10 ½ Months Update: Victory and Devastation

This is going to be a short update, but I wanted to share a victory that I consider huge, but I am also experiencing a very devastating loss right now. First of all, my back is still fine, I didn’t get as many workouts in as I wanted over the last couple of weeks, mostly due to a nasty sinus infection. Right now, it’s not my back that is broken but my heart.

Victory
I have fought hard and long to get my ADR surgery approved and covered by my insurance carrier, Blue Cross Blue Shield (BCBS). At the beginning of my journey, I tried to get pre-authorization in the United States, first in Miami with Dr. Garcia, then Dr. Zigler at the Texas Back Institute. Both of these initial attempts, as well as the peer-to-peer reviews were unsuccessful (the procedure was deemed not medically necessary). I was denied appeal rights in Florida (which I still believe was not legal), and the written appeal through Dr. Zigler was again denied. That is when I paid out-of-pocket and went to Germany to have surgery with Dr. Desai, which has turned out to be the best decision of my life.

Upon my return to the US, I filed an international claim with BCBS for reimbursement. At that point I knew of so many others who got reimbursed for the exact same surgery and disc. But of course, I was denied coverage yet again still on the grounds of the procedure not being “medically necessary”. I filed a written appeal, complete with letter of medical necessity and my medical history, but I was denied again, but this time for the ESP disc not being FDA-approved. I had one last shot: filing an external appeal. I made one last effort, making my case and providing all the evidence I had, and submitted that last year in September. In early October, I received a letter from OPM (Office of Personnel Management), confirming that my appeal has been assigned a case number. Then I didn’t hear back until now .

A few days ago, I received the letter from OPM, stating that the reviewing physician ruled that my lumbar Artificial Disc surgery WAS INDEED medically necessary and an appropriate treatment option for me. I got the Explanation of Benefits from BCBC today, and also received a direct-deposit into my account this morning, covering the majority of my medical bill (but of course not all associated costs). So, later today, I will go to my credit union to pay off the loan I had to take out to finance my surgery in Germany.

I consider this not just a victory for myself, but for all others who seek coverage for ADR surgery. Health insurance is not cheap, and the least they should do is pay for our medical needs when we need it!

Devastation
I have posted about my sweet baby Ponce in the past. Due to a congenital heart defect, he developed severe congestive heart failure that became very evident during the summer of last year. We managed his condition with a sophisticated medication schedule as best we could, and he was such a happy puppy! As his condition progressed, we bought a “Ponce-mobile”, a pet stroller to be able to take him places. We would take him to Menchies’ frozen yogurt to have the sample cup of vanilla ice cream. We sometimes would go to that Italian restaurant close to our home, getting a table outside with Ponce sitting in his stroller, waiting for snacks. Even with that bad hand that nature has dealt him, he was so happy and the best puppy anybody could ever ask for.

Since November last year, we started to carry him up the stairs in our townhome, so his big heart didn’t have to work so hard (he had the tendency to race up the stairs, which wasn’t good for his condition). So, in hindsight, I got to hold him in my arms so many times, and I would give him kisses on the head while walking up the stairs. I would give anything to hold him just one more time.

On Saturday, February 9, 2019, I came home late from my midshift at work. As I was about to walk in, Ralf came out with Ponce on the leash because the puppy was restless. Around that time, Ponce went into significant respiratory distress, panting, coughing, not being able to settle down. At 2 am, we took him to an emergency vet to get a shot of Lasix, a diuretic (“waterpill”) to get the fluids out of his lungs. After all, that was what helped Ponce the last time this happened. But not this time. We didn’t want to leave him at the vet all alone, so we took him home. But he was still struggling to breathe. So, we turned around and took him right back, where he was placed on oxygen. The vet informed us that there is no realistic hope that he would recover again from this, so we had to make that horrible but kind decision. We made our baby a promise that we won’t let him suffer.

Our precious, innocent, sweet Poncebear passed away in peace, in the early morning hours on Sunday, nestled between both of our arms while we talked to him, kissing his little head, petting his fur that was supposed to be groomed the very next day on Monday. Then we had to walk out of that room, having to leave behind our baby laying on his angel blanket on that exam room table, then sitting in the car in front of the vet’s office, having to drive away without my baby in the backseat.

Words cannot describe what I feel right now. I am chocking on tears, re-living this moment, feeling guilty, even though I know it was the right thing to do. I hate coming home, where there is no Poncebear greeting me at the stairs. He left such a huge void, and I hate the thought that he is “out there” until we get his ashes back, hopefully on Thursday or Friday. Then our baby will come home forever. We love you so very much, Poncebear!