Many of the permanent impairment assessments undertaken by plastic surgeons appointed as medical assessors have involved what appear to be minor skin injuries such as minor lacerations, abrasions and scarring. Often there is limited evidence on file, or evidence suggests the injured person has sustained only a minor skin injury. In many of these matters there is also no evidence to indicate that the injured person has sought or undertaken any plastic surgery or other treatment for the skin injury.
Some of these assessments may be undertaken by a non-plastics medical assessor* in conjunction with their assessment of other injuries, provided the skin injuries meet the criteria for assessment by a non-plastics medical assessor and the they have undergone appropriate training in regard to the assessment of minor skin injuries.
It is anticipated that these non-plastic medical assessors will assess only minor skin injuries with the proviso that they may refer more complex and/or serious skin injuries to the specialist/plastic surgeon medical assessor.
* Non-plastic medical assessors are those medical assessors who do not possess formal training in the specialty of plastic surgery, but have successfully completed training and been approved by the State Insurance Regulatory Authority (SIRA) in the assessment of minor skin injuries.
Protocol for the assessment of minor skin injuries
This protocol applies to disputes where a skin injury, such as scarring, has been listed by the parties to be assessed.
1. Receipt of application
SIRA may seek clarification and further information from the parties if a skin injury is listed and:
- the parties have not indicated the site or sites of the skin injury. If the parties do not respond, the skin injury may not proceed to assessment
- photographs have not been provided and there is no documentation on file to support a skin injury. Photographs may be requested to determine whether the skin injury meets the criteria for assessment by a non-plastics medical assessor. If the parties do not respond, the skin injury will be assessed by a non-plastic medical assessor provided the site or sites have been identified and there are other injuries which that medical assessor would normally also assess
- if the requested information has been provided and/or no clarification was required, SIRA will review the file to determine whether the skin injuries are referred to a plastic surgeon, non-plastic medical assessor or dermatologist.
Skin injuries which should be referred to a plastic surgeon or dermatologist for assessment
If at the preliminary assessment stage the file reveals any of the following, the skin injury should be referred to a medical assessor who is a plastic surgeon or dermatologist for assessment:
- if the dispute is a treatment dispute – i.e. surgical intervention or treatment of the skin injury
- a treating plastic surgeon report has been submitted by the parties indicating the skin injury is not a minor injury
- medical/hospital notes indicate intervention by a plastic surgeon and/or plastic surgery treatment has been undertaken
- the skin injury has been submitted as the sole injury to be assessed
- the further assessment is lodged on the basis that the skin injury is capable of altering the outcome of the previous assessment
- the injury involves facial scarring (unless photos submitted indicate minimal scarring e.g. under hairline)
- medical reports in the file indicate that there is limitation to activities of daily living (ADLs) as a result of the skin injury and intermittent/constant treatment is required (Class 2)
- further treatment or intervention by a plastic surgeon is anticipated but not planned
- the skin injury has caused joint contracture
- there is uncertainty about the extent or seriousness of the skin injury
- the skin injury involves significant fat necrosis or significant scarring of the breast
- the injured person is a child.
Note: If there is documentation on file that the injured person has sustained a skin injury but no photographs have been provided, the matter can still be referred to a plastic surgeon if any of the above criteria are met.
Skin injuries which may be referred to a non-plastic medical assessor for assessment
The skin injury may be referred to a medical assessor approved to assess minor skin injuries if the file reveals any of the following:
- no documentation on file that the injured person has sought treatment or has been referred to a plastic surgeon (photographs should be provided)
- minor lacerations, abrasions and scarring have been listed, particularly when there is no documentation on file to suggest the injured person has sustained a skin injury
- minor surgical scarring such as due to arthroscopy (if there is any uncertainty about the extent or seriousness of the scar, the non-plastic medical assessor can refer the matter back for reallocation.
2. Allocation to the medical assessor
The parties will be advised of the appointment and details of the referral provided. If at assessment the non-plastic medical assessor believes the skin injury would be best assessed by a plastic surgeon or dermatologist, they should indicate this to SIRA in the agreed manner. The skin injury will then be referred to a plastic surgeon/dermatologist medical assessor for assessment. Non-plastic medical assessors are to refer back to SIRA any scarring which is greater than 4% WPI or outside their area of expertise.
3. If either party believes the matter should be referred to a plastic surgeon or dermatologist for assessment
Either party should contact SIRA and provide reasons and/or supporting documentation as outlined above.
4. The table for the evaluation of minor skin impairment (TEMSKI)
The TEMSKI is an extension of table 2 (page 280, American Medical Association’s Guides to the Evaluation of Permanent Impairment (Fourth Edition). The TEMSKI divides class 1 into five categories of impairment. When a medical assessor determines a skin disorder falls into class 1, they must assess the skin disorder in accordance with the TEMSKI criteria. The medical assessor must evaluate all scars either individually or collectively with reference to the five criteria and 10 descriptors of the TEMSKI. The medical assessor should address all the descriptors.