Download here. - Isle of Wight CCG

Procedures of Limited Clinical Value
&
Non-Commissioned Procedures
1
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Prior Authorisation Procedures
Procedure
Arthroscopic lavage and
debridement with or without
partial meniscectomy of the
knee in patients with nontraumatic and persistent knee
pain (PS010 Arthroscopy in knee
pain without true locking in
patients over 40)
Arthroscopic subacromial
decompression of the shoulder
(PS014)
Exclusions/Exceptions
Auth
Req
Secondary Care
Prior Approval is not required for cases of traumatic knee pain
In first instance patients should be referred to the local MSK community service
PA
PA Arthroscopic
Knee 40yrs
This should only be considered in the following scenario
The patient has persistent pain and a clear history of functional deficit caused by mechanical locking
Arthroscopic subacromial decompression will be considered as a treatment option for people if all the
following criteria are fulfilled:
 The person has had symptoms for at least 6 months.
 Symptoms are intrusive and debilitating (for example waking several times a night, pain when
putting on a coat).
 The person has been compliant with a physio intervention for at least 6 weeks.
 The person has had a positive response to a steroid injection.
Requestor &
Forms
Secondary Care
PA
Artho sub decom
shoulder Dec16.docx
The procedure will be performed as a day case if clinically reasonable
Secondary Care
Assisted Conception: Infertility
treatments (PS002)
Established criterion included within referral form
Carpal tunnel release/ nerve
entrapment at wrist
Funding may be considered under the following conditions:
 All conservative measures (e.g. wrist splint, anti-inflammatories and 2 injections into the carpal
tunnel) have failed; and
 There have been symptoms for longer than 6 months or
 Evidence of neurological deficit such as sensory blunting or weakness of thenar (thumb base)
abduction
PA
Criterion in place for Labia refashioning
PA
Cosmetic Surgery:
PA
Assisted
Conception.docx
Primary Care
(Secondary Care
depending on
clinical pathway)
Carpal tunnel release
Dec16.docx
Primary Care
2
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Labia refashioning



Cosmetic Surgery: Excision of
skin following massive weight
loss
Dupuytren’s contracture/
Palmar Fasciectomy
Auth
Req
/Secondary Care
Medical reasons e.g. cancer, congenital malformations, infection.
Repair of trauma after childbirth or accident, or as a result of Female Genital Mutilation (FGM)
When there is extreme asymmetry of labia causing significant functional impact on quality of
life*
 When the labial are bilaterally enlarged causing significant functional impact on quality of life
issue*
* GP and Consultant should both agree patient meets this criterion
All professionals have a mandatory duty to report any identified cases of Female Genital Mutilation in
young women under 18 years old to police, via the Safeguarding Children team
Excision of skin following massive weight loss: funding may be considered under the following
conditions:
 Patient’s starting BMI was >45
Current BMI of patient is <30 or that this is unachievable and that they have lost 50% of their
excess weight
 Patient’s weight has been stable for at least two years or, at the surgeon’s discretion, the
underlying tissue is suitable for surgery
 There is documented clinical pathology (e.g. recurrent intertrigo/infection, cellulitis or inability to
exercise due to the excess skin)

Funding may be considered under the following conditions:
 There is functional impairment which may include safety concerns
 Patient has a fixed flexion in one or more joints exceeding 25° or
 Patients under 45 years of age with 2 or more affected digits and fixed flexion exceeding 10° and
Requestor &
Forms
Labia Refashioning
Dec16.docx
Primary Care
PA
Skin reduct weight
loss Dec16.docx
Primary Care
PA
Dupuytren
contracture Dec16.docx
3
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Blepharoplasty or eyelid surgery will only be funded in one of the following circumstances:
 There is significant effect on visual fields
OR
This must be documented by attaching a visual field test results or by clinical photography.
 Other demonstrated complications causing visual dysfunction as detailed by the referring
clinician: OR
 There is ectropion or entropion of the eyelid
Eye Lid Surgery
Female Sterilisation
Primary Care
/Secondary Care
PA
Chalazia (Meibomian cysts)
Surgical excision will only be funded when all the following criteria are met:
 All conservative measures have been tried (regular application of heat packs 4 times a day) and
that it has been present for six months
AND
 Is situated subcutaneously in the upper or lower eyelid AND
 It is causing blurring of vision
Female sterilisation will not be available on non-medical grounds unless non-surgical options have
been found to be unsuitable or intolerable. [Women should be informed that male vasectomy carries
a lower failure rate and less risk.] It will only be considered in ONE of the following circumstances:
 Sterilisation is to take place at the time of another procedure e.g. planned Caesarean section OR
 There is a clinical contra-indication to conservative options such as a Mirena coil or contraceptive
implant (Implanon) OR
 There is an absolute clinical contra-indication to pregnancy, such as women under 45 undergoing
endometrial ablation for menorrhagia, women with severe diabetes or women with heart
disease.
Requestor &
Forms
Blepharoplasty
Dec16.docx
Chalazion excision
Dec16.docx
Primary Care
PA
Female sterilisation
Dec16.docx
Secondary Care
FES in the Management of drop
foot of central neurological
origin (specifically post stroke
and multiple sclerosis) (PS005)
Functional Electrical Stimulation may be considered as a second line treatment option for carefully
selected patients with drop foot (most commonly due to multiple sclerosis or stroke) who have
clearly failed trials of orthosis (for example due to pressure sores, spasticity).
Functional nasal airways surgery
(which may include septorhinoplasty)
Emergency procedures do not require prior authorisation
This procedure is not routinely funded: Prior approval will be considered under the following
conditions
 There is continuous nasal airway obstruction causing significant symptoms such as diagnosed
obstructive sleep apnoea; and
 Obstructive symptoms persisting despite conservative management for > 3 months including
PA
FES Drop Foot
Dec16.docx
Secondary Care
PA
Functional nasal
airways surgery Dec16.docx
4
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
nasal steroids or immunotherapy
Correction of complex congenital conditions that are not otherwise covered under specialised
commissioning arrangements will also be considered
Ganglion Surgery
(PS52)
Gastric fundoplication for
chronic reflux oesophagitis
(PS51)
Hallux Valgus
Treatment of bunions
Hysterectomy in heavy
menstrual bleeding
(menorrhagia)
Funding for excision may be considered under the following conditions:
 The ganglion is the likely cause of reduced function or persistent pain either through local effects
or nerve pressure causing neuropathy OR
 There is a sudden increase in size suggesting an alternative diagnosis: Please detail (required)
Funding may be considered under the following conditions:
The procedure is recommended as a treatment option in adults who have at least one of the
following characteristics:
 Regular, significant symptoms of gastro-oesophageal reflux despite receiving at least one year of
continuous pharmacological treatment up to the maximum dose licensed for reflux oesophagitis
 Significant volume reflux placing them at risk of aspiration
 Anaemia because of oesophagitis
Funding may be considered under the following conditions
 Have been managed via MSK or podiatry services first before consideration of orthopaedic
surgery and
 Has documented functional impairment and
 Inability to wear suitable footwear and
 Patient is fully aware of pros and cons of surgery having used patient decision aids
Hysterectomy for cases of heavy menstrual bleeding/ menorrhagia should not be offered unless ALL
the following criteria are met:
 An intra-uterine device has been trialled for >6 months and failed or is medically contraindicated: Please detail with dates of trial, reason for failure, harm or contraindication
(required). AND
 A second drug treatment e.g. tranexamic acid, NSAIDS, combined oral contraceptives, oral or
injected progesterone has proved ineffective: Please document treatments or attach GP
referral/practice record (required) AND
 Endometrial resection/ ablation has failed or is clinically contra-indicated: Please detail that this
has been attempted and failed or that it was considered but contra-indicated e.g. fibroids>3cm
or a uterine abnormality AND
 That the patient wishes for amenorrhoea and no longer wishes to retain her uterus or fertility
Primary Care
PA
Ganglion excision
Dec16.docx
Primary Care/
Secondary Care
PA
Gastric
fundoplication Dec16.docx
Primary Care
PA
Hallux valgus
(bunions) Dec16.docx
Secondary Care
PA
Hysterectomy for
menorrhagia Dec16.docx
5
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Male Circumcision
Myringotomy / grommet
insertion for adults
Myringotomy / grommet
insertion for children
Exclusions/Exceptions
Funding may be considered under the following conditions:
 Suspected cancer
 Balanitis xerotica obliterans (BXO)
 Congenital urological abnormality where skin grafting is required
 Interference with normal sexual activity
 Phimosis interfering with urine flow and/or recurrent urinary tract infections
 Recurrent paraphimosis
 Symptomatic or minor hypospadias
 Recurrent balanophosphitis resistant to antibiotics
 Circumcision during or after surgery for correction of penile curvature
 Where appropriate conservative measures e.g. topical steroids for six weeks should have been
exhausted first. Paraphimosis is not a routine indication for circumcision
This procedure is not routinely funded in over 18s unless they meet ONE of the following conditions:
 Middle ear effusion causing measured hearing loss persisting > 3 months, leading to disability
relating to deafness and resistant to medical treatments: Please detail (required). Medication
utilised and options considered, including that of a hearing aid. OR
 Persistent Eustachian tube dysfunction resulting in pain e.g. flying OR
 As a possible treatment for Meniere’s disease OR
 Severe irreversible eardrum retraction of the tympanic membrane OR
 As part of treatment for diagnosis or management of head and neck cancer or its complications

Grommet insertion in children > 3 years of age is not offered unless under the following exceptions.
[NB Treatment of children under 3 is not subject to the prior approval process.]
 The child has a disability such as Down’s syndrome or cleft lip and palate and grommet insertion
is part of an established pathway of care OR
 There is a tympanic membrane retraction pocket OR
 There is Otitis Media with Effusion for > 3 months of watchful waiting in primary care + > 3
months watchful waiting in secondary care, with documented speech or language delay or
behavioural problems and a documented hearing level in the better ear of worse than 25-30dBHL
averaged at 0.5, 1, 2 and 4 kHz: Please detail hearing levels and date of initial presentation
(required)
Auth
Req
Requestor &
Forms
Primary Care /
Secondary Care
PA
Male circumcision
Dec16.docx
Secondary Care
PA
Grommet in adults
Dec16.docx
Secondary Care
PA
Grommet in children
Dec16.docx
6
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
Interventional treatments should only be offered in the context of a comprehensive multi-disciplinary
programme of care with arrangements for ongoing assessment following a trial of treatment that
shows no evidence of response.
Diagnostic facet joint injections and medial branch block or spinal/ epidural injections should be part
of a comprehensive MDT led programme.
They are only funded for patients with chronic back pain if performed by a clinician trained in the
assessment, diagnosis and management of back pain as part of an MDT.
Pain Management
Specific Back Pain
Facet joint and medial branch
blocks
These should only be funded as:
 A diagnostic tool to improve the specificity of radio-frequency lesioning where this is being
considered
OR
 One injection where all the following criteria are met;
o Pain lasting > 12months that has failed to respond to conservative treatment including
maximal oral and topical analgesia
AND
o The patient has been assessed by a clinician trained in the diagnosis and management of
back pain who considers it would enable mobilisation and participation in rehabilitation
Primary Care
/Secondary Care
PA
Specific Back
Dec16.docx
AND
o
There is documented use of a standardised Pain and Quality of Life tool before and after
the procedure
Repeat injections will only be funded as part of that pain management pathway where there is
significant improvement in the Pain and Quality of Life score. No more than TWO injections will be
funded within any one year.
Where appropriate it is expected that some procedures will be offered on an outpatient basis and
priced accordingly.
7
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Pain Management
Chronic Back Pain
Primary hip and knee
replacement in patients with a
BMI above 35
Surgical removal of skin lesions:
For Symptomatic Lumps &
Bumps
Exclusions/Exceptions
Radiofrequency denervation/ endothermal ablation should be part of a comprehensive MDT-led plan
with ongoing assessment and only following a trial of treatment (medial branch/facet joint block)
demonstrating evidence of response.
 One diagnostic medial branch/facet joint block may be funded prior to denervation techniques
and this should demonstrate >50% improvement in pain using a validation scoring tool before
proceeding with denervation
 Repeat denervation procedures may only be offered following a previous successful response (as
above) with benefits lasting >6 months but with a minimum interval of 12 months (Therefore
those patients experiencing < 12 months relief following two procedures will not be offered
further denervation treatment)
These procedures are not routinely funded for patients with a BMI above 35.
All patients should be offered a review appointment at around 6-8 weeks post discharge; further
follow up should not be offered.
Trauma (for acute admissions identified as emergency procedures recorded under admission)
Funding may be considered under the following conditions:
 In patients whose pain is so severe and/or mobility compromised that they are at risk of losing
their independence and that joint replacement would relieve this risk
 In patients whose destruction of the joint is of a severity that delaying surgery would increase the
technical difficulty of the procedure
Referral should also have been made for referral to the commissioned ‘Tier 2’ or ‘Tier 3’ obesity
management programme prior to offering surgery. Details for the referral process are attached
Referrals to secondary care for skin lesions should only be made where there is suspicion of
malignancy. All other referrals for benign lesions including lipomas are not routinely funded and can
only be supported via prior approval including reported symptoms.
Removal should not be offered except via prior approval where the patient meets ONE or more of the
following (please highlight relevant):Obstruction of an orifice or vision
 Functional limitation to movement or activity
 Moderate to large facial lesions causing disfigurement
 Significant symptoms such as recurrent bleeding, infection or inflammation; marked itching or
severe pain failing to respond to medical or conservative management
 Located in an area of recurrent trauma
Auth
Req
Requestor &
Forms
Primary Care
/Secondary Care
PA
Chronic Back Pain
Dec16.docx
Primary Care /
Secondary care
PA
Hip Knee BM1 35+
Dec16.docx
Weight Management
referral.docx
PA
Primary Care/
Secondary Care
Minor Skin
Procedures Dec16.docx
8
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Symptomatic Inguinal Hernia
(PS148)
Tonsillectomy
Trigger Finger
Varicose veins
(PS001)
Exclusions/Exceptions
For those inguinal hernias where the patient has the following symptoms then prior approval for
funding is required
 History of incarceration of, or real difficulty in reducing, the hernia
 An inguino-scrotal hernia
 An increase in size
 Pain or discomfort significantly interfering with activities of daily living
 Specific problems with work or activities of daily living because of the hernia
Funding may be considered under the following conditions:
 Children and adults with suspected cancer; OR
 Children and adults with quinsy (peritonsillar abscess); OR
 Severe halitosis due to tonsillar debris following conservative management; OR
 Children and adults in a high risk category e.g. downs syndrome, cerebral palsy, cranio-facial
disorders, chronic lung disease, sickle cell disease, neuro-muscular disorders, genetic or
metabolic disease, central hyperventilation syndromes; OR
 In children and adults with diagnosed obstructive sleep apnoea where other treatments have
failed or are inappropriate; Please detail here (supportive evidence is required such as clinic
letter, confirmation of diagnosis and evidence of previous treatments, reason for failure and that
the tonsillar contribution is significant) OR
 Sore throats caused by documented recurrent tonsillitis for >1 year with at least 5 episodes in the
past year disabling normal function.
The patient’s practice record should be attached or the episodes listed
Funding may be considered under the following conditions:
 Patient fails to respond to conservative treatment, including no response from up to two
corticosteroid injections; And
 Patient has moderate to severe pain/locking sufficient to cause interference with hand function
And
 Patient has persistent symptoms > 3 months
People with a body mass index less than 32 kg/m2 who satisfy at least one of the following criteria
may be considered for interventions to treat varicose veins:
 A first venous ulcer persists despite a six-month trial of conservative management of the ulcer
 Recurrent venous ulcer
 Haemorrhage from a superficial varicosity
Auth
Req
Requestor &
Forms
Primary Care
PA
Symptomatic inguinal
hernia Dec16.docx
Primary Care
PA
Tonsillectomy
Dec16.docx
Primary Care
/Secondary Care
PA
Trigger finger
surgery Dec16.docx
Primary Care
/Secondary Care
PA
Varicose vein
treatment Dec16.docx
9
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Individual Funding Request Procedures
Procedure
Exclusions/Exceptions
Adenoidectomy for Children
with Recurrent Upper
Respiratory Tract Infections
(PS008)
Not routinely funded
When offered in combination with myringotomy (grommet insertion) and/or tonsillectomy which are
subject to separate prior authorisation arrangements
Auth
Req
Requestor &
Forms
Secondary Care
IFR
IFR Secondary Care
Form.docx
Primary Care
Appliances and devices for
cosmetic purposes (high-grade
silicon cosmesis and/or –
prosthesis)
IFR Primary Care
Form.docx
None
IFR
Secondary Care
IFR Secondary Care
Form.docx
Arthroscopic Femoro-acetabular
Surgery for Hip Impingement
(Arthroscopoic & Open
Approaches) (PS006)
Secondary Care
None
IFR
IFR Secondary Care
Form.docx
Primary Care
Asymptomatic Inguinal Hernia –
(PS148)
Bone Morphogenetic Protein
and Low-Intensity Pulsed
Ultrasound in delayed and nonunion fractures (Exogen)
(PS139)
Asymptomatic Inguinal Hernias are not routinely funded
IFR
IFR Primary Care
Form.docx
Secondary Care
None
IFR
IFR Secondary Care
Form.docx
10
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
Secondary Care
Cholecystectomy for Patients
with Asymptomatic Gallstones
(PS012)
None
IFR
IFR Secondary Care
Form.docx
Primary Care
Chronic Fatigue Syndrome
(CFS)/ Myalgic
Encephalomyelitis (ME)
inpatient treatment (PS10)
IFR Primary Care
Form.docx
None
IFR
Secondary Care
IFR Secondary Care
Form.docx
Primary Care
Complementary
therapies/medicines/Alternative
/homeopathic therapies (PS60)
None
IFR
IFR Primary Care
Form.docx
Secondary Care
Continuous Glucose Monitoring
(CGM) for Adults with Type 1
Diabetes Mellitus (PS007)
None – But see SHIP PS 007 February 2016
IFR
IFR Secondary Care
Form.docx
11
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
Primary Care
Cosmetic Laser Treatment: e.g.
 Excessive hirsutism
 Port Wine stains/benign
facial lesions
 Rosacea
 Surgical shaving
 Chemical destruction of
skin
 Plastic surgery
 Scars
 Tattoo removal, warts,
thread veins etc
Cosmetic Surgery: e.g.
 Abdominoplasty
 Botox
 Breast,
 Buttock lift,
 Liposuction, lipectomy
 Mastopexy
 Pinnaplasty
 Rhinoplasty
(Functional
Nasal Surgery excluded –
see
here
for
more
information)
 Breast and Nipple
procedures (PS15)
NB:SHIP Policy Statement 121
provides information regarding
Aesthetic Procedures in Children
IFR Primary Care
Form.docx
None
IFR
Secondary Care
IFR Secondary Care
Form.docx
Primary Care
IFR Primary Care
Form.docx
None; except when as part of an established pathway, e.g. Cancer reconstructive surgery; or for
Excision of Skin Following massive weight loss (Appendix 5, Page 3)
IFR
Secondary Care
IFR Secondary Care
Form.docx
12
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Cryopreservation – preservation
of fertility (Male and Female)
(PS135)
Male Criterion: Funding should be available for the retrieval and cryopreservation of sperm from
patients who meet the criteria specified by NICE:
 Sperm cryopreservation should be considered in circumstance that impair fertility or need
treatment likely to impair fertility, such as malignancies of the genital tract
Female Criterion: Funding should be available for the retrieval and cryopreservation of oocytes from
patients who meet the criteria specified by NICE:
 Women of reproductive age (including adolescent girls) who are preparing for medical treatment
for cancer that is likely to make them infertile if:
- They are well enough to undergo ovarian stimulation and egg collation and
- This will not worsen their condition and
- Enough time is available before the start of their cancer treatment



Gender Reassignment Surgery
for the treatment of Gender
Dysphoria in Adults (PS46)
Auth
Req
Requestor &
Forms
Secondary Care
IFR
IFR Secondary Care
Form.docx
NHS funding should be available for the retrieval and cryopreservation of ovarian tissue from
patients in circumstances where it is not possible to retrieve oocytes
NHS should be available for the subsequent storage of cryopreserved material for the period of
time recommended by NICE
NHS funding for the subsequent use of cryopreserved material will be subject to the assisted
conception eligibility criteria in operation at the time that this use is considered
From April 2013 NHS England’s Specialised Commissioning team is responsible for the provision of
care and treatment for people with gender dysphoria. NHS England’s Interim Gender Dysphoria
Protocol and Service Guideline 2013/141 sets out their commissioning responsibilities. The ‘core’
gender dysphoria treatments included in the funding remit of national Specialised Commissioning
are:
 Ongoing psychotherapy and counselling
 Hormone therapy (clarification on shared care responsibilities is being sought from NHS England
 Facial hair removal
 Speech therapy
 Hair removal from donor site for genital reconstructive surgery
 Core surgical treatments for male to female and female to male procedures
Non-core procedures that are not commissioned by NHS England are not routinely funded by the NHS
and will only be provided on an exceptional clinical need basis, following an application to the IW CCG
IFR Panel
Secondary Care
IFR
IFR Secondary Care
Form.docx
13
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
Secondary Care
Hyperbaric Oxygen therapy
Emergency decompression is only funded by exception
IFR
IFR Secondary Care
Form.docx
Primary Care
Inpatient pain management
programmes for adults with
chronic pain
IFR Primary Care
Form.docx
None
IFR
Secondary Care
IFR Secondary Care
Form.docx
Secondary Care
Non-NHS residential placements
for mental health concerns
None
IFR
IFR Secondary Care
Form.docx
Pain Management:
Corticosteroid Injections for
patellar tendinopathy
(PS 123/124)
Primary Care
None
IFR
IFR Primary Care
Form.docx
14
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
Primary Care
Pain Management
Spinal Manipulation for the
treatment of chronic nonspecific low back pain
(PS 61)
IFR Primary Care
Form.docx
None
IFR
Secondary Care
IFR Secondary Care
Form.docx
Primary Care
Pain Management
Non-Specific Back Pain:
As per NICE guidance, injections of therapeutic substances into the back for non-specific low back
pain should not be offered. Therapeutic facet joint injections should only be offered in the context of
either special arrangements for clinical governance and clinical audit or research and are not
routinely funded. Epidural injections, (either sacral or interlaminar) or nerve root injections are not of
value for patients with non-specific low back pain.
IFR Primary Care
Form.docx
IFR
Secondary Care
IFR Secondary Care
Form.docx
Secondary Care
Patellar resurfacing as part of
primary total knee joint
replacement
None
IFR
IFR Secondary Care
Form.docx
Primary Care
Pre-implantation genetic
diagnosis (PGD)
(PS090)
None
IFR
IFR Primary Care
Form.docx
15
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
Primary Care
Reversal of
sterilisation/vasectomy
None
IFR
IFR Primary Care
Form.docx
Secondary Care
Short sight/long sight corrective
(laser) surgery (refractive
keratoplasty)
None
IFR
IFR Secondary Care
Form.docx
Primary Care
Sports Limbs (Rehabilitation)
None
IFR
IFR Primary Care
Form.docx
16
Clinical Funding Authorisation: Procedures List December 2016 v1.0
Procedure
Exclusions/Exceptions
Auth
Req
Requestor &
Forms
Primary Care
IFR Primary Care
Form.docx
Secondary Care
Surgical removal of skin lesions:
For Asymptomatic Lumps &
Bumps
Applications in cases which are asymptomatic but considered severely disfiguring may be made with
appropriate photography to demonstrate the level of disfigurement. The DLQI (Dermatology Life
Quality Index) offers a useful guide and should be included with the request. A summary of how the
patient’s daily function is affected must be provided.
IFR Secondary Care
Form.docx
IFR
Adult Derm Life
Quality Index.docx
Child Derm Life
Quality Index
Treatments for erectile
dysfunction
(PS96)
Funding approval via IFR is required for:
 Treatment with psychosexual interventions
 Treatment with vacuum erection devices
 Treatment with penile implants
Primary Care
IFR
IFR Primary Care
Form.docx
Primary Care
Treatments for People who
Snore (PS009)
Not routinely funded
Funding for snoring is not available as a standalone condition and the snoring needs to be
distinguished from sleep apnoea.
IFR
IFR Primary Care
Form.docx
17
Clinical Funding Authorisation: Procedures List December 2016 v1.0