Subverting criteria: The role of precedent in decisions to finance surgery

Abstract

This paper investigates prospective utilisation review for tympanostomy. In the studied procedure, a medical corporation reviews cases for third-party payers (insurance companies), and used explicit criteria to determine whether a case is appropriate for surgery. Earlier findings that inappropriate decisions to approve surgery are strongly related to previous surgeries for the same condition are investigated to trace the emergence of this theme within the review process and its consolidation into a 'precedent' for further surgery, notwithstanding the explicit criteria which the reviewers are mandated to enforce. The significance of previous surgeries as a factor favouring further surgery emerges at all levels of the review process, indicating a medical culture that validates precedent in medical decision making despite the absence of evidence-based findings that would support it.