Brandon Bennett can't ride a bike. Astroworld has warned him to stay off its roller coasters. And to get comfortable at night he must position six pillows just right, and even then he'll stop breathing at least half a dozen times.

This is all because the 16-year-old, through little fault of his own, weighs 420 pounds. He has tried the Atkins diet, Sugar Busters, Slim Fast, hypnosis and calorie counting. He grew up drinking Diet Coke, wondering why he wasn't allowed, like his sister, to drink regular Coke. Brandon 's problem is probably genetic, doctors say.

The excess weight may soon cause Brandon to become diabetic. He already has high blood pressure and heart problems. Clear Lake High School officials routinely call Brandon 's parents when he begins sweating, his heart rate soars and he has trouble breathing - all while sitting in class.

"How many kids do you think get sent home in the ninth grade for high blood pressure?" asks his father, Michael Bennett .

As his pediatricians and parents see it, Brandon really has just one shot at a normal life. But it's a drastic one. Doctors want to perform bariatric surgery, which will cut the size of his stomach to less than 10 percent of its current size.

The surgery was planned until last week, when Brandon 's insurance company declined to cover the potentially life-saving procedure.

Long-term effects

The decision highlights a growing divide between medical practice and insurance coverage in the emerging health issue of childhood obesity. Pediatricians are increasingly, if reluctantly, recognizing bariatric surgery as the only viable option for children like Brandon . But insurance companies are pulling back coverage for adults and children.

"Given the increasing number of procedures, insurance companies feel threatened by the rising costs," said Dr. Harvey Sugerman, president of the American Society for Bariatric Surgery. "It's unfortunate, because it's shortsighted. In the long run, the surgery will be cost-effective."

Bariatric surgery is not cheap. It can cost less than $25,000, but with follow-ups and complications, it sometimes costs as much as $100,000. Until recently, the procedure had a relatively high death rate from complications, such as internal bleeding, of 1 percent or slightly higher.

But as the procedure has become more accepted, and moved from smaller hospitals to large medical centers, the survival rate has improved to well above 99 percent. And doctors are getting more practice. A decade ago, surgeons performed about 16,000 a year. In 2003, according to the New England Journal of Medicine, they did about 103,000.

Pediatricians say fewer than 1,000 bariatric surgeries were performed on children last year. That number is on the rise, however.

Dr. William Klish, head of Texas Children's Hospital's department of medicine, says the popularity of a talk he gives to other pediatricians on bariatric surgery has grown in recent years.

"I find that interesting, because five years ago most pediatricians would have been appalled at the thought of this surgery in children," said Klish, who is also head of pediatric gastroenterology at Baylor College of Medicine.

Texas Children's abruptly reversed its opposition to the procedure earlier this year when it performed its first two operations on teenage girls. Both girls had successful surgeries and have lost weight.

The big question is whether the procedure is safe and effective for most obese children.

To answer this question, Texas Children's embarked on a study in May to eventually enroll 30 children a year and carefully measure their health problems and weight before and after the surgery. The hospital is also setting up a databank so other children's centers can contribute information.

This is the data insurance companies say they are waiting for, in both adults and children, to decide whether to cover the procedure. A true cost analysis has never been done.

For adults, Sugerman and other bariatric surgeons point to data from Canada in last month's issue of Annals of Surgery. The researchers found that adults with morbid obesity - those with a body mass index of 40 or above - who got the surgery had a 90 percent better survival rate after five years than those of similar weight without the surgery, and had a reduced risk of developing heart disease, cancer and a host of other ailments.

`Affordable health care'

The study also found that, with these reduced health problems, the surgery paid for itself after less than four years.

Dr. Adam Naaman, a bariatric surgeon practicing at Memorial Hermann Memorial City Hospital, says his results in adolescents have been even better than in adults.

"They seem to be more committed after the surgery," said Naaman, who has done 25 adolescent surgeries in the past four years.

Insurance companies say that, at least for now, the procedure is a money loser.

Roger Rollman, a spokesman for UnitedHealthcare, - which with 1 million customers in Texas is one of the state's largest providers - said that adding bariatric surgery to its general policy would drive premiums above the level of affordability for companies.

"Our focus is on providing people with access to affordable health care," he said.

Companies who cover their employees' health insurance can add bariatric surgery to their policy for an extra cost, but few have, he said. If evidence comes that shows the procedure saves money, United would definitely pay attention, Rollman said.

Not many covered

Just 23 percent of U.S. employers covered gastric bypass surgery in their primary medical plans in 2003, according to Mercer Human Resource Consulting's National Survey of Employer-Sponsored Health Plans, a report released earlier this year.

And that percentage may be dropping. Bariatric surgery, a benefit previously offered to Florida Blue Cross and Blue Shield customers, will not be covered beyond Jan. 1, 2005. Blue Cross and Blue Shield does not cover it in Texas.

Two weeks ago, Brandon was to become the third patient to have a gastric bypass as part of the Texas Children's study. But just four days before the surgery, it was canceled because of an insurance mix-up.

When he enrolled in May, the hospital checked his insurance for coverage of doctor's visits to test his heart, lungs and sleeping problems as part as preparation for the surgery. But it didn't check whether the surgery was covered.

Instead, they waited until Brandon became a candidate for surgery, months later. By then he had been visiting the hospital twice weekly as part of the surgical work-up and for support groups and nutrition classes with other prospective patients.

When the insurance was finally checked in August, the administrators found that the procedure was not covered. The hospital and the Bennett family asked for a waiver, but the insurance company declined, just four days before the scheduled surgery. A secondary appeal was rejected last week.

Now the Bennett family is working with the hospital to try to come up with alternate arrangements. At first, Michael Bennett said, the hospital asked him to pay about $37,000 up front. Now they are seeking just $10,000, with the remainder of costs to come later.

"We'll work out financial arrangements that work for the family," said David Campbell, senior vice president of finance at Texas Children's.

Texas Children's Dr. Michael Helmrath said the hospital now checks insurance for surgical coverage when patients first ask about the procedure.

Alternate route

Helmrath and other surgeons and pediatricians are working with Texas Medicaid and the Children's Health Insurance Program to add coverage for the procedures, but given state budget cuts, it is a difficult sell, just as it is to private insurance companies.

"They do not have enough experience with this procedure," Helmrath said. "We don't have the outcomes data yet."

Brandon is lucky. His parents can pay for the procedure in installments.

The surgery, which should take place later this month, will financially strain the family, Michael Bennett said. But he wants to give Brandon a chance to be healthy.

"I just want to live a normal life, to be like everyone else," Brandon said.

"Hey, I like motorcycles and fast cars. What 16-year-old boy doesn't? I never imagined being able to own a sports car. I'm too big. But now I can at least dream about it."

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