[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.205.111.118. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Article
December 1990

Does Anyone Know How to Differentiate a 'Functional' Defect From a Cosmetic One?

Author Affiliations

Salt Lake City, Utah; Galveston, Tex

Arch Ophthalmol. 1990;108(12):1685-1686. doi:10.1001/archopht.1990.01070140039024

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.

Abstract

With the recent changes in medicine and reimbursement, it is important for physicians to differentiate cosmetic from functionally debilitating (functional) problems. In the past, most insurance companies covered surgery for functional problems. Physicians are now being placed between the proverbial rock and a hard place by patients who are accustomed to superior medical care and by insurance carriers cutting costs by rejecting claims on grounds that the surgery is cosmetic in nature and not functional.

Some insurance, such as Medicare, will not preauthorize surgery. However, if they later determine the surgery was cosmetic, the physician is not reimbursed. The physician may even be fined for charging if the patient was not informed that the claim might be rejected, even though there are no definitive criteria for what is judged cosmetic or functional. These rules limit care and create anxiety for both patients and physicians, thereby discouraging both parties from treatment.

References
1.
Meyer DR, Linberg JV, Powell SR, Odum JV.  Quantitating the superior visual field loss associated with ptosis . Arch Ophthalmol . 1989;107:840-843.Article
2.
American Medical Association. Guides to Evaluation of Permanent Impairment . 2nd ed. Chicago, Ill: American Medical Association; 1984.
3.
Cahill KV, Burns JA, Weber PA.  The effect of blepharoptosis on the field of vision . Ophthalmic Plast Reconstr Surg . 1987;3:121-127.Article
4.
Anderson RL, Baumgartner SA.  Amblyopia in ptosis . Arch Ophthalmol . 1980;98:1068-1069.Article
5.
Putterman AM.  Evaluation of the cosmetic oculoplastic surgery patient . In: Putterman A, ed. Cosmetic Oculoplastic Surgery . New York, NY: Grune & Stratton; 1982:18-19.
×