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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

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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.

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