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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