Policy for Procedures Not Funded

Transcription

1 Document purpose Policy for Procedures Not Funded This policy lists procedures that are not funded by NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG (Greater Nottinghamshire). This policy is based on and supersedes the Nottinghamshire (less Bassetlaw) Procedures of Limited Clinical Value Policy 2015 and the East Midlands Cosmetics Policy Version Version 1.0 Version 2-5/6/17 Version 3 11/7/17 Version Version Version Title Policy for Procedures Not Funded Associated Policy Service Restriction Policy (2017) Nominated Lead Director of Contract Delivery Approval Date October 2017 Approving Committee NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG Governing Bodies Review Date This policy will be reviewed in 1 year or earlier if additions or changes are required. Groups/staff Consulted Clinical leads across Greater Nottinghamshire CCGs Target audience All CCG staff All providers All Clinicians Circulation list CCG Websites All providers Primary Care Clinicians Page 1 of 12

2 Associated documents Individual Funding Requests (IFR) V2 April 2011 Page 2 of 12

3 Contents Purpose of the policy...4 Introduction...4 Commissioning Principles...4 Procedures not expressly covered in this policy...4 Policy Exclusions...5 Exceptionality and Special Circumstances... Error! Bookmark not defined. Implementation and Compliance... Error! Bookmark not defined. Statement of Cosmetic Procedures...5 List of procedures covered under this policy...5 Page 3 of 12

4 Purpose of the policy The purpose of this policy is to ensure that the Greater Nottinghamshire Clinical Commissioning Groups (the Commissioners) only fund treatment for clinically effective interventions that are then delivered to the right patients. It sets out the treatments deemed to be of insufficient priority to justify funding from the available fixed budget. This policy lists a number of procedures and services that the Commissioners do not fund. If a provider undertakes one of the procedures contained within this policy commissioners will not pay unless explicit agreement has been given by the appropriate CCG. This policy should be read in conjunction with the Service Restriction Policy (2017). These two policies have been based on and include all the procedures that were part of the Procedures of Limited Clinical Value Policy (2015) or the East Midlands Cosmetic Policy (2015) which has now been superseded. Approved prescribing of medicines falls outside the scope of this document and is covered in the guidelines and protocols produced by the Nottinghamshire Area Prescribing Committee. Further information can be obtained from the Pharmacy/Medicines Management Department or via Introduction This policy identifies procedures that the Greater Nottinghamshire CCGs do not fund. These procedures have either previously been identified as not routinely funded in the Procedures of Limited Clinical Value 2015, East Midlands Cosmetics Policy 2015, or are new to Greater Nottinghamshire CCGs but have been adopted where the procedures are not routinely commissioned in a number of other CCGs Commissioning Principles Commissioning decisions are made in accordance with the general principles set out below: Clear evidence of clinical and cost effectiveness will be sought before NHS resources are invested in the treatment The cost of the treatment for individual patients and others within any anticipated cohort is a relevant factor. The extent to which the individual or patient group will gain a benefit from the treatment will be considered and balanced against the benefit which could be gained by alternative investment possibilities to meet the needs of the community The process and policies will consider all relevant national standards, take into account all proper and authoritative guidance along with due regard to the funding available for local health services. Procedures not expressly covered in this policy If a procedure is not covered in either this policy or the service restrictions policy and is documented on the indicative activity plan, with or without an activity value or finance value, this would indicate that both provider and commissioner recognize the activity as commissioned and therefore is chargeable. If a procedure is not shown on the indicative activity plan and is also not covered in either this policy or the service restrictions policy this would indicate that both the provider and commissioner acknowledge that the procedure is unlikely to have been actively commissioned and on that basis the provider should seek clarification and appropriate approval before carrying out the procedure otherwise the procedure will not be funded. Page 4 of 12

5 The above scenario would be applicable should new guidance be published by NICE or any other body suggesting that criteria for procedures or new procedures are available. Commissioners require the opportunity to ensure that a procedure is actively commissioned before funding is available. Policy Exclusions Patients should not be referred for or undergo the procedures listed in this policy, except in the case of: Emergency, OR A reasonable suspicion of cancer, OR As part of reconstruction following treatment for cancer, traumatic injury or the correction of congenital malformation The procedures covered by this policy are not commissioned unless the treatment is: posttrauma, part of reconstruction following surgery (e.g. for cancer), part of the management of a congenital abnormality which results in a serious health function deficit, or for an iatrogenic condition arising from treatment previously delivered within the NHS. The term iatrogenic condition refers to a condition that was directly attributable to previous medical treatment. In this context, iatrogenic condition specifically excludes known side effects of a treatment or possible complications which the patient would normally be notified about when they were informed of the benefits and risks when consenting to the original treatment. If a patient falls within the above categories then the expectation is that the patient will receive the appropriate treatment without delay. Commissioners will require assurance and evidence that the reason for carrying out the procedure meets the above criteria but this assurance will be sought retrospectively. The policy will be implemented across providers in primary and secondary care. It will be formally incorporated into contracts and will be subject to routine monitoring for compliance. Statement of Cosmetic Procedures "Cosmetic" surgery means procedures to improve appearance. It is also known as "aesthetic" surgery. This policy lists many procedures that are judged to be cosmetic and will not normally be funded by the NHS. This policy applies to cosmetic surgery irrespective of the sub specialty of the surgeon concerned, including plastic surgery, ear nose and throat surgery, oral and maxillofacial surgery, dermatology, and other surgical specialties. List of procedures covered under this policy Description of Procedure/Treatment Abdominoplasty (Apronectomy/ Panniculectomy) Acupuncture for non-specific low back pain of up to 1 year duration Page 5 of 12 Status under previous East Midlands Policies Previously restricted * Previously restricted *

6 Acupuncture for all other purposes (see above) Aesthetic operations on the umbilicus Alternative therapies not explicitly listed in this policy Alexander technique Anal rectal skin tags Applied kinesiology Aromatherapy Autogenic training Autologous Chondrocyte Implantation (ACI) Ayurveda Back pain - Facet joint injections Benign skin lesions Brow Lift / Face lift / Ptosis surgery Body Contouring Botulinum Toxin Treatment, lontophoresis or surgical treatments for Axillary Hyperhidrosis Botulinum Toxin treatment for wrinkles frown lines or aging neck Brachioplasty/Upper arm lift Breast Uplift Buttock Lift Calf implants Cheek Implants (except in post-trauma cases and/ or part of planned reconstruction following surgery e.g. for cancer Chemical peels Previously restricted * * Previously restricted * * * * Page 6 of 12

7 Chin implant (genioplasty, mentoplasty) Chinese medicine Chiropractic therapy Cholecystectomy for asymptomatic gallstones - Where there are no symptoms, cholecystectomy confers no benefit to patients with asymptomatic gallstones, even in patients with one attack of uncomplicated gallstone pain. * Only funded for patients at risk of developing gallbladder carcinoma or gallstone complications special cases process will apply Circumcision for non-medical reasons Collagen implant (except in post-trauma cases and/ or part of planned reconstruction following surgery e.g. for cancer Congenital pigmented lesions on the face (removal of) Correction of deviated septum (see surgical treatment of snoring) Cranial banding for positional plagiocephaly Dermabrasion of skin * * Previously restricted** * Page 7 of 12

8 Diagnostic investigations for Irritable Bowel Syndrome (IBS) The following tests will not be funded for confirmation of diagnosis in adults who meet the IBS diagnostic criteria: Ultrasound Rigid/flexible sigmoidoscopy Colonoscopy; barium enema Thyroid function test Faecal ova and parasite test Faecal occult blood Hydrogen breath test Dupuytrens Contracture; Previously restricted The Commissioner does not fund collagenase injections (Xiapex) nor does the commissioner fund radiation therapy for early Dupuytrens. Dilatation and Curettage (D&C) / Hysteroscopy Including the treatment of menorrhagia (Heavy Menstrual Bleeding) Previously restricted Dilation and Curettage will not be funded in the following circumstances: As a diagnostic tool for heavy menstrual bleeding. Or as a therapeutic treatment for heavy menstrual bleeding Earlobe repair Electrolysis Environmental medicine Removal of Epidermoid/Pilar (Sebaceous Cysts) with the exception of recurrent infection and size greater than 0.5cm diameter Epidural injections of non-radicular pain Page 8 of 12 * * Previously restricted

9 Epidural injections of non-specific low back pain Excimer laser for Astugmatism and Xanthelasma Excimer laser for corneal erosions Excision of excessive skin from thigh, leg, hip, buttock, arm, forearm or other areas Extracorporeal shock-wave therapy for planta fasciitis Face lifts (unless part of the treatment of facial nerve palsy/ congenital facial abnormalities/treatment of specific facial skin condition e.g. cutis laxa, pseudoxanthoma elasticum) Fat Grafts Forearm implants Hair depilation (removal) for excessive hair growth (hirsutism) Hair transplant/ Hair graft/ Hair replacement/ Intralace hair system for abnormal hair loss Healing Herbal medicine Hip resurfacing Homeopathy Hydrotherapy unless part of an established care package Hymen reconstruction Hypnosis Joint revisions including hip and knee. The commissioner will only fund revisions using standard prosthesis Knee - Diagnostic Arthroscopy Knee Washout Labial reduction/ labiaplasty * * * * * * Previously resitricted** * Page 9 of 12

10 Laser - general Laser Treatment for skin conditions causing scarring including post acne and post traumatic scarring Laser Treatment for facial hyperpigmentation Laser treatment for myopia Laser Treatment/ therapy/ tunable dye laser for aesthetic reasons Lipoma (removal of) * * Liposuction (Suction assisted lipectomy) (except as part of planned reconstruction surgery for the treatment of cancer or congenital syndrome) * Lymphoedema treatment in private specialist units Male Breast reduction Surgery for Gynaecomastia Massage Meditation Natruropathy Neck Lift Nipple inversion correction of Nutritional therapy Osteopathy Out of area or referrals to the independent sector for Children with suspected Autism- referrals to the independent sector or out of area will only be considered where the child s care has been assessed by CAMHS or paediatric services and where there is a recommendation by either or both agencies that such a referral is necessary NHS standard Lymphoedema treatment funded by NHS England * * Page 10 of 12

11 Out of area treatment for chronic fatigue syndrome / ME (local pathways in place) Patella resurfacing Penile Implants Phalloplasty Pinnaplasty ( correction of prominent ears) Procedures related to gender reassignment not included in the original package of care Radiofrequency Denervation (RFD) to treat osteoidostemoma Reflexology Reiki Removal of anal/ rectal skin tags Removal of excess skin following weight loss whether through surgery or natural means Removal of Supernumerary Nipples (Polymastia) Repair of chronic clefts due to avulsion of body piercing Repair of chronic tear of lobe of external ear Residential pain management programmes Reversal of Female Sterilization Reversal of Vasectomy Scar Reduction including skin grafts for scars Septo-Rhinoplasty or Rhinoplasty Shiatsu Submental Lipectomy (neck lift) Surgery for divarication of the abdominal rectus Previously Restricted** Previously not routinely funded ** (funded by NHS England for Gender Reassignment Surgery) * * * Previously restricted * Page 11 of 12

12 Surgical procedures to correct rhinophyma "bulbous nose" or "phymatous rosacea" Surgical reduction of the tongue (see surgical treatment for snoring) Surgical treatment for myopia or short sight Surgical Treatment for Snoring Surgical treatment of Lipoma Surgical treatment of Myopia Tattoo removal Therapeutic community method for treatment of borderline personality disorder Therapeutic use of ultrasound in hip and knee osteoarthritis Tonsillectomy as a treatment for snoring Toric Intraocular Lens Implant for Astigmatism Trigger finger (non-surgical treatment is funded by commissioners) Vaginoplasty X-ray (plain) of back for low back pain * * * * Value-based commissioning: procedures of limited clinical value. A joint commissioning policy of clinical commissioning groups in Nottinghamshire County (excluding Bassetlaw and Nottingham City) (2015) ** East midlands commissioning policy for cosmetic procedures (2015) Version 2 15 Page 12 of 12