Download SOMERSET CCG INDIVIDUAL FUNDING REQUEST PANEL

SOMERSET CCG INDIVIDUAL FUNDING REQUEST PANEL
Guidance for Clinicians Policies Document
for INTERVENTIONS NOT NORMALLY FUNDED (INNF)
Applications cannot be considered from patients personally and all applications must be
signed by an NHS GP or Consultant.
1.
Procedures/treatments which are indicated as CBA (Criteria Based Access) will
only be funded where the published criteria is met and detailed within the patient’s
medical records. Referrals to secondary care should clearly demonstrated how the
published criteria is fulfilled.
2.
Procedures/treatments which are indicated as PA (Prior Approval) will require
completion of the generic IFRP application form and should clearly indicate how the
published criteria is fulfilled.
3.
Procedures/treatments which are indicated as IF (Individual Funding) will require
completion of the generic IFRP application form.
4.
In order for funding to be authorised for IF applications put forward there must be
some unusual or unique clinical factor about the patient that suggests that they are
exceptional as defined below:
 Significantly different to the general population of patients with the condition in
question
 Likely to gain significantly more benefit from the intervention than might be
expected from the average patient with the condition
5.
Provided these patients receive the full support of their general practitioner, or NHS
consultant, in pursuing a funding request an application may be made to the
Individual Funding Request Panel for consideration.
6.
For some procedures, criteria relating to BMI and smoking status have been
included. These criteria have been agreed following discussions with plastic
surgeons and take into account their impact on clinical outcomes including wound
healing.
7.
It is expected that clinicians will have ensured that the patient, on behalf of who they
are forwarding the application for, is appropriately informed about the existing
policies prior to an application to the IFRP. This will reassure the panel that the
patient has a reasonable expectation of the outcome of the application and its
context.
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ITEM
PAGE
NO:
PLASTIC & RECONSTRUCTIVE SURGERY
Abdominoplasty or Apronectomy – Policy listed separately
1
4
2
/
3
4
4a/b/c
/
5
4
Liposuction (Cosmetic)
IF
6
5
Pinnaplasty / Otoplasty
IF
7
5
8
5
9
/
10
5/6
11
6/7
ITEM
PAGE
NO:
12
7/8
Breast Reduction
IF
13
8/9
Breast Augmentation
IF
12
9/10
Breast Asymmetry
IF
13
10/11
Breast – Revision of Implants
IF
14
11/12
15
12/13
ITEM
PAGE
NO:
16
13/14
17
14/15
18
15
19
16/17
Blepharoplasty/Ptosis – Policy listed separately
Complete Blepharoplasty/Ptosis IFR PA Application Form
Buttock, Thigh or Arm Lift / Reduction
Labiaplasty / Vaginoplasty / Hymenorrhaphy – Policy listed
separately and renamed Female Genitalia Surgery
Penile Implants / Prosthesis – Complete Penile Prosthesis
Application Form
Rhinoplasty
Split Earlobes – Policy listed separately renamed External Ear
Repair
Surgery of the Face (including but not restricted to facelift
or brow lift)
Facial Blushing, including Erythrophobia
IF
PA
IF
IF
PA
IF
IF
IF
IF
BREAST PROCEDURES
Mastopexy (breast lift/repositioning of nipple)
Correction of inverted nipples for cosmetic purposes
Gynaecomastia
IF
IF
SKIN PROCEDURES
General Guidance on;
Removal of Benign Skin Lesions / Moles
Cysts
CBA
CBA
Chalazions
CBA
Ganglia Removal
CBA
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20
17
Removal of Lipomas
IF
21
16
Warts
IF
22
16
Telangiectasia / Thread Veins - Policy listed separately
IF
23
16
Scar Revision – Policy listed separately
IF
24
17
Dermabrasion for Acne Scarring – Policy listed separately
IF
25
17
Tattoo Removal - Policy listed separately
IF
26
17
ITEM
PAGE
NO:
27
28
/
18
29
/
30
18
ITEM
PAGE
NO:
31
/
32
18/19
33
19
34
19/20
35
/
36
/
Removal of Port Wine Stains & Other Birthmarks – Policy
listed separately
IF
EAR NOSE & THROAT PROCEDURES
Grommet Insertion 3-18 years - Policy listed separately
PA
Tonsillectomy
CBA
Surgical Intervention for Simple Snoring - Policy listed
separately
Ear Wax Removal
IF
CBA
OTHER PROCEDURES/TREATMENTS
Circumcision – Policy listed separately
CBA
Varicose Veins
CBA
Immunology
CBA
Hair Depilation
IF
Reversal of Sterilisation / Vasectomy – Policy listed
separately
Laser Surgery to correct Visual Acuity – Policy listed
separately
IF
IF
37
/
38
20
39
21/21
Gastro-electrical Stimulation – As of 1 April 2015 all
GES Paed/Adults is part of the NHS England
commissioning remit
Percutaneous Tibial Nerve Stimulation Treatment for
Urinary Incontinence
Functional Electrical Stimulation (FES) Lower Limb
39
21/22
Functional Electrical Stimulation (FES) Upper Limb
IF
40
/
Botulinum Toxin – hyperhidrosis - Policy listed separately
Complete Botulinum Toxin IFR Application Form
PA
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NHS E
IF
IF
/
/
/
/
Cataract – Policy listed separately
Open/Upright MRI - Policy listed separately
Complete Open/Upright MRI IFR PA Application Form
CBA
PA
Guidance for Clinicians
PLASTIC AND RECONSTRUCTIVE SURGERY
1
Abdominoplasty or Apronectomy – Policy listed separately
2
Blepharoplasty (repair of drooping eyelids) – Policy listed separately
Complete the Blepharoplasty/Ptosis IFR Application form V1
3
Buttock, Thigh or Arm Lift / Reduction
Buttock, Thigh or Arm Lift / Reduction procedures are not available on cosmetic grounds.
Cases will only be considered as a result of:

post-traumatic surgery and/or thinning of skin flaps
Photographic supporting evidence must be sent with the IFRP application form.
4a Labiaplasty – Policy listed separately and renamed Female Genitalia Surgery
4b Vaginoplasty - Policy listed separately and renamed Female Genitalia Surgery
4c Hymenorrhaphy - Policy listed separately and renamed Female Genitalia
Surgery
5
Liposuction (Cosmetic)
Liposuction treatment will not be considered for any of the following:

The reduction and correction of symmetrically distributed fatty deposits for
enhancement of appearance

Limb recontouring

Age, sun and cigarette-related laxity of skin giving rise to poor performance. It would
be unusual for this to be requested on the basis of functional problems

Patients seeking a liposuction for cosmetic reasons should be offered dietary advice
when appropriate
It could be considered as an exception in the management of certain conditions including
Lymphedema or as part of other surgery, for example, thinning of a transplanted flap.
Photographic supporting evidence must be sent with the application form
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6
Pinnaplasty/Otoplasty
Pinnaplasty surgery is considered a procedure of low clinical priority and is funded on a
restricted basis on. Approval must be sought by the IFRP and there must be evidence of :


significant functional impairment or
asymmetry or congenital abnormality of the structure of the pinna - not just prominence
Photographic evidence of the front and rear view must be sent with the application form.
7
Penile implants / Prosthesis
Complete the Penile Prosthesis IFR Application Form V1
Completion of the Penile Prosthesis IFR application form should be put forward in the
following circumstances with clinical correspondence to support the PA application;



8
there is an identified or underlying disease or condition
evidence of all conservative treatments trialled
secondary care consultant advises there is no other clinical option
Rhinoplasty
Rhinoplasty is not routinely funded as this procedure is considered cosmetic. Consideration
may be given in the following cases:

as part of reconstructive head and neck surgery (including traumatic deformity) or

if there is functional impairment or

to correct complex congenital conditions e.g. cleft lip or palate
Photographic supporting evidence will be required and must be sent with the application
form.
9
Split Earlobes – Policy listed separately and renamed External Ear Repair
10
Surgery of face (including but not restricted to facelift or brow lift)
Surgery of the face is regarded as a procedure of low clinical priority and is therefore not
routinely funded by NHS Somerset. Surgery to improve appearance alone, normal changes
such as those due to aging, is not funded.
Patients may be considered on an individual basis where their GP or treating consultant
believes that exceptional circumstances exist. Photographic supporting evidence must be
forwarded with the IFRP application form.
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GPs and Consultants must obtain approval before proceeding for the following;
 as part of treatment of specific conditions affecting facial skin, e.g., neurofibromatosis
 to correct deformity following surgery to correct the consequences of trauma
Surgery of the face is commissioned for patients where there is:
1. Severe deformity
AND
2. Significant functional impairment that prevents performance of physical activities of
daily living, meaning:
 as part of the treatment of congenital facial abnormalities
 for treatment of congenital or acquired facial palsy
 symptoms preventing the patient fulfilling vital work responsibilities
 symptoms preventing the patient carrying out vital domestic or carer activities
AND
3. There is evidence that surgery will relieve their symptoms
Patients not fulfilling the above criteria can be considered by the IFRP where there is:
Anatomical abnormalities in children <18, likely to cause impairment of normal emotional
development pathological abnormalities e.g. facial palsy, progeria or cutis laxa.
Photographic supporting evidence must be forwarded with the IFRP application form.
11
Facial Blushing, including Erythrophobia
Somerset CCG does not routinely commission:
 Drug and/or surgical treatments which can be used to treat facial blushing, including
erythrophobia
 Botulinum Toxin treatment by injection for facial blushing is not routinely
commissioned or funded
 Endoscopic Thoracic Sympathectomy [ETS] for facial blushing is not routinely
commissioned or funded.
Where a patient is suffering from facial blushing which causes;
 functional impairment which prevents the individual from fulfilling work/study/carer or
domestic responsibilities, the patient should be treated conservatively including
being provided with reassurance and advice
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Applications may be considered by the IFR Panel where there is evidence of:

Anatomical abnormalities in children <18, likely to cause impairment of normal
emotional development pathological abnormalities
e.g. facial palsy, progeria or cutis laxa
Photographic supporting evidence must be forwarded with the IFRP application form
BREAST PROCEDURES
Please note: breast reconstruction following mastectomy for breast cancer should
be routinely funded and is not considered an exceptional treatment.
12
Breast Reduction
The following classes of patient should NOT be referred for consideration of breast
reduction:

patients with a BMI greater than 27 (Note 1)

patients who have smoked/used nicotine replacement therapy over preceding
3-months (Note 2)

patients who intend to have children and breast feed

patients who are pregnant or who have had a baby within past 12 months

patients who have not yet attained full breast development

patients who are under the age of 23

weight loss has been sustained for a minimum of 6 months at the current level and
further weight loss is unlikely
Note 1: It is recognised that not every woman’s breasts reduce when they lose weight but it
is felt appropriate to seek to exclude those whose problem would be addressed with
weight loss by setting a BMI limit.
Note 2: The restriction to non-smokers relates to associated surgical complications and
problems with healing as a result of the effects of nicotine on the peripheral
circulation.
Applications should only be made when breast size is causing functional symptoms and
should include the following information:

actual breast size, assurance that the patient’s breasts have been professionally
measured by a reputable underwear fitter, and that the patient is wearing appropriate
support underwear

a detailed account of functional problems as a result of breast size including detail of
any pain experienced, intetrigo, etc

the patient’s height, weight and BMI

basic detail of breast volume reduction required, that is, ensuring volume for
reduction is at least 500g each side, as equivalent to half a bag of sugar each side
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
detail of any body disproportion (including asymmetry detail) including photographic
supporting evidence (if the patient is referred to the Breast Care Nurse Service a photograph will be taken
by the nurse)


where the condition is affecting psychological and social well being, a detailed
account of specific problems encountered, along with any previous referrals treatment
and outcomes
past medical history detailing all prescribed drugs and medication
Evidence will need to be provided that conservative measures pursued, including corsetry
advice or non-surgical referral, have failed to alleviate the symptoms:

for physical symptoms such as neck or back pain all other appropriate interventions
should have been tried and failed for a minimum of 6 months and should include:
wearing appropriate support, NSAIDS (if not contraindicated) and exercises (as
directed via physiotherapy assessment)

where intractable intetrigo is the justification for referral, conservative treatment for
submammary intertrigo should have been trialled for a minimum of 6 weeks and
should include: appropriate hygiene, appropriate pharmacological treatment and
utilisation of an appropriate support bra

where psychological difficulties are cited as the justification for the proposed
intervention, all efforts should have been made already to manage these problems. It
is expected that appropriate interventions to improve psychological wellbeing would
have been used over a period of time before surgery would ever be considered as an
option.
Patients’ who meet the above criteria and are referred to the Individual Funding Request
Panel, will be referred onto the Breast Care Nurse Team at Yeovil District Hospital for an
assessment and support, prior to their case being considered by the Panel.
13
Breast Augmentation
Breast augmentation surgery is not routinely funded as this procedure is considered
cosmetic.
These procedures are not available on cosmetic grounds.
Patients must have reached physical maturity and would not normally be considered below
the age of 23 years.

where psychological difficulties are cited as the justification for the proposed
intervention, all efforts should have been made already to manage these problems. It
is expected that appropriate interventions to improve psychological wellbeing would
have been used over a period of time before surgery would ever be considered as an
option.
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PLEASE NOTE: Patients who received morbid obesity surgery and other previously obese
patients who have achieved significant weight loss;



These procedures are not available on cosmetic grounds
Weight loss has been maintained for at least 2 years at the current level and further
weight loss is unlikely
The scale of the weight loss and the period for which it has been sustained must be
verified in the patient’s clinical record
Consideration will be given to patients who present exceptional need such as:

congenital absence of breasts

significant developmental abnormalities

reconstruction needed after surgery/trauma
The following classes of patient should NOT be referred for breast augmentation:

patients with a BMI less than 19 or greater than 27

patients who have smoked/used nicotine replacement therapy over preceding 3months

patients who intend to have children and breast feed

patients who are pregnant or who have had a baby within past 12 months

patients who have not yet attained full breast development
Requests should include the following information:


actual breast size, assurance that the patient’s breasts have been professionally
measured by a reputable underwear fitter
detail of body disproportion including photographic supporting evidence ( if the patient is
referred to the Breast Care Nurse Service a photograph will be taken by the nurse)


detail of height, weight and BMI
where the condition is affecting psychological and social well being, a detailed
account of specific problems encountered, along with any previous referrals treatment
and outcomes.
Patients who meet the above criteria and are referred to the Individual Funding Request
Panel, will be referred onto the Breast Care Nurse Team at Yeovil District Hospital for an
assessment and support, prior to their case being considered by the Panel
12
Breast Asymmetry
Surgery to correct breast asymmetry is not routinely funded as this procedure is considered
cosmetic. The following classes of patient should NOT be referred for surgery to correct
breast asymmetry:

younger than 18 years of age
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



patients who have smoked/used nicotine replacement therapy over preceding 3months
patients who intend to have children and breast feed
patients who are pregnant or who have had a baby within past 12 months
patients who have not yet attained full breast development.
Consideration may be given where there is:

a disparity of greater than 2 or more cup sizes in the lower range (size C or below) –
based on the smaller breast size

a disparity of 3 or more cup sizes in the upper range (size D upwards) – based on the
smaller breast size (For cup sizes D and upwards there are intermediate sizes – DD,
E, EE, G, GG etc. A difference of B to D would count as 2 cup sizes; a difference of
DD to F would count as 3 cup sizes).
Patients must have reached physical maturity and would not normally be considered below
the age of 18:

where psychological difficulties are cited as the justification for the proposed
intervention, all efforts should have been made already to manage these problems. It
is expected that appropriate interventions to improve psychological wellbeing would
have been used over a period of time before surgery would ever be considered as an
option.
Requests should include the following information:

actual size of each breast with assurance that the patient’s breasts have been
professionally measured by a reputable underwear fitter

detail of body disproportion including photographic supporting evidence (if the patient
is referred to the Breast Care Nurse Service a photograph will be taken by the nurse)

detail of height, weight and BMI (cases will not normally be considered where the BMI
is less that 19 or greater than 27)

where the condition is affecting psychological and social wellbeing, a detailed account
of specific problems encountered, along with any previous referrals treatment and
outcomes.
Patients that meet the above criteria will be referred onto the Breast Care Nurse Team at
Yeovil District Hospital for an assessment and support, this would be prior to any
application being considered by the Panel.
13
Revision of Breast Implants
Breast implant surgery is a regarded as a procedure of low priority and is not therefore
funded by NHS Somerset unless patients meet the following criteria;
Insertion of breast implants:
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Insertion of breast implants is commissioned if one of the following indications applies:

Reconstructive surgery needed following mastectomy

Congenital amastia, where breast tissue is completely absent
Insertion of breast implants is not otherwise commissioned
Removal and replacement of breast implants:
There are instances for clinical indications where breast implants will need to be removed
and replaced. These include when both of the following indications are met:

Original procedure was provided by the NHS (e.g. as part of treatment for breast
cancer or other clinically required surgery)
AND

Implant is proven to be ruptured causing health problems
The removal and replacement of breast implants is not otherwise commissioned.
Removal of breast implants:
This includes breast implants which were originally privately funded by the patient.
The removal of breast implants, both unilaterally and bilaterally, is commissioned where
there is a clinical reason requiring removal, such as the implant is proven to be ruptured.
The replacement of privately funded breast implants, either unilaterally or bilaterally, where
removal is required is not commissioned by NHS Somerset.
14
Mastopexy (breast lift/repositioning of nipple)
Correction of inverted nipples for cosmetic purposes
Mastopexy is regarded as a procedure of a low clinical priority. Breast ptosis (droopiness)
is inevitable in most women and is normal with the passage of age and after pregnancy.
Mastopexy is not available on cosmetic grounds. Surgery to improve appearance alone is
not routinely commissioned.
Mastopexy is commissioned if a necessary part of the treatment of breast asymmetry or in
breast reduction, in patients meeting criteria for access to these procedures.
Corrective surgery for inverted nipples is not routinely available, GPs should be aware that
there are now well proven non-operative ways of correcting inverted nipples by devices
which can be obtained relatively cheaply commercially and are suitable for simple lack of
nipple protrusion. Surgery may be funded if there is a co-existing clinical reason such as
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chronic infection.
Please Note: Patients must have completed puberty. Therefore surgery is not normally
commissioned for people below the age of 18 years. Note: any acquired nipple inversion
should be assessed to rule out carcinoma of the breast.
Gynaecomastia
15
Breast reduction for gynaecomastia is funded on a restricted basis only. GPs and
Consultants must obtain approval before proceeding. Surgery is not normally
commissioned to improve appearance alone in benign gynaecomastia. Requests for breast
reduction for gynaecomastia will be considered when all of the points below are met:









the patient has reached physical maturity, surgery is not normally commissioned for
people below the age of 18 years
have a BMI of 27 or below
have not smoked/used nicotine replacement therapy over preceding 3-months
there has been insufficient response to reassurance and where normal medical
treatments or management with exclusion of causative pointers have failed
confirmation that the problem is not due to a medical condition or from drug side
effects
Pseudo-gynaecomastia (when the proposed volume of reduction is greater than
200g per site or for gross asymmetry)
cases will not be approved unless there is clear evidence that the problem has
persisted in spite of rigorous dieting and weight loss and the BMI has remained
below 27 for at least 6-months
photographic supporting evidence must be sent with the IFRP application
patient experiences persistent pain
Cancers are diagnosed in about 1% of cases of gynaecomastia 1. Where history or physical
examination raises suspicion of cancer, urgent referral for further investigation should be
made.
Background to condition: Gynaecomastia is common and usually temporary in neonates
and adolescent boys. In later life, prevalence rises with increasing age. It is thought to
occur in about 30% of men. Gynaecomastia is enlargement of breast tissue in men where
there is >2cm palpable, firm, subareolar gland and ductal tissue (not fat) reflecting an
increased ratio of oestrogen to testosterone. There are many causes: it can be normal, a
side effect of medication or a sign of diseases that affect hormonal balance. It is a common
feature of obesity.
Treatments for painful or embarrassing gynaecomastia include an anti-oestrogen, such as
tamoxifen, or surgery (liposuction or ammoplasty).
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Physiological gynaecomastia requires no treatment unless accompanied by pain or
significant embarrassment i.e. sufficient to cause functional problems. Withdrawing an
offending drug or treating an underlying disorder may be sufficient, especially if
gynaecomastia is relatively recent.
SKIN PROCEDURES
16
General Guidance on Removal of benign skin lesions or moles
The surgical removal, laser treatment, or cryotherapy of a benign asymptomatic skin lesion
is regarded as a procedure of low clinical priority. These procedures are therefore not
routinely funded by the NHS Somerset.
Surgery to improve appearance alone is not provided for normal changes such as those
due to aging.
This policy includes:















warts and plantar warts
seborrhoeic keratoses (benign skin growths, basal cell papillomas, warts)
spider naevi
thread veins
benign pigmented naevi (moles)
cherry angiomas or Campbell de Morgan spots
Molluscum contagiosum
dermatofibromas (skin growths)
skin tags
‘sebaceous’ cysts (pilar and epidermoid cysts) – see information section 21
chalazion – see information section 22
ganglion removal – see information section 23
lipomas (lipomata) (fat deposits underneath the skin) – see information section 24
xanthelasmas (cholesterol deposits underneath the skin)
and port wine stains
The removal of benign skin lesions in secondary care is therefore funded on a restricted
basis only. The vast majority of skin lesions are of no great consequence but some in
certain places are a cause for concern and may be referred on to secondary care. If
referring to secondary care ensure the referral indicates how the patient fulfils any of the
criteria (below) and that there is supporting clinical evidence that the patient fulfils any of
the following criteria:
1. Rapid growth or other features suspicious of dysplasia/malignancy
2. Obstruction of an orifice or vision
3. Lesions on the face (not scalp or neck) where the extent and size of the lesion can
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be regarded as disfigurement (minimum greater than 1cm in diameter)
4. Site or size that interferes with normal day to day activity, for example, a naevus on
the bridge of the nose that interferes with the wearing of glasses
Removal of all other benign skin lesions is considered a low priority procedure. Prior
approval is therefore required for those that fail to meet the above criteria. Completion of
an IFRP application form is required and a photograph of the area.
Limited provision for excision of lesions through GPwSI services and secondary care
continues to be available to patients where clinically appropriate, in circumstances whereby
the practice does not have the competency to undertake such procedures as part of the
Minor Surgery Enhanced Service.
Please note: viral warts should be treated in Primary Care, typically with topical salicylic
acid; treatment of viral warts on the margins of the eyelids is problematic and these should
be referred to an Ophthalmic Plastic Surgeon (or if not available an Ophthalmic surgeon)
for treatment.
17
Cysts
(Sebaceous cysts are now known as epidermal or pilar cysts. Trichilemmel cysts are a type of pilar cyst )
Cysts will usually grow slowly and only need removal if causing symptoms. Epidermal and
pilar cysts which are less than 5mm in diameter and/or give no trouble can be left alone.
Corticosteroid injections. GPs may inject an inflamed, but uninfected, epidermoid cyst
with a corticosteroid to help reduce the inflammation
Requests for the removal of sebaceous cysts should only be considered where there has
been more than one episode of infection.
The vast majority of sebaceous cysts are of no
great consequence but some in certain places are a cause for concern and may be
referred to secondary care. Surgery to improve appearance alone is not funded. If
referring to secondary care ensure the referral indicates how the patient fulfils any of the
criteria (below) and that there is supporting clinical evidence that the patient fulfils any of
the following criteria;
1. Uncertainty on whether the lesion may be malignant in nature
2. More than one episode of infection
3. Genital and umbilical lesions sometimes extending into the pelvis or below the
midline fascia, which may not be apparent until they are being removed.
4. Obstruction of an orifice
5. Lesions on the face (not scalp or neck) and greater than 1cm diameter where the
extent and size of the lesion can be regarded as disfigurement
6. Lesions which cause functional impairment which prevents the individual from
fulfilling work/study/carer or domestic responsibilities
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7. Lesions over the skull which can have an intracranial or intraosseous connection Features suggestive of intracranial or intraosseous extension include the following:
– Present since birth or appearance in early childhood (although small lesions may
remain unnoticed until adulthood)
– Bruits, pulsation or fluctuation in size with straining or crying
– Fixation to underlying tissue, fluid-filled consistency, or ability to transilluminate
– Location along the nasal, forehead, or scalp midline, or along cranial suture lines
– Dimple or unusual overlying hair growth pattern
– History of cranial trauma or surgery
–
Family history of neural developmental anomalies, neurological symptoms or history
of meningitis.
Removal of cysts is considered a low priority procedure. Prior approval is therefore
required for those that fail to meet the above criteria. Completion of an IFRP application
form is required and a photograph of the area.
Limited provision for excision of lesions through GPwSI services and secondary care
continues to be available to patients where clinically appropriate, in circumstances whereby
the practice does not have the competency to undertake such procedures as part of the
Minor Surgery Enhanced Service.
18
Chalazion
Chalazia are benign, granulomatous lesions caused by blockage of the Meibomian gland
duct, which will normally resolve within 6 months with conservative management in primary
care.
Removal of Chalazia is regarded as a procedure of low clinical priority and is subject to the
criteria below. If patient’s fulfil the criteria below approval is not required from IFRP, please
indicate clearly on the referral to the secondary care how the patient fulfils the criteria and
that there is clinical evidence to support this:



Present continuously for more than six months, verified in clinical notes or
Present on the upper eyelid, and interferes significantly with vision or
Source of regular infection (2 times within six month time frame) requiring medical
treatment or
 The site of the lesion or lashes renders the condition as requiring specialist
intervention within the acute trust
A chalazion that keeps coming back should be biopsied to rule out malignancy, therefore
use the appropriate referral route for suspected malignancy in this instance.
19
Ganglion Removal
Ganglion removal is not routinely commissioned. If patient fulfil the criteria below and
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evidence is within the medical records funding approval is not required. Please ensure the
referral to secondary care indicates how the patient fulfils the criteria (below) and forward
the supporting evidence.

The ganglion has resulted in functional impairment which prevents the individual from
fulfilling work/study/carer or domestic responsibilities or

The individual is experiencing considerable pain as a result of the ganglions size or
position or

Where there is doubt about the diagnosis (with or without pain)
If a patient doesn’t fulfil the above criteria but there is exceptionality that can be
demonstrated an IFRP application form must be completed.
Photographic supporting evidence must be included with the application form.
20
Removal of Lipomas (Lipomata)
Lipomas should normally be managed in the context of the local general surgical services.
Multiple lipomas or those presenting particular technical difficulties may be considered if
there are exceptional reasons for their removal.
An IFRP application form must be completed and photographic supporting evidence must
be included with the application form.
Lipomas that are under 5cms, without other clinical symptoms, should be observed only
using soft tissue sarcoma guidelines (SIGN 2003)
Severely functionally/disabling and/or subject to repeated trauma due to size/position
Lipomas located on the body that are over 5cms in diameter, or in a sub-fascial position,
which have also shown rapid growth and/or are painful can be referred to an appropriate
surgical clinic for removal if clinically appropriate.
21
Warts - These are self-limiting viral infections that can be managed in Primary Care
22
Telangectasia/Thread Veins – Policy listed separately
23
Scar Revision – Policy listed separately
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24
Dermabrasion for Acne scarring – Policy listed separately
25
Tattoo Removal – Policy listed separately
26
Removal of Port Wine Stains and Other Birthmarks – Policy listed separately
EAR NOSE AND THROAT PROCEDURES
27
Grommet Insertion 3-18 years – Policy listed separately
Secondary Care to request Prior Approval
28
Tonsillectomy
If patients fulfil the following criteria IFRP approval is not required. The referral to
secondary care must indicates how the patient fulfils the criteria and the evidence is
recorded in the medical notes.

Suspected/diagnosed malignancy of the tonsils
Recurrent sore throat where the following documented evidence applies:

7 or more episodes in the last year

OR 5 or more episodes in each of the last two years

OR 3 or more episodes in each of the last 3 years
AND
There has been significant severe impact on quality of life indicated by documented
evidence of absence from work/school.
OR

2 or more episodes of tonsillitis or peritonsillar abscess (quinsy) requiring admission
to hospital.
OR

Tonsillitis exacerbating disease such as febrile convulsions, guttate psoriasis,
glomerulonephritis or rheumatic fever.
NHS Somerset IFRP will consider funding for tonsillectomy in sleep apnoea syndrome for
children when one or more of the following apply:
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
A positive sleep study or

A significant impact on quality of life demonstrated or

A strong clinical history suggestive of sleep apnoea
Note:
The case is much more likely to be approved where there is supporting evidence such as
sleep studies, growth charts, letters from GPs and letters from employer/school.
If a general practitioner feels that a patient may have other exceptional circumstances then
an application to the Individual Funding Request Panel must be made.
Surgical Intervention for Simple Snoring – Policy listed separately
29
30 Ear Wax Removal
Ear Wax Removal - Criteria based access - Treatment in primary care as per
Modernisation Agency Ear Care Guidance
Patients should only be referred to secondary care if the patient is:
a)
b)
undergoing regular appropriate treatment, such as de-waxing a mastoid cavity
if they require microsuction because of anatomical abnormalities
Removal of ear wax from children with hearing aids is normally carried out within an
audiology assessment in a secondary care setting
OTHER PROCEDURES/TREATMENTS
Circumcision – Policy listed separately
31
32 Varicose Veins
Patients with varicose veins should not be referred to secondary care except where there
are any complications listed below. If patients fulfil the criteria below no prior approval is
required from IFRP. Please ensure that the referral to secondary care indicates how the
patient fulfils the criteria and there is clinical evidence within the medical records:




a documented history of recurrent superficial thrombophlebitis or a single episode of
ascending (migratory) thrombophlebitis
spontaneous bleeding (not including spontaneous bruising)
severe trophic skin changes
lipodermatosclerosis, atrophie blanche
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

extreme Varicose eczema associated with varicose veins
venous leg ulceration with evidence of varicose veins
If a general practitioner feels that a patient has other exceptional circumstances then these
patients must be referred to the IFRP for consideration of funding by completing the IFRP
application form along with the evidence of exceptionality.
Additional information
Management of patients with significant symptoms (pain, swelling, ache) adversely
affecting daily activities in the presence of varicose veins
These patients may have symptoms that relate to their varicose veins and in order to clarify
whether or not venous disease is responsible for their symptoms, we would recommend
that in patients with a full complement of peripheral pulses (i.e. no evidence of arterial
disease) a trial of below knee or full length (as appropriate) Class II graduated compression
hosiery should be tried. Hosiery should be worn during the daytime and removed prior to
going to bed. Patients who notice no significant improvement in symptoms after a 6 week
trial of compression hosiery are unlikely to benefit from varicose vein surgery.
Patients not suitable for referral to vascular surgical clinics for NHS treatment
 Patients with no symptoms or skin changes associated with venous disease
 Patients whose concerns are cosmetic including Telangectasia and reticular veins
 Patients with mild symptoms including itch, ache, mild swelling, minor changes of
skin eczema and haemosiderosis
33
Immunology – Allergy Testing
NHS Somerset CCG referrals to an NHS Immunologist within secondary care for simple
allergies, does not require funding authorisation from the Somerset CCG IFR panel.
Please note that recommended treatment following an assessment within secondary care
which is not routinely commissioned or is not normally funded within NHS guidance/criteria
would require completion of generic IFRP application form for consideration of funding.
34
Hair Depilation
Somerset CCG does not routinely commission treatments for permanent or semipermanent hair removal for cosmetic purposes. Patients concerned with the appearance of
their body and facial hair should be advised about managing their condition through
conservative methods including shaving, waxing, and dilapatory creams although such
treatments are also not routinely commissioned or funded by NHS Somerset. Hair
depilation will be considered if any of the following criteria are met:


following reconstructive surgery leading to abnormally located hair-bearing skin
the patient is undergoing treatment for pilonidal sinus, to reduce recurrence
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
patients who have an underlying congenital and/or endocrine abnormality resulting in
exceptionally excessive hair (for example, patients with polycystic ovary syndrome)
will be considered
AND
there must be reason to believe that treatment will lead to improvement in health status

all applications must be accompanied by an opinion from a secondary Care
Consultant (that is, a dermatologist or endocrinologist)

photographic supporting evidence must be sent with the application form

must be for face and neck only and for a fixed number of treatments (maximum of 8)

top up treatments are not funded
35
Reversal of Sterilisation / Vasectomy – Policy listed separately
36
Laser Surgery to correct visual acuity – Policy listed separately
37
Gastro-electrical Stimulation – As of 1 April 2015 all GES Paed/Adults is part of
the NHS England commissioning remit
38
Percutaneous Tibial Nerve Stimulation Treatment for Urinary
Incontinence
Percutaneous Tibial Nerve Stimulation (PTNS) treatment for Urinary Incontinence is
regarded as a procedure of low clinical priority.
This procedure is therefore not routinely funded by NHS Somerset.
There is currently insufficient evidence of clinical and cost effectiveness of this treatment.
39
Functional Electrical Stimulation (FES)
Lower Limb Functional Electrical Stimulation (FES) is an evidence-based, intervention
recommended by the National Institute for Health and Care Excellence (NICE PG278).
http://www.nice.org.uk/guidance/IPG278
FES is a means of producing useful movement in partially paralysed muscles. The
intervention is commonly used as a practical assistive device to assist daily mobility for
people who have dropped foot due to upper motor neurone neurological conditions such as
stroke, brain injury, spinal cord injury and multiple sclerosis.
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Somerset FES Service - Outpatient referrals for lower limb
 All patients currently not receiving lower limb FES therapy can be referred by their
GP or Medical Consultant through the patient’s local ILT Team
Referral criteria
1. All patients must be aged 18 and over
2. Cause and functional deficit
a. Neurological deficit due to an upper motor neurone lesion
An upper motor neurone lesion is defined as one that occurs in the brain or spinal cord at or above the level of T12
Upper motor neurone lesions that may benefit form FES are stroke, multiple sclerosis, incomplete spinal cord injury at T12 or above, cerebral palsy, familial / hereditary spastic paraparesis, head injury and Parkinson's disease
Referrals outside of local pathway for FES for Lower Limb
Prior approval is required for funding authorisation for a referral outside of the local
pathway for an assessment of FES for lower limb dropped foot due. PA should be sought
by completion of the generic IFRP application form.
Criteria:
3. All patients must be aged 18 and over
4. Cause and functional deficit
a Neurological deficit due to an upper motor neurone lesion
An upper motor neurone lesion is defined as one that occurs in the brain or spinal cord at or above the level of T12
Upper motor neurone lesions that may benefit form FES are stroke, multiple sclerosis, incomplete spinal cord injury at T12 or above, cerebral palsy, familial / hereditary spastic paraparesis, head injury and Parkinson's disease
FES FOR UPPER LIMB IS NOT ROUTINELY COMMISSIONED
Funding authorisation should be sought by completion of a generic IFRP application form
for consideration by the IFR Panel. Please ensure the following is provided with the
application form;
 Clinical evidence to support the treatment requested
 Evidence of exceptionality
 Associated costs
40
Botulinum Toxin Treatment – Policy Listed Separately
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