The Appeal

To whom it may concern:

I am writing to appeal your decision to deny authorization for laparoscopic adjustable gastric band surgery, a decision which was made in February 2008. It is acknowledged that weight-loss surgeries are currently excluded under my insurance plan. However, this surgery is medically necessary to treat my case of Obstructive Sleep Apnea (OSA). I implore you to reconsider coverage for the reasons below.

I have been fighting OSA for nearly my entire adult life. Over the last 12 years I’ve endured excessive daytime sleepiness, fallen into deep depression, nearly died one night when I stopped breathing for an extended period of time during sleep, missed countless hours of work, and suffered through relentless side effects. These include depression, memory loss, mental dullness, sleep paralysis, general fatigue, restlessness, dizziness, numbness in my upper body, morning headaches, mood swings, panic attacks and general lack of motivation.

My sleep apnea has been maddeningly resistant to a myriad of treatments. I’ve had 12 overnight sleep studies since 1996. Each time, doctors have prescribed treatment, which I have followed carefully, but in the end have been ineffective. I have undergone four surgeries in attempt to open my airways:

• Tonsillectomy/Adenoidectomy in 1996
• Uvulapalatopharyngoplasty (UPPP) in 1997
• (Repeat) Adenoidectomy in 2003
• Sinus surgery in 2007 (cauterization of turbinates, removal of scar tissue and clearing of sinuses)

In addition, I’ve tried four different CPAP and BiPAP devices; tried 15 different CPAP masks; tried countless combinations of CPAP air pressures, both heated and non-heated humidifiers; chin straps; embarked on exercise and eating regimens; gone through repeated CPAP mask desensitizations; tried three different adjustable mandibular advancement devices; tried two different tongue restraint devices; and taken two years of allergy shots in attempt to improve my breathing. With my current BiPAP device, I’m using the maximum air pressure available (25 cm H2O, which is extremely high) and still have not had relief. I’ve taken various prescriptions in attempt to mitigate the effects of sleep apnea and improve my breathing. (Currently I am taking Provigil, Paxil, Nasonex and Claritin daily; and Albuterol as needed.)

I have family history of stroke. As you know, OSA dramatically increases the chances of having a heart attack or stroke. On several occasions this year, I have felt as if blood was not circulating properly to my head. On one occasion I nearly passed-out. On another occasion, I fell asleep on my keyboard at work. In 2007 I had five episodes of sleep paralysis, during which I was alert to my surroundings, but unable to move my body.

In the space of just 6 years I gained 100 pounds. I’ve made repeated attempts to lose weight, including two periods supervised by medical professionals. Each time, I lost some weight, but it rebounded within months, and I gained more.

Over the same period of time I have missed approximately 500 hours of work, and spent approximately $30,000 on various treatments, devices, medications and copays. (Similarly, my medical insurers have already paid-out over $150,000 in sleep apnea-related medical bills for me; a large portion of those were paid by your company.) It’s become agonizingly clear to me that devices, prescriptions and diets are wholly insufficient to treat my severe OSA.

Obstructive Sleep Apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness. According to my most recent sleep study a few months ago, I have 120 apnea/hypopnea episodes per hour; quite literally I can’t even sleep for 30 seconds without stopping breathing. (After my last surgery, the doctor insisted I stay in the hospital overnight because my apnea was so bad.) I am over 100 pounds overweight, I have a BMI of 45, and I score 14 on the Epworth Sleepiness Scale, which is considered dangerous. As you can imagine, I’m at extremely high risk for some very big health problems.

As my condition has grown worse, I have had several episodes where I wake-up choking. My significant-other has witnessed events where I stop breathing for long periods of time. When I lay down to go to sleep, I sometimes really do wonder if it will be for the last time.

My doctors have advised me that I should have weight loss surgery, since we’ve exhausted all other possible treatments (other than tracheotomy). These doctors include Dr. xxxxx, MD (my family doctor), Dr. xxxxx, MD (ENT specialist and surgeon), Dr. xxxxx, MD (sleep specialist), Dr. xxxxx, DMD (sleep dentist) and Dr. xxxxx, MD (gastric surgeon), and they consider the surgery medically necessary to treat my condition. Over the long term, weight loss surgery has a significantly higher success rate than eating/exercise regimens alone. By losing the weight, the layers of fat in my throat will shrink, thereby clearing my airways. This is my only hope of escaping the stranglehold that OSA has had on my life.

I fully understand that under my policy, gastric surgeries are normally not covered as treatment… at least, not for morbid obesity. However I would respectfully ask you to please consider it as treatment for severe and otherwise un-treatable Obstructive Sleep Apnea. We’ve exhausted all other options, and I’m barely able to function. Without the surgery, I fear I will be stuck in an endless cycle of failed attempts to lose weight, risking stroke, losing more work, taking endless prescriptions and aimlessly trying variations on treatments that just don’t work for me.

I am certain that by covering the cost of the Lap Band procedure, your company would save a lot more money down the road. If left untreated, my condition may require even more complex and costly treatment in the future.

I have included a few documents with this letter, notably a letter from my first diagnosis in 1996, as well as the current surgery authorization request from Dr. xxxxx. I am happy to furnish any additional documentation that you may require, including medical records, doctor letters, sleep studies, weight histories, receipts, etc. Please let me know if any additional information will be helpful to my request. I can be reached any time at (xxx) xxx-xxxx (cell/home/work).

Thank you for your immediate attention to this matter.

Sincerely,

Michael _____,
Subscriber # __________

A little dramatic? Yes, but it’s all true.

My intention here is not to demonize the insurance company. They actually offer packages that cover the surgery, but last year my employer elected not to spend the additional funds required. In any case, I’m still waiting to hear back if they’ll cover the procedure. But I’m going to have the surgery done, no matter what.

Why weight?

Why am I so focused on the weight? And why am I bringing it up again now?

It has nothing to do with vanity, and everything to do with my health.

My sleep apnea is out of control. My CPAP (technically it’s a BiPAP) is not enough, even though I’m at maximum pressure. I can’t stay awake long enough to do much work; when I don’t work, I don’t get paid. I’ve probably lost about $7,000 since November because I’ve missed work. I’ve already missed three days this week. (For the record: my boss knows what’s up. He’s been completely supportive, but acknowledges my performance at work has suffered greatly.)

I’m drained. I’m not motivated. I’m sleepy. My head is fuzzy. I’m moody. I can’t get anything done.

I’ve managed to keep it somewhat hidden from the view of my friends… usually I accomplish this by staying in my cave when it’s really bad. And I’m usually pretty good at putting-on the brave face.

I’ve also been using prescription medications to help, notably Provigil, a stimulant that is also used by narcoleptics to keep from falling asleep. It’s been helpful, and keeps me alert in certain situations. But I know it’s a crutch, and it can never replace the lost sleep, the lost oxygen, the lost productivity.

The only person who has seen the whole, unfettered drama is Matt. He’s been wonderful and supportive and understanding. But still, my health has put a heavy strain on our relationship and our friendship.

Why is weight so important with apnea? It has very little to do with the beer belly. Instead, my airway is constricted by layers of fat (in my throat, near my soft palate, etc.)

After a myriad of treatments, surgeries, prescriptions, devices and therapies, my doctors have left me with some options:

• Get a jaw restructuring surgery. They break the jaw and reposition it forward, then re-fuse it. 15 weeks recovery time, during which my jaw would be wired-shut. The most common side-effect afterwards, is feeling numbness on the face.
• Get a tracheotomy. (I’m not kidding.)
• Have weight loss surgery (gastric bypass or Lap Band.)
• Continue fumbling, as I have been for the last few years, with other treatments, try different CPAP masks, and try to lose weight myself. (The charts say I’m 176 pounds overweight, but my doctor thinks it’s more like 100 pounds.)

These options are not new. I’ve known about most of them for several years.

The weight loss surgery, in particular, I’ve been considering for a long time; I first began researching it in 2005.

I’ve decided to do it.

I’ll be posting a lot more on the topic very soon.

Swimming in the Serotonin Sea

Photo by rsconnett on Flickr.

Beautiful.

From the artist:

“Even though I be a fish, living for the sake of being alive and no more.“

“Even though at any moment I might be eaten up by something I have no understanding of.”

A different kind of coming-out

Wow, there have been a lot of great coming-out posts today!

So here goes mine.

I take an antidepressant called Paxil.

The word “depression” carries a palpable stigma with it. It’s a condition that very few people discuss in public, yet it affects 7 to 18% of the population (or more) at some point in their life.

Symptoms differ from person to person. For me, I get to where I feel unmotivated, hypersensitive, hopeless, isolated, and in general lose interest in things.

For some, it’s a lifelong struggle. For others (like me), it’s a phase. There have been two phases in my life where I’ve experienced depression. (I’m in one of those phases now.)

It’s no coincidence that these phases correspond to the times in my life where I have had severe sleeping problems… mostly sleep apnea, but with a bit of insomnia thrown in. As one doctor said it, “there’s one sure way to drive a person insane, and that’s to deprive him of his sleep.” (It’s no wonder that sleep deprivation is used a method of torture.) Thankfully I do eventually get to sleep, but it’s still disruptive and my oxygen levels are wholly insufficient. I function, but I am always drained.

I recognize that the pill is something of a crutch. I realize that I need to attack the problem at its source. But if you’ve followed my blog at all, you know that my case of sleep apnea is severe… and maddeningly resistant to the treatments we’ve tried. We’ve still got a few things left to investigate, though, and I hope we find something that will sustainably improve things.

In the meantime, Paxil has helped me. I probably won’t need it forever. But it keeps me out of the pit of despair. It helps me lead a productive life, and dramatically reduces the periods of sadness and lethargy.

Depression can be caused by many things: neurological issues, genetic predisposition, certain medical conditions, poor sleep and pregnancy can trigger it. (Or exacerbate it, or make you more susceptible.) Or it can be caused by life experiences such as stress, trauma, personal loss, emotional issues, etc.

People can experience one or more of these types of symptoms:

• Sadness, emptiness, general loss of interest or pleasure, change in appetite, weight change, sleep issues, fatigue, guilt, nervousness, helplessness, hopelessness, worthlessness, isolation, loneliness, anxiety, trouble concentrating, focus, inability to make decisions, thoughts of death, decrease in self-esteem, periods of sobbing, aggression, irritability, avoiding social situations, excessive procrastination, withdrawal.

Sometimes, these things are obvious… but not always. You may want to confide in a trusted friend and ask if they’ve observed these factors.

Certainly we all go through periods of sadness. We all have bad days. And it’s perfectly healthy to mourn a great loss. But if things don’t improve over time, it’s important to do something. It can be a difficult first step. But it’s not so horrible to admit to yourself. This thing happens, and you are not alone.

For some, therapy can be very helpful. Others deal with depression with supplements and exercise. Still others report that the symptoms fade over time. A prescription can also be considered.

They say that antidepressants are over-prescribed. And I believe they are right. When I first saw a therapist about my problems, she prescribed an antidepressant after chatting with me for only about 15 minutes. I refused to take it, and then asked to see a new therapist. I really felt (and still feel) that other options should at least be considered first. Perhaps there are emotional issues that need to be addressed.

Conversely, I think that sometimes people refuse antidepressants, when they can offer real and remarkable relief. Especially after other avenues have been exhausted. I am here to tell you that there are situations where depression is simply a question of messed-up body chemistry. My sleep deprivation is an example of that. Deny your body (and brain) sufficient oxygen and rest… no wonder things go out of whack. The proverbial “chemical imbalance” is a very real thing. It took me a long time to learn that.

Think of your car. If you deprive it of fluids (brake, steering, transmission, oil, gas), it doesn’t work so well, does it?

Prescriptions carry side effects and potential withdrawal effects. But like any decision in life, you’ve got to compare the benefits to the drawbacks.

Some people say that antidepressants are “mind-altering drugs” and should therefore be avoided. But let us not forget that depression itself is mind-altering… and debilitating. I recently posted a link to an interesting article about a study that finds depression does more damage to your body than asthma, angina, arthritis and diabetes.

The antidepressant has helped me get through life and I do not regret the decision to utilize it. And I look forward toa time when I won’t need it anymore.

If you are having feelings of depression, I urge you to talk to your doctor about it. Some employers offer an Employee Assistance Program (EAP), usually with a confidential toll-free phone number you can call to talk with someone. In many cases, appointments can be made at little or no cost.

It is hard to gather-up the courage to take the first step. But regardless of the causes, there are options out there. You are not alone.

Please. Take the next step.

About…

In my last entry, I posted lyrics from a song that I like. The words always resonated with me. I was browsing through some Flickr photographs (from people I don’t know) and found that particular photo really lent itself to the spirit of the song.

The post was not intended to imply that I want to physically move… rather, I was relating the words to something that’s been on my mind a lot…

• “Every morning comes too soon” (I’m not sleeping… every morning I wake-up feeling like I’ve been hit by a truck.)
• “Poison arrows” (There are things that are keeping me from getting better.)
• “Should I pack my fear and go?” (I need to get my shit together and do something about my health.)

The lyrics also remind me of a time in my life where I actually did “pack my fear and go.”

Anyways… no I’m not actually fixin’ to go anywhere

The song, by the way, is called Smalltown and it’s by the band Chumbawamba. (Yes, that Chumbawamba.) I totally love the vibe of the song, too.

In other news, I am reading Brave New World and I am really diggin’ it.

Ethereal Highway

(Disclaimer: not my photo, and not my verse.)

Click photo above, or see shadeshots‘ Flickr photos.

And every morning comes too soon
All your nights are sleepless
Poison arrows
To ruin your tomorrows

Below suspicion
Cafés full of people dressed as spies

And all I know
Is guilt for being different

It’s always raining stones
There’s a killer in the home

In a small town
Everybody looks the same

There are unwritten rules
Unspoken words

Should I pack my fear and go?

I have to leave somehow
Before they run me out of town
I have to leave somehow…

Should I pack my fear and go?

One year… and making the change.

One year ago, February 1st, 2005. I arrived in San Diego with just one suitcase. It contained a few days-worth of clothes, an Aerobed, a laptop, and a cable modem. Seriously. This was my survival kit until the moving van arrived from Connecticut.

The move was several years in the making. There were points where I thought it might not happen. But it did, and it has been amazing.

Moving here has brought just exactly the change of pace, change of scenery, change of routine that I was looking for. The job transfer couldn’t have been more perfect… though it was a gamble, in retrospect it was a smart decision.

I miss some of my friends back in the Northeast, most notably Nick & Rob. Other than missing them and a few other friends, I don’t miss Connecticut much at all.

Though I don’t talk about it much, there was another reason why I needed to leave Connecticut. To call my move “an escape” is probably appropriate. I truly believe that I was subject to a condition called Seasonal Affective Disorder. (Uggh… I hate labels, much less slapping the “disorder” or “syndrome” onto things as nebulous as one’s mood.) For those of you not familiar with the term, this is a situation where during winter months you have symptoms of depression. Ever the skeptic, I fought the idea that a mere shortage of sunlight could affect my mood so much. And on a higher level, I despised the idea that my own well-being could be drained by a stupid change in the weather.

But over time I came to realize that I had all the symptoms. Though I was never formally diagnosed, I know that it was real. During the winter seasons, I became a hermit (moreso than usual!) and just felt down all the time, and for no apparent reason. The winters of 2002 and 2003 were the most difficult, and it got to the point where I was dreading winter several months before it even got cold.

I tried various means to counteract the effects… I tried to spend time outside when it was sunny, added lots of light at home. (It certainly didn’t help that all my computer geek co-workers preferred to work with the office lights low.) I even stopped wearing sunglasses, even on bright days. (Scientists have shown a direct link between detected light and mood, which I am convinced is true).

Certainly there were other factors at play. I’m sure that my ongoing sleep apnea and my weight were contributors to the situation.

I didn’t really tell anyone I was feeling down, but I was pretty free and blunt about hating winters. Some people told me I hated winter because I was raised in California. While I don’t argue that this could have been an influence… I do not believe that this is the sole explanation for my symptoms. After all… there are plenty of people who move to colder climates (or rather, locations where the sun shines less, or days are shorter) and don’t have a problem with it.

But clearly I did.

One year later, I reflect on the move and today I suddenly realized: I just got through my first full winter without the struggle that I’d been going through each winter for nearly 8 years. And I am excited about it.

Some people will say that you should be happy, no matter where you are. Whether it be difficulties at home, a bad job, a city you don’t like, or a medical condition… you should always make the best of it, and try to be happy in any situation. But I don’t believe this is always true, and maybe the suggestion is too altruistic. Sometimes there are situations that are bigger than you… and no matter what attitude you adopt, things don’t get better. To people who are stuck in the rut, I say… move on… there are better roads to travel. Life is short. Don’t sit and suffer. Do what makes you happy. (This is not the same as being selfish.)

(Exceptions: there are some people who try to blame their troubles on something else, to escape responsibility for their own actions. There are others who never seem to be satisfied, no matter what happens. In these cases, “moving-on” is not going to make things better.)

But if you’re in a situation where you know you’re not happy… where you dream of escape… where you know there is a better future… MAKE THE CHANGE. And don’t look back.

Open the sunroof

Open the sunroof. Thankfully, it opens all the way this time. I look out and see if there are any stars. Not dark enough yet. Still it’s beautiful, a very deep blue clear sky… pierced every few seconds by the flash of a street light. Doing 65 mph, I figure out the timing and blink my eyes shut to miss each of them.

Moby:18:Fireworks. Play this song at night when you’re feeling lonely.

“You look tired,” he said to me an hour ago. “Yep.” I replied. A few minutes later he said it again. How else did he WANT me to reply? SIGH I didn’t try very hard to convince him otherwise. Was I wearing my feelings on my shoulder? Nah. Just too tired to get into it.

God. Whatever chemical it is that has gone missing from my body… I’ll pay handsomely for it.

And how does one explain to his supervisor the reason why he didn’t work 40 hours this week? I’m damn lucky. What if I worked somewhere where they weren’t so understanding?

I wish I could just sleep-in tomorrow. And the day after that. In fact… if the world stopped for about 2 weeks. I’ll bet I could catch up.