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Service Restriction Policy
Version 1:
Ratified by:
Date ratified:
Author
Executive Sponsor
Lead Director
September 2015
Mid Essex CCG
September 2015
Paula Wilkinson-Chief Pharmacist
Dr. Donald McGeachy-Medical Director
Dan Doherty-Director of Clinical
Commissioning
Name/Title of responsible
committee/individual:
Mid Essex CCG Clinical Commissioning
Committee
Mid Essex CCG Board
12th February 2016
September 2016
Version 5 Date issued:
Review date:
GPs, Optometrists, Dentists, Secondary care
consultants, Central Referral Service
Triagers, Public and Patients
Target audience
Version Control
Version
Version 1
Version 2
Version 3
Version 4
Version 5
Version 6
Key Changes
Restoration of criteria for apronectomy,
pinnaplasty, breast implants; clarification of
cosmetic surgery statement; criteria for referral to
specialist obesity services; removal of
collagenase.
Referral for assessment of bariatric surgery
Patient has completed a Tier 2 weight
management course within the last 12 months.change from 6 months
Inclusion of restriction of vasectomy and female
sterilisation- not routinely funded
Inclusion of continuous glucose monitoring-not
routinely funded
Restoration of SRP for snoring- omitted from this
document in error.
Authorisation
CCG Board
Clinical Commissioning
Committee and Board.
Clinical Commissioning
Committee
CCG Board
Clinical Commissioning
Committee
Clinical Commissioning
Committee
1
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Document Summary
Mid Essex CCG’s policy is that treatments/ interventions/ procedures not currently included in
commissioned established care pathways (as identified for example in the Schedules to the service
agreements with acute care provides) or identified for funding through the commissioning process are
not routinely funded. For a number of commissioned interventions the CCG has specific policy
statements setting out restrictions on access, based on evidence of effectiveness or relative priority for
funding. Those related to treatments/ interventions/ procedures are included within this document;
those relating to prescribing can be found on the Mid Essex CCG website Medicines Optimisation- .
Providers must not assume that because a treatment/intervention/procedure is not included in this
policy that by default it will be funded.
Policy development is an on-going process and future policy on further treatments as developed or in
response to NICE Guidance/Guidelines, health technology assessments etc. will be produced and
published periodically on the CCG website-Service Restriction Policies
Each new referral, regardless of advice provided following a previous referral or episode of care, must
be assessed against the policy in place on the date the referral is made. The fact that a patient has
previously been treated for the referral condition, or a related condition, and previously met the policy in
place at the time does not support a referral or treatment outside the current service restriction policy.
This policy document sets out the access to treatments/ interventions/ procedures* where there is a
specific policy in place:
Threshold Approvals – Those procedures* which are commissioned by Mid Essex CCG on a routine
basis but only for patients who meet the defined criteria set out within this policy but for which
individual prior approval is not required e.g. cataract surgery. CCG notification of compliance or audit
will be required according to contractual arrangements. Providers should be aware that payment may
be withheld where it cannot demonstrate that patients treated meet the criteria specified.
Individual Prior Approvals - Those procedures* which are commissioned by Mid Essex CCG but
only for patients who meet the defined criteria set out within this policy and which require individual
approval on a patient by patient basis.
For these procedures, the criteria listed form guidance to both the referring and treating clinicians and
if a patient is deemed to meet these criteria prior approval should be sought. In instances in which
eligibility is unclear the final decision is made through the application of the Exceptional Cases
process.
Not Funded – Those procedures* which have been assessed as Low Clinical Priority by Mid Essex
CCG and which will not be funded unless there are exceptional clinical circumstances.
Applications for funding for these procedures can be made to the Exceptional Case Team but should
only be made where the patient demonstrates true clinical exceptionality.
Individual Funding Requests-Mid Essex CCG always allows patients the opportunity to make
specific funding requests via its Exceptional Case Team. Requests may include patients with
conditions for which the CCG does not have an agreed policy, including patients with rare conditions
and whose proposed treatment is outside agreed service agreements. Such requests should not
constitute a request for a service development.
The responsibility for adherence to these policies lies with the treating clinician and failure to adhere to
these criteria may result in non-payment of the activity.
All patients being referred for non-urgent elective surgery and who are smokers should be referred to
smoking cessation services at the initial assessment appointment.
There is strong clinical evidence that obese patients undergoing surgery are at significantly higher risk of
getting infections and suffering heart, kidney and lung problems than people who are a healthy weight.
They are also likely to have to spend more time in hospital recovering and their risk of dying as a result of
surgery is higher compared to patients with a normal weight. Overweight patients should be strongly
encouraged to lose weight before their operation and consider delaying referral for non-urgent elective
surgery. *includes treatments, interventions and procedures
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Index
A
Abdominoplasty/Apronectomy
Acne Vulgaris
Aesthetic Facial Surgery
Autologous Cartilage Transplantation
H
B
Bariatric surgery and access to specialist obesity
services
Benign Skin lesions
Blepharoplasty
Bobath Therapy
Bone anchored hearing aid
Breast Asymmetry
Breast Augmentation/ Implants
Breast reduction
Bunions
I
C
D
Capsule Endoscopy and Double Balloon
Enteroscopy
Carpal Tunnel
Cataracts
Chalazia
Chronic Fatigue Syndrome
Circumcision
Cochlear Implants
Complementary and alternative therapies
Continuous Glucose Monitoring
Continuous Positive Airways Pressure (CPAP)
Dental Procedures (orthodontics)
Dilatation and curettage / hysteroscopy
Dupuytren's Contracture
Dysthyroid eye disease
Drugs-see Medicines Management-CCG
K
L
M
N
O
Hernia (surgical treatment)
Hip Arthroscopy
Hip Injections
Hip Replacement
Hip Resurfacing
Hirsutism Hair Depilation
Hysterectomy
IngrownToeNail
Interventional Procedure Guidance-policy
statement
IVF (assisted conception)
Knee Arthroscopy
Knee replacement
Labial Reduction-Refashioning
Liposuction
Lymphoedema
MRI (See Open MRI)
Nasal Surgery (Rhinoplasty and
Septorhinoplasty)
Nipple Inversion
Open MRI
Orthoses
P
Penile implants
Pinnaplasty/ Otoplasty
R
Repair of ear lobes
Reversal of sterilisation
Rhinophyma
S
Sacroneuromodulation
Scar revision
Shoulder arthroscopy
Skin contouring
Sleep Studies/Snoring
Snoring
Sperm, Embryo or Oocyte storage
Spinal Cord Stimulation
Spinal Injections
Spinal surgery for non-acute lumbar conditions
Surrogacy
Tattoo removal
Temporomandibular joint replacement
Temperomandibular Joint Retainers and
Appliances
Tinnitus
Tonsillectomy
Toric Lens implants
Trigger Finger
E
Exogen Bone Healing Ultrasound Systems
F
Face lifts and brow lifts (Rhytidectomy)
Facet Joint Injections and Medial Branch Blocks
Female Sterilisation
Fibroid embolization and Uterine Artery
Embolisation
Functional Electrical Stimulation (FES)
T
G
Ganglion
Gastroelectrical Stimulation (GES)
Gender Dysphoria
Grommets
Gynaecomastia
V
Varicose veins
Vasectomies
W
Wigs, Hairpieces and Hair
Transplant/Replacement Systems
3
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Policy statement:
Abdominoplasty or Apronectomy
Status:
Individual Prior Approval
MECCG commissions abdominoplasty and apronectomy on a restricted basis in patients who meet the
following criteria:
A
Where it is required as part of abdominal hernia correction or other abdominal wall surgery
OR
B
Those patients from the following groups who have significant abdominal aprons as a result of
weight loss and the flap (panniculus) hangs at or below the level of the symphysis pubis and
have severe functional problems*:
 Patients with excessive abdominal folds who had an initial BMI >40 and have achieved a
reduction in BMI < 25 and have maintained the BMI < 25 for at least 2 years
OR
 Patient with excessive abdominal folds who have an initial BMI > 50 and have achieved a
minimum drop of 20 BMI points and have maintained this BMI (reduction of a minimum of 20
points) for at least 2 years.
*Severe functional problems include:

Chronic and persistent skin condition (for example, intertriginous dermatitis, cellulitis or skin
ulcerations) that is refractory to at least six months of medical treatment. In addition to good
hygiene practices, treatment should include topical antifungals, topical and/or systemic
corticosteroids and/or local or systemic antibiotics

Abdominal wall prolapse with proven urinary symptoms

Problems associated with poorly fitting stoma bag
Funding for patients not meeting the above criteria will only be granted in clinically exceptional
circumstances.
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Policy statement:
Bariatric Surgery and access to specialist obesity services
Status:
Individual Prior Approval
Essex County Council is responsible for commissioning Tier 2 services and currently
commissions courses for overweight or obese patients with a BMI over 25kg/m2 or 23kg/m2
for those from African-Caribbean or Asian [South Asian and Chinese] populations
GP or patient self-referral contact current provider-ACE Weight Management Service (‘My
Weight Matters’) on 0800 022 4524 then option 3.
MECCG does not commission specialist multidisciplinary obesity services (Tier 3)
Individual prior approval
Patients will be considered for referral to tertiary services (assessment for bariatric surgery) if
they meet the following criteria:

Patient is 18 year or older.

Patient has BMI > 35 for at least 5 years with significant co-morbidities (for example type 2
diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia and sleep
apnoea), OR Patients with BMI > 40 for at least 5 years without co-morbidities

Patient provides evidence of attendance, engagement and full participation in a weight
management programme. Engagement can be judged by attendance records and
achievement of pre-set individualised targets (for example steady and sustained weight
loss of 5-10%, or maintaining constant weight whilst stopping smoking).

Patient has completed a Tier 2 weight management course within the last 12 months.Examples of Tier 2 courses would include My Weight Matters (delivered by ACE),
Slimming World and Weight Watchers, although others are available. Such a
programme should be in the spirit of a lifestyle weight management service as
described by NICE (“Managing overweight and obesity in adults”, NICE Public Health
Guidance 53, May 2014):o Are multi-component, e.g. consider diet, physical activity levels and behaviour
change;
o Focus on life-long lifestyle change;
o Last at least 3 months, and that sessions are offered at least weekly or fortnightly
and include a 'weigh-in' at each session;
o Ensure specific dietary targets are agreed and progress monitored;
o Ensure discussions take place about how to reduce sedentary behaviour and the
type of physical activities that can easily be integrated into everyday life and
maintained in the long term;
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o Use a variety of behaviour-change methods, e.g. how to make changes to the social
environment; self-monitoring of weight and behaviours that can affect weight.
AND

Patient has completed a Tier 3 weight management programme or has kept a 12
month (minimum) diary recording physical exercise undertaken, diet consumed and
weight progress which has been reviewed and signed by a registered healthcare
professional at least once every 3 months. The healthcare professional should keep
a record of their discussion with the patient re progress. Patients who partially
complete a Tier 3 management programme may count time spent within Tier 3
towards this 12 month minimum requirement.

Patient is a non-smoker at the time of referral (as confirmed by CO monitor) and
maintains this status.

GP has addressed and optimised management of any underlying social circumstances
or clinical conditions which may be affecting weight management in the patient e.g.
hormone problems such as underactive thyroid, Cushing's syndrome, polycystic ovarian
syndrome (PCOS); substance misuse
o lack of sleep- exclude obstructive sleep apnoea-Epworth score of 10 or less
o depression- patients with a score of more than 17 on PHQ9 screening tool must
be referred to IAPT and condition managed before referral
o alcohol consumption-refer to http://openroad.org.uk/contact_us/ and condition
managed before referral
o social circumstances- refer to appropriate service through Essex Connects
(social prescribing project) http://www.nice.org.uk/guidance/PH53
Funding for patients to be referred for assessment not meeting the above criteria will only be
granted in clinically exceptional circumstances.
Patients will only be considered for surgery if the patient fulfils the criteria for treatment as per
the NHS England’s Clinical Commissioning Policy: Complex & Specialised Obesity Surgery,
www.england.nhs.uk/wp-)content/uploads/2013/04/a05-p-a.pdf) released April 2013.
Please note: The NHS England complex obesity surgery policy states that bariatric surgery
should not be commissioned for children under 18 years. Such cases would be reviewed on
an exceptional treatment case basis by the local CCG.
Ref:
http://www.nice.org.uk/guidance/PH53
https://www.nice.org.uk/guidance/cg189/resources/guidance-obesity-identificationassessment-and-management-of-overweight-and-obesity-in-children-young-people-andadults-pdf
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Policy statement:
Benign Skin Lesions/Conditions
Status:
Threshold and Individual Prior Approval
MECCG does not commission surgical removal, laser treatment or cryotherapy of clinically
benign skin lesions/conditions for purely cosmetic reasons. Surgery or treatments to improve
appearance alone is not provided for normal changes such as those due to ageing. The fact
that a patient wants to have a lesion removed does not constitute a sound reason for doing
so at NHS expense.
MECCG commissions the removal of benign skin lesions on a restricted basis only. This
restriction applies to referrals to secondary care dermatology/plastic surgery services
commissioned by the CCG. GPs should not refer patients who do not meet the criteria
detailed below.
Referrals to CCG commissioned community based dermatology or minor surgery clinics must
meet the criteria laid down in the service specification. Providers will not be funded where
patients are treated outside the commissioned service.
This policy does not apply to minor surgery undertaken in primary care which is outside the
remit of this policy as it falls under the commissioning responsibility of NHS England. GPs
providing Minor Surgery as an Additional Service (curettage and cautery and, in relation to
warts, verrucae and other skin lesions e.g. seborrhoeic keratosis, cryocautery) or Minor
Surgery as a Directed Enhanced Service (DES) under GMS/PMS contracts must adhere to
the restrictions as detailed within those service specifications. GPs should note that removal
of benign skin lesions for purely cosmetic reasons will not be funded by NHS England under
this DES.
All suspected malignant lesions are excluded from this policy – these should be managed
via the 2 week wait with the exception of Basal Cell Carcinoma (BCC), where low risk BCC
may be removed in the community in line with NICE recommendations and high risk BCC
should be referred through the usual pathway.
Once it is established that a skin lesion is not malignant its removal will not normally be
funded by the NHS though a clinician may request exceptional funding. Clinicians referring
on this basis should make the patient explicitly aware that removal of the lesion may not
occur.
The list below gives examples of lesions included in this policy. This list is not exhaustive.
 Benign pigmented naevi (moles)
 Seborrhoeic keratoses (benign skin growths,
basal cell papillomas)
 Comedones

Skin tags including anal tags
 Dermatofibromas (skin growths)
 Spider naevus (telangiectasia)
 Lipomas
 Thread veins
 Milia
 Warts and plantar warts
 Molluscum contagiosum
 Xanthelasma (cholesterol deposits
 Sebaceous cysts (epidermoid and pilar cysts)
underneath the skin),
 Port wine stains
 Neurofibromata
 Post acne scarring
Individual prior approval must be obtained before referral except where a patient meets
criteria A below.
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A. Threshold Approval
If a benign skin lesion of the eye obscures vision or is causing a separate ocular problem then
the patient can be referred to an ophthalmologist for removal
B. Individual Prior Approval
Requests for the removal of benign skin lesions will be considered where one or more of the
following apply:






There is confirmed, evidenced history of recurrent infection requiring regular courses
of antibiotics.
There is significant pain as a direct result of the lesion requiring regular prescribed
strong analgesics.
Lesions are rapidly growing or abnormally located (e.g. sub-fascial, sub-muscular).
Lesions cause functional impairment which prevents the individual from fulfilling
work/study/carer or domestic responsibilities
Lesions are on the face where the extent, location and size of the lesion can be
regarded as considerable disfigurement, and which sets them apart from the cohort of
people with lesions.
There is clinical evidence that a commonly benign or non-aggressive lesion may be
changing to a malignancy, or there is sufficient doubt over the diagnosis to warrant
removal.
Evidence that previous treatment has been pursued before requesting approval to refer will be
required.
For those requiring prior approval this evidence must be provided with the request for funding.
Funding for patients not meeting the above criteria will only be granted in clinically exceptional
circumstances.
Ref: Greater Manchester EUR Policy Statement Common Benign Skin Lesion November 2014
Reference: GM013
http://northwestcsu.nhs.uk/BrickwallResource/GetResource/587b2fcf-ac0b-4b8c-ae8e3f900d9649d1
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Policy statement:
Blepharoplasty
Status:
Individual Prior Approval
MECCG commissions blepharoplasty on a restricted basis in patients who meet the following
criteria:
Upper Lid
This procedure will be funded to correct visual functional impairment (not purely for cosmetic
reasons).
Indications:
 Impairment of visual fields in the relaxed, non-compensated state. Evidence will be
required that eyelids impinge on visual fields reducing field to 120° laterally and 40°
vertically (to be confirmed by visual fields test).
Lower Lid
This will be funded for correction of ectropion or entropian or for the removal of lesions of the
eyelid skin or lid margin which impair function.
Individual prior approval for funding is required.
Also see related policy Dysthyroid eye disease.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Breast Augmentation/Implants
Status:
Threshold/Individual Prior Approval
MECCG does not commission plastic surgery for purely cosmetic reasons. Funding for
surgery or treatments to improve appearance alone is not provided.
Breast augmentation
Breast augmentation is routinely funded for the following indication:
 reconstructive following or as part of surgery for breast malignancy or its prevention
as defined in the commissioned pathway (threshold approval)
 congenital amastia (complete absence of breast tissue)-individual prior approval
Individual Prior Approval
Removal and replacement of breast implants:
MECCG only commissions the removal/replacement of breast implants in the following
circumstances as detailed:
 Breast implants were originally funded by the NHS (e.g. as part of treatment for breast
cancer), and the implant(s) need to be removed/replaced for clinical reasons,
such as implant rupture, infection or capsular contraction
OR
 The implant(s) were privately funded and need to be removed for clinical
reasons, such as implant rupture, infection or capsular contraction. Patients
will be offered the choice of removing both prostheses in the event that only
one has ruptured with the intention of preserving symmetry. The replacement
of privately funded breast implants where removal is clinically required is not
routinely commissioned.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Bunion (Hallux valgus) surgery
Status:
Individual Prior Approval
MECCG commissions surgery for bunions on a restricted basis.
Bunion surgery is justified and appropriate when:

AND

AND

the patient experiences persistent pain and functional impairment that is interfering
with the activities of daily living.
all appropriate conservative measures have been tried over a 6 month period and
failed to relieve symptoms, including up to 12 weeks of evidence based non-surgical
treatments, i.e. analgesics/painkillers/bunion pads, footwear modifications
the patient understands that they will be out of sedentary work for 2-6 weeks and
physical work for 2-3 months and they will be unable to drive for 6-8 weeks, (2 weeks
if left side and driving automatic car)
OR

there is a higher risk of ulceration or other complications, forexample, neuropathy, for
patients with diabetes. Such patients should be referred for an early assessment.
A patient should not be referred for surgery for prophylactic or cosmetic reasons for
asymptomatic bunions.
Funding for patients not meeting the above criteria will only be made available in clinically
exceptional circumstances.
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Policy statement:
Capsule Endoscopy
Double Balloon Enteroscopy
Status:
Individual Prior Approval
MECCG commissions wireless capsule endoscopy and double balloon endoscopy on a
restricted basis in the following circumstance
Diagnostic - Wireless capsule endoscopy (WCE) and double balloon enteroscopy
(DBE) in obscure gastrointestinal bleeding
Criteria
MECCG will fund wireless capsule endoscopy or double balloon enteroscopy for obscure
gastrointestinal bleeding when:
Patients with gastrointestinal bleeding have undergone a gastroscopy and/or endoscopy and
results are negative then

Capsule endoscopy for investigation
A) If wireless capsule endoscopy identifies source of bleeding in small bowel then

Where indicated, double balloon enteroscopy for treatment
B) If results of wireless capsule endoscopy are normal but there is persistent bleeding then

OR
Consider second look wireless capsule endoscopy

Double balloon enteroscopy for investigation and treatment where appropriate
Rationale

The evidence available shows that WCE and DBE are safe and effective diagnostic
procedures for the detection of OGIB. Both have a higher diagnostic yield than conventional
methods.

WCE and DBE have common indications but different features. WCE can cover the
whole GI tract, requires no sedation and is better tolerated by patients. Its major limitations
are the inability to obtain a biopsy, precisely localise a lesion, or perform therapeutic
endoscopy. DBE has the advantage of being controllable and enabling therapeutic treatment
to take place simultaneously. The procedure is invasive and not as well tolerated as WCE,
requiring additional staff, typically two physicians or an additional specialist nurse.

Cost-effectiveness modelling suggests that that CE-guided DBE may be associated
with better long-term outcomes because of the potential for fewer complications and
decreased utilisation of endoscopic resources.
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Diagnostic - Wireless capsule endoscopy and double balloon enteroscopy in Crohn’s
disease
Criteria
CCGs will fund wireless capsule endoscopy or double balloon enteroscopy for Crohn’s
disease when:
Following inconclusive ileocolonoscopy and/or small bowel radiology clinical suspicion of
Crohn’s disease remains then:
A) If pain is not a significant feature or where pain is a significant feature and there is no
evidence of strictures on small bowel radiography.

Wireless capsule endoscopy for diagnosis
B) If pain is significant feature and there is evidence of strictures on small bowel radiography
or wireless capsule endoscopy results are inconclusive.

Double balloon enteroscopy to obtain histology
Rationale


The evidence available shows that WCE is a safe and effective diagnostic
procedure for the detection of Crohn’s disease. WCE has a higher diagnostic
yield than push enteroscopy and other conventional methods. The results
suggest that it is superior to conventional radiological procedures in the
detection of lesions in patients with Crohn's disease. However, the high number
of patients with strictures limits its use as a first line diagnostic test in patients
previously diagnosed.
Capsule retention remains a risk in patients with Crohn’s disease with significant
strictures. The risk is greater in patients with established Crohn’s disease
compared to patients suspected to have Crohn’s disease.
Evidence
NICE produced interventional procedure guidance on WCE in 2004
Guidelines produced by British Society of Gastroenterologists in 2008, state DBE should be
used complementary to WCE, particularly in the context of therapeutic intervention beyond
the reach of push enteroscopy.
References:
1. NICE. 2004. IPG 101. Wireless capsule endoscopy for investigation of the small bowel –
guidance.
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Policy statement:
Carpal Tunnel
Status:
Threshold Approval
MECCG commissions surgery for carpal tunnel syndrome on a restricted basis.
Nerve conduction studies are NOT generally needed to confirm the diagnosis. In elderly
patients the condition may develop insidiously and nerve conduction studies may be useful to
assess severity.
Community based conservative treatment should be initiated for all patients with suspected
Carpal Tunnel Syndrome for a period of 6 months, excluding those noted below.
Conservative treatment will include the following:
Analgesia
Splinting with Futuro-type cock up splint (night time only or constant)
Steroid injection – should be administered twice prior to referral for consideration of
surgery.
All GPs should seek access to carpal tunnel injections in the community.
Patients with Carpal Tunnel Syndrome should be referred if any of the following apply:
 Severe symptoms (fewer than 5% of patients) uncontrolled by conservative
measures, significantly interfering with daily activities.
 Neurological deficit i.e. constant sensory blunting or weakness of thenar abduction
(wasting or weakness of abductor pollicis brevis).
 Unclear diagnosis or dual pathology
 Rheumatoid
 Recent trauma
 Previous surgery
Where applicable, referral letter must detail conservative methods tried and the length of time
that each of these was carried out.
Uncomplicated cases who have NOT responded to conservative management for 6 months
should be referred to community based service.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Cataracts
Status:
Threshold Approval
MECCG commissions surgery for cataracts/lens extraction on a restricted basis.
Referrals should not be based simply on the presence of a cataract. Cataract surgery
should, therefore, not normally be offered to patients with a visual acuity better than 6/12 in
the worst eye. This applies to both first and second eye surgery.
Patients with the following symptoms or clinical conditions may benefit from cataract surgery
when their visual acuity in the worse eye is 6/12 or worse. This list is not exhaustive:
1.
2.
3.
4.
5.
6.
Patients experiencing significant glare and dazzle in daylight or difficulties with night
vision when these symptoms are due to lens opacities. This indication applies
particularly, but not exclusively to driving.
Patients requiring particularly good vision for employment purposes.
Difficulty with reading due to lens opacities.
Significant optical imbalance (anisometropia or anisekonia) following cataract surgery
on the first eye.
Management of coexisting other eye conditions.
Refractive error primarily due to cataract.
Cataract surgery/lens extraction should not normally be performed solely for the purpose of
correcting longstanding pre-existing myopia (short sighted or near sighted) or hypermetropia
(long sightedness).
The reasons why the patient’s vision and lifestyle are adversely affected by cataract and the
likely benefit from surgery must be documented in the clinical records.
All patients referred to be considered for cataract should, whenever possible, have completed
the Patient Decision Aid on http://sdm.rightcare.nhs.uk/pda/. This is available on website, on
paper and phone app.
The referring optometrist or GP should discuss the risks and benefits using an approved
information leaflet (national or locally agreed) and ensure that the patient understands and is
willing to undergo surgery before referring.
Second eye: As the benefits of second eye surgery have been demonstrated patients will be
offered second eye surgery provided they fulfil the referral criteria. Second eye surgery
should be deemed urgent when there is resultant anisometropia (a large refractive difference
between the two eyes of 2 ½ dioptas) which would result in poor binocular vision or diplopia
(this should be clearly recorded in the patient’s notes).
The reasons why the patient’s vision and lifestyle are adversely affected by cataract and the
likely benefit from surgery must be documented in the clinical records.
Providers will be audited on the indications for cataract surgery.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Chalazia
Status:
Threshold Approval
MECCG commissions surgery for chalazia on a restrictive basis.
MECCG operates a community service for excision of chalazia when the patient presents
with two or more of the following:
 Present for more than six months
 Present on the upper eyelid
 Interferes with vision
 Conservative management has been tried & failed and there is no appropriate
alternative to surgical intervention.
 The site of the lesion or lashes renders the condition as requiring specialist
intervention.
Only the patients meeting the following criteria should be referred to secondary care:
 All children should be referred on.
 Any recurrent chalazion should be referred.
 Any atypical features i.e lash loss, bleeding should be referred.
 Any patient with previous history of Basal cell carcinoma (BCC) or Squamous cell
carcinoma (SCC) should be referred on.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Circumcision
Status:
Threshold Approval
MECCG commissions circumcision on a restricted basis.
Circumcision should only be performed for the following indications:
 Phimosis (inability to retract the foreskin due to a narrow prepucial ring) in children
when associated with recurrent infection. This does NOT include normal non-retractile
foreskin of childhood.
 Adult phimosis, usually caused by recurrent balanitis or Balanitis Xerotica Obliterans
(BXO)
 Suspicion or evidence of malignancy, dermatological disease (such as lichen planus or
eczema) which is unresponsive to other treatment, where biopsy is required and
occasionally for selected patients with urinary tract infections (normally referred by a
paediatrician)
There are several alternatives to treating retraction difficulties ( e.g. steroid creams) before
circumcision is carried out.
It is important that all those performing circumcision should follow the General Medical
Council (GMC) guidelines
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Continuous Positive Airway Pressure (CPAP) in Adults
Status:
Threshold Approval
MECCG commissions Continuous Positive Airway Pressure (CPAP) for patient with
moderate or severe Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS) in Adults
(≥15 hypopnoea events/hour per night)
CPAP is the first choice therapy for patients with moderate or severe OSAHS that is
sufficiently symptomatic to require intervention.
Persistent low CPAP use (less than two hours per night) over six months, following efforts to
improve patient comfort, should lead to a review of treatment.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Dilatation and Curettage/Hysteroscopy
Status:
Threshold Approval
MECCG commissions Dilatation and Curettage/Hysteroscopy on a restricted basis.
MECCG only funds D&C and hysteroscopy when used in line with NICE guidance (CG44,
2007)
Funding for patients to undergo hysteroscopy will only be made available for the investigation
and management of heavy menstrual bleeding when it is carried out:
 as an investigation for structural and histological abnormalities
o where ultrasound and endometrial biopsy has been used as a first line
diagnostic tool
and
o where the outcomes are inconclusive, for example to determine the exact
location of a fibroid or the exact nature of the abnormality;
 where endometrial ablation is required hysteroscopy should be considered immediately
prior to the ablative procedure to ensure correct placement of the device.
Funding will not be made available for patients to receive D&C:
 as a diagnostic tool for heavy menstrual bleeding; or
 as a therapeutic treatment for heavy menstrual bleeding.
Postmenopausal women who have had a pelvic scan and endometrial biopsy and who
present with further bleeding 6 months later should be offered hysteroscopy to be sure no
small cancer has been missed without a mandatory preliminary scan.
Hysteroscopy for the majority of women can be performed as an outpatient procedure.
NICE Heavy Menstrual Bleeding –Clinical Guideline January 2007
http://www.nice.org.uk/nicemedia/live/11002/30404/30404.pdf
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Dupuytren’s Contracture
Status:
Threshold Approval
Surgical and specialist drug treatment for Dupuytren’s contracture is commissioned by
MECCG on a restricted basis.
Cases will only be funded if they meet the criteria below:



Metacarpophalangeal joint (MCPJ) or Proximal IP joint contracture of 30° or more
(inability to place hand flat on table) AND
Where such condition (either MCPJ or PIPJ) is severely impacting on activity of daily
living OR
Young patients with early onset disease (25-40) +/- family history, who may benefit
from early assessment
The use of Collagenase clostridium histolyticum (Xiapex®) is not funded.
Radiation therapy for early Dupuytren’s contracture is not funded.
For audit purposes the referral letter should detail loss of extension and functional
impairment.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
Ref:
www.nice.org.uk/guidance/IPG43
www.nice.org.uk/guidance/IPG368
www.nice.org.uk/guidance/indevelopment/gid-tag364
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Policy statement:
Dysthyroid eye disease
Status:
Individual Prior Approval
MECCG commissions surgery for proptosis on a restricted basis for which individual prior
approval is required.
Funding will be provided to treat proptosis, arising from thyroid disease, as a result of
enlargement of muscles in the socket and increased fatty tissue or abnormality of position of
eyelid which causes extra exposure to the eye surface.
Surgery will only be offered for abnormality of the eyelid position after artificial tears have
been tried for at least 6 months and failed
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Exogen® Bone healing ultrasound system
Status:
Individual Prior Approval
MECCG commissions EXOGEN® ultrasound bone healing system for non-union in
long bone fracture on a restricted basis. 1
The case for adopting the EXOGEN® ultrasound bone healing system to treat long
bone fractures with non-union- i.e. failure to heal after 9 months but less than 12
months - is supported by the clinical evidence, which shows high rates of fracture
healing.
On this basis MECCG only funds EXOGEN® in the following circumstances:









In patients with non-union fractures in long bones which have failed to heal after 9
months but less than 12 months.
Patient age > 18 years
Patient does not have unstable surgical fixation
Bones are well aligned
Inter-fragment gap is ≤ 10mm
Patient is not pregnant
Patient does not have a pacemaker, poor blood circulation or clotting problems
Patient does not have fractures due to bone cancer or vertebral/skull fractures
Patient has the ability to comply with usage protocol and criteria in line with the
EXOGEN® International* Performance Program which includes a 90% minimum
adherence to the treatment regimen
MECCG does not commission the use of EXOGEN® in patients with delayed
healing fractures that have no radiological evidence of healing after 3 months.
MECCG does not commission the use of EXOGEN® for any other indications
Patients not meeting these criteria will only be funded in exceptional clinical
circumstances.
NOTE: For treatment failures, providers will ensure that a reimbursement is obtained in
accordance with the manufacturers “money back guarantee” arrangement; commissioners
will not fund these patients.
1
NICE guidance Medical Technology Guidance 12 found at http://guidance.nice.org.uk/mtg12
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Policy statement:
Ganglion
Status:
Threshold Approval
Surgical removal of ganglion in secondary care is commissioned by MECCG on a restricted
basis.
Cases will only be funded if they meet the criteria below:




Painful seed ganglia
OR
Mucoid cysts that are disturbing nail growth or have a tendency to discharge (risk of
septic arthritis in distal inter-phalangeal joint)
OR
Neurological loss or weakness of the wrist
OR
Where the ganglion has resulted in functional impairment which prevents the
individual from fulfilling work/study/carer or domestic responsibilities, but has not
responded to all appropriate conservative1 treatments over a minimum period of 3
months.
1
Conservative treatments include:
Reassurance – 35-45% of wrist ganglia resolve with no treatment at all.
Aspiration – There is a significant recurrence rate after a single aspiration (using wide bore
needle) but after 3 serial aspirations the recurrence rate is only 12-15% which is comparable
with surgery
There is no indication for the routine excision of simple ganglia; these should not
generally be referred.
For audit purposes, the referral letter and hospital records should include detail on:
 Precise location of ganglion e.g. flexor tendon
 Size in cm/inches (length and width)
 How function of the area is impaired? i.e. what is the patient unable to do as a result
of the ganglion?
 Degree of pain
 How long it has existed plus dates of 3 serial aspirations
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Grommets
Status:
Threshold Approval/Individual Prior Approval
MECCG commissions grommet insertion on a restricted basis.
Threshold Approval
Patients will be funded for grommet (ventilation tube) insertion if they meet the following criteria:

Children with persistent bilateral OME documented over a period of 3 months with a
hearing level in the better ear of 25–30 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz (or
equivalent dBA where dBHL not available)
OR

Children who have had at least 5 occurrences of acute otitis media in the last year with
additional complications such as perforations, persistent discharge, febrile convulsions,
sensor neural deafness or cochlear implantation.
The persistence of bilateral OME and hearing loss needs to be confirmed over a period of 3
months before surgical intervention will be considered. The child’s hearing should be re-tested
at the end of this time. During this active observation period of 3 months, advice on educational
and behavioural strategies to minimise the effects of the hearing loss should be offered.
Individual prior approval
Patients will be considered for funding if they meet one of the following criteria- individual prior
approval is required:

Children with persistent bilateral OME with a hearing loss less than 25–30 dBHL where the
impact of the hearing loss on a child’s developmental, social or educational status is judged to
be significant.

Adjuvant adenoidectomy will not be considered in the absence of persistent and/or frequent
upper respiratory tract symptoms in the child.

Children with Down’s Syndrome or cleft palate, as an alternative to hearing aids for treating
persistent bilateral OME with hearing loss (and/or significant impact on child’s developmental,
social or educational status)
For children with Down’s syndrome, the following factors need to be considered before the
intervention is offered:
o
o
o
o
o
the severity of hearing loss
the age of the child
the practicality of ventilation tube insertion
the risks associated with ventilation tubes
the likelihood of early extrusion of ventilation tubes
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Hernia (surgical treatment)
Status:
Threshold Approval
MECCG commissions surgical treatment of hernias on a restrictive basis for patients
meeting the defined criteria below. This policy covers the management of inguinal,
femoral, umbilical, ventral and incisional hernias, with criteria for referrals/treatment.
Inguinal:
For asymptomatic or minimally symptomatic hernias, we advocate a watchful waiting
approach, under informed consent.
Surgical treatment should only be offered when one of the following criteria is met:
 Symptomatic i.e. symptoms are such that they interfere with work or activities of daily
living OR
 The hernia is difficult or impossible to reduce, OR
 Inguino-scrotal hernia, OR
 The hernia increases in size month on month OR
 The patient is currently asymptomatic but works in a heavy manual occupation (for e.g.
in removal firms lifting heavy weights) and there is an increased risk of strangulation
and future complications.
Femoral:
 All suspected femoral hernias should be referred to secondary care due to the
increased risk of incarceration/strangulation
Umbilical:
Surgical treatment should only be offered when one of the following criteria is met:
 pain/discomfort interfering with Activities of Daily Living OR
 increase in size month on month OR
 to avoid incarceration or strangulation of bowel OR
 The patient is currently asymptomatic but works in a heavy manual occupation (for e.g.
in removal firms lifting heavy weights) and there is an increased risk of strangulation
and future complications
Incisional
Surgical treatment should only be offered when both of the following criteria are met:
 Pain/discomfort interfering with Activities of Daily Living
AND
 Appropriate conservative management has been tried first e.g. weight reduction where
appropriate OR
 The patient is currently asymptomatic but work in a heavy manual occupation (for e.g.
in removal firms lifting heavy weights) and there is a risk of strangulation and future
complications.
Divarication of Recti:
Diastases/Divarication of recti is a separation between the left and right side of the rectus
abdominis muscle, and causes a protrusion in the midline, but is not a 'true' hernia and does
not carry the risk of bowel becoming trapped within it and thus does not require repair.
Evidence suggests that divarication does not carry the same risks as that of actual herniation.
MECCG considers repair of divarication of recti as a cosmetic procedure and a low
priority and as such does not routinely fund.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Status:
Hip Arthroscopy- including surgery for FemoroAcetabular Impingement (FAI)
Individual Prior Approval/Threshold Approval
MECCG commissions hip arthroscopy on a restricted basis.
Patients will be considered for funding if they meet the following criteria for the conditions
listed.
Individual Prior Approval
Femoro-Acetabular Impingement (FAI)
The CCG will fund open or arthroscopic hip surgery for the treatment of femoro-acetabular
impingement (FAI) ONLY when patients fulfil ALL of the following criteria:






Diagnosis of definite femoro-acetabular impingement defined by appropriate
investigations, X-rays, MRI and CT scans.
An orthopaedic surgeon who specialises in young adult hip surgery has made the
diagnosis. This should include discussion of each case with a specialist musculoskeletal
radiologist.
Severe symptoms typical of FAI with duration of at least six months where diagnosis of
FAI has been made as above.
Failure to respond to all available conservative treatment options including activity
modification, pharmacological intervention and specialist physiotherapy.
Compromised function, which requires urgent treatment within a 6-8 months time frame,
or where failure to treat early is likely to significantly compromise surgical options at a
future date.
Treatment with more established surgical procedures is not clinically viable.
Exclusions for FAI
MECCG will not fund hip arthroscopy in patients with femoro-acetabular impingement where
any of the following criteria apply:
•
•
•
•
•
•
Patients with advanced Osteo-Arthritic change on preoperative X-ray (Tonnis grade 2 or
more) or severe cartilage injury (Outerbridge grade lll or lV).
Patients with a joint space on plain radiograph of the pelvis that is less than 2mm wide
anywhere along the sourcil.
Patients who are a candidate for hip replacement.
Any patient with severe hip dysplasia or with a Crowe grading classification of 4.
Patients with generalised joint laxity expecially in diseases connected with hypermobility
of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome.
Patients with osteogenesis imperfecta.
Treatment of FAI should be restricted to centres experienced in treating this condition and
staffed by surgeons adequately trained in techniques addressing FAI and all governance and
audit undertaken in accordance with NICE IPG 403 and 408.
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Threshold Approval
Sepsis of the hip joint
Hip arthroscopy is supported in the washout of an infected hip joint in patients refractory to
medical management, patients with underling disease or patients who are
immunosuppressed.
Loose bodies
Hip arthroscopy is supported for the removal of radiologically proven loose bodies within the
hip joint with an associated acute traumatic episode. Arthroscopy is not supported as a
diagnostic tool where there is suspicion of loose bodies.
Excision/repair of Radiological Proven Labral Tears in the Absence of OA or FemoroAcetabular Impingement Syndrome
Hip arthroscopy is supported for the excision of radiological proven labral tears associated
with an acute traumatic episode in the absence of OA or FAI syndrome.
Funding for hip arthroscopy for all other circumstances will only be made available for
clinically exceptional cases.
NICE interventional procedure guidance 408 and 403
https://www.nice.org.uk/guidance/ipg408/resources/guidance-arthroscopic-femoroacetabularsurgery-for-hip-impingement-syndrome-pdf
https://www.nice.org.uk/guidance/ipg403
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Policy statement:
Hip Injections
Status:
Individual Prior Approval
Current evidence on safety and efficacy does not appear adequate to routinely recommend
hip injections. On this basis MECCG only funds Hip injection in the following circumstances:





Diagnostic aid
To introduce contrast medium to the joint as part of hip arthrogram
Babies for hip arthrography
Children and adults with inflammatory arthropathy
Investigation of infection in biological and replaced hips.
Individual prior approval is required.
Funding outside the above circumstances will only be made available in clinically exceptional
cases.
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Policy statement:
Hip Replacement
Status:
Threshold Approval
MECCG commissions surgery for hip replacement on a restricted basis.
Referral should be when other pre-existing medical conditions have been optimised AND
conservative measures have been exhausted and failed.
MECCG will only fund hip joint replacement surgery if:

The patient complains of severe joint pain AND has radiological features of severe
disease AND has severe functional limitation irrespective of whether conservative
management has been trialled, OR

The patient complains of severe joint pain AND has radiological features of severe
disease AND has minor to moderate functional limitation, despite the use of nonsurgical treatments such as adequate doses of NSAID analgesia, weight control
treatments and physical therapies. OR

The patient complains of mild to moderate joint pain AND has radiological features of
severe disease AND has severe functional limitation, despite the use of non-surgical
treatments such as adequate doses of NSAID analgesia, weight control treatments
and physical therapies AND is assessed to be at low surgical risk.
Prostheses for total hip replacement are recommended as a treatment option for people with
end-stage arthritis of the hip only if the prostheses have rates (or projected rates) of revision
of 5% or less at 10 years.
Please refer to the classification of pain levels and functional limitations in the table on the
next page.
Referrals will not be accepted if the patient has an Oxford Hip Score greater than or
equal to 20. This scoring should be completed in Primary Care prior to referral. The tool can
be found at http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html
All patients referred to be considered for hip replacement should have completed the Patient
Decision Aid on http://sdm.rightcare.nhs.uk/pda/. This is available on website, on paper and
phone app.
Patients who do not fulfil the above criteria may be considered where there are exceptional
clinical circumstances
Evidence suggests that the following patients would be INAPPROPRIATE candidates
for hip joint replacement surgery:

Where the patient complains of mild joint pain AND has minor or moderate functional
limitation

Where the patient complains of moderate to severe joint pain AND has minor
functional limitation AND has not previously had an adequate trial of conservative
management as described above
Patients who are inappropriate for hip replacement surgery should not be listed for surgery.
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Hip replacement: Classification of Pain Levels and Functional Limitations
Variable
Pain Level
Definition
Mild
Pain interferes minimally on an intermittent basis with usual daily activities.
Not related to rest or sleep.
Pain controlled by one or more of the following: NSAIDs with no or
tolerable side effects, aspirin/paracetamol at regular doses.
Moderate
Pain occurs daily with movement and interferes with usual daily activities.
Vigorous activities cannot be performed.
Not related to rest or sleep.
Pain controlled by one or more of the following: NSAIDs with no or
tolerable side effects, aspirin/paracetamol at regular doses
Severe
Pain is constant and interferes with most activities of daily living.
Pain at rest or interferes with sleep.
Pain not controlled, even by narcotic analgesics.
Previous non-surgical treatments
Correctly Done
NSAIDs, paracetamol, aspirin or narcotic analgesics at regular doses
during 6 months with no pain relief; weight control treatment if overweight,
physical therapies done.
Incorrectly Done
NSAIDs, paracetamol, aspirin or narcotic analgesics at inadequate doses
or less than 6 months with no pain relief; or no weight control treatment if
overweight or no physical therapies done.
Functional Limitations
Minor
Functional capacity adequate to conduct normal activities and self care.
Walking capacity of more than one hour.
No aids needed.
Moderate
Functional capacity adequate to perform only a few or none of the normal
activities and self care.
Walking capacity of about one half hour.
Aids such as a cane are needed.
Severe
Largely or wholly incapacitated.
Walking capacity of less than half hour or unable to walk or bedridden.
Aids such as a cane, a walker or a wheelchair are required.
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Policy statement:
Hip resurfacing
Status:
Individual Prior Approval
MECCG commissions hip resurfacing on a restricted basis.
MECCG will only fund those patients who otherwise qualify for primary total hip replacement,
but are likely to outlive conventional primary hip replacements as restricted by NICE
Guidance Hip disease - metal on metal hip resurfacing (TA44). Hip resurfacing is not
generally considered the best option for women over the age of 65. Clinicians applying for
funding approval should provide full clinical rationale for choice.
Prostheses for resurfacing arthroplasty are recommended as a treatment option for people
with end-stage arthritis of the hip only if the prostheses have rates (or projected rates) of
revision of 5% or less at 10 years.
http://www.nice.org.uk/guidance/ta304/resources/guidance-total-hip-replacement-andresurfacing-arthroplasty-for-endstage-arthritis-of-the-hip-review-of-technology-appraisalguidance-2-and-44-pdf
Issued: February 2014
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Policy statement:
Hysterectomy for heavy menstrual bleeding
Status:
Threshold Approval
Hysterectomy for heavy menstrual bleeding will only be funded by MECCG within NICE
guidance and when

There has been a trial, after appropriate clinical assessment, with a levonorgestrelreleasing intrauterine system LNG-IUS, e.g. Mirena®, unless contraindicated, for at
least 6 cycles and this has not successfully relieved symptoms or has produced
unacceptable side effects.
AND

At least one of another treatment has failed, is not appropriate or is contra-indicated
in line with NICE guidelines2:
• Alternative hormonal treatment in keeping with NICE guidance
• NSAIDs and Tranexamic Acid
For those who for ethical reasons cannot accept the use of Mirena®, they should
have tried at least two of the alternative treatments.
AND

Either of the following are not clinically appropriate
• Endometrial ablation if normal uterus
or if LNG-IUS contraindicated or if ablation is contraindicated e. g. previous multiple
caesarean section
• Endometrial resection
Contraindications to the levonorgestrel intrauterine system are:





Distorted or small uterine cavity (with proven ultrasound measurements; Uterocervical
canal length < 5cm)
Genital malignancy
Active trophoblastic disease
Active pelvic inflammatory disease
Large cavity over 10cm length
Funding for hysterectomy outside the above criteria will only be funded in clinically
exceptional circumstances.
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Policy statement :
Status:
Ingrown Toe Nails (surgery)
Threshold Approval/Individual Prior Approval
MECCG commissions surgery for ingrown toe nails on a restricted basis.
Threshold Approval
Referrals to commissioned community providers for nail surgery for ingrowing toenails will
only be accepted for patients with moderate to severe symptoms where primary care
management has failed
Moderate-Severe Symptoms include:
 Increased pain and inflammation of the toe
 Purulent drainage
 Bleeding
 Recurrent Infection





Severe and disabling pain
Substantial erythema and inflammation
Severe infection
Chronic inflammation and granulation
Nail fold hypertrophy
Individual Prior Approval
Surgery for ingrown toe nails is not routinely commissioned in a secondary care setting
unless future orthopaedic surgery would be compromised- for example a recurrent infected
ingrown toenail requiring treatment prior to joint replacement surgery. Individual prior
approval must be sought.
Funding for surgery for ingrown toenails for patients not meeting the above criteria will only
be made available in clinically exceptional circumstances.
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Policy statement:
Knee Arthroscopy
Status:
Threshold Approval
Knee arthroscopy in secondary care is commissioned by MECCG on a restricted basis.
Cases will only be funded if they meet the criteria below:
Arthroscopy of the knee can be undertaken where a competent clinical examination (or MRI
scan if there is diagnostic reason) has demonstrated clear evidence of an internal joint
derangement (meniscal tear, ligament rupture or loose body) and where conservative
treatment has failed or where it is clear that conservative treatment will not be effective.
Knee arthroscopy can therefore be carried out for:
 Removal of loose body
 Meniscal repair or resection / repair of chondral defects
 Ligament reconstruction/repair (including lateral release)
 Synovectomy / symptomatic plica
 To assist selection of appropriate patients for uni-compartmental knee replacement
Knee arthroscopy should NOT be carried out (and will not be funded) for any of the following
indications:
 Investigation of knee pain (MRI is a less invasive alternative for the investigation of
knee pain)
 Treatment of osteoarthritis including arthroscopic washout and debridement.
In line with NICE guidance CG59; this should not be offered as part of treatment for
osteoarthritis unless the individual has knee osteoarthritis with a clear history of
mechanical locking (not gelling, ‘giving way’)
Funding for knee arthroscopy outside the defined criteria will only be funded in clinically
exceptional circumstances.
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Policy Statement:
Knee Replacement
Status:
Threshold Approval
MECCG commissions knee replacements on a restricted basis.
Referral should only be made when other pre-existing medical conditions have been
optimised AND conservative measures have been exhausted and failed. This will include
weight reduction, NSAIDs and analgesics, changing activity, and introducing a walking aid.
Please refer to the classification of pain levels and functional limitations in the table on the
next page.
MECCG will only fund knee replacements if:

The patient complains of intense or severe symptomatology AND has radiological
features of severe disease AND has demonstrated disease within all three
compartments of the knee (tri-compartmental) or localised to one compartment plus
patello-femoral disease (bi-compartmental). OR

The patient complains of intense or severe symptomatology AND has radiological
features of moderate disease AND is troubled by limited mobility or stability of the
knee joint.
Referrals will not be accepted if the patient has an Oxford Knee Score greater than or
equal to 20. This scoring should be completed in Primary Care prior to referral. The tool can
be found at http://www.orthopaedicscore.com/scorepages/oxford_knee_score.html
All patients referred to be considered for a knee replacement should have completed the
Patient Decision Aid on http://sdm.rightcare.nhs.uk/pda/. This is available on website, on
paper and phone app.
Patients who do not fulfil the above criteria may be considered where there are exceptional
clinical circumstances
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Knee replacement: classification of pain levels and functional limitations
Variable
Pain Level
Back to index
Definition
Mild
Pain interferes minimally on an intermittent basis with usual daily activities.
Not related to rest or sleep.
Pain controlled by one or more of the following: NSAIDs with no or
tolerable side effects, aspirin/paracetamol at regular doses
Moderate
Pain occurs daily with movement and interferes with usual daily activities.
Vigorous activities cannot be performed.
Not related to rest or sleep.
Pain controlled by one or more of the following: NSAIDs with no or
tolerable side effects, aspirin/paracetamol at regular doses
Severe
Pain is constant and interferes with most activities of daily living.
Pain at rest or interferes with sleep.
Pain not controlled, even by narcotic analgesics.
Previous non-surgical treatments
Correctly Done
NSAIDs, paracetamol, aspirin or narcotic analgesics at regular doses
during 6 months with no pain relief; weight control treatment if overweight,
physical therapies done.
Incorrectly Done
NSAIDs, paracetamol, aspirin or narcotic analgesics at inadequate doses
or less than 6 months with no pain relief; or no weight control treatment if
overweight or no physical therapies done.
Functional Limitations
Minor
Functional capacity adequate to conduct normal activities and self care.
Walking capacity of more than one hour.
No aids needed.
Moderate
Functional capacity adequate to perform only a few or none of the normal
activities and self care.
Walking capacity of about one half hour.
Aids such as a cane are needed.
Severe
Largely or wholly incapacitated.
Walking capacity of less than half hour or unable to walk or bedridden.
Aids such as a cane, a walker or a wheelchair are required.
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Policy statement:
Labial Reduction/Refashioning/Vaginoplasty/Cliteroplasty
Status:
Individual Prior Approval
MECCG does not routinely commission elective vaginal labia reduction/refashioning or
hymenorrhaphy or vaginoplasty or cliteroplasty as these are considered to be cosmetic
procedures
except
•
•
vaginoplasty for congenital absence, significant developmental/endocrine abnormalities of
the vaginal canal or post-traumatic vaginal stenosis
reconstructive surgery for patients who have gone through female genital mutilation or
cutting
where individual funding requests will be considered.
Repair of labia at the time of trauma will be routinely funded. Post immediate trauma
applications will only be considered where there are clinically exceptional circumstances.
Funding for patients outside this policy will only be granted in clinically exceptional
circumstances
N.B. NHS England is responsible for commissioning gender identity disorder services from
Specialist Gender Identity Disorder Clinic Centres. This includes specialist assessment, nonsurgical care packages, transgender surgery and associated aftercare.
.
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Policy statement:
Lymphoedema Services
Status:
Threshold Approval
MECCG commissions community based lymphoedema services. MECCG does not routinely
commission intensive inpatient therapy or treatment in specialist units outside commissioned
pathways.
As lymphoedema is only one cause of oedema, the GP should ensure
 the correct diagnosis (remembering that most causes of peripheral oedema are cardiac,
renal, hepatic or venous in origin, rather than lymphoedema)
 The oedema is persistent or greater than 3 months duration; or
 Patient is at known risk of lymphoedema.
 Patient must have tried and failed all available conservative management options before
referral to a community based lymphoedema service.
GPs must include evidence of meeting these requirements and confirm meets the criteria
below before referral to a community based lymphoedema service.
Patients who are restricted from having treatment for an unrelated condition that is usually
available on the NHS and has the effect of increasing life-expectancy or quality life years as a
direct result of the lymphoedema will be offered treatment.
Funding for patients not meeting the above criteria will only be approved in clinically
exceptional circumstances.
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Policy statement:
Status:
Nasal Surgery (including Rhinoplasty and
Septorhinoplasty)
Individual Prior Approval
Nasal surgery to correct deformity and the cosmetic appearance of the nose, including
Rhinoplasty and Septorhinoplasty, is not routinely funded by MECCG.
Primary care must obtain prior approval before referring patients to secondary care providers
and secondary care providers must satisfy themselves that the patient has funding secured
prior to seeing the patient. This is to ensure inappropriate out-patient appointments are
avoided and patient expectations are properly managed.
NB: This policy does not apply to immediate post trauma nasal manipulation which
normally occurs two to three weeks after the trauma and does not require prior
approval from the Commissioner.
Requests for corrective nasal surgery will be considered where the patient has:

Post-traumatic nasal injury causing continuous and chronic nasal airway obstruction
associated with septal/bony deviation of the nose which is causing significant
functional impairment.

Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial
deformity causing significant functional impairment

Part of reconstructive head and neck surgery.
OR
OR
MECCG will not approve funding for patients who are unhappy with the outcome of previous
surgeries including immediate post-trauma corrections (whether provided by the NHS or
private providers) or for snoring unless they meet the criteria above.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Nipple Inversion
Status:
Threshold approval
MECCG commissions surgery to correct nipple inversions on a restricted basis.
Nipple inversion may occur as a result of underlying breast malignancy. If the inversion is
newly developed, it requires urgent referral and assessment.
Surgical correction of nipple inversion is only funded for functional reasons i.e inability to
feed their child in a post-pubertal woman and where the inversion has not been corrected by
correct use of a non-invasive suction device. GPs who refer must ensure that patients
comply with this criteria.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Open MRIs
Status:
Individual Prior Approval
Referral for open MRIs in secondary care is commissioned by MECGG on a restricted basis.
Cases will only be funded if they meet the criteria below:

Open MRI scans will only be funded for morbidly obese patients unable to
access local MRI services because of their size.
Patients with claustrophobia are not eligible for open MRI scans.
Funding outside this criterion will only be provided in clinically exceptional circumstances.
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Policy statement:
Orthoses
Status:
Threshold Approval
MECCG commissions orthoses on a restricted basis.
MECCG does not routinely fund assessment for and/or orthoses (custom; off-the shelf; ‘inshoe’ appliances) except for conditions listed below.
Referrals for assessment for orthoses will only be accepted for the following conditions.
1. Neurodisability
2. Talipes equinovarus
3. Adolescent tendinopathy at risk of developmental compromise
4. Post operative patients
5. Congenital skeletal abnormality
6. Burns
MECCG only funds customised orthoses for these listed conditions where the clinical need of
a patient cannot be met using an ‘off-the-shelf’ orthoses.
Patients with structural/flexible flat foot requiring arch supports/pronation control orthoses
should not be referred but advised to purchase ‘off-the-shelf’ /’in-shoe’ orthoses if required.
Patients who have been funded for ‘off-the-shelf’ /’in-shoe’ orthoses by MECCG in the past
will no longer be funded on this basis alone.
Cervical Soft Collars
MECCG does not routinely commission cervical soft collars.
Lumbar Supports
MECCG does not routinely commission lumbar support orthoses other than custom moulded
back braces when prescribed following consultation with NHS commissioned spinal specialist
surgeons.
Funding outside these criteria will only be provided in clinically exceptional circumstances.
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Policy statement:
Penile Implants
Status:
Threshold Approval
MECCG will only fund penile implants for post-cancer reconstruction.
Funding outside this criterion will only be provided in clinically exceptional circumstances.
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Policy statement:
Pinnaplasty/Otoplasty
Status:
Individual Prior Approval
MECCG commissions Pinnaplasty/Otoplasty surgery on a restricted basis.
Cases will only be funded if they meet the criteria below:
Patients may be eligible for surgery to correct prominent ears if both of the following criteria
are met:

Patient is aged between 10 and 16 years old
AND

With very significant ear deformity or asymmetry-
All applications for funding must be accompanied by photographs
Funding outside these criteria will only be provided in clinically exceptional circumstances.
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Policy statement:
Repair of Ear Lobes
Status:
Threshold Approval
MECCG commissions surgical repair of ear lobes on a restricted basis.
This will be routinely funded for primary suture post trauma at the time of trauma only. e.g.
the patient is automatically eligible for emergency treatment when he/she presents for repair
at A&E at the time of trauma.
Post immediate trauma applications will only be considered where there are clinically
exceptional circumstances.
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Policy statement
Reversal of Sterilisation
Status:
Individual Prior Approval
MECCG commissions reversal of sterilisation on a restricted basis.
Funding will only be considered if death of an existing child of the man has occurred, OR
remarriage following death of spouse, OR loss of unborn child when vasectomy had taken
place during the pregnancy.
Funding will only be considered if death of an existing child of the woman has occurred, OR
remarriage following death of spouse AND partner has a satisfactory sperm count.
Patients should be aware that even if a successful reversal of sterilisation has taken place,
they will not be eligible for IVF treatment.
Funding outside these criteria will only be provided in clinically exceptional circumstances.
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Policy statement:
Scar Revision
Status:
Individual Prior Approval
MECCG commissions surgery for scar revision on a restricted basis.

Funding for surgery for revision of scars will only be considered where the scar
interferes with function.
GPs should not refer unless the above criterion applies and referrals must include objective
information to demonstrate this.
Photographs will be required to support any application for funding
Funding will only be made outside this criterion available where there are exceptional clinical
circumstances.
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Policy statement:
Shoulder Arthroscopy
Status:
Threshold approval
MECCG commissions shoulder arthroscopy on a restricted basis.
Shoulder arthroscopy will only be funded for patients with adhesive capsulitis (‘frozen
shoulder’) if the following treatments have all been tried and failed:
(a)
(b)
(c)
(d)
(e)
Activity modification
Physiotherapy and exercise programme
Oral analgesics including NSAIDs (unless contraindicated)
Intra-articular steroid injections
Manipulation under anaesthetic
GPs should not refer unless all the above have been tried and failed, and referrals must
include objective information to demonstrate this.
Providers should be aware that payment may be withheld if they cannot demonstrate that
patients meet these criteria.
Funding will only be made outside this criterion available where there are exceptional clinical
circumstances.
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Policy statement:
Sleep Studies including Diagnostic Investigations
and Treatments for Obstructive Sleep
Apnoea/Hypopnoea Syndrome (OSAHS) in Adults
Status:
Threshold Approval
MECCG commissions sleep studies for adults (over 18 years of age) with suspected sleep
apnoea, complex sleep disorders or where necessary to confirm a diagnosis of narcolepsy.
NHS England commissions sleep studies for children and young people from Specialist
Paediatric Respiratory Centres. http://www.england.nhs.uk/wp-content/uploads/2014/01/pssmanual.pdf
Oral Appliances/Mandibular Advancement Devices
Oral appliances have been shown to improve OSAHS and, in comparison with continuous
positive airway pressure (CPAP), no conclusive difference in daytime sleepiness was shown.
There are large cost, convenience and adherence implications for the use of CPAP and, for
some patients, oral appliances may be of benefit. Therefore, oral applications (self-funded)
should be promoted in primary care to avoid where possible the need for CPAP.
Driving
It is the responsibility of people who are sleepy during the day (regardless of the cause) to
cease driving until their symptoms resolve. If the symptoms are severe enough to affect
driving performance and are due or very likely due to a medical condition (including OSAHS)
the driver must inform the DVLA. Although clinicians are not required to inform the DVLA
about the patient’s symptoms, they are responsible for advising the patient appropriately.
Vocational drivers of Heavy Goods Vehicles (HGVs) or Public Service Vehicles (PSVs)
meeting the referral criteria of this policy may be referred for investigation with
oximetry/polysomnography without attempted lifestyle modification and, if diagnosed with
OSAHS at any level of severity may be offered oral devices or CPAP as initial options. For
vocational drivers, if a diagnosis of OSAHS has been made or is strongly suspected
adequate symptom control should be confirmed by a specialist before driving resumes and
annual licensing review is required
Limited Sleep Studies
MECCG commissions limited sleep studies (pulse oximetry) for patients with suspected sleep
apnoea where other causes of day time sleepiness have been excluded e.g. insufficient
sleep, psychological conditions and sedating drugs.
If obstructive sleep apnoea is suspected the patient should have attempted lifestyle
modification i.e. weight loss, stop smoking, reduce alcohol consumption- as appropriate
before referral.
The following criteria must be met prior to referral for limited sleep studies:
 Patient ≥ 18
 Patient snores
 Daytime sleepiness (rather than tiredness) assessed by Epworth scale with score ≥11
AND one or more of the following
• Witnessed regular or frequent nocturnal apnoeic episodes of stopping
breathing
• Waking with sensations of choking/obstruction
• Neck circumference ≥17ins in a man or > 15ins in a woman
• Significant retrognathia
• Small oedematous pharynx on visual inspection
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Polysomnograpy
Patient has ≥5 <15 hyponea events/hour per night measured by pulse oximetry
OR
Patients who have typical symptoms of excessive daytime somnolence but no objective
evidence of obstructive sleep apnoea on limited sleep study.
OR
Patient has suspected narcolepsy and confirmation of diagnosis Is required.
MECCG does not commission surgical procedures for OSAHS.
MECCG does not commission sleep studies for parasomnia, periodic limb movement
disorder, chronic insomnia or snoring.
MECCG does not routinely commission procedures for snoring where this is the sole
problem- Snoring
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
Ref: http://www.sign.ac.uk/pdf/sign73.pdf
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Policy statement:
Sperm, Embryo or Oocyte Cryostorage
Status:
Individual Prior Approval
MECCG commissions Sperm, Embryo or Oocyte Cryostorage on a restricted basis.
Funding for fertility preservation will be offered to patients who have a disease or a condition
requiring medical or surgical treatment that has a significant likelihood of making them
infertile.
The following fertility preservation methods will be considered for funding: 


Sperm cryostorage
Embryo cryostorage
Oocyte cryostorage
Patients must meet the following criteria:

Commenced puberty and be aged up to 41 years old for women or up to 55 years old for
men.

Women not only need to be well enough to undergo ovarian stimulation and egg
collection but this should not worsen their condition and that sufficient time is available
prior to starting treatment.

No Living or Adopted Children - From either current or any previous relationships. The
adoption of children confers the legal status of parent to the adoptive parents; this will
apply to both adoptions in and out of the family.
Embryo or oocycte cryostorage will not be available where a woman:
 chooses to undergo medical or surgical treatment whose primary purpose is that it will
render her infertile, such as sterilisation
 requests cryostorage for personal lifestyle reasons, such as wishing to delay trying to
conceive.
The sperm, embryos or oocytes will be stored for an initial period of 10 years. It is possible to
extend the time of storage, if the material has not been used. This will require additional
approval from MECCG.
Funding for use of stored material for assisted conception is considered to be low
priority by MECCG and is not routinely funded.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
It should be noted that the CCG is not the responsible commissioner for Pre-i
mplantation Genetic Diagnosis and associated IVF/ICSI. This service is commissioned by
NHS England
Specialist fertility services for members of the Armed Forces are commissioned separately by
NHS England
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Policy statement:
Spinal cord stimulation
Status:
Individual Prior Approval
MECCG commissions spinal cord stimulation in accordance with NICE TA 159.
Spinal cord stimulation is recommended as a possible treatment for adults with chronic pain
of neuropathic origin if they:


continue to experience chronic pain (measuring at least 50 mm on a 0–100 mm visual
analogue scale) for at least 6 months despite standard treatments, and
have had a successful trial of spinal cord stimulation as part of an assessment by a
specialist team
Treatment with spinal cord stimulation should only be given after the person has been
assessed by a specialist team experienced in assessing and managing people receiving
treatment with spinal cord stimulation.
MECCG will not routinely fund high frequency stimulators.
Re-chargeable batteries for implantable pulse generators will be funded where this avoids the
need for further surgery. It is expected that where there are different systems of equal
effectiveness, the least costly system is used
MECCG does not commission Spinal cord stimulation as a treatment option for adults
with chronic pain of ischaemic origin
Funding for patients not meeting the above criteria will only be funded in clinically exceptional
circumstances.
Ref: Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin
NICE technology appraisal guidance [TA159] Published date: October 2008
https://www.nice.org.uk/guidance/ta159
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Policy statement:
Spinal Injections (Therapeutic) for
Pain Related to the Lumbar Spine
Status:
Threshold Approval
NB. This policy addresses therapeutic use of spinal injections. It does not address diagnostic
indications.
(1) Any spinal therapeutic injection for patients with chronic pain1
Injections of therapeutic substances for pain related to the lumbar spine are not routinely
commissioned for patients with chronic non-specific back pain.
MECCG routinely commissions spinal therapeutic injections for chronic radicular pain only
where recommended as part of a specialist multidisciplinary pain clinic management plan
AND
A programme of conservative management* has been unsuccessful or is not possible due to
coexisting physical or mental illness or frailty.
*Conservative management must include the following from a NHS commissioned
service: advice and information on back pain management; group or customized
exercise programme and where appropriate (according to specialist reassessment)
manual therapy or hydrotherapy.
On referral to the specialist multidisciplinary pain clinic, patients must be informed that the
referral is for assessment and development of a pain management plan. Patients should not
be under the impression that the decision to provide an injection has already been made or
that repeat injections are routinely available.
(2) Therapeutic epidural injections, sacroiliac injections and nerve root blocks in
patients with acute episodes of pain (including acute on chronic)
Commissioning of single injections is restricted to the following indications:
The patient needs urgent relief of severe acute spinal pain.
OR
A specialist pain clinician judges that a single injection is necessary and appropriate to
enable participation in a conservative pain management programme.
OR
The patient is unable to participate effectively in conservative pain management due to
coexisting physical or mental illness or frailty.
Repeat injections should not be routinely provided as there is a lack of high quality supporting
evidence for long term pain relief and clinical advice suggests diminishing returns with
increased risk of adverse events
contd
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Repeat injections are commissioned only:
If a specialist pain clinician taking account of multi-disciplinary team assessment, concludes
that benefits outweigh harms:
AND
The patient has been clinically assessed as having had a substantial and sustained benefit
from their first injection;
AND
The patient has been assessed as continuing to be unable to benefit from conservative
management;
AND
Up to a maximum of 3 injections in 6 months.
On referral to the specialist multidisciplinary pain clinic, patients must be informed that the
referral is for assessment and development of a pain management plan. Patients should not
be under the impression that the decision to provide an injection has already been made or
that repeat injections are routinely available.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Spinal Surgery for Non-Acute Lumbar Conditions
Status:
Individual Prior Approval
Recent changes in who commissions which aspects of back surgery are outlined below
The NHS England commissions:
 All spinal deformity surgery (adults and children)
 All spinal reconstruction surgery (adults and children)
 Palliative or curative spinal oncology surgery (adults and children)
 Revision surgery for which the primary surgery is specialist, for example,
 revision surgery with instrumentation for over 2 levels
 All primary thoracic and primary anterior lumbar surgery
 Posterior cervical decompression surgery using instrumentation
 Cervical corpectomy
CCGs may commission:
 revision surgery for which the primary surgery is non-specialist, i.e. revision surgery
with instrumentation for 2 levels or under
 posterior cervical decompression surgery without instrumentation
 anterior cervical decompression surgery (discectomy or fusion)
 all spinal injections
 primary lumbar decompression/discectomy
 posterior lumbar un-instrumented fusions
 lumbar instrumented fusion for 2 levels or less
 revision, instrumented lumbar fusion for 2 levels or less
MECCG only commissions spinal surgery for non-acute lumbar conditions on a
restricted basis.
Funding for patients to receive non-acute+ spinal surgery will only be made available under
the following circumstance:
Surgical discectomy (standard or microdiscectomy) in selected patients with sciatica
secondary to disc prolapse where conservative management for at least 4-6 weeks has
failed.
NHS England does not routinely fund spinal surgery for lower back pain.
Mid Essex Clinical Commissioning Group does not accept requests to fund spinal surgery for
lower back pain.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
+Acute
conditions include back pain due to fracture, dislocation, complications of tumour or infection and/or nerve
root or spinal compression responsible for progressive neurological deficit.
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Policy statement:
Tinnitus
Status:
Threshold Approval
MECCG provides funding for investigation of tinnitus on a restricted basis.
Investigation is funded if the patient has:
 Consistent bilateral tinnitus (persistent for over 20 weeks) and hearing loss.
 Unilateral tinnitus (persistent over 2 months)
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Tonsillectomy
Status:
Threshold Approval
MECCG commissions tonsillectomy on a restrictive basis for those patients who meet the
SIGN Guidance 117 (April 2010) http://www.sign.ac.uk/pdf/sign117.pdf or one of the
conditions listed below.
A period of 6 months watchful waiting by the GP is recommended prior to tonsillectomy to
establish firmly the pattern of symptoms and allow the patient to consider fully the
implications of operation.
Patients should meet all of the following criteria:

AND

AND

Sore throats that are due to acute tonsillitis
Episodes of sore throat that are disabling and prevent normal functioning
Seven or more well documented, clinically significant, adequately treated sore throats
in the preceding year.
OR

Five or more such episodes in each of the preceding two years.

Three or more such episodes in each of the preceding three years.
OR
OR the patient should have one of the following conditions:

intractable cough with a high level of streptococcal antibody for longer than one year;

severe halitosis which has been demonstrated to be due to tonsil crypt debris for
longer than one year. (diagnosed by an ENT surgeons)

lymphoma and Ca tonsil,

obstructive sleep apnoea,

peritonsillar abscess not responding to antibiotics and incisional drainage.
GPs should not refer unless the above criteria have been met, and referrals must include
objective information to demonstrate this.
Once a decision is made for tonsillectomy, this should be performed as soon as possible, to
maximise the period of benefit before natural resolution of symptoms might occur (without
tonsillectomy).
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Trigger Finger
Status:
Threshold Approval
Referral for trigger finger in secondary care is commissioned by MECCG on a restricted
basis. Cases will only be funded if they meet the criteria below:

Patients who fail to respond to all appropriate conservative1 treatments for a minimum
of 6 months.
Conservative1 treatments include:
Reassurance – up to 83% have been found to resolve spontaneously after a few
months.
Steroid injection – 50-80% will resolve after a single injection and a second injection
should be carried out after 6 weeks if no response to first injection.
OR

Patients who have a fixed flexion deformity that cannot be corrected and that is
severely impacting on activity of daily living
OR

Patients who have recurrent triggering after 2 injections
For audit purposes, the referral letter and hospital records must include evidence that the
patient meets the criteria, including the dates of the corticosteroid injections and any other
conservative management.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
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Policy statement:
Varicose Veins
Status:
Threshold Approval
Treatments for varicose veins are considered as procedures of low clinical priority and
therefore not routinely funded by the Commissioner.
Conservative management is the first line of treatment and applications will not normally be
accepted without evidence that conservative management of asymptomatic and symptomatic
varicose veins has been tried, and failed, for a period of at least six months.
Prior to consideration for intervention patients should be given information regarding
 Weight loss if they have a raised BMI
 Light to moderate physical activity
 Avoiding factors which are known to make their symptoms worse, if possible
 Use of compression stockings for a 6 month duration, where this is considered
appropriate
 When and where to seek further medial help
MECCG commissions treatment or surgery for varicose veins on a restrictive basis.
Funding for treatment or surgery will only be made available for Grade III and above
Varicose Veins.
Grade III: Varicose veins with complications, including bleeding, recurrent phlebitis or
eczema.



Patients who have had bleeding associated with varicose veins should be referred
urgently.
Patients with recurrent thrombophlebitis and persistent varicose veins may be
referred, especially if phlebitis has affected veins above the knee.
Patients with eczema near the ankle or associated with varicose veins below the
knee should be referred for specialist advice.
VARICOSE ECZEMA
STASIS GRAVITATIONAL ECZEMA
Interventional treatment should be in line with NICE guidance which identifies endothermal
ablation as the first line intervention where suitable.
Funding for patients not meeting the above criteria will only be granted in clinically
exceptional circumstances.
In drafting this policy it was noted that NICE CG 168 recommends that all symptomatic varicose veins should be
referred for investigation and, where appropriate, treatment. Current resources cannot meet the demand that this
would generate either in commissioning costs or in the capacity to undertake Doppler examinations etc. This
policy is intended as a holding position until resources are available and the required pathway and contracting
changes have been made to enable full adoption of NICE CG 168.
http://www.nice.org.uk/guidance/CG168/chapter/introduction
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Policy statement:
Wigs, Hairpieces and Hair Transplant/Replacement
Systems
Threshold Approval
MECCG commissions hair pieces and wigs for patients experiencing total or severe hair loss
as a result of alopecia totalis, cancer treatment, previous surgery or trauma, and are available
from local NHS Trusts through commissioned pathways-referral to dermatologists or
oncologist as appropriate.
Patients requiring reconstruction of the eyebrow following cancer or trauma will be treated
within existing contracts.
MECCG does not routinely commission treatments for the correction of male or female
pattern baldness as it is a normal process of ageing.
MECCG does not routinely commission hair transplantation or the use of the ‘Interlace’ or
other hair systems, regardless of gender. Patients who are already being treated and funded
by the NHS and who require ongoing funding for maintenance and support will be considered
on an individual patient basis, and continued funding only granted in clinically exceptional
circumstances.
Funding for patient outside this policy will only be granted in exceptional clinical
circumstances.
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Policy statement:
Low Clinical Priority Procedures
Status:
Not Funded
The following procedures have been assessed as Low Clinical Priority by Mid Essex CCG
and will not be funded unless there are exceptional clinical circumstances. Applications
for funding for these procedures can be made to the Exceptional Case Team but should only
be made where the patient demonstrates true clinical exceptionality.
This list includes recently assessed areas of care, and providers must not assume that
because a treatment/intervention/procedure is not included in this list that by default it will be
funded. Mid Essex CCG’s policy is that treatments/interventions/procedures not currently
included in established care pathways (as identified for example in the Schedules to the
service agreements with acute care provides) or identified for funding through the
commissioning process are not routinely funded.
Cosmetic/plastic surgery is not routinely funded outside commissioned pathways e.g.
following surgery, trauma or for congenital malformation as detailed in policies or
commissioned pathways. Post-surgical reconstruction is commissioned as per service level
agreements for surgical services.
The effect of the problem on essential activities of day-to-day living is a key factor in
decision-making. In such cases, psychological treatment such as counselling or cognitive
behavioural therapy may be considered as an appropriate alternative to surgery.
It is not necessary to obtain a psychiatric opinion to support an application. MECCG expects
mental health professionals to treat related problems through established procedures
commissioned from the mental health trust and this would not include surgery. MECCG
Exceptional Cases Panel consistently takes the view that psycho-social considerations
should not be a justification for surgery.
Where referrers consider that there may be exceptional clinical circumstances they must
provide details of these exceptional clinical circumstances bearing in mind the points above.
All individual funding requests should be accompanied by suitable clinical photography that
demonstrates the extent of the problem. This, of course, would be subject to patient consent.
Policy statement:
Acne Vulgaris
MECCG does not routinely fund resurfacing or other surgical treatments.
Policy statement:
Aesthetic Facial Surgery
MECCG does not routinely fund Aesthetic Facial Surgery.
Policy statement:
Autologous Cartilage Transplantation
MECCG does not routinely fund autologous cartilage transplantation
Policy statement:
Bobath Therapy
MECCG commissions a number of Bobath trained therapists as part of its routine therapy
services. Referral for assessment and/or treatment at specific Bobath centres will not be
routinely funded.
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Policy statement:
Bone Anchored Hearing Aid
MECCG does not commission BAHAs; this is the responsibility of NHS England.
NHS England routinely commissions unilateral BAHAs for patient’s meeting the
commissioning policy but will not normally commission bilateral Bone Anchored Hearing Aid
(BAHA) implantation. Such requests for funding will only be considered through an
exceptions route.
See full policy: http://www.england.nhs.uk/ourwork/d-com/spec-serv/policies/
Policy statement:
Breast Asymmetry/Breast Reduction/Mastopexy
(including revision and replacement)
MECCG does not routinely fund surgery or treatments e.g. prosthetics for Breast Asymmetry
or Breast Reduction or Mastopexy (including revision and replacement).
Policy statement:
Chronic Fatigue Syndrome
Patients should be managed by GPs as recommended by NICE clinical guideline number 53
– Chronic Fatigue syndrome/ myalgic encephalomyelitis (or encephalopathy) – Diagnosis and
management of CFS/ME in adults and children’.
However MECCG will not routinely fund referral to a secondary care specialist in CFS/ME
care for assessment or treatment on either an in-patient or outpatient basis outside routinely
commissioned pathways.
The clinical guideline also states the following:
 Do not use the following drugs for the treatment of CFS/ME: monoamine oxidase
inhibitors, glucocorticoids (such as hydrocortisone), mineralocorticoids (such as
fludrocortisone), dexamphetamine, methylphenidate, thyroxine or antiviral agents.
 There is insufficient evidence for the use of supplements – such as vitamin B12,
vitamin C, co-enzyme Q10, magnesium, NADH (nicotinamide adenine dinucleotide) or
multivitamins and minerals – for people with CFS/ME, and therefore they should not
be prescribed for treating the symptoms of the condition. However, some people
with CFS/ME have reported finding these helpful as a part of a self-management
strategy for their symptoms.
 People with CFS/ME who are using supplements should be advised not to exceed the
safe levels recommended by the Food Standards Agency
Policy statement:
Cochlear Implants
NHS England commissions cochlear implantation services. This includes the multidisciplinary assessment, surgical implantation and rehabilitation (including maintenance of
the implant). MECCG only commissions the initial general hearing assessment for patients
who go on to have specialist assessment for cochlear implants.
http://www.england.nhs.uk/wp-content/uploads/2013/04/d09-ps-a.pdf
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Policy statement:
Complementary and Alternative Therapies
MECCG does not routinely fund standalone treatment with complementary or alternative
therapies. This restriction applies equally to primary and secondary care provision, and GPs
must not prescribe such products on FP10s.
This includes (but is not exhaustive):
Acupuncture
Hypnosis
Alexander Technique
Homeopathy
Applied Kinesiology
Massage
Aromatherapy
Meditation
Autogenic Training
Naturopathy
Ayurveda
Nutritional Therapy
Chiropractic Environmental Medicine
Reflexology
Osteopathy
Reiki
Healing
Shiatsu
Herbal Medicine
Other alternative therapies
Policy statement:
Continuous Glucose Monitoring in Type 1 Diabetes
MECCG does not routinely fund continuous glucose monitoring in adults, children or young
people with Type 1 Diabetes.
Mid Essex CCG commissions the provision of continuous subcutaneous insulin infusions (via
insulin pumps) in line with NICE Technology Appraisal 151. In accordance with NICE
principles and the ethos of NICE clinical guideline Type 1 diabetes in adults: diagnosis and
management (nice.org.uk/guidance/ng17) the CCG supports funding of the insulin pump with
the lowest acquisition cost that meets the clinical needs of the patient, and without
consideration of a patient’s desire to self-fund CGM. Co-funding, which involves both private
and NHS funding for a single episode of care, is not permitted for NHS care. The choice of
pump in very young children should take into account the ability to deliver a very low basal
rate
The CCG recognises that NICE guidelines [NG17] and NICE guidelines [NG18] on management of
type 1 diabetes in adults, children and young people include recommendations on use of CGM. This
policy is intended as a holding position until resources are available
Policy statement:
Dental Procedures (Orthodontics, Wisdom Teeth)
Commissioning of all dental treatments and procedures including orthodontic treatment and
wisdom tooth removal is now the responsibility of NHS England, and is therefore not
commissioned or funded by MECCG
Policy statement:
Face Lifts and Brow Lifts (Rhytidectomy)
MECCG does not routinely fund Face Lifts and Brow Lifts.
Policy statement:
Facet Joint Injections and Medial branch blocks
MECCG does not routinely fund Therapeutic facet joint injections and medial branch
blocks
Facet joint injections are only commissioned for diagnostic assessment and only in patients
being assessed for surgical management of chronic spinal pain.
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Policy statement:
Female Sterilisation
MECCG does not routinely fund female sterilisation.
Policy statement:
Fibroid Embolisation / Uterine Artery Embolisation
MECCG does not routinely fund Fibroid Embolisation / Uterine Artery Embolisation.
Policy statement:
Functional Electrical Stimulation (FES)
MECCG does not routinely fund Functional electrical stimulation (FES) for the treatment of
dropped foot in patients with neurological conditions as this is considered a low priority
procedure
For patients already being treated and funded by the NHS, who require ongoing
funding for maintenance and support, prior approval will be required and the following
criteria apply:
 The patient will have objectively demonstrated (using validated tools) that the
use of FES is still clinically appropriate, e.g. by
o foot drop which impedes gait and evidence that this is not satisfactorily
controlled using ankle–foot orthoses
o gait improvement from its use
Policy statement:
Gastroelectrical Stimulation
MECCG does not routinely fund Gastric nerve/Gastro electrical simulation for use in
intractable nausea and vomiting from idiopathic or diabetic gastroparesis.
Policy statement:
Gender Dysphoria
MECCG does not commission gender identity disorder services. This is the
responsibility of NHS England.
NHS England commissions gender identity disorder services from Specialist Gender Identity
Disorder Clinic Centres. This includes specialist assessment, non-surgical care packages,
transgender surgery and associated aftercare. In this context, commissioning includes
deciding which treatments should be commissioned by the NHSE – in the light of clinical and
cost effectiveness information – and which should not. Clinical Commissioning Groups
(CCGs) do not commission any elements of this service, regardless of whether or the NHSE
funds them. MECCG will not accept requests to fund these treatments.
GPs are responsible for the initiation and on-going prescribing of hormone therapy and for
organising blood and other diagnostic tests as recommended by the Specialist Gender
Identity Disorder Clinic Centres.
GPs should ensure that a patient has been accepted on an NHS treatment pathway at an
NHS England commissioned Specialist Gender Identity Disorder Clinic before accepting any
prescribing responsibility for hormone therapy.
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Policy statement:
Gynaecomastia
MECCG does not routinely fund surgery for gynaecomastia.
Policy statement:
Hirsutism/hair depilation
MECCG does not routinely fund hair depilation procedures or medication e.g. Vaniqa.
Policy statement:
IVF (Assisted Conception Using IVF/ICS/IUI -Specialist
Fertility Services)
MECCG does not routinely fund Specialist Fertility Services- including assisted conception
using IVF/ICS/IUI.
Policy statement:
Liposuction
MECCG does not routinely fund liposuction procedures.
Policy statement:
Rhinophyma
MECCG does not routinely fund rhinophyma.
Policy statement:
Sacroneuromodulation
MECCG does not routinely commission sacroneuromodulation.
NHS England are
responsible for commissioning Sacroneuromodulation for faecal and urinary incontinence.
Policy statement:
Skin Contouring
MECCG does not routinely fund skin contouring
Policy statement:
Snoring
MECCG does not routinely fund procedures for simple snoring where this is the sole problem.
Surgical interventions for simple snoring include, but may not be limited to, the following and
will not be routinely funded:
Uvulopalatopharyngoplasty (UP3 or UPPP)
Laser assisted uvulopalatoplasty (LAUP)
Radiofrequency ablation (RFA)
Soft palate implants
If associated with sleep apnoea see Sleep Studies
Policy statement:
Surrogacy
MECCG does not routinely fund surrogacy.
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Policy statement:
Tattoo Removal
MECCG does not routinely fund procedures for the removal of tattoos.
Policy statement:
Temporomandibular Joint Replacement
MECCG does not routinely fund temporomandibular joint replacement.
Policy statement:
Temporalmandibular Joint Retainers and Appliances
MECCG does not routinely fund TMJ appliances e.g. Therabite. GPs should not accept
requests to prescribe such appliances on FP10s.
Policy statement:
Toric intraocular lens implant for astigmatism
MECCG does not routinely fund toric intraocular lens implants as there is insufficient
evidence to demonstrate safety, clinical and cost effectiveness. Toric IOLs refer to
astigmatism correcting intraocular lenses used at the time of cataract surgery to decrease
post-operative astigmatism.
Policy statement:
Vasectomies
MECCG does not routinely fund vasectomies.
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Policy statement:
Interventional Procedure Guidance
NICE issues Interventional Procedure Guidance (IPGs) with the aim of protecting the
safety of patients and supporting the NHS in the process of introducing new
procedures. The IPGs are not covered by the Secretary of State’s directions to NHS
organisations to fund the implementation of NICE recommendations within a given
timescale because this direction relates only to NICE Technology Appraisal Guidance
(TAGs).
Interventional Procedure Guidance makes recommendations on the safety of the procedure
and how well it works. The guidance does not recommend whether the NHS should fund a
procedure; or not and these decisions are therefore for the CCGs.
ME CCG recognises that it is not within the remit of the NICE IPG Programme to evaluate the
cost-effectiveness of interventional procedures or to advise the NHS whether interventional
procedures should be funded.
Specific commissioning position with respect to different categories of IPG
1.1 Special Arrangements
Mid Essex CCG will not routinely fund health care interventions that are subject to a NICE
IPG where the IPG states:
 Current evidence on safety is inadequate.
 Current evidence on efficacy is inadequate.
 Evidence of safety and efficacy is on small numbers of patients and of limited quality.
 No major safety concerns, but efficacy has not been shown.
 Evidence is limited to a small number of patients. Good short term efficacy but little
evidence of long term efficacy.
 There is adequate evidence of safety and efficacy but the technical demands are such
that is should not be used without special arrangements.
 Evidence for short term efficacy is limited and long term outcomes are uncertain.
1.2 Research Only
Mid Essex CCG will not routinely fund health care interventions that the NICE IPG
programme has recommended should only be undertaken in the context of research.
Clinicians wishing to undertake such procedures should ensure they fulfil the normal
requirements for undertaking research.
Where there is a possibility that there may be impacts on NHS funded care following the
cessation of the trial, or a patient’s completion of a trial, clinicians must discuss this with the
CCG at the earliest opportunity.
1.3 Do not use
Mid Essex CCG will not fund health care interventions where a NICE IPG recommends that
the intervention should not be used in the NHS.
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