Restricted Procedures,Treatments and Interventions (Prior Approval Scheme) 2015/16

Transcription

1 Newbury and District Clinical Commissioning Group North and West Reading Clinical Commissioning Group South Reading Clinical Commissioning Group Wokingham Clinical Commissioning Group Berkshire West Federated CCGs Restricted Procedures,Treatments and Interventions (Prior Approval Scheme) 2015/16 Berkshire West Federated CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V2

2 Introduction This document sets out those services, procedures, treatments and interventions where Berkshire West Federated CCGs (BWCCGs) require Providers to work with them to ensure patients are treated in line with commissioning policies, approval process and decisions. It outlines treatments not routinely commissioned or restricted to clinical criteria. The function for addressing individual funding requests lies with Central Southern Commissioning Support Unit (CSCSU) through its IFR service which acts on behalf of BWCCGs. This work is driven by the need to ensure that NHS funded treatments are effective and evidencebased. It also attempts to define more clearly and openly the limits of NHS funding for procedures with social but not physical benefits e.g. cosmetic procedures. Although not the main driving force, it is also linked to the need to ensure that the NHS provides value for money and achieves financial balance. The current proposals can be broadly classified into three categories: RED: Excluded procedures not routinely funded by Berkshire West Federated CCGs (formerly known as, including and not limited to, Low Priority, PLCV and Never Dos) AMBER: Procedures that require prior approval by written communication through the IFR team who manage these requests on behalf of Berkshire West CCGs (formerly known as threshold dependent procedures (TDP) GREEN: Funded Subject to Audit procedures that are routinely funded subject to criteria and will be subject to audit of an agreed sample of activity. Red - Procedures not routinely funded (excluded) These are procedures that will not be routinely funded by the CCGs due to a lack in clinical benefit, limited resource or the responsibility of specialised commissioning. Individual funding requests (IFR) may be made to the patient s CCG for consideration, where exceptional circumstances exist via the IFR team through the IFR process, as outlined on the following website: Amber - Procedures that require prior approval For these procedures it is known that the benefit from the intervention is expected to be more effective when the patient meets the criteria, as outlined on the following website. Prior approval is required for all procedures, treatments and interventions in this category. Where available a proforma/checklist is to be completed. Green - Funded and Subject to Audit For these procedures prior to referral and/or treatment the patient must meet the criteria as outlined on the following website These cases will be audited and monitored for compliance against the criteria. These procedures will only be commissioned from Providers who will work with us to ensure that patients are only offered treatment where the funding criteria are met. Where patients do not meet the criteria, individual funding requests (IFR) may be made to the patient s CCG for consideration, where exceptional circumstances exist. For all categories - procedures carried out that do not follow the above outlined processes will not be paid for. Retrospective funding requests are also not accepted and will not be funded. A list of procedures, treatments and interventions can be found in table 1. Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 1

3 Table 1 Procedure / Treatment Excluded Prior Approval Funded Subject to Audit All specialties Anal Irrigation systems for the Management of Faecal incontinence/constipation Botox for the treatment of Hyperhidrosis Botulinum toxin Type A for chronic headaches (excluding migraines) Electrical stimulation (including Functional Electrical Stimulation) for Upper and Lower Limb Dysfunction Endoscopic Thoracic Sympathectomy for Facial Blushing and/or sweating Erectile Dysfunction treatments - Including: Erectile pumps/devices, the drugs Sildenafil, Vardenafil and Tadalafil outside of policy and psychosexual interventions Excess Treatment Costs (ETCs) for non-commercial clinical trials Facet Joint Injections (FJI) and Medial Branch Blocks for Chronic Low Back Pain Diagnostic/ Therapeutic Functional Electrical Stimulation in Drop Foot of Central Origin Gallstones (treatment of patients with previously symptomatic gallstones who are now free of symptoms) Hernia (Inguinal) Hernia (Umbilical) Laparoscopic fundoplication for chronic reflux oesophagitis (funding for use in any other circumstance is excluded) Manipulation of the Temporomandibular Joint together with intra-articular injection of steroids under general anaesthesia Multiple Chemical Sensitivity (MCS) and Clinical Ecology/ Environmental Medicine Neuro-rehabilitation inpatient stay (ABI and Stroke 2b placements) Non pharmacological services for dementia patients Sacral Nerve Stimulation for constipation Speech and Language Therapy in Parkinson's Disease Spinal manipulation for the treatment of chronic, non-specific low back pain Surgical techniques for the treatment of Oesophageal Stricture Transforaminal epidural injections for sciatica (therapeutic use) Transforaminal epidural injections for sciatica (diagnostic use) Bariatric Surgery Pre-operative weight loss inpatient programmes Cardiac Radiofrequency ablation Complementary medicine / alternative therapies Acupuncture Acupuncture of the treatment of chronic, non-specific low back pain Body Massage Functional Therapy Session Homeopathy -Complementary therapy Hypnosis Movement Therapy Osteopathy and Chiropractic Relaxation Therapy Session Cosmetic Procedures Abdominoplasty, Apronectomy, (tummy tucks) Aesthetic/cosmetic genital surgery male or female Appliances & devices for cosmetic purposes (high-grade silicon cosmesis and/or prosthesis) Blepharoplasty -(upper and lower eye lid surgery) Body contouring procedures (buttock, thigh, arm lifts) Botox for cosmetic reasons Procedure / Treatment Excluded Prior Funded Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 2

4 Cosmetic Procedures (continued) Brachioplasty (arm lift) Breast asymmetry Breast augmentation Breast mastopexy Breast prosthesis removal or replacement Breast reduction Clitoroplasty Correction of hair loss (Alopecia) including Intralace Correction of male pattern baldness Correction of Ptosis Corrective surgery to nipple Excision of skin tag of anus (not including fistula s) Excision of sweat bearing glands Facelift (Rhytidectomy/ Surgical removal of wrinkles)/ Brow lift and Submental lipectomy Hair Transplantation / hair grafting/ intralace Hymenopathy Labiaplasty Laser removal of skin lesions (haemangioma, portwine stain, HHT) and excessive hirsutism Laser Treatment Liposuction Male breast reduction for Gynaecomastia Mammoplasty Minor skin procedures (not including BCC and SCC) Pinnaplasty (bat ears adult and children) Reconstruction/Revision of breast (not including post breast cancer) Reconstruction/Revision of nose Reconstruction/Revision of external ear Reconstruction/Revision of body (excess skin removal for all areas) Reconstruction/Revision of body (excess skin removal for all areas) post bariatric surgery/weight loss Removal of lipomata Removal of supernumerary nipples Removal of Tattoos Revision of Breast Augmentation Rhinoplasty (cosmetic nose surgery) does not include Septorhinoplasty where there is nasal obstruction Scar Revision (keloid and hypertrophic scars) Sebaceous cysts (pilar and epidermoid cysts) Seborrhoeic keratoses (benign skin growths, verrucas, warts), acne vulgaris, rosacea Skin resurfacing (dermabrasion, laser and chemical peels) Spider naevia, Split earlobes, meatoplasty/ plastic operations on external ear (e.g. lobe repair) Telangiectasia Vaginoplasty Xanthelasmas Approval Subject to Audit Ear Nose and Throat Adenoidectomy Grommets /Myringotomy(children) Surgery in the management of chronic rhino sinusitis and nasal polyposis Tonsillectomy Prior Funded Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 3

5 Procedure / Treatment Excluded Approval Subject to Audit Gastroenterology Capsule endoscopy Gastric Pacemakers Gynaecology Dilation and curettage in women under 40 for dysfunctional uterine bleeding Female Sterilisation and reversal Hysterectomy Uterine Artery Embolisation of Fibroids Infertility treatments Cryopreservation (male and female) In vitro fertilisation (including the prescriptions of infertility drugs) and ICSI (intracytoplasmic sperm injection) Maxillofacial Temporomandibular Joint Replacement Mental Health ADHD Treatment Pathway for Adults with Attention Deficit Hyperactivity Disorder Chronic Fatigue Syndrome / Myalgic Encephalomyelitis inpatient stay Psychological Medicines Unit /Inpatient psychotherapy Ophthalmology Cataract removal in adults Chalazia (meibomian cysts) Second eye cataract surgery Short sight/long sight corrective (laser) surgery (Refractive keratoplasty) Trauma and Orthopaedics Arthroscopic Lavage & Debridement for Patients with Osteoarthritis of the knee Carpal Tunnel Syndrome Cortocosteroid injections for elbow tendinopathy (tennis elbow) Cortocosteroid injections for patellar tendinopathy (jumper s knee) Dupuytren s Contracture (Palmar Fasciectomy) Femoro-acetabular (Hip) Impingement (Arthroscopic and open Approaches) Surgical Treatment - Hip Impingement surgery Ganglion Surgery Hip and Knee Replacement additional follow up appointments Hip Prostheses / primary hip and knee replacement surgery Hip Resurfacing for Advanced Arthropathy Low-intensity pulsed ultrasound (LIPUS, marketed in the UK as the Exogen system) for delayed non-union fracture Referral for Hip Joint Replacement (Revision) Surgery Referral for Knee Joint Replacement (Revision) Surgery Spinal Surgery (spinal fusion or discectomy) for the treatment of chronic nonspecific low back pain Treatment of bunions (hallux valgus) Trigger finger surgery Vertebroplasty and Kyphoplasty Respiratory Short Burst Oxygen Therapy(SBOT) for the relief of episodic breathlessness Urology Female genital prolapse/stress incontinence surgery Male Circumcision Penile prosthesis / enlargement Penile Rehabilitation following prostate surgery Reversal of sterilisation and reversal of vasectomy Vasectomy Vascular Surgery Varicose Veins Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 4

6 Process for managing restricted procedures, treatments and interventions This document includes the absolute criteria which must be met in order for the patient to be treated and the associated charges to be paid by Berkshire West Federated CCGs. It is important to note that the clinical case for an individual s treatment should be assessed on its own merits and if a patient does not meet the criteria for funding an application can be made via an Individual Funding Request. The NHS Confederation document "Priority setting: managing individual funding requests", drafted for Primary Care Trusts in 2008, gives a clear definition of an individual funding request as follows:- "An Individual Funding Request (IFR) is a request to a CCG (formerly PCT) to fund healthcare for an individual who falls outside the range of services and treatments that the CCG (formerly PCT) has agreed to commission. There are several reasons why a CCG may not be commissioning the healthcare intervention for which funding is sought. It might not have been aware of the need for this service and so has not incorporated it into the service specification It may have decided to fund the intervention for a limited group of patients that excludes the individual for whom the request is made It may have decided not to fund the treatment because it does not provide sufficient clinical benefit and/or does not provide value for money It may have accepted the value of the intervention but decided it cannot be afforded in the current year Such requests should not be confused with Decisions that are related to care packages for patients with complex healthcare needs which include Continuing Health Care packages of care. The above list is not exhaustive and is at the sole discretion of the Commissioners. Where patients do not meet criteria in the Amber category or are under the Red category Individual Funding Requests will usually be considered on the basis of exceptionality. A guide to what constitutes exceptionality or exceptional health need, can be found here: Central to the CCG s consideration of IFRs is the question: Why should this treatment be provided for this patient, when it would not be funded for other patients who have the same, or a substantively similar, condition? If funding is to be agreed for the proposed treatment, there must be some unusual or unpredictable or unique factor about the patient s clinical circumstances, which suggests that: the presentation/effect of the condition in the patient differs significantly from that found in the general population of patients with the condition and, as a result, the patient is likely to gain significantly more benefit from that treatment than might generally be expected for these patients. In addition to this: There should be sufficient evidence of the effectiveness of the treatment in bringing about the expected benefit for the patient. Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 5

7 IFRs must be supported by a summary statement of evidence for the proposed treatment. NB: It is the requesting clinician s responsibility, where relevant, to set out the case for an exception to be made. Please note: It is not possible to predict in advance what might provide a basis for exceptional funding, given the individual nature of each patient s clinical circumstances. Meeting the accepted indications for a treatment does not, in itself, provide a basis for an exception. The fact that a patient is likely to respond to the requested treatment does not, in itself, provide a basis for an exception. Non-medical or social factors will rarely be considered as a basis for an exception. Social value judgements will not be considered as a basis for an exception. For a further explanation of exceptionality, please refer to the UK Faculty of Public Health document available at (accessed 15/01/15) and Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 6

8 Figure 1 Process for managing policies. Berkshire West CCGs process for restricted treatments, procedures and interventions Referral arrives into Provider for a Consultants opinion only Referral arrives into Provider for a specific treatment / procedure / intervention/ drug OPA for consultant s opinion only can take place to determine treatment. If treatment required is covered by the IFR policies for either RED or Amber or GREEN the following process must be followed RED or Amber procedure with no IFR Prior approval GREEN procedure outside of criteria OR Retrospective funding request (these will not be paid) NO REJECTED - back to referrer explaining why Approval must be obtained prior to First OPA NO RED AMBER GREEN Refer Individual Funding Request to berkswest.ifrrequests@nh s.net for consideration Does not meet criteria Check against policy criteria Declined Seek prior approval from berkswest.ifrrequests@nh s.net Criteria met Approved by IFR Treat Patient Not treated within relevant timescale Document that patient meets criteria (proforma / case notes) Approved by IFR Prior approval considered by IFR Treat Patient Treat Patient within timescale 6 months for procedures 12 months for drugs Treat Patient within timescale 6 months for procedures 12 months for drugs Rejected Berkshire West CCGs audit and review Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 7

9 Description of Prior Approval Process All Providers N.B. For clinically urgent requests which require Prior approval there is a fast-track process which manages these requests within 48 hours of receiving a complete case. Therefore these will not delay clinically urgent treatments where the patient meets the criteria. This process applies for referrals into All Providers for restricted procedures, treatments and interventions outlined in Table 1. The process is: 1. Check the procedure is on the list (Table 1). 2. Check the policy for this procedure and assess the patient against the policy as per the categories below: RED Red procedures without Individual Funding Requests must not be treated as they are not routinely commissioned. Reject referral and send back to referrer explaining why. AMBER Check prior approval has been granted. If yes, proceed. If no apply for IFR GREEN Check criteria. If patient is outside of criteria. Reject referral and send back to referrer explaining why or you have the option to apply for IFR 3. If prior approval is in place for red / amber categories or if patient meets criteria for green patient can be invited for First Outpatient Attendance for assessment only. PLEASE NOTE: Where consideration is required for assessment of the patient s health needs (and can only be determined by the Consultant in an outpatient assessment) then the patient should be invited for an assessment for an opinion only. 4. Decision made to clinically proceed based on initial assessment: No Reject back to referrer explaining why Yes Proceed 5. What process is followed for the required procedure / treatment, check is it Red, Amber or Green: RED Clinician believes patient has extenuating circumstances, exceptional health need and completes an Individual Funding Request to berkswest.ifrrequests@nhs.net for necessary approval and funding. If IFR rejected, patient referred back to referrer. Where IFR approved, proceed to treat. AMBER Prior approval required from BWCCGs. Clinician completes form detailing need for treatment and required procedure/ dosage or regimen to berkswest.ifrrequests@nhs.net. Where prior approval granted, proceed to treat. Where prior approval rejected, refer back to referrer explaining why GREEN Check criteria. If patient is outside of criteria. Reject referral and send back to referrer explaining why. If believe patient has extenuating circumstance and exceptional health need, clinicians to apply for IFR. If patient meets the criteria, proceed with treatment documenting how patient meets criteria (proforma / patient notes). Berkshire West CCGs to audit and review compliance 6. Red Policies These procedures are not commissioned by Berkshire West CCGs. The clinician can apply for an Individual Funding Request (IFR) if they believe the patient has extenuating circumstances and their health will benefit from the procedure / treatment /intervention. Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 8

10 7. Amber Policies Written communication must be submitted to the IFR Team on behalf of the BWCCGs at for prior approval completing the appropriate proforma and explaining the patients need for treatment. The team will respond within 3-5 working days of the decision being made. Approved - Where patients are approved, proceed with treatment. Providers must treat patients within 6 months of approval date for procedures/interventions or 12 months of approval for drug treatment. Not Approved Where patients are not approved DO NOT proceed with treatment and refer back to original referrer explaining why with necessary management plan. 8. Green Policies - Does the patient meet the criteria within the policy? No DO NOT treat. If the patient does not meet the criteria in the policy, BWCCGs will not fund the procedure. Clinician can apply for IFR if believes patient has extenuating circumstances and will benefit from procedure / treatment/ intervention. Otherwise refer back to original referrer Yes Proceed with treatment. Document in proforma / patients notes where criteria have been met according to the individual policy. PLEASE NOTE: Retrospective funding will not be considered or agreed. Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2015/16 V7 9