Policy for Procedures Not Routinely Funded

Transcription

1 Policy for Procedures Not Routinely Funded Document purpose This policy lists all the procedures that are not routinely funded by NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG. This policy is based on and superseded the Nottinghamshire (excepting Bassetlaw) Procedures of Limited Clinical Value Policy 2015 and the East Midlands Cosmetics Policy Version Title Associated Policy Nominated Lead Version 3 incorporating change to special cases panel Policy for Procedures Not Routinely Funded Service Restriction Policy (2017) Chief Nurse and Director of Quality and Governance Approval Date Approving Committee Review Date Groups/staff Consulted Joint NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG Governing Body This policy will be reviewed in 1 year or earlier if additions or changes are required. Joint NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG Clinical and Cost Effectiveness Committee Joint NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG Clinical Executive Committee Joint NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG Governing Body Target audience All CCG staff All providers All Clinicians Circulation list CCG Websites All providers Primary Care Clinicians Associated documents Individual Funding Requests (IFR) V2 April

2 Contents Purpose of the policy... 7 Introduction... 7 Commissioning Principles... 7 Policy Exclusions... 7 Exceptionality and Special Circumstances... 8 Statement of Cosmetic Procedures... 8 List of procedures covered under this policy... 9 Description of Procedure/Treatment... 9 Abdominoplasty (Apronectomy/ Panniculectomy)... 9 Acupuncture for non-specific low back pain of up to 1 year duration- complimentary therapy... 9 Acupuncture for all other purposes (see above) - complimentary therapy... 9 Aesthetic operations on the umbilicus... 9 Alternative therapies not explicitly listed in this policy... 9 Alexander technique- complimentary therapy... 9 Anal rectal skin tags... 9 Applied kinesiology-complimentary therapy... 9 Aromatherapy- complimentary therapy... 9 Autogenic training- complimentary therapy... 9 Autologous Chondrocyte Implantation (ACI) - complimentary therapy... 9 Ayurveda- complimentary therapy... 9 Back pain - Facet joint injections... 9 Benign skin lesions cosmetic... 9 Blepharoplasty/ Brow Lift Face brow lift /Ptosis surgery -cosmetic... 9 Body Contouring cosmetic... 9 Botulinum Toxin Treatment, lontophoresis or surgical treatments for Axillary Hyperhidrosis... 9 Botulinum Toxin treatment for wrinkles frown lines or aging neck- cosmetic... 9 Brachioplasty/Upper arm lift - cosmetic... 9 Breast Enlargement/augmentation asymmetry surgery Female... 9 Breast implant removal / reinsertion Breast Reduction- cosmetic

3 Breast Uplift - cosmetic Buttock Lift- cosmetic Calf implants cosmetic Removal of Chalazion Cheek Implants cosmetic (except in post-trauma cases and/ or part of planned reconstruction following surgery e.g. for cancer Chemical peels- cosmetic Chin implant (genioplasty, mentoplasty) - cosmetic Chinese medicine- complimentary therapy Chiropractic therapy complimentary 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- cosmetic Collagen implant- cosmetic (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- cosmetic Dermabrasion of skin -cosmetic 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 Earlobe repair-cosmetic Electrolysis - cosmetic Environmental medicine-complimentary medicine

4 Removal of Epidermoid/Pilar (Sebaceous) Cysts Epidural injections of non-radicular pain 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 cosmetic (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- cosmetic Forearm implants cosmetic Hair depilation (removal) for excessive hair growth (hirsutism) cosmetic Hair transplant/ Hair graft/ Hair replacement/ Intralace hair system for abnormal hair loss - cosmetic Healing- complimentary therapy Herbal medicine complimentary therapy Hip resurfacing Homeopathy- complimentary medicine Hydrotherapy unless part of an established care package Hymen reconstruction- cosmetic Hypnosis- complimentary therapy Joint revisions including hip and knee. The commissioner will only fund revisions using standard prosthesis Knee - Diagnostic Arthroscopy Labial reduction/ labiaplasty Laser - general Laser Treatment for skin conditions causing scarring including post acne and post traumatic scarring - cosmetic Laser Treatment for facial hyperpigmentation- cosmetic 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)

5 Lymphoedema treatment in private specialist units Male Breast reduction Surgery for Gynaecomastia Massage- complimentary medicine Meditation complimentary medicine Natruropathy- complimentary medicine Neck Lift- cosmetic Nipple inversion correction of- cosmetic Nutritional therapy- complimentary medicine Osteopathy- complimentary medicine Out of area or referrals to the independent sector for Children with suspected Autism- 13 Out of area treatment for chronic fatigue syndrome / ME (local pathways in place) Patella resurfacing Penile Implants Phalloplasty- cosmetic Pinnaplasty ( correction of prominent ears) - cosmetic Procedures related to gender reassignment not included in the original package of carecosmetic Radiofrequency Denervation (RFD) to treat osteoidostemoma Reflexology complimentary medicine Reiki- complimentary medicine Removal of anal/ rectal skin tags Removal of excess skin following weight loss whether through surgery or natural means 14 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 cosmetic Septo-Rhinoplasty or Rhinoplasty Shiatsu- complimentary medicine Submental Lipectomy (neck lift) Surgery for divarication of the abdominal rectus

6 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- cosmetic X-ray (plain) of back for low back pain Annex A Individual Funding Request (IFR) policy... 6

7 Purpose of the policy The purpose of this policy is to ensure that the Mid Nottinghamshire Clinical Commissioning Groups (the Commissioner) 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 Mansfield and Ashfield and Newark and Sherwood Clinical Commissioning Groups do not routinely 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 policy for 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 Mid Nottinghamshire CCGs do not routinely 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 Mid 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. 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 Exceptional or Special circumstances through IFR. 7

8 Exceptionality and Special Circumstances The Commissioner will consider funding individual cases for the procedures restricted by this commissioning policy through the Individual Funding Request Policy, where there are exceptional circumstance. Implementation and Compliance 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. Conditions resulting from major trauma or burns, which need reconstructive surgery, will usually be funded by the NHS. 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. 8

9 List of procedures covered under this policy Description of Procedure/Treatment Status under previous East Midlands Policies Abdominoplasty (Apronectomy/ Panniculectomy) Acupuncture for non-specific low back pain of up to 1 year duration- complimentary therapy Acupuncture for all other purposes (see above) - complimentary therapy Aesthetic operations on the umbilicus Alternative therapies not explicitly listed in this policy Alexander technique- complimentary therapy Anal rectal skin tags Applied kinesiology-complimentary therapy Aromatherapy- complimentary therapy Autogenic training- complimentary therapy Autologous Chondrocyte Implantation (ACI) - complimentary therapy Ayurveda- complimentary therapy Back pain - Facet joint injections Benign skin lesions cosmetic Blepharoplasty/ Brow Lift Face brow lift /Ptosis surgery -cosmetic Body Contouring cosmetic Botulinum Toxin Treatment, lontophoresis or surgical treatments for Axillary Hyperhidrosis Botulinum Toxin treatment for wrinkles frown lines or aging neck- cosmetic Brachioplasty/Upper arm lift - cosmetic Breast Enlargement/augmentation asymmetry surgery Female Previously restricted * Previously restricted * Previously restricted * * Previously restricted * * * 9

10 Breast implant removal / reinsertion Breast Reduction- cosmetic Breast Uplift - cosmetic Buttock Lift- cosmetic Calf implants cosmetic Removal of Chalazion Cheek Implants cosmetic (except in post-trauma cases and/ or part of planned reconstruction following surgery e.g. for cancer Chemical peels- cosmetic Chin implant (genioplasty, mentoplasty) - cosmetic Chinese medicine- complimentary therapy Chiropractic therapy complimentary 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. Previously restricted** Previously restricted** * * Only funded for patients at risk of developing gallbladder carcinoma or gallstone complications special cases process will apply Circumcision for non-medical reasons- cosmetic Collagen implant- cosmetic (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 plagiocephalycosmetic * * Previously restricted** * 10

11 Dermabrasion of skin -cosmetic 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 Earlobe repair-cosmetic Electrolysis - cosmetic Environmental medicine-complimentary medicine Removal of Epidermoid/Pilar (Sebaceous Cysts) with the exception of recurrent infection and size greater than 1cm diameter Epidural injections of non-radicular pain 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 cosmetic (unless part of the treatment of facial nerve palsy/ congenital facial abnormalities/treatment of specific facial skin condition e.g. cutis laxa, pseudoxanthoma elasticum) * * Previously restricted * * 11

12 Fat Grafts- cosmetic Forearm implants cosmetic Hair depilation (removal) for excessive hair growth (hirsutism) cosmetic Hair transplant/ Hair graft/ Hair replacement/ Intralace hair system for abnormal hair loss - cosmetic Healing- complimentary therapy Herbal medicine complimentary therapy Hip resurfacing Homeopathy- complimentary medicine Hydrotherapy unless part of an established care package Hymen reconstruction- cosmetic Hypnosis- complimentary therapy Joint revisions including hip and knee. The commissioner will only fund revisions using standard prosthesis Knee - Diagnostic Arthroscopy Labial reduction/ labiaplasty Laser - general Laser Treatment for skin conditions causing scarring including post acne and post traumatic scarring - cosmetic Laser Treatment for facial hyperpigmentationcosmetic Laser treatment for myopia Laser Treatment/ therapy/ tunable dye laser for aesthetic reasons Lipoma (removal of) * * * * * * * 12

13 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- complimentary medicine Meditation complimentary medicine Natruropathy- complimentary medicine Neck Lift- cosmetic Nipple inversion correction of- cosmetic Nutritional therapy- complimentary medicine Osteopathy- complimentary medicine 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 Out of area treatment for chronic fatigue syndrome / ME (local pathways in place) Patella resurfacing Penile Implants Phalloplasty- cosmetic Pinnaplasty ( correction of prominent ears) - cosmetic Procedures related to gender reassignment not included in the original package of care- cosmetic Radiofrequency Denervation (RFD) to treat NHS standard Lymphoedema treatment funded by NHS England * * Previously Restricted** * (funded by NHS England for Gender Reassignment Surgery) * 13

14 osteoidostemoma Reflexology complimentary medicine Reiki- complimentary medicine 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 cosmetic Septo-Rhinoplasty or Rhinoplasty Shiatsu- complimentary medicine Submental Lipectomy (neck lift) Surgery for divarication of the abdominal rectus 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 * * Previously restricted * * * 14

15 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- cosmetic 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 Annex B Exceptionality and Special Circumstances Process Please see Exceptionality and Special Circumstances section. Associated forms to be appended and published. 15