Impaired function is a workable test that neither general answer offers

The argument

A second argument offered for this position identifies a criterion that does not depend on how a condition arose. Proponents point out that some conditions usually classed as cosmetic also impair function in ways a clinician can observe: tissue that obstructs vision, that causes pain, chafing or recurrent infection, that interferes with eating, breathing or speech, or that prevents the use of a limb. Where that is so, the case for treatment can be made in the ordinary terms medicine uses for everything else, without anyone having to adjudicate how a patient feels about their appearance. The argument is that this test is attractive precisely because it is modest. It can be applied by examination rather than by interview, it is comparatively hard to manipulate, and it produces decisions that can be explained to the person refused as well as the person approved. Proponents argue that it also captures many of the cases that make the blanket exclusion look unreasonable, since a good number of procedures that attract the cosmetic label are sought by patients with a functional complaint, and that it does so without opening coverage to procedures where no such complaint exists. Holders of the view conclude that the demand for a single answer is itself the error. Taken together with the restoration criterion, the functional test yields a workable position: fund where there is impairment or unchosen disfigurement, decline where there is neither, and decide the cases near the boundary individually. Proponents note that this is how coverage is determined in every other area of medicine, where categories are guides and clinical judgement settles particular cases, and argue that there is no reason this field should be the exception.

Premises

Counter-arguments

Opponents argue that a functional test does far less than it appears to. Functional complaints are easy to acquire and easy to describe, so a criterion that rewards them creates an incentive to present a wish as an impairment, and clinicians asked to confirm such complaints are not well placed to refuse. Others argue the test is too narrow rather than too loose, since it funds the patient whose condition happens to obstruct something and refuses the patient equally affected in every other respect, which reintroduces arbitrariness at a different point. Several add that case by case judgement is slow, inconsistent between assessors and effectively unappealable.

Rejecting the premises

[Rejecting P2] Functional complaints are easy to describe and hard to disconfirm, so a criterion that rewards them creates an incentive to present a wish as an impairment. [Rejecting P3] Case by case judgement in other areas of medicine is slow, inconsistent between assessors and in practice difficult to appeal. [Rejecting C] The test funds the patient whose condition happens to obstruct something and refuses one equally affected in every other respect, which reintroduces arbitrariness at a different point.