Wednesday, August 26, 2009

It Means The End Begins

AM: 7.25 Miles, 43:07, Blvd.
PM: 80 Minutes Ride, 45 Min on Trainer 35 Min Outside

Tonight I enjoyed a few pints of Dogfish Head Ale at Abes. The company was excellent with Max Smith making an appearance and the Ancient Aged Advisor Jay Romasco. Abes has a really nice vibe and we ended up spending many hours discussing running and music. What else is there really? You know the night is good when the bartender plays Wolf Parade "Apologies To Queen Mary" as the background music. Where would you get it? One of the best albums I've heard and here it is ringing out around the empty pub while we get the scoops in. Fantastic.

From a training perspective the day was really good too. I ran an easy 7.25 in the AM and finished with a little lift in my stride. Max brought his bike in the afternoon so we could do a few hours but a couple of delays quashed any opportunity we had of getting in the long ride. We will have to wait for the weekend.

The big news of the day is that Blue Cross Blue Shield of New England has denied to pay for my surgery. I am not going to rant too much about it. Earlier on I was beyond upset. I had to listen to a lot of Amiina to get through the afternoon. They have a new EP out called Re Minore and it is beautiful. This kind of music mellows me out and encourages a more positive outlook.
According to the "experts" at BCBS of New England my Knee Surgery is not a medical necessity.

Services are denied because you did not meet the medical necessity criteria required for coverage of an osteochondral autograft transplantation because you did not have the symptoms of disabling localized knee pain for at least 6 months, which has failed to respond to conservative treatment. The size of the lesion is not documented to be between 1.5 and 2.5 cm squared in total area, the criterion used to guide the decision was BCBS of MA Policy #374 criteria; policy encolsed.

So what they are saying in lay terms is that because I can function in society, ride my bike, walk, swim, and even jog with average pain I do not qualify. My lesion is about 1cm so slightly smaller than the required minimum. Furthermore I am high risk based on the policy because I do not have an intact meniscus and I have "wear and tear from years of overuse". The doctor is one of the best and has made it clear that if I ever want to run at a high level again or if I want to compete in events such as the marathon I may have to get this procedure done or else I will be limited to using pain as a guide of how much I can run. Not being cocky but I am not the average person. I am a serious runner but there is no distinction and after a shouting match with a lady on the phone I was told that they make no distinction between serious athletes and regular sedentary persons. So I said, I could be an overweight, high risk patient who has a defect because I am fat and the surgery would be covered but because I am fit and very healthy I do not qualify. And she said that because I run so much I am considered high risk. So runners are basically considered the same as obese people in the eyes of the healthcare companies. Finally she said that I am more than welcome to pay for the operation if I deem it necessary. I think she was being condescending but I'll give her the beneift of the doubt. She was nice and was following rules. Think outside the box for 30 seconds? No, that would be too much to ask for.

I am going to follow up with the Doc tomorrow or Friday so I should have a new plan in place. Right now it is to start training and tolerate the pain. If the legion gets worse then maybe I'll get it covered. I ain't giving up hope.

I just got the new Asobi Seksu - Transparance. Looking forward to hearing it.

Here is some Amiina Live, with one of the tracks off the new EP.

Love Kel --


  1. I bet you could tear it another .5cm to make it fall into their guidelines.

  2. Wow, that's just one more reason to dislike the state of health care in this country. Sorry to hear it, man. Good luck - hopefully the slate of good runs lately is a sign that things are improving and this is just there to prevent what is hopefully an unnecessary surgery no matter what you've been told. (Let's hope.)

  3. Wow. This is a poster-example of what is wrong with US health insurance. I had meniscus surgery a few years ago and the health insurance tried about five ways to avoid paying for it. Finally they did though - my magic was going through all the PT recommended pre-surgery. If you can survive the 6 months they note it should improve in (I know, I know... it won't) maybe then they will. Good luck getting back to healthy again! Fingers crossed for you!

  4. I'm with Matt, you've gotta find a way to make that sucker grow. Also, I could be mistaken, but I do believe that would be covered in Canada. Even from a purely financial point of view, isn't your OVERALL healthy lifestyle going to save them money on your care in the long run? Talk about short-sighted.

  5. O crap Keith, I'm just looking at your blog today, trying to get caught back up with how you Providence peeps are doing, and this post just breaks my heart. Yes, this is a major part of what is wrong with health care in the U.S.
    I am hoping that with the conservative training you are doing that you're able to eventually heal enough to push hard again (stranger things have happened). If, 6 months from now, you are again denied surgery and have made no headway in getting it paid for, let me be the first to sign on to help out with whatever fund raising events could happen that could help to raise money and get you the procedures you need to be able to continue to pursue your running career.
    take care,