Herefordshire CCG. Treatment Policies

Transcription

1 Herefordshire Clinical Commissioning Group (CCG) Item 10b NHS Herefordshire Clinical Commissioning Group Herefordshire CCG Treatment Policies This Policy should be read in conjunction with the CCGs Policy on Optimising Your Health, which seeks to provide support and guidance to patients so that they get the most benefit from any treatments or procedures. Name of Responsible Board / Committee for Ratification: Date Issued: Review Date:

2 Contents 1 Introduction Background Principles Lifestyle Factors And Surgery Psychological Factors And Surgery Scope Implementation Monitoring And Review Copies Of This Policy Glossary Of Terms Treatment Policies...13 Section 11.1 Cosmetic Surgery (Including Dermatology And Plastic Surgery)...14 Section 11.2 Ear, Nose And Throat...53 Section 11.3 General Surgery...66 Section 11.4 Mental Health...83 Section 11.5 Musculo-Skeletal...86 Section 11.6 Neurology/Neurosurgery Section 11.7 Obstetrics And Gynaecology Section 11.8 Ophthalmology Section 11.9 Oral Surgery Section Other Procedures And Treatments Section Pain Section Prescribing Guidelines Section Urology Appendix 1 - Herefordshire Low Priority Treatments Medicines Section November 2016 Version

3 1 INTRODUCTION The policy describes the access and exclusion criteria which the Herefordshire CCG will apply to Procedures of Limited Clinical Value. The term Procedures of Limited Clinical Value (POLCV), refers to procedures and treatments that are of value, but only in the right clinical circumstances. The main objective for having this treatment policies is to ensure that: Patients receive appropriate health treatments in the right place and at the right time; Treatments with no or a very limited evidence base are not used; and Treatments with minimal health gain are restricted. The procedures, to which this relates, are listed in the Scope section below. THIS POLICY APPLIES TO ROUTINE, PLANNED CARE ONLY. FOR URGENT AND EMERGENCY CARE DIRECT REFERRAL TO SECONDARY AND TERTIARY SERVICES MAY BE APPROPRIATE. 2 BACKGROUND Herefordshire Clinical Commissioning Group (CCG) and Herefordshire County Council Public Health Commissioners have worked collaboratively to develop this core set of commissioning policies. The policy aims to ensure that Herefordshire approach is consistent with other CCGs following a review of policies across Birmingham, Solihull and the Black Country, Shropshire and Staffordshire. This helps us to avoid variation in access to NHS services in different areas (which is sometimes called postcode lottery in the media) and allow fair and equitable treatment for all local patients. CCGs have limited budgets; these are used to commission healthcare that meets the reasonable requirements of its patients, subject to the CCG staying within the budget it has been allocated. By using these policies, we can prioritise resources using the best evidence about what is clinically effective, to provide the greatest proven health gain for the whole of the CCG s population. Our intention is to ensure access to NHS funding is equal and fair, whilst considering the needs of the overall population and evidence of clinical and cost effectiveness. In cases of diagnostic uncertainty, the scope of this policy does not exclude the clinician s right to seek specialist advice. This advice can be accessed through a variety of different mediums and can include both face to face specialist contact as well as different models of consultant and specialist nurse advice and guidance virtually. We recognise there may be exceptional circumstances where it is clinically appropriate to fund each of the procedures listed in this policy and these will be considered on a case-by-case basis. Funding for cases where either: a) the clinical threshold criteria is not met, or b) the procedure is not routinely funded, will be considered by the CCG following application to the CCG s Individual Funding Request Panel, whereby the IFR process will be applied.

4 3 PRINCIPLES Commissioning decisions by CCG Commissioners are made in accordance with the commissioning principles set out below, and in the CCGs Individual Funding Request Policy: CCG Commissioners require clear evidence of clinical effectiveness before NHS resources are invested in the treatment. In doing so, the CCG will look to evidence from the National Institute for Clinical Effectiveness, Royal Colleges, the Public Health services and published research; CCG Commissioners require clear evidence of cost effectiveness before NHS resources are invested in the treatment; The cost of the treatment for this patient and others within any anticipated cohort is a relevant factor; CCG Commissioners will consider the extent to which the individual or patient group will gain a benefit from the treatment as well as the potential for harm to be caused by an intervention; CCG Commissioners will balance the needs of each individual against the benefit which could be gained by alternative investment possibilities to meet the needs of the community; CCG Commissioners will encourage patients to take a full part in decision making about what treatments they will receive, within the list of treatments that the CCG has agreed to fund; CCG Commissioners will consider all relevant national standards and take into account all proper and authoritative guidance; and Where a treatment is approved CCG Commissioners will respect patient choice as to where a treatment is delivered. In determining the procedures that will be funded, the CCG will take into account the resources available to it. 4 LIFESTYLE FACTORS AND SURGERY Lifestyle factors can have an impact on the functional results of some elective surgery. For example, smoking is known to affect the outcomes of some foot and ankle procedures, smoking and obesity increase the risk of post-operative complications, alcohol affects the body s ability to process medicines. Therefore, to ensure optimal outcomes, all patients who smoke or have a body mass index of 35 or greater and are being considered for referral to secondary care, will be strongly advised to access CCG and Local Authority Public Health commissioned smoking cessation and weight reduction management services prior to surgery. The CCGs policy on Optimising Your Health requires GPs and Providers to ensure that these patients have been offered access to these services and encouraged to use them. Patient engagement with these preventive services may influence the immediate outcome of surgery and/or impact on the amount of benefit that a patient gets from the procedure. While failure to quit smoking or lose weight will not be a contraindication for surgery, GPs and Surgeons should ensure patients are fully informed of the risks associated with the procedure in the context of their lifestyle and how changes to their lifestyle would benefit their health and, specifically, how the benefits of the procedure would be affected.

5 5 PSYCHOLOGICAL FACTORS AND SURGERY Commissioners acknowledge that there is a psychological dimension for patients in seeking or considering the option of treatment and surgery. However, as there are no universally accepted and objective measures of psychological distress, such factors are not taken into account in any policy clinical thresholds. Nevertheless, where a clinician believes that a condition is leading to severe psychological distress s/he may refer the patient for an Independent Funding Review (IFR). The IFR Panel may seek a formal psychological or psychiatric assessment to aid its decision making. 6 SCOPE This Policy refers to patients whose treatment is funded by Herefordshire CCG only. Patients whose care is funded by other CCGs or Welsh Health Boards will have decisions about treatments guided by their local policies. The following policies and procedures are within the scope of this policy, each policy is categorised as either not routinely funded or restricted these are defined as follows: This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. This means CCG will fund the treatment if the patient meets the stated clinical threshold for care and where the patient meets the required criteria, this is clearly recorded in the patients notes. SPECIALITY/PROCEDURE CCG POLICY Pag COSMETIC SURGERY (including Dermatology and Plastic Surgery) 14 Abdominoplasty / Apronectomy Alopecia (Hair Loss) Blepharoplasty, Ptosis and Brow Lift - Eyelid Surgery (Upper and Botulinum Toxin Treatments (Botox) for the face Breast Augmentation Breast Reduction Eyelid Surgery (Upper and Lower) - Blepharoplasty Gynaecomastia (Male Breast Reduction) Haemangioma Hair Grafting male pattern baldness Hirsutism (Hair Depilation) Hyperhidrosis Inverted Nipple Correction Labiaplasty Lipoma Liposuction Mammoplasty Revision (including prosthetic removal or replacement) Mastopexy (Breast Lift) Other Cosmetic Procedures Penile Implants, labial trimming and cosmetic genital procedures Pinnaplasty Removal/Repair of Ear Lobes Resurfacing Procedures: Dermabrasion, Chemical Peels and Laser Treatment Rhinoplasty Rhinophyma

6 Rhytidectomy Scars and Keloids - Medical and Surgical Treatment of Skin Lesions Surgical removal of benign (non-cancerous) Tattoos - Surgical Removal of correction of body piercings and correction of respective problems Thigh Lift, Buttock Lift and Arm lift, Excision of Redundant Skin or Fat Thread / Telangiectasis / Reticular Veins Vaginoplasty Viral warts EAR NOSE & THROAT PROCEDURES 53 Adenoidectomy Bone anchored Hearing Aids Chronic Rhinosinusitis: Functional endoscopic sinus surgery Chronic Rhinosinusitis: Balloon catheter dilation of paranasal sinus ostia Ear Wax Grommets Snoring (with Obstructive Sleep Apnoea) Tonsillitis GENERAL SURGERY 66 Bariatric Surgery Cholecystectomy For Asymptomatic Gallstones Circumcision Endoscopic Radiofrequency Ablation For Gastric Reflux Haemorrhoidectomy Inguinal (Groin) Hernia Repair Linx Procedure For Gastric Reflux Lymph Node Transplant Post Mastectomy Varicose Veins Vascular Lower Limb Arterial Procedures Venous Angioplasty For Multiple Sclerosis MENTAL HEALTH 83 Borderline Personality Disorder - Therapeutic Community Treatment Method Liothyronine Prescribing MUSCULO-SKELETAL HEALTH 86 Acromio Clavicular Joint Excision Or Surgical Decompression Of Subacromial Space Back Pain - Non Specific, Specific And Chronic (See Also Management Of Pain) Carpal Tunnel Syndrome Dupuytren s Disease/Contracture Foot Treatments Ganglion Hip Arthroscopy For Femuro-Acetabular Impingement Syndrome Hip Replacement Surgery Hip Resurfacing Techniques (Primary Resurfacing Arthroplasty Of The Joint) Joint Injections Site Of Procedure Knee Arthroscopy Knee Autologous Cartilage Transplantation

7 Knee Replacement Surgery Spinal Fusion For Low Back Pain Trigger Finger NEUROLOGY/NEUROSURGERY 111 Inpatient Neuro-Rehabilitation OBSTETRICS and GYNAECOLOGY 113 Caesarian Section for Non-Clinical Reasons Dilation and Curettage (D&C) for Menorrhagia (Heavy Menstrual Bleeding) Doppler Ultrasound of Umbilical and Uterine Artery in Antenatal Care Hysterectomy for Menorrhagia (Heavy Menstrual Bleeding) Hysterectomy +/- Oopherectomy Hysteroscopy for Menorrhagia Infertility Treatment Reversal of Female Sterilisation OPHTHALMOLOGY 128 Cataract Surgery Laser (Photorefractive) Surgery for Short Sight (Myopia) ORAL SURGERY 132 Apicectomy Cosmetic Dental Procedures Orthodontic Treatment Wisdom Tooth Removal OTHER PROCEDURES and TREATMENTS 137 Chronic Fatigue Syndrome/Myalgic Encephalomyelitis Complementary Medicines and Therapies Hyperbaric Oxygen Therapy PAIN 141 Epidural Injections (Lumbar and Caudal), Facet Joint Injections for Lower Back Pain, Medial Branch Block Prolotherapy Radiofrequency and Electrothermal Ablation for Chronic Back Pain Spinal Cord Stimulation and Chronic Pain PRESCRIBING GUIDELINES (see appendix 1) 149 Prescribing Unlicensed Medicines/Substances not in the Advisory Committee on Borderline Substances (ACBS) List Items available on NHS FP10 Prescription but not Recommended in Herefordshire The PresQIPP Drop List ( Greater Manchester Medicines Management Group (GMMMG) - Do not Prescribe and Grey List UROLOGY 151 Male circumcision Medicines for Erectile Dysfunction Penile Implants Reversal of Male Sterilisation APPENDIX 1 PRESCRIBING GUIDELINES

8 7 IMPLEMENTATION GPs, service providers and clinical staff treating CCG funded patients are expected to implement this policy. The decision and rationale to provide a treatment contained within this policy should be clearly documented within the clinical notes together with an explanation of which criteria apply. This request allows the CCG to ensure that it is funding treatments that fall within its policies and that it is not funding treatments that have not been agreed. GPs and clinical staff treating patients are also encouraged to consult the CCGs list of previous decisions relating to Individual Funding Requests, to inform their discussions with patients. This list is available by contacting the CCG at the address below. The guidance contained in this policy is also appended to the CCG EMIS Web e-referral templates which have been previously distributed to practices. GPs and other referring clinicians are asked to make use of these templates when referring patients to WVT. Where a treatment is listed in this document and treatment is provided to a patient, the CCG will not pay for a procedure that is Not Routinely Funded unless there is an IFR panel approval. The IFR policy can be found at ( and is attached as Appendix A. The CCG will be entitled to decline payment for procedures unless it has clear evidence that the exception criteria have been applied and recorded in the medical record. Patients with problems or conditions that might require treatments included in this policy should be referred to a consultant or specialist only after a clinical assessment is made by the GP or consultant; AND the patient meets all the criteria set out in the policy. GPs and consultants wishing to seek a specialist opinion for patients who meet the above criteria should ensure the essential clinical information is included in the referral letter confirming the patient has been assessed in line with this policy. The CCG recognises that there will be exceptional, individual or clinical circumstances when funding for treatments designated as low priority will be appropriate. Where a treatment is either not routinely funded, or the patient does not meet the specified clinical criteria, this means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG IFR panel. Individual Funding Requests should only be sent to the NHS.net account as below. regarding IFRs and an application form can be found on the CCG s website. IFR contact information follows, however please refer to the CCG IFR policy for more information. Individual Funding Request Case Manager Countess of Chester Health Park 1829 Building Liverpool Road Chester Cheshire CH2 1HJ Telephone: ifr.hereford@nhs.net

9 8 MONITORING AND REVIEW This policy will be subject to continued monitoring using a mix of the following approaches: Prior approval process Audits of referrals and of the management of referrals Post activity monitoring through routine data Post activity monitoring through case note audits This policy will be kept under regular review, to ensure that it reflects developments in the evidence base regarding clinical and cost effectiveness. 9 COPIES OF THIS POLICY Electronic copies of this policy can be found on the CCG website Alternatively, you may contact the CCG and ask for a copy of the Policies of Limited Clinical Value. Copies of the policy will be distributed to all providers and general practices.

10 10 GLOSSARY OF TERMS TERM MEANING Abdominoplasty/Apronectomy A procedure to reduce excess skin and fat, improve abdominal contours and scars, and tighten muscles. This is sometimes called a tummy tuck. Active treatment Treatment and care to manage a particular disease / condition, e.g. cancer treatment, renal dialysis. Adenoidectomy A procedure to remove the adenoids lumps of tissue at the back of the nose. Aesthetics These are procedures which relate to cosmetic procedures which are intended to restore or improve a person s appearance. Alopecia Hair loss. Analgesics Painkillers. Asymptomatic Without symptoms. Augmentation Increasing in size, for example breast augmentation. Benign Does not invade surrounding tissue or spread to other parts of the body; it is not a cancer. Binocular vision Vision in both eyes. Body Mass Index (BMI) Body Mass Index - a measure that adults can use to see if they are a healthy weight for their height. BWH Birmingham Women s Hospital NHS Foundation Trust. Cataract When the lens of an eye becomes cloudy and affects vision. CCG Clinical Commissioning Group. CCGs are groups of General Practices that work together to plan and design local health services in England. They do this by 'commissioning' or buying health and care services. Cholecystectomy Removal of the gall bladder. Chronic Persistent. Co-morbidities Other risk factors alongside the primary problem. Congenital Present from birth. Conservative treatment The management and care of a patient by less invasive means; these are usually non-surgical. Depilation Removal. For example hair depilation. DOH Department of Health. Eligibility/Threshold Whether someone qualifies. In this case, the minimum criteria to access a procedure. Exceptional clinical circumstances A patient who has clinical circumstances which, taken as a whole, are outside the range of clinical circumstances presented by a patient within the normal population of patients, with the same medical condition and at the same stage of progression as the patient. Functional health problem/difficulty/impairmen Difficulty in performing, or requiring assistance from another to perform, one or more activities of daily living. Ganglion A non-cancerous fluid filled lump. GP General Practitioner. Page 10 of 91

11 TERM Gynaecomastia Haemorrhoidectomy Histology Hyperhidrosis Hysteroscopy Individual Funding Request (IFR) MEANING Benign enlargement of the male breast. A procedure to cut away haemorrhoids, sometimes called piles. The structure of cells or tissue under a microscope. Excess sweating. A hysteroscopy is a procedure used to examine the inside of the womb (uterus) using a hysteroscope (a narrow telescope with a light and camera at the end. Images are sent to a monitor so your doctor or specialist nurse can see inside your womb). A request received from a provider or a patient with explicit support from a clinician, which seeks funding for a single identified patient for a specific treatment which would otherwise not be routinely funded. Irreducible Unable to be reduced. Labiaplasty A procedure to reduce and/or reshape the labia. Lipomata Fat deposits under the skin. Liposuction A procedure using a suction technique to remove fat from specific areas of the body. Malignant/malignancy Harmful. Mastopexy A reconstructive procedure to lift the breast. Menorrhagia Abnormally heavy or prolonged bleeding at menstruation. Monocular vision Vision in one eye only. Multi-disciplinary Involving several professional specialisms for example in a Multi-disciplinary team (MDT). NICE guidance The guidance published by the National Institute for Health and Care Excellence. (a This means the CCG will only fund the treatment if an procedure) Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. NSAIDS Non-steroidal anti-inflammatory drugs medication that reduces pain, fever and inflammation. Paediatric(ian) Medical care concerning infants, children and adolescents usually under 18. Pathology/pathological The way a disease or condition works or behaves. This may for example include examination of bodily fluids or tissue e.g. blood testing. PCT Primary Care Trust (PCTs were abolished on 31 March 2013, and replaced by Clinical Commissioning Groups). Pinnaplasty A procedure to pin or correct deformities the ear. PLCV Procedures of Lower Clinical Value; routine procedures that are of value, but only in the right circumstances. Precipitates Brings about/triggers. Primary care A patient s first point of interaction with NHS services e.g. a GP surgery. Prophylactic Preventative or prevention. Rationale Explanation of the reason why. (a procedure) This means CCG will fund the treatment if the patient meets the stated clinical threshold for care. Page 11 of 55

12 TERM Rhinophyma Rhinoplasty Rhytidectomy Secondary care Stakeholders Symptomatic Tonsillectomy Vaginoplasty MEANING A condition causing development of a large, bulbous, ruddy (red coloured), nose. A procedure to shape the size and/or shape of the nose. A procedure to restore facial appearance or function. These are sometime called face or brow lifts. Services provided by medical specialists, who generally do not have the first contact with a patient e.g. hospital services. Individuals, groups or organisations who are or will be affected by this consultation, e.g. patients who currently use the service, carers, specific patient groups, etc. Something causing or exhibiting symptoms. A procedure to remove the tonsils. A procedure to reconstruct the vaginal canal.

13 11 TREATMENT POLICIES SECTION CONTENTS 11.1 Cosmetic Surgery (Including Dermatology And Plastic Surgery) 11.2 Ear Nose And Throat 11.3 General Surgery 11.4 Mental Health 11.5 Musculo-Skeletal 11.6 Neurology/Neurosurgery 11.7 Obstetrics And Gynaecology 11.8 Ophthalmology 11.9 Oral Surgery Other Treatments And Procedures Pain Prescribing Guidelines Urology

14 SECTION 11.1 Surgery) COSMETIC SURGERY (Including Dermatology And Plastic COSMETIC SURGERY (including Dermatology and Plastic Surgery) Abdominoplasty / Apronectomy Alopecia (Hair Loss) Blepharoplasty, Ptosis and Brow Lift - Eyelid Surgery (Upper and Lower) Botulinum Toxin Treatments (Botox) for the face Breast Augmentation Breast Reduction Eyelid Surgery (Upper and Lower) - Blepharoplasty Gynaecomastia (Male Breast Reduction) Haemangioma Hair Grafting male pattern baldness Hirsutism (Hair Depilation) Hyperhidrosis Inverted Nipple Correction Labiaplasty Lipoma Liposuction Mammoplasty Revision (including prosthetic removal or replacement) Mastopexy (Breast Lift) Other Cosmetic Procedures Penile Implants, labial trimming and cosmetic genital procedures Pinnaplasty Removal/Repair of Ear Lobes Resurfacing Procedures: Dermabrasion, Chemical Peels and Laser Treatment Rhinoplasty Rhinophyma Rhytidectomy Scars and Keloids - Medical and Surgical Treatment of Skin Lesions Surgical removal of benign (non-cancerous) Tattoos - Surgical Removal of correction of body piercings and correction of respective problems Thigh Lift, Buttock Lift and Arm lift, Excision of Redundant Skin or Fat Thread / Telangiectasis / Reticular Veins Vaginoplasty Viral warts

15 Abdominoplasty Or Apronectomy Abdominoplasty and apronectomy (Tummy Tuck) are surgical procedures performed to remove excess fat and skin from the mid and lower abdomen. Many people develop loose abdominal skin after pregnancy or substantial weight loss, whether due to surgical or dietary weight loss. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Abdominoplasty (Apronectomy) is not routinely commissioned. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Unless all of the criteria detailed below are met abdominoplasty or apronectomy following weight loss will not normally be funded: Documented evidence of clinical pathology due to the excess of overlying skin e.g. recurrent infections, intertrigo which has led to ulceration requiring repeated courses of treatment for a minimum period of one year or disability resulting in severe restrictions in activities of daily living AND AND AND The patients BMI before weight loss must have been 40kg/m2 or above The patients BMI must be < 28 kg/m2 and has been within this range for 1 year as measured and recorded by the NHS. In some patients this may not be achievable due to the weight of excess skin - in such cases the patient must have lost 50% of their excess weight and the clinician must confirm that further reduction in BMI will not be possible without removal of excess skin An abdominoplasty/apronectomy has not already been performed. This is because purely removal of surplus skin or fat irrespective of site on body is deemed to be cosmetic and does not meet the principles laid out in this policy. S02.1/.2/.8/.9

16 Alopecia Areata Alopecia refers to hair loss on either the head or the body although typically at least the head will be involved. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Surgical treatment for hair loss is deemed to be cosmetic and does not meet the principles laid out in this policy. The British Association Dermatologists state Leaving alopecia areata untreated is a legitimate option for many patients. Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (< 1 year). Such patients may be managed by reassurance alone, with advice that regrowth cannot be expected within 3 months of the development of any individual patch. The NHS Choices guidance below provides a range of non-surgical options for hair loss, including prescription medication from the GP. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. References British Association of Dermatologists - Guidelines for the management of alopecia areata (2012) Weblink: British Association of Dermatologists - alopecia areata patient information leaflet Weblink: NHS Choices Guide to Hair Loss Treatment Weblink: S21.1/.2/.8/.9; S33.1/.2/.3/.8/.9

17 Blepharoplasty, Ptosis And Brow Lift - Eyelid Surgery (Upper And Lower) Blepharoplasty is a surgical procedure performed to correct puffy bags below the eyes and droopy upper eyelids. It can improve appearance and widen the field of peripheral vision. Blepharoplasty type procedures may form part of the treatment of pathological conditions of the lid or overlying skin and not for cosmetic reasons. This procedure may be commissioned by the NHS to correct functional impairment. Surgery on the upper eyelid (upper lid blepharoplasty) Many people acquire excess skin in the upper eyelids as part of the process of ageing and this may be considered normal. However if this starts to interfere with vision or function of the eyelid then this can warrant treatment. Excessive skin in the lower lid may cause eyebags but does not affect function of the eyelid or vision and therefore does not need correction. This policy refers to upper and lower eyelid surgery which is Not routinely funded This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Note: The following eyelid surgery procedures will not be funded: Surgery for cosmetic reasons Surgery for cyst of moll Surgery for cyst of zeis Removal of eyelid papillomas or skin tags Surgery for pingueculum Excision of other lid lumps Upper eyelid blepharoplasty, treatment for Ptosis and Brow lift This procedure is restricted. The CCG will fund this treatment if the patient meets the required criteria: Lower Eyelid The CCG will fund this treatment if the patient meets the required criteria: ectropion (eyelid turned outwards from the eyeball), and/or entropion (eyelid folds into the eyeball) or for the removal of lesions of the eyelid skin or lid margin. This is because all eyelid surgery procedures are deemed to be cosmetic and do not meet the principles laid out in the Cosmetic Surgery policy. Removal of Benign (non-cancerous) or Congenital Skin Lesions that does not meet the criteria below is deemed to be cosmetic and does not meet the principles laid out in the Cosmetic Surgery policy unless there are clear clinical symptoms significantly affecting the patient s vision/visual field (see upper and lower eyelid surgery categories below). This means (for patients who either DO NOT meet the eligibility criteria below or require treatment for cosmetic reasons) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

18 Upper eyelid blepharoplasty, treatment for Ptosis and Brow lift This procedure is restricted. The CCG will fund this treatment if the patient meets the required criteria: Impairment of vision in the relaxed, non-compensated state as determined by the Visual field test reducing visual field to 120 laterally and/or more than 40 reduction vertically OR Severe congenital (from birth) ptosis (drooping of the upper eyelid) OR Chalazion (meibomian cyst) - unless acutely infected, it is harmless and nearly all resolve if given enough time. However if conservative therapy fails, chalazia can be treated by surgical incision into the tarsal gland followed by curettage of the retained secretions and inflammatory material under local anaesthetic. This criterion applies to ptosis as well as brow lift cases. This is because all eyelid surgery procedures other than for the eligibility criteria are deemed to be cosmetic and do not meet the principles laid out in the Cosmetic Surgery. Eyelid surgery will not be routinely commissioned for purely for cosmetic reasons. References Royal College of Surgeons Blepharoplasty Guide Weblink: Commissioning Guide - Referrals and Guidelines in Plastic Surgery (Modernisation Agency 2005) Weblink: -bee1-413a-8da1-8098b0495cf6 NHS Choices Cosmetic Surgery Procedures Weblink:` C13.1/.2/.3.4/.5/.8/.9; C16.1/.2/.3/.4/.5/.8/.9

19 Botulinum Toxin Injection For The Ageing Face Botulinum toxin A is a powerful neurotoxin which is used medically to relax muscles and for certain conditions there are recognised clinical benefits to patients. However, due to its mechanism of action botulinum toxin A can be used for medical conditions for which the clinical benefits have not been proven or are unclear and inconsistencies have arisen before this policy existed. Botulinum toxin injections, such as Botox, are used to help relax facial muscles and make lines and wrinkles less obvious. During the procedure, the skin is cleaned and small amounts of botulinum toxin are injected into the area to be treated. Several injections are usually needed at different sites. The injections usually take effect about three to five days after treatment and it can take up to two weeks for the full effect to be realised. The effects generally last for about three to four months. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Botulinum Toxin Injection for the ageing face will not be routinely commissioned. This is because Botulinum Toxin Injection for the ageing face is deemed to be cosmetic and does not meet the principles laid out in this policy. References NHS Choices Guide to Nonsurgical cosmetic procedures Weblink: X37.5; X85.1; Z60.1

20 Breast Augmentation Breast Augmentation/enlargement involves inserting artificial implants behind the normal breast tissue to improve its size and shape. This procedure is not routinely funded. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. The CCG will fund, subject to IFR request being received, patients who are having treatments for breast cancer. The CCG may fund this treatment if the patient meets the following criteria and an application is made through an Individual Funding Request: Contra-lateral treatment of the unaffected breast following cancer surgery will be commissioned if undertaken at the same time as reconstructive surgery on the affected breast as part of the original treatment plan. It is important that patients understand that they may not automatically be entitled to replacement of the implants in the future if they do not meet the criteria for augmentation at that time. Separate later/subsequent applications for such contra-lateral surgery would however be not routinely commissioned. The CCG may fund this treatment if the patient meets the following criteria and an application is made through an Individual Funding Request: Developmental problems of breasts Breast asymmetry due to trauma, burns, endocrine abnormalities. Breasts asymmetry due to mastectomy, excision breast surgery for cancer/lumpectomy, prophylactic mastectomy for cancer prevention in high risk cases The minimum age for surgery is 18 years of age and evidence that pubertal growth of breasts has ceased must be documented. Patients who are offered breast augmentation in the NHS should be encouraged to participate in the UK national breast implant registration system and be fully counselled regarding the risks and natural history of breast implants. It would be usual to provide patients undergoing breast augmentation with a copy of the DoH guidance booklet Breast implants information for women considering breast implants. This is because breast augmentation deemed to be cosmetic and does not meet the principles laid out in this policy. References Royal College of Surgeons - Cosmetic Surgery Categorisation Weblink: surgery/documents/cosmetic-surgery-categorisationand-requirements/at_download/file Royal College of Surgeons Breast Augmentation Guide Weblink:

21 NICE CG80 - Early and locally advanced breast cancer: diagnosis and treatment (2009). Weblink: NICE Quality Standard 12 Breast Cancer (2011) Weblink: British Association of Plastic Reconstructive and Aesthetic Surgeons Oncoplastic Breast Reconstruction Best Practice Guidelines (2012) Weblink: guidelines---healthcare-professionals.pdf?sfvrsn=0 Breast Cancer Care Breast Reconstruction Weblink: treatment-breast-cancer/surgery/breastreconstruction B30.1/.8/.9; B31.2; B37.5

22 Breast Reduction Breast Reduction procedures involve removing excess breast tissue to reduce size and improve shape. This procedure is restricted. The CCG will fund this treatment if the patient meets the required eligibility criteria. GUIDANCE The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability related to excessive breast weight. The patient is suffering from functional problems: Breast size limits physical activity Back, neck and shoulder pain caused by the weight of breasts Has regular indentations from bra straps that support heavy, pendulous breasts Has skin irritation, intertrigo, beneath the breast crease Breasts hang low and has stretched skin Nipples rest below the breast crease when breasts are unsupported Enlarged areolas caused by stretched skin where any possible causes of these conditions have been considered and excluded AND Symptoms are not relieved by physiotherapy and a professionally fitted brassiere has not relieved symptoms AND The patient has a body mass index (BMI) of less than 27kg/m² AND Has a cup size of F+ (excised breast weight of 500 grams and upwards) AND Is 21 years of age or over Patients should have an initial assessment prior to an appointment with a consultant plastic surgeon to ensure that these criteria are met. At, or following, this assessment, there should be access to a trained bra fitter where it is available. For patients with Breast Cancer, this procedure is restricted. The CCG will fund this treatment if the patient meets the following criteria: Contra-lateral treatment of the unaffected breast following cancer surgery will be commissioned if undertaken at the same time reconstructive surgery on the affected breast as part of the original treatment plan. Separate later/subsequent applications for such contra-lateral surgery would however be not routinely commissioned. This means (for breast cancer patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. This is because Breast Reduction places considerable demand on NHS resources (volume of cases and length of surgery). There is published evidence showing that most women seeking breast reduction are not wearing a bra of the correct size and that a well fitted bra can sometimes alleviate the symptoms that are troubling the patient. Recent evidence has

23 shown that not all commercial bra fitters meet the required standards and so commissioners will need to satisfy themselves that a suitable service is available. Patients seeking breast reduction have physical restrictions on their ability to exercise and additional weight in their excess breast tissue (sometimes 3-4 Kg). References Royal College of Surgeons Commissioning Guide for Breast Reduction (2014). Weblink: Royal College of Surgeons Breast Reduction Guide Weblink: NICE CG80 - Early and locally advanced breast cancer: diagnosis and treatment (2009). Weblink: NICE Quality Standard 12 Breast Cancer (2011) Weblink: British Association of Plastic Reconstructive and Aesthetic Surgeons Oncoplastic Breast Reconstruction Best Practice Guidelines (2012) Weblink: policy/finaloncoplastic-guidelines---healthcareprofessionals.pdf?sfvrsn=0 Breast Cancer Care Breast Reconstruction Weblink:

24 Gynaecomastia Gynaecomastia is the enlargement of the male breast tissue and a common benign (not cancer) condition that can occur at any age. It is defined as the presence of >2 cm of palpable, firm, subareolar gland and ductal breast tissue. There are a number of causes, some physiological and others pathological. During puberty it tends to resolve as the post- pubertal fat distribution is complete. Pathological causes involve an imbalance between the activity of androgens and oestrogens - the former is decreased compared with the latter. Most cases of gynaecomastia are idiopathic. It can also occur secondary to medication such as oestrogens, gonadotrophins, digoxin, spironolactone and cimetidine, as well as anabolic steroids. More rarely it can be due to endocrinological disorders and malignancy. Surgery for Gynaecomastia is not routinely funded, funding will only be provided where the required criteria are met. Gynaecomastia is deemed to be cosmetic procedure and does not meet the principles laid out in this policy. As such, all of the criteria below should be met and an Individual Funding Request made prior to treatment. Post pubertal AND BMI 25 Kg/m2) AND The patient has been screened to exclude endocrinological, drug related causes, or underlying malignancy AND The patient has not been taking any medication that may causing gynaecomastia for > 12 months AND It is anticipated that the reduction will involve 100g tissue from a single breast This policy relates to cosmetic procedures and explicitly excludes investigation or management of suspected malignancy. References Royal College of Surgeons - Cosmetic Surgery Categorisation Weblink: surgery/documents/cosmetic-surgerycategorisation-and-requirements/at_download/file B31.1

25 Haemangioma Haemangioma, including Port Wine stain, are a collection of blood vessels that form a lump under the skin; it's often called a 'strawberry mark' as it looks like the surface of a strawberry. Superficial haemangiomas are usually raised, red areas of skin, which feel warm because the blood vessels are close to the surface. Treatment for Haemangioma (including Port Wine Stain) are not routinely funded. The CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional circumstances and that is supported by the CCG. Rosacea Laser Treatment for Port Wine Stain is not routinely commissioned regardless of age Paediatric haemangiomas surgical treatment may be offered for those which: Threaten life or function, including compromising eyesight, respiratory, cardiac or hepatic functions Other internal lesions sited in an area liable to scar Large facial haemangiomas that have failed to regress by school age Show a tendency to bleed or to become infected Kasabach-Merritt syndrome (giant haemangioma, thrombocytopenia, and consumptive coagulopathy "Infantile haemangioma: topical timolol Evidence summary [ESUOM47] 2015 OUTCOME The British Association of Dermatologists haemangioma of infancy information leaflet states that most haemangiomas do not require treatment except in the following situations: If the haemangioma is particularly large or affects areas where resolution may be incomplete such as around the nose, lips or ears. If the haemangioma is ulcerating. If the haemangioma is interfering with important functions or development of the senses, such as feeding, breathing, hearing or vision. Treatments, which are generally off label, can include topical, oral, intravenous or intralesional corticosteroids, topical timolol, oral propranolol, laser treatment or surgery. Emollients, non adherent dressings, pain relief and antibiotics may also be required." References "Infantile haemangioma: topical timolol, Evidence summary [ESUOM47] 2015 Safety of Oral Propranolol for the Treatment of Infantile Hemangioma: A Systematic Review Leaute-Labreze et al 2016 Y088, Y113/Y133, S065, S091/2

26 Hair Grafting (Male Pattern Baldness) Male pattern baldness is a common type of hair loss and for many men it is a normal process at whatever age it occurs. Almost all men have some baldness in their 60s. Hair grafting is almost always done for cosmetic reasons. References This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. This is because purely Hair Grafting is deemed to be cosmetic and does not meet the principles laid out in this policy. Varothai, S., Bergfeld, W. and F. (2014) Androgenetic alopecia: an evidencebased treatment update. American Journal of Clinical Dermatology. 15(3), Mysore, V., Shashikumar, B. and M. (2016) Guidelines on the use of finasteride in androgenetic alopecia. 82(2), Gupta, A., K. and Charrette, A. (2015) Topical minoxidil: systematic review and meta-analysis of Its efficacy in androgenetic alopecia. Skinmed. 13(3), Irwig, M. and S. (2015) Safety concerns regarding 5α reductase inhibitors for the treatment of androgenetic alopecia. S21.1, 21.2, 21.8, 21.9, 33.1, 33.3, 33.8, 33.9 The ICD 10 for male pattern baldness are L64.8, 64.9

27 Hirsutism (Hair Depilation) Hair depilation can be used for excess hair in a normal distribution pattern, or for abnormally placed hair. It is usually achieved permanently by electrolysis or laser therapy. References Treatment for Hirsutism will only be funded where the required criteria are met. Unless one or more of the following criteria are met, hair depilation will not normally be funded: Have undergone reconstructive surgery leading to abnormally located hair-bearing skin OR Have a documented underlying endocrine disturbance resulting in hirsutism (e.g. polycystic ovary syndrome) OR Are undergoing treatment for pilonidal sinuses to reduce recurrence OR Is receiving specialist treatment for a psychological or psychiatric illness directly related to hirsutism Interventions for hirsutism (excluding laser and photoepilation therapy alone) Cochrane Database of Systematic Reviews 2015, Issue 4. S60.6, 60.7 ICD 10 for excess hair are L68 and Q84.2. There are no appropriate ICD 10 for the clinical criteria other than polycystic ovaries (E28.2)

28 Hyperhidrosis Hyperhidrosis (excessive sweating) can be generalised (usually an underlying condition), primary (no underlying cause) or secondary (underlying cause identified) Primary focal hyperhidrosis may affect the axillae, palms, soles or scalp, and has no underlying cause. It usually starts in childhood or adolescence, but can occur at any age. Palmar and plantar hyperhidrosis may be present at birth. It can be associated with social phobias Secondary focal hyperhidrosis involves specific areas of the body, but is caused byan underlying condition. Generalised hyperhidrosis affects the entire body and is usually caused by medical conditions (an infectious, endocrine or neurological disorder) or drugs. Treatments include: First-line management of primary hyperhidrosis includes lifestyle measures such as avoiding known triggers and tight clothing, and using antiperspirants (including aluminium chloride hexahydrate). Aluminium chloride-based topical treatments e.g. aluminium salts are the most common ingredient in over-the-counter antiperspirants Lontophoresis, which is primarily used for the hands and feet (the easiest parts of the body to submerge), this procedure entails placing the hands or feet in a shallow basin of water, through which electric current is passed Botulinum Toxin: BTX-A is the best-studied treatment to date for focal hyperhidrosis. When injected intradermally it acts to inhibit the release of acetylcholine at the presynaptic nerve endings of the motor endplates, so excessive sweating is reduced. It is effective, with a good safety profile, although the effectiveness cost effectiveness compared to other treatment options is yet to be established. Furthermore it is only licensed for the treatment of severe axillary hyperhidrosis. Surgical options include local sweat-gland excision by subcutaneous curettage or tumescent liposuction, or sympathectomy. Sympathectomy can be done either by open or endoscopic approaches: endoscopic sympathectomy is now usually the preferred technique because it is associated with less pain, improved cosmesis and more rapid recovery than open sympathectomy, but recommended as a last resort. [NICE 2014]. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Unless all the required criteria are met, Botulinim Toxin therapy for the treatment of Hyperhidrosis will not normally be funded. Endoscopic Thoracic Sympathectomy for the treatment of hyperhidrosis will not normally be funded. Treatment may be funded where documentation that the patient has failed a 6 month trial of conservative management including the use of topical aluminium chloride or extra strength antiperspirants and an Individual Funding Request has been considered by the CCG and exceptional circumstances determined. There are risks associated with surgical interventions, and a lack of good quality evidence to demonstrate their clinical and cost-effectiveness. References NICE interventional procedures guidance [IPG487] (2014)

29 S53.2 with X85.1 (to identify Botulinum Toxin) and Z49.2, A75.2, 76.2, 77.2, 78.2, The ICD 10 Code for hyperhidrosis is R61

30 Inverted Nipple Correction An inverted nipple (invaginated nipple) is a condition where the nipple, instead of pointing outward, is retracted into the breast. In some cases, the nipple will be temporarily protruded if stimulated. Women and men can have inverted nipples. Nipple inversion may occur as a result of an underlying breast malignancy and it is essential that this be excluded Inverted Nipple Correction is not routinely funded. Patients with breast cancer who meet the required criteria may receive funding for the treatment. Inverted Nipple Correction is not routinely commissioned because correction of inverted nipples is deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG where: Functional reasons (i.e. to enable breast feeding) in post-pubertal women AND The inversion cannot be corrected by correct use of a non-invasive suction device. For patients with Breast Cancer, this procedure is restricted. The CCG will fund this treatment if the patient meets the following criteria: Contra-lateral treatment of the unaffected breast following cancer surgery will be commissioned if undertaken at the same time as reconstructive surgery on the affected as part of the original treatment plan. Separate later/subsequent applications for such contra-lateral surgery would however be not routinely commissioned. This means (for breast cancer patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG References Royal College of Surgeons - Cosmetic Surgery Categorisation Weblink: surgery/documents/cosmetic-surgery-categorisationand-requirements/at_download/file B35.4/.6