Options for refund?
 

I recently purchased a return flight for my wife using my CSR (CLT to MKE) for late July. We used points to book through the portal with AA (ticket was ~$423). I don't have any status with AA. She's unable to make this flight now after throwing out her back and having a appointment with the surgeon booked for the flight date.

What are my options for any sort of refund or regaining value?

Pay the $200 AA cancellation fee and get back the remaining $223?
Plead my case to AA?
Where would a refund go? Back on as points to the CSR?
Does the CSR offer any travel protection here?

Yes.

Begin by reading the Wikipost at the top of this thread:

https://www.flyertalk.com/forum/chas...-comments.html

...then read the benefits guide for your card to see if you can validate the Wikipost summary, and come back if you have specific questions based on reading both.

Definitely pursue travel protection. As you alluded, without credit card protections, your best option is to cancel the itinerary and use the value (less $200+) towards another flight.

Thanks Mia ... that wiki was helpful.
Specific questions:
1-It looks like I need to cancel the flight with AA. If so, would a pro-rated amount go back on the CSR as points?
2-Do I then request the $200 AA cancellation fee through the cancellation process?

If you have a documented medical issue that precludes flying a nonrefundable ticket, many airlines will waive change fees and--depending on how long you are precluded from flying--even refund your flight. Call the airline.