KNOXVILLE (WATE) – Imagine there’s a medical procedure that can save your life, but your insurance company says no to the operation. That happened to a Knoxville woman who says she doesn’t understand the insurance company’s position.
Kristel Brown, a mother of two, needs gastric bypass surgery to improve her health, not her figure. Gastric bypass is prescribed to treat morbid obvesity and health problems associated with it, specifically diabetes and high blood pressure. The surgery helps you lose weight by changing how your stomach and small intestine handle the food you eat. After the surgery, your stomach is smaller.
Brown is overweight at 355 pounds. She has a rare stomach disorder called gastroparesis.
“It’s where your food doesn’t digest. You have a hard time getting it to go down. I’ve had my esophagus stretched four times,” she said.
Some of her surgeries were done at Vanderbilt Medical Center in Nashville. Now Dr. Matt Mancini at the University of Tennessee Medical Center in Knoxville has recommended gastric bypass surgery for Brown that could possibly save her life.
“She is on the upper scale of morbid obesity. She has four five health problems that are directly related to her obesity. Her diabetes would maybe go away, her high blood pressure,” said Dr. Mancini.
A few weeks ago, Brown received devastating news. Blue Cross Blue Shield of Tennessee, her provider through the health insurance exchange, said in it’s letter, “Gastric bypass surgery is not covered” because it is a cosmetic procedure.
“Cosmetic because people that get the bypass lose so much weight and it’s considered a cosmetic procedure and not a necessity,” said Brown.
“We don’t want any money. That’s not what we’re after. We’re after her to feel better. Her to be able to get the surgery that she needs,” said her husband Joe.
The Browns say their insurance won’t budge on their decision.
“It’s been hard. Hard on my family. Hard on me being sick everyday. Can’t go anywhere, can’t hardly do anything because I’m too sick to get out of bed,” she said.
A Blue Cross Blue Shield spokesperson said in a statement: “We do not cover surgical obesity treatments in our individual or standard group plans.” Furthermore, “determining what’s covered in our policies requires balancing affordability and coverage of appropriate medical care.”
Dr. Mancini says since he started gastric bypass procedures, the cost of the surgery has dropped over the last five to seven years from $30,000 to under $20,000, but he says insurance companies are reluctant to pay the bill.
“They’re very black and white; there is not a gray zone. I think data is now showing is that the improvements of the patients health after gastric bypass surgery will usually pay the insurance company back in about 18 months,” said Mancini.
All Kristel Brown can do for now is treat her symptoms.
“It’s a miserable existence,” she said. “I want to get better. I need to get better for my family and for myself.”
Blue Cross Blue Shield says its competitors who sell on the marketplace also exclude bariatric surgery. However, they say Brown has a right to appeal the decision denying the procedure. She is looking into several alternatives to fight the company’s decision because she wants to live. She says in her situation, Blue Cross Blue Shield’s blanket policy to reject bariatric surgery is unfair.