Download Procedures of Limited Clinical Effectiveness policy

Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
Procedures of Limited Clinical Effectiveness policy 2016/17 – 2017/18
Introduction
This document is the Procedures of Limited Clinical Effectiveness (PoLCE) policy for Barking and Dagenham, Havering and Redbridge Clinical
Commissioning Groups (BHR CCGs). It is arranged in chapters covering the different surgical and medical areas and sets out the exclusion and
access criteria against which Individual Funding Requests (IFRs) for the listed procedures will be considered. Only when patients meet these
criteria, or where exceptional and evidenced circumstances exist, will IFRs be granted.
The document is valid for the period 1 December 2016 until 31 March 2018. It will be kept under regular review to ensure that it reflects
developments in the evidence base regarding clinical and cost effectiveness.
The PoLCE policy does not include description of the IFR process, the forms required, the appeals process or timescales.
General principles
1. A guiding principle of the PoLCE review process was that procedures funded by the BHR CCGs should only be funded and undertaken to
address medical conditions and symptoms; therefore, no procedures will be funded for cosmetic purposes only. Where significant psychological
distress is cited as a reason for seeking cosmetic treatment, the CCGs would expect that this distress be identified and treated via the standard
mental health pathways, rather than by approving cosmetic interventions.
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2. Another guiding principle was that no group of patients with similar conditions should be disadvantaged in accessing procedures
compared with others. For this reason, the PoLCE policy recommendations do not specify that procedures will be funded if a
condition affects an individual’s ‘ability to work’ (which had been used in previous policies but may disadvantage, for example,
people who are retired or students or unemployed). Therefore the policy refers to restrictions to an individual’s functions and daily
living.
3. The PoLCE policy does not include procedures which are not considered to be ‘of Limited Clinical Effectiveness’ and are
therefore not restricted on the ground of their effectiveness. Therefore, referring clinicians should consider any procedure not
covered within the policy to be unrestricted.
Review of Individual Funding Request process
The Individual Funding Request process will be reviewed by BHR CCGs following development of the POLCE policy for 2017/182018/19. This is a result of the feedback received from both primary and secondary care clinicians during the POLCE review
process, and of the IFR team’s continuing commitment to deliver a robust, clinically sound, clear process within as short turnaround
timescales as possible.
Contacts
For information about the IFR process, forms, timescales or application of criteria:
Individual Funding Requests team,
North and East London Commissioning Support Unit, Second Floor, Clifton House,
75-77 Worship Street,
London, EC2A 2DU.
Telephone: 020 3688 1290
Email: [email protected]
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
1. Breast
Augmentation
BHR CCGs will not routinely fund breast augmentation (augmentation mammoplasty).
Reduction of the larger breast should be regarded as the first line treatment for patients seeking to correct breast asymmetry
(see breast asymmetry policy below).
In rare situations and with prior approval, funding for breast augmentation may be considered if the criteria below are met
and evidenced:
1.
developmental failure resulting in unilateral or bilateral absence of breast tissue or asymmetry ≥ two cup
sizes(Congenital amastia)
OR
2.
breast asymmetry ≥ two cup sizes due to mastectomy, excision breast surgery for cancer/lumpectomy, prophylactic
mastectomy for cancer prevention in high risk cases
OR
3.
for breast asymmetry ≥ two cup sizes due to trauma or burns, or endocrine abnormalities
BHR CCGs do not provide breast augmentation for the following patient cohorts unless there are exceptional circumstances:
•
patients that have reduced breast tissue following weight loss – (including after bariatric surgery)
•
patients that have reduced breast tissue following pregnancy
•
patients that perceive that they have small symmetrical breasts
N.B: Evidence that pubertal growth of breasts has ceased must be documented, i.e. there has been no change in the size of
either breast over the previous 18 months and the woman is over 18 years old.
2. Revision of breast
augmentation
BHR CCGs will commission the removal of breast implants for any of the following indications in patients who have
undergone cosmetic augmentation mammoplasty:
1. breast disease
2. implants complicated by recurrent infections
3. implants with capsule formation that is associated with severe pain
4. implants with capsule formation that interferes with mammography
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
5. intra or extra capsular rupture of silicon gel-filled implants
Reinsertion of new breast implants will only be commissioned if the original implant insertion was funded by the NHS and the
patient would still be eligible for breast implant under BHR CCGs commissioning policies, for example post mastectomy or to
correct asymmetry.
BHR CCGs will not contribute funding to procedures funded privately, irrespective of whether part of that procedure involves
removal of breast implants.
3. Female breast
reduction, correction
of breast asymmetry
and breast lift
(mastopexy)
N.B. This breast reduction policy is not applicable to the removal of symptomatic accessory breast tissue, which is routinely
commissioned by the CCGs.
Bilateral breast reduction surgery is not routinely funded by BHR CCGs.
In rare occasions and with prior approval funding may be considered if the criteria below are met and evidenced:
1. the patient’s breast size is cup size H or larger
AND
2. the breast reduction surgery should result in a reduction in breast size of at least three cup sizes*/ 500gm per side
AND
3. the patient has a BMI equal to or below 27 kg/m2 for at least two years (documented).
AND
4. evidence to be submitted to demonstrate patient is symptomatic – with at least two of the following for at least one year
(documented evidence of GP visits for these problems):
•
pain in the neck
•
pain in the upper back
•
pain in the shoulders
•
painful kyphosis documented by X-rays
•
pain / discomfort / ulceration from bra straps cutting into shoulders
AND
5. Evidence to be submitted to demonstrate pain symptoms persist as documented by the physician despite a six month trial
of therapeutic measures including all of the following:
•
supportive devices (e.g., proper bra/support bra fitted by a trained bra fitter, wide bra straps)
•
analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
•
physical therapy / exercises / posturing manoeuvres
AND
6. there are significant muskulo-skeletal pain or symptoms that are causing significant functional impairment which in the
opinion of the referrer (in the opinion of an appropriate specialist) are likely to be corrected or significantly improved by
surgery.
Chronic intertrigo, eczema or dermatitis alone will not be considered as grounds for this procedure unless the entire above
are met and the patient has failed to respond to six months of conservative treatment.
Correction of breast asymmetry is not routinely funded by BHS CCGs. Unilateral breast reduction (NOT
augmentation) will be funded only in the following circumstances:
1. where there is gross asymmetry (difference in size a minimum three cup* sizes)
AND
2. where there is no ability to maintain a normal breast shape using non-surgical methods (e.g. padded bra)
AND
3. the woman’s breasts are fully developed i.e. there has been no change in the size of either breast over the previous 18
months
AND
4. the woman is aged over 18 years
*Cup sizing - AA, A, B, C, D, DD, E, F, FF, G, GG, H, HH, J, JJ, K, L
Breast lift surgery or ‘Mastopexy’ is not routinely funded by BHR CCGs as either:
•
a component of breast reduction surgery
OR
•
as a stand-alone procedure
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
4. Male breast
reduction
This procedure is not routinely funded by BHR CCGs. With prior approval it will be funded in the following circumstances:
5. Abdominoplasty
and excess skin
excision
Abdominoplasty and other excess skin excision surgery including buttock, thigh and arm lifts will not be routinely funded by
BHR CCGs.
1. the applicant demonstrates that they have screened for and excluded all treatable causes of gynaecomastia (drug related
– particularly abuse of anabolic steroids, endocrine)
AND
2. the patient is both post pubertal AND in the case of idiopathic gynaecomastia has had this for at least 18 months (to allow
spontaneous resolution)
AND
3. gynaecomastia is causing pain unrelieved by standard analgesia
AND
4. the patient has a BMI of less than 27 kg/m2
AND
5. a consultant surgeon has confirmed that the patient has grade III gynaecomastia (i.e. gross breast enlargement with skin
redundancy and ptosis so as to simulate a pendulous female breast) AND the proposed reduction is greater than 100gm per
side. AND
6. the patient is aged 25 years or older
Additional information:
Gynaecomastia is commonly seen during puberty and may correct once the post pubertal fat distribution is complete if the
patient has a normal BMI. It may be unilateral or bilateral. Rarely, it may be caused by an underlying endocrine abnormality
or a drug related cause including the abuse of anabolic steroids.
It is important that male breast cancer is not mistaken for gynaecomastia and, if there is any doubt, an urgent consultation
with an appropriate specialist should be obtained.
Requests for funding will be considered with prior approval for patients who meet both criteria 1 and 2 below plus one of
criteria 3a-c.
1.
2.
following weight loss have a stable BMI of less than 27 Kg/m2 for at least 24 months
AND
in the case of bariatric surgery, had their surgery at least two years previously
AND
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
3a.
3b.
3c.
have severe functional problems from excessive abdominal skin folds as defined as:
Severe difficulties with daily living (i.e. walking, dressing, toileting) which have been formally assessed, and for which
abdominoplasty will provide a clear resolution.
OR
documented evidence of clinical pathology due to the excess of overlying skin e.g. recurrent infections or intertrigo
which has led to ulceration requiring four or more courses of antibiotics in the 24 month period of stable weight.
OR
where overhanging skin makes it impossible to maintain care of stoma bags.
BHR CCGs do not routinely commission surgery to correct divarification (or diastasis) of the rectus abdominis muscles
irrespective of whether additional abdominoplasty is requested because there is no good evidence that this surgery is
anything other than cosmetic.
6. Excision of skin and
subcutaneous lesions
These procedures are not routinely funded by BHR CCGs.
A patient with a skin or subcutaneous lesion that has features suspicious of malignancy must be referred to an
appropriate specialist for urgent assessment.
Benign skin lesions may occasionally be excised for a differential diagnosis. Clinically benign moles should not be
referred for cosmetic reasons.
Suspicious pigmented lesions should always be subjected to excision biopsy and sent for histology, if referred to
secondary care this should be to a pigmented lesions clinic.
For all other benign skin lesions the CCG will only routinely fund surgery in patients meeting one of the following criteria:

the lesion is unavoidably and significantly traumatised on a regular basis and this results in significant
infections such that the patient requires two or more courses of oral or intravenous antibiotics per year.
OR
 the lesion is obstructing an orifice OR impairing field vision
OR

the lesion significantly impacts on function e.g. restricts joint movement by >20 degrees
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
7. Treatment of
vascular lesions
BHR CCGs will not routinely fund treatments for vascular lesions as most interventions are for cosmetic purposes and there is
a limited evidence of effectiveness.
Any IFR application on the basis of significant facial disfigurement should be accompanied by high quality colour photographs
and a statement that the patient is fully aware that treatment effect may be modest.
The IFR panel will consider each case.
For all patients a very clear statement of exceptionality would be required given that this intervention is not routinely
commissioned.
8. Keloid and other
scar revision
BHR CCGs will not fund procedures to re-fashion scars for cosmetic purposes.
Funding for surgery for revision of scars will be considered through the IFR process where the scar interferes with physical
functioning.
Keloid Scars
BHR CCGs will not fund surgical procedures to re-fashion keloid scars for cosmetic purposes. Symptomatic keloid scars may
be treated if the scar:
•
interferes with physical function
OR
•
causes pain or itchiness for six months and as unrelieved by standard medication
Patients should be informed that having surgery on a scar will in itself leave a new scar that will take up to two years to
improve in appearance. If surgery is used to treat a hypertrophic scar, there is a risk that the scarring may be worse after the
surgery.
Corticosteroid injections and Haelan tape should therefore be considered the first line treatment for keloid scars. The aim of
injections and tape is to improve the appearance of the scar. Patients should be informed of the need to wear the tape for 12
hours daily for at least 3 months.
Low-dose, superficial radiotherapy may reduce the recurrence rate of hypertrophic and keloid scars after surgery. Because of
the possibility of long-term side effects, it is only reserved for the most serious cases. IFR applications must describe the
clinical exceptionality for any case. IFR applications have been received and approved for surgery with radiotherapy
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
9. Pinnaplasty or
otoplasty
BHR CCGs will commission surgical ‘correction’ of prominent ear(s) only when all of the following criteria are met:
1. referral only for children aged five to 18 years at the time of referral
AND
2. with very significant ear deformity or asymmetry demonstrated by clinical photography
Patients not meeting these criteria should not be routinely referred for surgery.
Applications for funding made on the basis of disfigurement should be supported by high quality clinical photography.
10. Botulinum toxin
BHR CCGs will not fund the use of Botulinum for cosmetic treatments. Please see separate section on use of Botulinum toxin
in oculoplastics.
Botulinum A toxin is routinely funded only for:
1.
spasticity, hand and wrist disability associated with stroke, hemofacial spasm, spasmodic torticollis
2.
severe hyperhidrosis, overactive bladder syndrome
Botulinum B toxin is routinely funded only for:
1.
spasmodic torticollis
2.
as alternative to Botulinum toxin A in presence of antibodies to Botulinum A.
For palmar or plantar hyperhidrosis, other procedures such as iontophoresis appear to be more effective and have fewer side
effects and should be considered as initial treatment.
Botox treatment needs to be repeated after six to nine months.
Botulinum A will also be approved for treatment of migraine for patients who meet the criteria described in NICE TA
260:
1.1 Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with chronic migraine
(defined as headaches on at least 15 days per month of which at least eight days are with migraine) that has not responded
to at least three prior pharmacological prophylaxis therapies and whose condition is appropriately managed for medication
overuse.
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
1.2 Treatment with botulinum toxin type A that is recommended according to 1.1 should be stopped in people whose
condition: is not adequately responding to treatment (defined as less than a 30% reduction in headache days per month after
two treatment cycles) or has changed to episodic migraine (defined as fewer than 15 headache days per month) for three
consecutive months.
Botulinum Toxin applications in oculoplastics
BHR CCGs will fund the use Botulinum A/ by an oculoplastics specialist in the following circumstances:
Blepharospasm
Botulinum A toxin is routinely funded for the treatment of blepharospasm.
Entropion
Botox will be commissioned by BHR CCGs for patients with INVOLUTIONAL entropion who meet one of the following criteria:



have a corneal ulcer/keratopathy secondary to entropion
OR
where surgery is contraindicated due to medical co-morbidities not warranting cessation of anticoagulation
OR
patient with advanced dementia, who is not fit for surgery under local, with or without sedation or general
anaesthesia
Corneal Ulcer/lagophthalmos
Botox will be commissioned by BHR CCGs for patients with corneal ulcer/ lagophthalmos who:
 have a corneal ulcer due to facial palsy and lagophthalmos to induce a protective ptosis
OR
 have a corneal ulcer due to lagophthalmos secondary to eyelid retraction, trauma or proptosis to induce a
protective ptosis
Botox treatment may need to be repeated after three to six months.
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
11. Hair epilation (hair
removal by
electrolysis or laser)
Hair epilation is not routinely funded by BHR CCGs.
Funding for hair epilation may be approved by the IFR panel for patients who:
1.
have undergone reconstructive surgery leading to abnormally located hair-bearing skin to the face, neck or upper
chest (areas not covered by normal clothing)
OR
2.
are undergoing treatment for pilonidal sinuses to reduce recurrence
For patients who do not meet these criteria, an IFR application will ONLY be considered (for facial, neck or upper chest areas
not covered by normal clothing) on completion of the relevant section explaining for the benefit of the IFR panel why the
patient differs from the cohort of similarly hirsute patients such that they are likely to gain more health benefit from
depilation which is not available to other similar patients.
Patients undergoing gender reassignment procedures will be assessed in accordance with this policy as it applies to a natural
born male or female, as appropriate. An IFR application would need to be submitted in this context explaining precisely why
the transgender person is likely to gain significantly greater health benefit than other patients for whom the same
procedures are not funded.
In the event that NHS funding is agreed it will be for a maximum of six treatments. By including this statement we are
implying we will fund ‘a trial of treatment’ and it could be contradictory to the paragraph below
Because BHR CCGs do not fund maintenance treatment for hirsuitism, it is not considered appropriate to commission an
intervention whose effects are likely to be transitory and psychological distress would be likely to recur.
Severe hirsutism due to an endocrine disorder may be referred to an endocrinology department but this is not an indication
for NHS funding of epilation.
This policy does not cover the treatment of symptomatic trichiasis, which is funded by BHR CCGs.
12. Nipple inversion
Nipple inversion may occur as a result of an underlying breast malignancy and it is essential that this be excluded.
Surgical correction of nipple inversion will be funded by BHR CCGs (with prior approval) only for functional reasons in a postpubertal woman, if the inversion has not been corrected by correct use of a non-invasive suction device.
Additional information:
Idiopathic nipple inversion may be corrected by the application of sustained suction. Commercially available devices are
available from major chemists or online without prescription. Best results are seen where this is used correctly for up to
three months.
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
13. Liposuction
This procedure is not routinely funded by BHR CCGs.
14. Treatment for hair
loss
The standard management of significant hair loss is the NHS funded provision of a limited range of wigs.
Therefore, alternative interventions for hair loss, including but not limited to:

hair grafting and flaps with/ without tissue expansion

The non-NHS provided ‘Interlace system’

Alternative, non-NHS wigs are not routinely funded by BHR CCGs.
Funding for treatment may be approved by the IFR panel when the alopecia is a result of previous surgery or trauma
including burns IF there is sufficient evidence to demonstrate to the IFR panel that:
•
AND
•
the intervention is clinically necessary rather than cosmetic (photographs may be helpful in this regard) but this
would still be a value judgement by the panel who will need guidance on how to define ‘clinically necessary
the intervention is likely to be clinically effective in the context of the patient’s previous surgery or trauma
Additional information:
‘Male pattern’ baldness is a normal process for many men at whatever age it occurs and affects significant numbers of
women.
15. Hair
transplantation
This procedure is not routinely funded by BHR CCGs.
Funding may be approved by the IFR panel as part of the treatment pathway for reconstruction following cancer or trauma.
IF there is sufficient evidence to demonstrate to the IFR panel that:
•
the intervention is clinically necessary rather than cosmetic (photographs may be helpful in this regard)
•
the intervention is likely to be clinically effective
16. Face lifts and brow
lifts (rhytidectomy)
This procedure is not routinely funded by BHR CCGs.
Funding will only be considered to correct:
•
•
impairment of vision OR
impairment of the visual field(s) (as described in the criterion for blepharoplasty below).
Rhinoplasty
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
This cosmetic procedure is not routinely funded by BHR CCGs.
Funding will be approved for patients with:
1. demonstrable obstruction of the nasal airway
AND
2. significant symptoms confirmed by an ENT consultant as resulting from nasal obstruction
AND
3. symptoms that persist despite at least three months of conservative management with, where appropriate, nasal steroids
or immunotherapy.
Additional information:
Correction of complex congenital conditions e.g. cleft lip and palate is commissioned by NHS England.
17. Surgery on the
upper or lower eyelid
(blepharoplasty)
This procedure is not routinely funded by BHR CCGs.
NHS funding will only be considered to correct:
1. impairment of visual field(s) in the relaxed, non-compensated state where visual field test results are submitted to show
that eyelids impinge on visual fields reducing them to 1200 laterally and 400 vertically
OR
2. clinical observation of poor eyelid function, discomfort, e.g. headache worsening towards end of day and / or evidence of
chronic compensation through elevation of the brow
OR
3. significant ectropion or entropion that requires correction.
Additional information:
Excessive skin in the lower lid may cause “eyebags” but does not affect eyelid function or vision and therefore does not need
correction.
18. Repair of totally
split ear lobes (or
lobules)
This procedure is not routinely funded by BHR CCGs.
19. Tattoo removal
This procedure is not routinely funded by BHR CCGs.
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
20. Cosmetic genital
procedures
(Labiaplasty)
Labiaplasty is not routinely funded by BHR CCGs.
IFR applications for labiaplasty should be made by a gynaecologist and describe the clinical circumstances which necessitate
surgery. This procedure will be considered and limited to cancer and congenital malformations. Discomfort during sexual
intercourse and difficulty with certain lifestyle choices are both very subjective criteria and may be influenced by
psychological factors.
21. Double balloon
enteroscopy
BHR CCGs will not routinely fund double balloon enteroscopy (DBE) for diagnostic purposes.
BHR CCGs will not routinely fund DBE for therapeutic interventions, but in some cases where alternative interventions have
been exhausted (including but not limited to wireless capsule endoscopy, radiological imaging, the patient is symptomatic,
and surgical first line therapy is not suitable, an IFR application may be considered if submitted by the acute trust gastrointestinal MDT
22. Abdominal wall
hernia management
and repair
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, the commissioner advocates a watchful waiting approach including
providing reassurance, pain management etc. under informed consent.
Surgical treatment will only be approved when one of the following criteria is met:
•
symptomatic i.e. Significant symptoms that interfere with activities of daily living or the ability to work
OR
•
the hernia is difficult or impossible to reduce
OR
•
history of incarceration
OR
•
Inguino-scrotal hernia
OR
•
The hernia increases in size month on month.
Umbilical:
Surgical treatment will only be approved when one of the following criteria is met:
•
significant symptoms that interfere with activities of daily living or the ability to work
OR
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
•
OR
•
increase in size month on month
to avoid incarceration or strangulation of bowel
Incisional:
Surgical treatment will only be approved when both of the following criteria are met:
•
significant symptoms that interfere with activities of daily living or the ability to work AND
•
appropriate conservative management has been tried first e.g. weight reduction where appropriate
Femoral:
All suspected femoral hernias are approved for a referral to secondary care due to the increased risk of
incarceration/strangulation and do not require prior approval to be sought.
Impalpable hernia and groin pain
Patients with groin pain and occult hernia (without clinical evidence of hernia) should be offered watchful waiting for their
‘hernia’.
23.
Haemorrhoidectomy
BHR CCGs will fund for 3rd degree and 4th degree haemorrhoids through haemorrhoidectomy in cases where the
following conditions are met:
•
Conservative treatment has failed:
- diet modification to relieve constipation
- topical applications
- stool softeners and laxatives
- rubber band ligation
- sclerosant injections
- infrared coagulation
AND
•
haemorrhoids are recurrent
OR
•
there is persistent bleeding
OR
•
haemorrhoids cannot be reduced.
Surgical treatment options include:
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
•
•
•
surgical excision (haemorrhoidectomy)
stapled haemorrhoidopexy
haemorrhoidal artery ligation
NB: Policy does not apply to referrals for suspected cancer and acute, profuse rectal bleeding.
24. Varicose veins
Intervention, including open surgery (ligation and stripping), endovenous laser ablation, and radiofrequency ablation is
appropriate only for significant and intractable symptoms and signs including:
 Symptomatic primary or symptomatic recurrent varicose veins, unresolved by at least 6 months conservative
management (exercise, elevation)

Lower-limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency

Superficial vein thrombosis (characterised by the appearance of hard, painful veins) and suspected venous incompetence

A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)
 A healed venous leg ulcer.
NICE Guidance
http://www.nice.org.uk/guidance/qs67/resources/guidance-varicose-veins-in-the-legs-pdf
25. Autologous
chrondocyte
(cartilage)
implantation
BHR CCGs will not fund this procedure.
26. Circumcision
Non-medical circumcision is not routinely funded.
Female circumcision is prohibited under the Prohibition of Female Circumcision Act 1995. Circumcision is funded for medical
indications, including:
1. phimosis seriously interfering with urine flow and/or associated with recurrent infection
2. some cases of paraphimosis
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
3. suspected cancer or balanitis obliterans
4. congenital urological abnormalities when skin is required for grafting and interference with normal sexual activity in adult
males
5. recurrent, significantly troublesome episodes of infection beneath the foreskin
6. to restore functional anatomy after female circumcision to facilitate childbirth where mutilation renders this hazardous
27. Cholecystectomy
for asymptomatic gall
stones
Surgery for asymptomatic gallstones is not routinely funded as there is limited evidence that intervention under these
circumstances is beneficial.
Additional information:
Approximately 10-20% of people in western countries have gallstones, and most (50-70%) are asymptomatic at the time of
diagnosis. Asymptomatic disease has a benign natural course and progression to symptomatic disease is relatively low,
ranging from 10-25%. The majority of patients do not develop gallstone-related complications without first having at least
one episode of pain.
28. Treatment for
varicocoele
BHR CCGs will fund treatment of varicocoele only if patient experiences persistent discomfort of pain despite normal
conservative management.
Additional information:
There is no evidence that treating varicocoele can help male sub-fertility problems.
29. Surgical excision of
ganglia
Surgical excision of ganglia will be funded in the following circumstances:
1. they are painful seed ganglia
OR
2. they are mucoid cysts arising at the distal inter-phalangeal joint and cause significant skin breakdown, significant nail
deformity or repeatedly discharge
OR
3. they cause significant functional impairment and/ or pain is unrelieved by aspiration or injection
OR
4. there is diagnostic uncertainty.
Additional information:
Patients should be re-assured about the benign nature of other ganglia and be informed that:
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Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
•
•
33% of dorsal ganglions and 45% of volar-wrist ganglia would resolve spontaneously in six years
the recurrence rate after excision of wrist ganglia is between 10 – 45%.
30. Trigger finger
BHR CCGs will only fund treatment if the following conditions are met:
• patients diagnosed with trigger finger who fail to respond to conservative non-invasive treatment methods e.g.
exercise/massage, rest from aggravating activities, splinting, NSAIDs
AND
• who fail to respond to at least one corticosteroid injections
OR
• who have a fixed flexion deformity that cannot be corrected by conservative measures
OR
• where corticosteroid injection is contraindicated
31. Dupuytren’s
contracture
BHR CCG will fund surgical treatment when:
•
the patient has a 30 degree fixed flexion deformity at either the metacarpophalanageal joint or proximal
interphalangeal joint
AND
the patient cannot flatten their fingers or palm on a table
OR
•
there has been rapid progression over a few months
32. Sympathectomy
for severe
hyperhidrosis (palmar,
plantar, axillary)
Sympathectomy will only be funded if the following conditions are met:
1. significant focal hyperhidrosis and a one to two month trial of aluminium salts (under primary care supervision to ensure
compliance) has been unsuccessful in controlling the condition
OR
2. significant focal hyperhidrosis and intolerance of topical aluminium salts despite reduced frequency of application and use
of topical 1% hydrocortisone
AND all of the following conservative therapies have been tried and found to be unsuitable or unsuccessful:
3. treatment of underlying anxiety if it is an exacerbating factor
4. referral to a dermatologist for modified topical therapy
5. prescription of oral anticholinergics (which block the effect of the nerves that stimulate the sweat glands) iontophoresis
(for palmar or plantar hyperhidrosis) or botulinum toxin injections (for axillary hyperhidrosis).
Additional information:
18
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
Sympathectomy is an established intervention for this condition BUT should be considered only after all other non- invasive
non-surgical treatment options have been tried and failed.
Compensatory sweating following sympathectomy is common and can be worse than the original problem. Patients should
be made aware of this risk.
33. Occipital nerve
stimulation for cluster
headache
This procedure will not be routinely funded by BHR CCG on the basis of limited evidence of effectiveness.
34. Functional
electrical stimulation
(FES) for footdrop
Based on the evidence of clinical and cost effectiveness provided, FES is not routinely commissioned.
For patients with ongoing funding for maintenance and support, prior approval will be required and the following criteria will
apply:
The patient will have objectively demonstrated that the use of FES is still clinically appropriate by:
•
foot drop which impedes gait and evidence that this is not satisfactorily controlled using ankle –foot orthosis
•
gait improvement from its use
35. Exogen bone
healing
BHR CCGs will fund the use of the EXOGEN ultrasound bone healing system to treat long bone fractures with non-union only
(failure to heal after 9 months).
NICE Guidance
MTG12: EXOGEN ultrasound bone healing system for long bone fractures with non-union or delayed healing.
36. Spinal injections/
surgery
BHR CCGs will support the following tiered interventions for the treatment of back pain which is not responsive to
conservative treatment:
•
a single steroid epidural or intrathecal injection or sclerosant injection for acute back pain.
•
steroid epidural or intrathecal injection only if recommended by a specialist pain MDT where MDT pain management
is ‘unsuccessful’
•
diagnostic facet joint injection only in patients being assessed for surgical management
The CCG will not routinely fund the following interventions:
•
intradiscal electrothermal Therapy (IDET)
19
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
•
•
percutaneous intradiscal radiofrequency thermo-coagulation (PIRFT)
radio-frequency facet joint denervation
Clinicians wishing to use these procedures will need to submit an application to the IFR panel demonstrating that the
patient’s clinical condition is sufficiently different from all others with non-specific low back pain such that the patient is
likely to gain more benefit than all other patients with the condition
BHR CCGs will routinely fund spinal surgery only in the following circumstances:
• discectomy for lumbar disc prolapse in patients >18 years, who have MRI disc herniation at level and side corresponding
to clinical symptoms AND
demonstrable neurological deficit OR radicular pain despite conservative therapy under the care of a specialist back pain
MDT for at least six weeks
• fusion only where there is unequivocal root compression, spinal stenosis, instability and failure of conservative
management for >six months
• severe spinal stenosis with symptoms of neurogenic claudication and the MRI confirms significant caudal stenosis
(NICE IPG 365)
37. Hip Arthroscopy
Open or arthroscopic femero-acetabular surgery for hip impingement is commissioned if the indications are clearly specified
and if the following criteria are met:
1. labral tear or impingement has been confirmed on MRI; and
2. where hip arthroscopy is supported in the washout of an infected native hip joint in patients refractory to medical
management, patients with underlying disease or patients who are immunosuppressed.
3. where 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.
4. the clinician has ensured that the patient understands what is involved, is aware of the serious known complications
outlined in NICE patient information and agrees to the treatment knowing that there is only evidence of symptom relief
in the short and medium term, and
5. the surgeon must have completed specialist training and have experience of providing arthroscopic hip surgery; and
6. the provider will provide full data on100% patients undergoing this procedure to the British Hip Society register
(currently being established to support assessment of long term outcomes); and
20
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
7. the provider will undertake local review of cases to monitor safety and short term outcomes.
Hip resurfacing
BHR CCGs will fund for those 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).
38. Hip replacement
BHR CCGs will commission Hip Replacement Surgery if the following conditions are met :
•
symptoms have a substantial impact on the patient’s quality of life as represented by a score ≤ 24 on the Oxford hip
Score (using the 0 to 48 scale)
AND
•
there is evidence that conservative means have failed to alleviate pain and disability
AND
•
symptoms are refractory to non-surgical treatment
AND
•
the prostheses used are standard
AND
•
patient complains of severe joint pain AND functional limitation, despite the use of non- surgical treatments such as
adequate doses of NSAID analgesia, weight control treatments and physical therapies.
Referral should be made before there is prolonged and established functional limitation and severe pain.
39. Knee replacement
surgery
BHR CCGs will commission knee replacement surgery if the following conditions are met :
•
symptoms have a substantial impact on the patient’s quality of life as represented by a score ≤ 20 of the Oxford
Knee Score (using the 0 to 48 scale)
AND
•
there is evidence that conservative means have failed to alleviate pain and disability
AND
•
symptoms are refractory to non-surgical treatment.
AND
•
the prostheses used are standard.
AND
•
patient complains of severe joint pain AND functional limitation, despite the use of non- surgical treatments such as
adequate doses of NSAID analgesia, weight control treatments and physical therapies.
21
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
Referral should be made before there is prolonged and established functional limitation and severe pain.
40. Knee washout for
osteoarthritis
This intervention is not routinely funded.
Referral for arthroscopic lavage and debridement should only be considered in the few patients with knee osteoarthritis AND
a clear history of mechanical locking i.e. true locking, not gelling, 'giving way' or X-ray evidence of loose bodies.
41. Bunion surgery
(Hallax Valgas)
1. significant pain on walking not relieved by chronic standard analgesia OR
2. deformity such that fitting adequate footwear is difficult
OR
3. overlapping or underlapping of adjacent toe(s)
OR
4. hammer toes
OR
5. recurrent or chronic ulceration
OR
6. bursitis or tendinitis of the first metatarsal head
42. Bartholin’s cysts
BHR CCGs will fund the surgical treatment of Bartholin’s cysts which either cause significant pain or have twice become
infected requiring anti-biotic treatment.
43. Elective caesarean
BHR CCGs will fund a planned Caesarean section in the following circumstances:
•
with a singleton breech presentation at term, for whom external cephalic version is contraindicated or has been
unsuccessful
•
in twin pregnancies where the first twin is breach
•
HIV+ mothers who are not receiving any anti-retroviral therapy or are receiving any anti-retroviral therapy and have
a viral load of 400 copies per ml or more.
•
mother with both hepatitis C virus and HIV
•
with primary genital herpes simplex virus (HSV) infection occurring in the third trimester of pregnancy
•
a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia)
•
a previous caesarean section where it is clinically indicated.
A planned Caesarean Section should NOT be routinely offered to women:
•
with an uncomplicated twin pregnancy at term where the presentation of the first twin is cephalic
22
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
•
with a 'small for gestational age' baby
•
on the grounds of HIV status to prevent mother-to-child transmission of HIV to women on highly active antiretroviral therapy (HAART) with a viral load of less than 400 copies per ml or women on any anti-retroviral therapy with a
viral load of less than 50 copies per ml.
•
with hepatitis B
•
with hepatitis C
•
with a recurrence of genital herpes simplex virus (HSV) at birth
•
with a body mass index (BMI) of over 50 alone as an indicator. This is in line with the updated NICE 2012 guidance on
Caesarean Section
44. Uterine fibroids
BHR CCGs do not routinely fund MRgFUS for uterine fibroids for:
•
fertility preservation because of lack of evidence of effectiveness
•
relief of symptoms because other, equally effective, better established interventions are available.
•
45. Hysterectomy for
menorrhagia (heavy
menstrual bleeding)
This procedure is not routinely funded by the BHR CCGs and will only be considered for funding if the criteria below are met
and evidenced.
Hysterectomy should not be used as a first-line treatment solely for HMB.
Criteria for eligibility
BHR CCGs will fund hysterectomy for heavy menstrual bleeding only when:
1. The patient has been managed medically for 3-6 months and trialled any two of the drugs from the list below
without benefit:
 Tranexamic acid
 Non-steroidal anti-inflammatory drugs (NSAIDs)
 Combined oral contraceptives
 Oral progesterone
 Injected progesterone
AND
2. There has been an unsuccessful trial (of at least six cycles) with a levonorgestrel intrauterine system (e.g Mirena®)
unless medically contraindicated
23
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
3. Before surgery is considered patients should be offered endometrial ablation if steps 1) and 2) above have failed to
control symptoms. Endometrial ablation is a compulsory step prior to surgery for any patient who has refused 2)
above.
NICE Guidance
http://www.nice.org.uk/guidance/cg44/resources/guidance-heavy-menstrual-bleeding-pdf
46. Reverse
sterilisation
Reversal of sterilisation and vasectomy are not routinely funded by BHR CCGs.
The IFR Panel will NOT consider funding, irrespective of the merits of the individual case if:
•
sterilization used diathermy (female) or two widely separated clips because reversal is unlikely to be successful:
written documentation of the original procedure should accompany any application OR
•
the female partner is not demonstrably ovulating (day 21 progesterone levels)
47. Laser surgery for
short sightedness
BHR CCGs will not routinely fund laser surgery to correct for short sightedness.
48. Tonsillectomy
Tonsillectomy in children and adults may be funded for:
1.
suspected malignancy
OR
2.
significant impact on quality of life resulting from documented recurrent acute tonsillitis (patients or parents should
keep a diary to verify this) comprising:
• seven or more episodes of tonsillitis in the preceding year OR
• five episodes/year in each of the preceding two years
NB. An eligible episode must have three of the following features:
• tonsillar exudates
• tender anterior cervical lymph nodes
• history of fever
24
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
• absence of cough over a 24 hour period.
OR
4.
OR
4.
OR
5.
OR
6.
OR
7
fever
documented evidence of absence from playgroup, school or work
failure to thrive
adults with proven recurrent group A streptococcal pharyngitis (GAHSP)
documented evidence of two or more episodes of tonsillitis or quinsy requiring admission to hospital
tonsillitis exacerbating existing disease such as febrile convulsions, guttate psoriasis, glomerulonephritis or rheumatic
In children as treatment for sleep apnoea syndrome, tonsillectomy should only be considered with:
Witnessed episodes or apnoea exceeding 10 seconds OR choking episodes during sleep AND daytime neuro- behavioural
abnormalities or excessive sleepiness.
It is not funded for adults with snoring or obstructive Sleep apnoea (based on limited evidence of effectiveness)
49. Grommet
1. children between the ages of three and 12 years who have documented, persistent, bilateral otitis media with effusion
(OME) AND documented persistent hearing loss on two occasions at intervals of three months or more AND hearing in the
better ear of 25-30 dBHL or less averaged at 0.5, 1, 2 and 4 kHz
OR
2. children between the ages of three and 12 years who have documented, persistent otitis media with effusion (OME) AND
documented persistent hearing loss on two occasions at intervals of three months or more
AND
3. hearing loss suggestive of additional sensori-neural deafness
OR
25
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
4. evidenced delay in speech development OR significant educational, social or behavioural problems attributable to
persistent hearing impairment AND a hearing level of 25-30 dBHL or less
OR
5. a second disability (e.g. Down’s syndrome)
OR
6. the otoscopic features are atypical and accompanied by a foul-smelling discharge suggestive of cholesteatoma
OR
7. five or more episodes of acute otitis media.
Insertion of ventilation tubes for patients of any age may be indicated as a component of tympanic membrane repair or to
preserve function.
Additional information:
Evidence base: Current NICE Guidance
•
surgery may resolve glue ear in the short term but there is less certainty about longer term outcomes and large
variation in effect between children
•
there is debate about how best to select children for intervention, given the high rate of resolution particularly in
younger children
•
a period of watchful waiting is widely recognized as good practice because timing of surgery is not critical to medium
term outcome
Grommets and adenoidectomy represent a trade-off between benefits and harms; adenoidectomy on its own is of unknown
effectiveness
50. Surgical
interventions for
snoring
BHR CCGs will not routinely fund treatment for simple snoring where investigations have discounted restricted airwaves and
sleep apnoea.
51. Surgical treatment
of chronic sinusitis
ENT referral is appropriate for suspected:
1. complications, e.g. periorbital infection
OR
26
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
2. suspected sinonasal tumour. Referral may be appropriate if there is:
3. recurrent or chronic sinusitis of uncertain cause
AND
4. unremitting or progressive facial pain
AND
5. a trial of intranasal corticosteroids for three months has been ineffective
AND
6. a significant anatomical abnormality.
Additional Information
Evidence Base: NHS Clinical Knowledge Summaries advise a trial of intranasal corticosteroids for three months for treatment
in the first instance.
Sinus puncture and irrigation has a poor diagnostic yield, and carries the risk of secondary contamination.
Only short-term benefit seen in patient refractory to medical management treated with balloon catheter dilation of sinus
ostia.
52. Cataract
1. Cataract surgery to be considered for patients with a best corrected visual acuity of 6/9 or worse in either the first or
second eye , AND have impairment in lifestyle such as substantial effect on activities of daily living, leisure activities, and risk
of falls
2. Surgery is indicated for management of ocular comorbidities such as control of glaucoma, view of diabetic retinopathy
etc.
3. Patients with cataract having visual acuity better than 6/9 does not imply automatic exclusion. In this circumstance,
where there is a clear clinical indication or symptoms affecting lifestyle, surgery should still be considered. For example, the
patient with the 6/6 symptomatic posterior subcapsular cataract, affecting activities of daily living and driving.
53. Continuous
glucose monitoring for
type 1 diabetes
BHR CCGs will not routinely fund the use of continuous glucose monitoring systems for patients with type 1 diabetes.
Applications for funding may be made through the Individual Funding Request team and will need to demonstrate the
specific clinical circumstances which differentiate the patient.
This policy will be reviewed in 2017 against new NICE guidelines for diagnosis and management of Type 1 diabetes.
54. Open MRI
BHR CCGs will not routinely fund open MRI.
27
Procedures of Limited Clinical Effectiveness (PoLCE) policy V03
Valid: 1 December April 2016 – 31 March 2018
Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)
Severely obese patients should be referred by a secondary care clinician to the bariatric MRI service at Barts Health.
Claustrophobic patients should be referred to the special Sunday MRI service for claustrophobic patients at BHRUT.
An IFR request may be made for claustrophobic patients who have attended the BHRUT special service but are still unable to
proceed with a scan.
For these patients the referrer will be expected to:
•
identify the service they wish to refer the patient too
•
state why no other diagnostic tests are suitable
•
state how the MRI would affect decisions about the patient’s treatment
55. Sacral nerve
stimulation for faecal
and urinary
incontinence
BHR CCGs will not routinely fund the use of sacral nerve stimulation to treat urinary or faecal incontinence.
56. Homeopathy
Homeopathy is not routinely funded by BHR CCGs due to the lack of evidence of clinical effectiveness.
57. Acupuncture and
osteopathy
Acupuncture and osteopathy are not routinely funded by BHR CCGs due to the limited evidence of clinical effectiveness. This
includes funding for acupuncture to treat dental pain and nausea and vomiting.
58. White cell
apheresis
BHR CCGs will not routinely fund this intervention as the evidence of effectiveness is currently insufficient to justify routine
commissioning this treatment for the cohort of patients with refractory, steroid unresponsive or steroid dependent
inflammatory bowel disease.
59. Ketogenic diet for
epilepsy
This intervention is not routinely funded by BHR CCGs due to the lack of evidence of clinical effectiveness.
28