(WBIR-New Tazewell) A change in policy for one of Tennessee's leading insurance companies could cost a Claiborne County woman her foot, and thousands of others the treatment they need.
In January, BlueCross BlueShield of Tennessee (BCBST) switched to the Milliman Care Guidelines (MCG). Under the new guidelines, fewer conditions qualify for a limb-saving treatment.
Hyperbaric oxygen therapy (HBOT) is commonly used on diabetic wounds and on radiation injuries for cancer patients. Patients sit or lay in a chamber that may be pressurized with pure oxygen or compressed air.
"We started getting denials on conditions that previously had sailed right through," said Dr. Vaughn Hall, a HBOT specialist who works for a HBOT company.
According to Dr. Hall, last year BCBST covered 11 different conditions for HBOT. Under the new guidelines, the insurance company covers four.
"In general, the reason why conditions would be deemed inappropriate for treatment are all based on a lack of scientific studies," said Mary Danielson, a BCBST spokesperson.
Danielson said the Milliman Care Guidelines are the standard for a majority of health insurance carriers in America. Under the MCG, hyperbaric oxygen therapy is considered medically necessary for fewer conditions. She said the change is not due to the Affordable Care Act.
"I think they've only done it for money. I mean there is no price on life really. But apparently they do have a price," said Kristy Mason Napier of New Tazewell.
Napier no longer qualifies under the MCG. She has a mild form of spina bifida and a 10-year-old foot infection that recently reached the bone. Doctors gave her two choices: amputation or antibiotics with hyperbaric oxygen therapy.
"I think I ask myself all the time, 'Am I not enough? Am I not worth it?' I think I'm worth living," Napier said.
Napier's doctor referred her to Dr. Hall.
"She's looking at an amputation at this point," he said. According to Dr. Hall, four of his patients who qualified last year for assistance are no longer covered for HBOT.
"I hope the insurance companies will realize that they're turning their back on decades of treatment, treatment that they paid for for decades and now suddenly they're saying that same treatment for those conditions is investigational," Dr. Hall said.
Dr. Hall appealed BCBST's decision to not cover Napier's treatments, which can cost thousands of dollars. Those appeals were denied.
"I've really reached the end of my ability to appeal their decision. I've basically done all I can do and as my patient's advocate; I'm frustrated," he said.
Napier said she has not decided what to do next. According to Dr. Hall, the infection has the possibility to spread to her blood. There is then the possibility the infection could be fatal.
Mobile Hyperbaric Centers, a company specialized in HBOT, said BCBS's new coverage plan could potentially cut the treatment population in half. The company said radiation injuries account for 50% of the center's clients. BCBST will no longer cover hyperbaric oxygen therapy for radiation patients.