficiencies or limb amputations—is that the condition followed under an SIA will require ongoing monitoring.
The initial special issuance application usually takes place while the pilot is grounded per FAR 61.53 or any whatever other FAR might apply. So there is a bit of a waiting game for that first FAA review, which requires some patience on the pilot’s part.
SIAs typically require documentation follow-up annually. There are some medical conditions that require more frequent follow-up—for example, the newer insulin-dependent diabetes protocol that permits first- and second-class medical certificates for professional pilots. Ditto for cases where a pilot has a cardiac pacemaker. But, for the most part, follow-up is annual.
The typically annual follow-up requirement will apply to all classes of medical certificates. Therefore, for example, if a third-class pilot is not due for the FAA medical examination that year, the special issuance documentation will still be required regardless.
Most professional pilots, holding first- or second-class medical certificates, will require FAA medical examinations at six- or 12-month intervals anyway, so the timing of the special issuance submission typically coordinates easily with the routine examination schedule.
Conditions followed under special issuance include heart disease requiring treatment; diabetes requiring medications; alcohol and other substance abuse or dependence; cardiac pacemaker implantation; sleep apnea; depression (there has been a program since 2010 to permit pilots to fly when being treated for depression or anxiety on any of four approved medications); and a countless host of any other conditions that the FAA deems appropriate to follow under an SIA.
The SIA letters are frightening for the pilot at first glance. They are quite intimidating to read. The opening paragraph states all of the FARs and other reasons why the pilot is disqualified.
But the next paragraph begins with “however” and states that the pilot has done wonderful things that permit their being ordained by special issuance to continue to fly. Then all of the follow-up requirements and timing of said testing are outlined in specific terms.
If the pilot follows the rules and timing, and the follow-up medical documentation is favorable, then the SIA will continue on an appropriate schedule without additional periods of grounding.
Disclaimer: some SIAs require that documentation be sent to the FAA in advance of the expiration of the existing medical certificate, to “hopefully” give enough time for the FAA to review the data and send yet another letter stating that the AME can issue the subsequent medical certificate.
This process sometimes seems never-ending and is laborious and exhausting logistically. One of my pilot patients described this waiting game like a “love-sick sailor going to the mailbox every day.”
Fortunately, more and more SIAs are permitting the AME to issue the subsequent medical certificates without needing FAA approval first. The documentation, which the AME reviewed prior to issuing the medical certificate, is then sent to the FAA.
Through this procedure, there is no “waiting game,” and the pilot gets the medical certificate issued “on the spot” at the time of the subsequent FAA examinations. As with the CACI program, the expectation of receiving a medical certificate at the time of the exam does reduce some pilot stress.
FAA letters come in many varieties, formats, and complexity. They are often quite intimidating at first glance. Always check with your AME to confirm the specifics and intent of any FAA letter received, as well as to confirm if and when follow-up data will be required for the medical condition in question.
The opinions expressed in this column are those of the author and not necessarily endorsed by AIN Media Group.