Download Doncaster Prior Approval Schedule.

NHS Doncaster Clinical Commissioning Group
Prior Approval Policy
1st April 2015
Final
1
Content
1. Purpose of this Schedule .......................................................................................................... 3
2. Treatments covered by DCCG Commissioning Policies ........................................................ 3
3. Procedures of Limited Clinical Value........................................................................................ 3
4. Principles..................................................................................................................................... 3
5. Process for operating the schedule .......................................................................................... 3
6. Exceptionality ............................................................................................................................. 4
7. Service Developments ............................................................................................................... 5
Appendix 1 Commissioner Exceptional Treatment Request/Appeal Contact Points ............... 6
Appendix 2 List of Treatments and Services Requiring Prior Approval .................................... 7
2
1.
Purpose of this Schedule
This schedule describes cost per case arrangements for NHS Doncaster CCG (DCCG) and
is subject to annual Public Health Reviews.
This schedule should be used by the provider to determine the procedures that NHS
Doncaster CCG has either not commissioned and will not pay for, or procedures that NHS
Doncaster CCG has deemed of limited clinical value. The schedule also outlines the process
for securing prior approval.
2.
Treatments covered by DCCG Commissioning Policies
The general NHS Doncaster commissioning policy is that treatments included in established
care pathways (as identified for example in the Schedules to the service agreements with
providers) are routinely funded.
Procedures of limited clinical value will be commissioned according to this schedule.
All other procedures are not routinely commissioned.
Procedures that are not commissioned by the CCG should not be carried out by providers
and if they are, the provider will not be paid for them.
For a number of these interventions the CCG has published specific policy statements
setting out restrictions on access based evidence of effectiveness or relative priority for
funding. These are available at http://www.doncasterccg.nhs.uk/1087/clinical-policies/
3.
Procedures of Limited Clinical Value
Procedures of limited clinical value are those that deliver a relatively poor output/outcome to
the population. This schedule sets out those procedures of limited clinical value that are not
routinely commissioned or only commissioned when certain criteria are met.
This policy also sets out procedures which may be effective but where there may be
significant difference in value depending on the setting in which the procedure is delivered.
4.
Principles
CCG commissioning decisions are made in accordance with the commissioning principles
set out in the CCG general policy and Individual funding request policy. These principles
include the need for evidence of clinical effectiveness, cost effectiveness, affordability of
equitable provision and best value for money.
5.
Process for operating the schedule
The prior approval process will operate as follows:
•
If a GP refers for a specific procedure on this schedule they should seek prior
approval before making the referral. Any requests for a specific procedure on this
schedule received by the Provider without prior approval should be returned to the
GP.
•
If a GP refers for an outpatient appointment with no specified procedure the clinician
should see the patient and determine if a procedure is necessary.
3
•
If a procedure is necessary that requires prior approval, the clinician will refer to the
Schedule and determine whether the patient meets the prior approval criteria and
prior approval should be sought from the CCG. The CCG will pay for the outpatient
attendance and the subsequent treatment providing prior approval has been granted.
•
If the patient does not meet the prior approval criteria they should not be treated and
the GP notified. The CCG will pay for the outpatient appointment.
•
If there is any doubt as to whether the patient meets the prior approval criteria, a
request to the CCG should be made, if deemed appropriate by the appropriate
Clinical Director.
•
Where prior approval is required it should be sought from the CCG in advance of the
treatment being provided. All requests should be sent to Individual Funding
Requests, 722 Prince of Wales Road, Sheffield, S9 4EU, or sent electronically to
[email protected] (safehaven) or by safehaven fax to 0114 305 1370
adhering to confidentiality procedures. Request by letter or proforma will be accepted.
Clinicians should include relevant information against exception criteria to enable
decisions to be made on funding request.
For routine requests the CCG will respond within 5 working days, providing all relevant
information is contained within the request. If there is no response then the Trust can go
ahead and list the patient with no future financial penalty.
The CCG reserves the right to audit providers to ensure that prior approval criteria are
adhered to and will expect evidence from providers to that effect.
6.
Exceptionality
The CCG commissions according to the policy criteria. Requests for individual funding can
be made only where exceptional circumstances exist and can be made through NHS
Doncaster’s Individual Funding Request (IFR) procedure.
Responsibility for demonstrating exceptionality rests with the requesting clinician.
Only evidence of clinical need will be taken into consideration. Factors such as gender,
ethnicity, age, lifestyle or other social factors such as employment or parenthood will not be
considered on grounds of equality.
In order to demonstrate exceptionality the patient:
•
Must be significantly different to the population of interest (ie patients with pulmonary
hypertension and/or the subpopulation)
AND
•
Be more likely to benefit from this intervention than might be expected than other patients
with the condition
The fact that the treatment might be efficacious for the patient is not, in itself, grounds for
exceptionality.
If a patient’s clinical condition matches the ‘accepted’ indications for a treatment or situation
which falls outside the commissioning policy the patient is, by definition, not exceptional.
4
7.
Service Developments
The CCG will not introduce new drugs/technologies in an ad hoc basis through the
mechanism of individual case funding. To do so risks inequity, since the treatment will not
be offered openly and equally to all with equal need. There is also the risk that diversion of
resources in this way will de-stabilise other areas of health care which have been identified
as priorities by the CCG.
The CCG expects consideration of new drugs/technologies to take place within the
established planning frameworks of the NHS. This will enable clear prioritisation against
other calls for funding and the development of implementation plans which will allow access
for all patients with equal need.
The CCG is required to achieve financial balance each year and therefore has a default
policy of not funding a treatment where no specific policy exists to approve funding for the
treatment. If the CCG has not previously been asked to fund an intervention that has the
potential to affect a number of patients, the applications should be made by clinicians for the
CCG to consider the intervention through its general commissioning policy and not by way of
an IFR application.
Interventional Procedure Guidance issued by NICE will be deemed by the CCG as a Service
Development and will not be routinely funded by the CCG unless agreed in advance.
5
Appendix 1 Commissioner Exceptional Treatment Request/Appeal Contact Points
Address:
Named Lead:
Job Title:
Phone:
E mail:
Patient information:
Safe haven fax:
722 Prince of Wales Road, Sheffield
Allison Ball
Head of IFR
0114 305 4535
[email protected] (safehaven)
[email protected] (safehaven)
0114 305 1307
6
Appendix 2
List of Treatments and Services Requiring Prior Approval
Speciality
Procedure
Commissioning Position
Homeopathy
Various procedures
Not Routinely Commissioned
AntiTNF’s
AntiTNF’s (Cytokine
Inhibitors) – outside
NICE Guidance
Prior Approval Required for those
patients not meeting the NICE
Guidance. Doncaster CCG does
not routinely commission outside of
NICE Guidance
Open P.V.A. (Pulmonary
Vein Ablation)
Routinely Commissioned for
patients meeting criteria.
Cardiology
OPCS
code
K62
HRG
7
Evidence
Base
Insufficient
high quality
evidence on
the clinical
effectiveness,
cost
effectiveness
and safety of
homeopathic
medicines.
NICE TAG’s
TA126,
TA104
TA141,TA125
TA130,TA35,
TA134,TA146
TA103,TA140
TA163,TA40
TA163
North Trent
Cardiac
Network
commissionin
g position
Monitoring
Contract
monitoring and
clinical audit
Contract
monitoring SLAM
Speciality
Cardiology
OPCS
code
K62
HRG
Procedure
Commissioning Position
Percutaneous P.V.A.
(Pulmonary Vein
Ablation)
Prior Approval Required
Evidence
Base
North Trent
Cardiac
Network
commissionin
g position
Monitoring
Custom Made Prosthesis Prior Approval Required.
Limbs
The CCG will only fund prosthetic
limbs which are available on the
NHS.
Custom Made
Prosthetic
Limbs
Dental
F08
F11.5
Dental
F09.1
F09.3
Dermatology
S069
CZ02S
CZ02T
CZ02W
CZ02Y
JC15Z
JC07Z
Dental Implants
Not Routinely Commissioned
(orthodontics and oral surgery)
Wisdom Teeth Removal
Routinely Commissioned for
patients meeting the NICE criteria.
NICE
TAG001
Routine contract
monitoring
Dermatology Minor
surgery:
Seborrhoeic warts
Molluscum contagiosum
Spider angiomas (thread
veins)
Cherry angiomas or
Campbell de Morgan
spots
Skin Tags and
papillomas
Naevi (moles) and other
benign haemangiomas
Xanthelasma
Lipomas
Sebaceous Cysts
Port Wine stains
Routinely Commissioned for the
Removal of skin lesions causing
functional or symptomatic problems
(itchy, bleeding or catching) and
suspicious lesions.
Adult
cosmetic
surgery and
non-surgical
aesthetic
treatments
policy
Contract
monitoring SLAM
Prior Approval Required
Interventions will normally only be
approved for visible lesions (face and
hands) of a significant size.
Potentially malignant lesions should
be referred under the local two-week
arrangements for cancer patients.
8
Contract
monitoring SLAM
Speciality
Updated
Nov 2011
ENT
OPCS
code
D15
HRG
Procedure
Commissioning Position
Myringotomy/Grommets
Prior Approval Required
Funding for grommets for children
with persistent otitis media with
effusion will be considered for the
following indications:
Otitis media with effusion has
persisted for a three month period of
watchful waiting after diagnosis in
primary care and the child suffers
from one of the following:
- at least five recurrences of
acute otitis media requiring
medical assessment and/or
treatment in the previous
year.
- hearing loss of at least 25dB,
particularly in the lower
tones with either delay in
speech development or
educational/behavioural
problems attributable to the
hearing loss.
- a second significant health
problem or disability, for
example learning difficulties,
developmental delay or
autism, with tympanometric
evidence of middle ear
effusions and where a
reliable hearing test has not
been achieved after three
attempts.
- severe retraction of the
tympanic membrane with risk
of developing cholesteatoma
or erosion of the ossicular
9
Evidence
Base
Monitoring
Contract
monitoring SLAM
But diagnosis
code not E081,
E201, E291, F34
or D191
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
chain.
- suspected underlying
sensorineural hearing loss,
as demonstrated by a single
hearing test with hearing
loss of at least 50dB on pure
tone audiometry or at least
65dB on free field testing
and flat tympanograms.
If the patient does not fully meet
these criteria the clinician may still
submit an application if exceptionality
can be demonstrated.
National supporting evidenceNICE CG 60 Surgical management
of otitis media with effusion February
2008
http://www.nice.org.uk/nicemedia/live
/11928/39564/39564.pdf
NHS England Interim Commissioning
Policy Grommets November 2013
http://www.england.nhs.uk/wpcontent/uploads/2013/11/NSC015.pdf
Adults
Funding for grommets for adults will
be considered for any of the
following indications:
a
middle
ear
effusion
causing
measured
conductive hearing loss of at
least 25 Db, persisting for at
least three months and
causing disability.
persistent Eustachian tube
10
Evidence
Base
Monitoring
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
SIGN
Guidance No.
117
Contract
monitoring SLAM
dysfunction resulting in pain.
as treatment for Meniere’s
disease.
severe retraction of the
tympanic membrane with risk
of developing cholesteatoma
or erosion of the ossicular
chain.
If the patient does not fully meet
these criteria the clinician may still
submit an application if exceptionality
can be demonstrated.
-
National supporting evidenceNHS England Interim Commissioning
Policy Grommets November 2013
http://www.england.nhs.uk/wpcontent/uploads/2013/11/NSC015.pdf
Updated
Nov 2011
ENT
E201
E208
E209
F341
F342
F344
F345
F346
F348
F349
F361
F368
F369
CZ05S
CZ05T
CZ05V
CZ05Y
C57
C58
Tonsillectomy
Prior Approval Required
If the indication for surgery is
suspected malignancy or acute
upper airways obstruction then
prior approval is not required.
Funding for tonsillectomy for both
adults and children will be
considered for the following
indications:
- sore throats are due to
acute tonsillitis and
episodes of sore throat
are disabling and prevent
normal functioning as
11
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
evidenced by three of the
following criteria: tonsillar
exudates, tender anterior
cervical lymph nodes,
history of fever, absence
of cough and
- seven or more well
documented such
episodes in the preceding
year or
- five or more such
episodes in each of the
preceding two years or
- three or more such
episodes in each of the
preceding three years or
- two documented
episodes of quinsy or
- severe halitosis
secondary to tonsillar
crypt debris.
Funding for tonsillectomy for
children will in addition be
considered for the following
indications:
- failure to thrive due to
difficulty eating solid foods
If the patient does not fully meet
these criteria the clinician may
still submit an application if
exceptionality can be
demonstrated.
12
Evidence
Base
Monitoring
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
NICE
IPG 101
Contract
monitoring SLAM
National supporting evidenceSIGN Guidance No 117 April
2010 Management of sore throat
and indications for tonsillectomy
http://www.sign.ac.uk/guidelines/f
ulltext/117/index.html
NHS England Interim Clinical
Commissioning policy for
tonsillectomy November 2013
http://www.england.nhs.uk/wpcontent/uploads/2013/11/NSC033.pdf
•
Updated
Nov 2011
Gastroentero
logy
G802
General
Surgery
L84
L85
L86
L87
L88
FZ15Z
FZ07B
FZ07A
Wireless Capsule
Enteroscopy for
Investigation of the
Small Bowel
Not Routinely Commissioned from
DBHFT
This investigation is commissioned
by the CCG at STHT.
Varicose Veins
Prior Approval or an application for
funding is required for all primary
varicose vein removal.
Patients with bleeding varicose veins
do not need prior approval and can
be referred to a vascular service
immediately.
Conservative management should
be the first line of treatment and
applications will not normally be
accepted for patients whose BMI is
over 30.
Interventional treatment of varicose
veins will only be commissioned for
13
Contract
monitoring SLAM
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
patients aged 18 and over when any
of the following criteria apply:
−
−
−
−
−
skin changes secondary to
chronic venous insufficiency,
for example pigmentation or
venous eczema.
at least two episodes of
superficial thrombophlebitis.
active or healed venous leg
ulcers.
a previous episode of
bleeding from the varicosity.
symptomatic varicose veins
(veins associated with
troublesome symptoms,
typically pain, swelling,
heaviness and aching).
If the patient does not fully meet
these criteria, the clinician may still
submit an application if exceptionality
can be demonstrated.
National supporting evidence:
NICE CG168 The diagnosis and
management of varicose veins July
2013
http://publications.nice.org.uk/varicos
e-veins-in-the-legs-cg168
NHS England Interim clinical
commissioning policy for varicose
veins November 2013
http://www.england.nhs.uk/wpcontent/uploads/2013/11/N-
14
Evidence
Base
Monitoring
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
Routinely commissioned for
patients meeting criteria
Use of Botox described in BNF
section 4.9.3. will continue
Not Routinely Commissioned
CCG policy
Contract
monitoring SLAM
IVF is approved in accordance with
Policy.
Prior Approval if referred via primary
care
NHS
Doncaster
Commissionin
g Policy for
IVF/ICSI
SC035.pdf
Neurology
S53.2
Obstetrics &
Gynaecology
Obstetrics &
Gynaecology
Q29
Q37
Y96
Botulinum Toxin –
Neurology/Spines/Neuro
rehabilitation.
Urology/Ophthalmology
Reversal of Female
Sterilisation
In-vitro fertilisation (IVF)/
Assisted conception
Contract
monitoring SLAM
Contract
monitoring SLAM
Has the new
policy been
through your
Governing
Body
Ophthalmolo
gy
Orthodontics
C46.1
F14
F15
Laser surgery for Short
Sight
Orthodontic treatment
Not Routinely Commissioned
Routinely Commissioned for
patients meeting criteria.
An Index of Orthodontic Treatment
Need of 3.6 or above.
Only patients under the age of 18
years are eligible for routine NHS
orthodontic treatment. These criteria
may be waived where the consultant
clinician considers that there are
exceptional or mitigating
circumstances and prior approval
has been sought from the CCG
15
Contract
monitoring SLAM
Contract
monitoring SLAM
Speciality
OPCS
code
Paediatrics
We are
currently
reviewing
the
plastics
policy
Plastic and
Cosmetic
surgery
S01
Updated
Nov 2011
Plastic and
Cosmetic
surgery
S02
HRG
Procedure
Commissioning Position
Cranial banding for
positional plageocephaly
Not Routinely Commissioned.
Cranial Banding will not be routinely
commissioned. The available
evidence does not show cranial
banding as a treatment for
brachycephaly and positional
plagiocephaly to be effective.
Prior Approval Required
Facelift
Browlift
Abdominoplasty/
apronectomy (tummy
tuck)
Face-lift procedures will only be
commissioned in the presence of an
anatomical abnormality or a
pathological feature, which
significantly affects appearance.
Prior Approval Required
Abdominoplasty may be approved
where the patient
• has lost a significant amount of
weight (moved down two levels of
the BMI SIGN guidance e.g. from
extremely obese to overweight)
and has a stable BMI, which
would normally be below 27 for a
minimum of 2 years, or
•
is experiencing severe difficulties
with daily living i.e. ambulatory
/urological restrictions.
Other factors may be considered.
• recurrent severe infection or
ulceration beneath the skin fold
• significant
abdominal
wall
deformity due to surgical scarring
16
Evidence
Base
Monitoring
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
or trauma.
Updated
Nov 2011
Buttock, thigh and Arm
lift surgery
Prior Approval Required
Plastic and
Cosmetic
surgery
S03
Plastic and
Cosmetic
surgery
S010.3
S011.3
Resurfacing procedures
e.g. Chemical peels to
face
Not Routinely Commissioned
Plastic and
Cosmetic
surgery
B30
B31.2
Breast Augmentation
Prior Approval Required
Buttock, thigh and arm surgery may
be approved if pathological condition
e.g. cutis laxa or severe weight loss
with resulting mechanical problems.
Patients must have attained a stable
BMI (below 25) for a minimum of 2
years.
Breast Augmentation will NOT
routinely be commissioned by the
NHS for cosmetic reasons, small
normal breasts or for breast tissue
involution (including post partum
changes).
It may be approved by the NHS if
BMI 18.5 to 25
Women with a complete absence of
breast tissue (amastia) or absence of
breast tissue unilaterally, or in
women with a significant degree of
asymmetry of breast shape and or
volume. Such situations may arise
17
Contract
monitoring SLAM
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
as a result of;
•
•
•
•
•
•
Previous mastectomy or other
excisional breast surgery
Trauma to the breast during or
after development
Congenital amastia (total failure
of breast development)
Endocrine abnormalities
Developmental disorder.
Transsexual patients who are
receiving feminising hormones for
an adequate length of time as
part of a recognised treatment
programme for gender dysphoria
will only be considered when they
meet the above criteria.
Patients
offered
NHS
breast
augmentation should be encouraged
to participate in the UK national
breast implant registration system
and be fully counselled regarding the
risks and natural history of breast
implants.
Breast augmentation will not be
funded to alleviate psychological
distress.
The NHS will NOT commission the
re-augmentation of breast implants
carried out in the private sector for
aesthetic reasons. The NHS will
NOT normally commission the
removal of implants that have been
18
Evidence
Base
Monitoring
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
implanted in the private sector for
aesthetic purposes.
If revision surgery is being carried
out for implant failure, the decision to
replace the implant rather than
simply remove it should be based on
the clinical need for replacement and
whether the patient meets the policy
for augmentation at the time of
revision.
If the criteria above is met then the
patient will be referred to Nottingham
for a breast scan, for objective
information regarding this request.
3 breast scans will be undertaken.
These are:
•
•
•
BMI
Breast Volume
Breast : Torso Ratio
The patient must pass BMI test and
one other test to be eligible for
funding
Updated
Nov 2011
Plastic and
Cosmetic
surgery
B31
Breast Reduction
Prior Approval Required
Breast reduction procedures will be
commissioned if there is significant
breast hypertrophy with a BMI of less
than 25, for example a DD and
above cup size, AND functional
problems which can be attributed to
the breast hypertrophy in the
19
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
absence of other pathology, with or
without intertrigo.
Functional problems may include
backache and neck ache and other
potential causes should be
considered prior to breast reduction.
If the criteria above is met then the
patient will be referred to Nottingham
for a breast scan, for objective
information regarding this request.
3 breast scans will be undertaken.
These are:
•
•
•
BMI
Breast Volume
Breast : Torso Ratio
The patient must pass all 3 tests to
be eligible for funding
Plastic and
Cosmetic
surgery
B31
Breast Reduction for
male gynaecomastia
Prior Approval Required
Surgery
to
correct
true
gynaecomastia may be allowable if
the BMI is in the normal range (18.525) AND when the reduction to be
obtained will be significant, i.e.
greater than 100g per side
(estimated), or where there is gross
asymmetry.
Individuals who are taking sport
performance-enhancing drugs, in
20
Speciality
Plastic and
Cosmetic
surgery
OPCS
code
HRG
Procedure
Commissioning Position
Breast Asymmetry
whom the gynaecomastia is
potentially drug induced, should be
refused surgery unless such drugs
have not been taken for more than a
year and they meet the criteria
above.
Prior Approval Required
Where there is significant breast
asymmetry of shape and/or volume
(2 or more cup sizes), approval will
normally be given for reduction of the
larger
breast
rather
than
augmentation of the smaller. If the
smaller breast fulfils the criteria for
breast augmentation this will be
considered.
The patient’s BMI must be between
2
18.5 – 25kg/m .
If the criteria above is met then the
patient will be referred to Nottingham
for a breast scan, for objective
information regarding this request.
5 breast scans will be undertaken.
These are:
•
•
•
•
•
BMI
Volume
Nipple to Fold
Areola Diameter
Notch to Nipple
The patient must pass BMI test and
21
Evidence
Base
Monitoring
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
Contract
monitoring SLAM
one other test to be eligible for
funding
Plastic and
Cosmetic
surgery
B31.3
Plastic and
Cosmetic
surgery
B35
Plastic and
Cosmetic
surgery
s60.
Plastic and
Cosmetic
surgery
Breast lift mastopexy
Correction of Nipple
inversion
Hair removal
ICD 10 I68.0
Not Routinely Commissioned
This is included as part of the
treatment of breast asymmetry but
will not be available for purely
cosmetic reasons, for example post
lactation or age related breast ptosis
(drooping).
Prior Approval Required
Nipple inversion may occur as a
result of malignancy and this must be
excluded. Surgical correction of
nipple inversion should only be
available for functional reasons and if
the inversion has not been corrected
by the use of a non invasive suction
device.
Prior Approval Required
Hair removal will NOT normally be
commissioned. Exceptions might
include those who have undergone
reconstructive surgery leading to
abnormally located hair bearing skin
or are undergoing treatment for
pilonoidal sinus to reduce recurrence
risk.
S33
S34
Hair transplantation
Facial laser in severe hirsuitism from
Polycystic Ovarian syndrome
Not Routinely Commissioned
Possible exceptions include
22
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
reconstruction of the eyebrow
following cancer or trauma.
Prior Approval Required
Plastic and
Cosmetic
surgery
S60.1,
s60.4
S60.2
Acne scarring
ICD10 L70
Plastic and
Cosmetic
surgery
C13
Blepharoplasty
Plastic and
Cosmetic
surgery
D06.2
Otoplasty
Earlobe repair in the
absence of traumatic
injury
Plastic and
Cosmetic
surgery
D03
Pinnaplasty
Prior Approval Required
Plastic and
Cosmetic
surgery
E02
Rhinoplasty
Correction of prominent ears will be
commissioned where there are
significant deformities or ear
asymmetry. Referral of patients over
the age of 21 years is usually
considered inappropriate and will not
normally be funded.
Not Routinely Commissioned
Procedures to treat facial acne
scarring will only be commissioned in
severe cases.
Prior Approval Required
Blepharoplasty will be commissioned
for eyelid ptosis and/or excessive
skin of the upper eyelid, which
causes obscured vision. This
excludes lower eyelids, as they do
not obscure vision.
Not Routinely Commissioned
Rhinoplasty is NOT normally
commissioned unless there are
significant functional problems. For
post traumatic airway obstruction, or
significant deviation post trauma
23
Evidence
Base
surgery
procedures
Monitoring
Policy for
specialist
plastic
surgery
procedures
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Contract
monitoring SLAM
Contract
monitoring SLAM
Speciality
Updated
Nov 2011
Updated
Nov 2011
Procedure
Commissioning Position
Plastic and
Cosmetic
surgery
Rhinophyma
Prior Approval Required
Plastic and
Cosmetic
surgery
Revision of Surgical
Scars
Plastic and
Cosmetic
surgery
Plastic and
Cosmetic
surgery
OPCS
code
HRG
The first line treatment of this
condition is medical. Severe cases
or where medical treatment fails
should be considered for surgery or
laser treatment.
Prior Approval Required
Revision surgery for scars following
complications of surgery, keloid
formation or other hypertrophic scar
formation will only be commissioned
where there is significant deformity
or to restore normal function.
S09.2
Congenital vascular
abnormalities
Scar revision for aesthetic
improvement may be commissioned
for the face in exceptional
circumstances.
Prior Approval Required
Interventions will normally only be
approved for visible lesions (face and
hands) of a significant size.
L86.1
(injecti
on)
S09.2
(laser)
S09.1
(head)
Thread
vein/telangectasia
Potentially malignant lesions should
be referred under the local two-week
arrangements for cancer patients.
Not Routinely Commissioned
24
Evidence
Base
Policy for
specialist
plastic
surgery
procedures
Monitoring
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Policy for
specialist
plastic
surgery
procedures
Contract
monitoring SLAM
Contract
monitoring SLAM
Speciality
Plastic and
Cosmetic
surgery
OPCS
code
S60.1
S60.2
S60.3
HRG
Procedure
Commissioning Position
Tattoo removal
ICD10 L81.8
Not Routinely Commissioned
Plastic and
Cosmetic
surgery
P05.5
P05.6
P05.7
Reduction of labia
minora (Labioplasty)
Not Routinely Commissioned
Plastic and
Cosmetic
surgery
N29
Phallaplasty
Not Routinely Commissioned
Plastic and
Cosmetic
surgery
S62.1
(head
and
neck)
S62.2
(other)
Liposuction
Not Routinely Commissioned
Pain
Management
A70
SNS for pain
Liposuction will NOT be
commissioned except for
lipodystrophies, large lipomas, fat
injuries due to trauma and diabetic
lipodystrophies.
Prior Approval Required.
SNS for Pain will be commissioned
in accordance with the NICE TAG
159 and the European Consensus
on Neuromodulation of pain1998.
25
Evidence
Base
Policy for
specialist
plastic
surgery
procedures
Policy for
specialist
plastic
surgery
procedures
Policy for
specialist
plastic
surgery
procedures
Policy for
specialist
plastic
surgery
procedures
Monitoring
NICE TAG
159
NHS
Doncaster
Commissionin
g policy
Contract
monitoring SLAM
Contract
monitoring SLAM
Contract
monitoring SLAM
Contract
monitoring SLAM
Contract
monitoring SLAM
Speciality
OPCS
code
Trauma &
Orthopaedics
Trauma &
Orthopaedics
A65.1,
65.9.
HRG
Procedure
Commissioning Position
Hip Arthroscopy for hip
impingement
Not routinely commissioned
Arthroscopic femoro-acetabular
surgery for hip impingement
syndrome should only be used with
“special arrangements for consent
and for audit or research” There are
no East Midlands Units currently
offering this service and the
arrangements for consent or
research at Coventry, the sole
provider are unclear at present.
Current evidence on safety and
efficacy does not appear adequate to
recommend hip arthroscopy for other
indications, treatments or diagnoses.
Carpal Tunnel Release
surgery
Routinely Commissioned where
• Neurological deficit i.e. sensory
blunting or weakness of thenar
abduction (APB)
• Weakness of grip
• Constant or progressive symptoms
• Symptoms are severe/ functionally
impairing
• Symptoms have not resolved to
patient’s satisfaction after 4 months
of conservative treatment from date
of 1st consultation with physician.
Prior Approval Required for all
26
Evidence
Base
NICE
Interventional
Procedure
Guidance 213
Monitoring
http://eng.m Contract
apofmedicin monitoring SLAM
e.com/evide
nce/map/car
pal_tunnel_s
yndrome_cts
_1.html.
Speciality
OPCS
code
HRG
Procedure
Commissioning Position
Evidence
Base
Monitoring
NICE TAG89
Contract
monitoring SLAM
other indications.
Updated
Nov 2011
Trauma &
Orthopaedics
X334
Trauma &
Orthopaedics
V25
V26
V33
V34
V3824
V3935
V433
V473
V4856
V493
Urology
N181
SA26A
SA26B
Autologous Cartilage
transplantation
Not routinely commissioned
ACI is not recommended for treating
knee problems caused by damaged
articular cartilage, unless it is used in
studies that are designed to produce
good quality information about the
results of the procedure. These
results should include measuring any
improvement in patients’ quality of
life and the benefits and risks of ACI
over a long period of time,
Lumbar Spine
procedures
Not Routinely Commissioned
Contract
monitoring SLAM
Lumbar spine procedures are not
routinely commissioned for nonspecific lower back pain.
LB34A
LB34B
LB34C
Reversal of Male
Sterilisation
Not routinely commissioned
27
Contract
monitoring SLAM
Speciality
OPCS
code
N303
Z426
HRG
Procedure
Commissioning Position
LB32A
LB32B
LB32C
Male Circumcision
Prior Approval Required.
Circumcision will only be considered
for a small number of therapeutic
reasons in line with policy
• True “pathological” Phimosis
either primary or secondary to
circumcision
• True recurrent Balanoposthis
(recurrent bacterial infection of
the prepuce).
Contract
monitoring SLAM
Urology
A483
Z112
AB01Z
Sacral Nerve Stimulation
for Faecal Incontinence
Prior Approval Required.
In accordance with NICE CG 49 and
NICE IPG64 treatment should also
be offered to patients who meet the
criteria outlined in the policy
Contract
monitoring SLAM
Urology
N17*
LB33Z
Vasectomy
Prior Approval Required.
Provision of vasectomy should only
be undertaken in a primary care
setting, it is not commissioned as a
secondary care service. However it
is noted that referral to secondary
care may be required in some
circumstances e.g. GA for
Needle phobics
Contract
monitoring SLAM
Urology
28
Evidence
Base
Monitoring