A review of selection criteria used by medical scheme advisers to approve or deny procedures with a cosmetic component

Objective. To review and apply statistical tests to the selection criteria used by two medical advisers to approve or deny applications for three common cosmetic or reconstructive procedures within a large group of medical schemes.Design. A retrospective descriptive study which applied multiple regression analysis, frequency analysis, comparison of means and simple correlations to the data sets for three procedures.Setting. Administrative records from the clinical files of medical advisers and the administrator's claims database.Subjects. Data were reviewed for 1 143 members who, between January and December 1996, submitted applications for breast reduction, excimer laser refractive surgery, or otoplasty.Main outcome measures. The primary outcome measure was the statistical relationship between medical advisers' selection criteria and final decision. In addition, the financial implications of these cosmetic/reconstructive procedures were assessed.Results. For the three procedures reviewed there was a statistically significant relationship behveen 5 of 13 preoperative criteria requested and the medical advisers' opinion. Excimer laser surgery was generally approved on the basis of the refractive error (myopia> -3.00; astigmatism > -1.5 dioptres); otoplasty was generally approved for children aged :≤ 12.years; and breast reduction was usually covered for women with a sternal-nipple distance > 29.0 cm and with a cup size ≥ DD. The other data submitted were similarly distributed between the approved and denied groups.Conclusions. Review of medical advisers' decisions is important in an era of protocols, guidelines and 'standard operating procedures'. Selection criteria for approval of applications for medically necesssary cosmetic/reconstructive surgery must be reviewed and revised to provide a reliable, reproducible and statistically valid process