Page 1 of 17. Version: 5 - Updated: 1 st September MBCCG Policy Ref No. 2 (Pan Lancs) Policy Name. 3 (Pan Lancs)

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1 No Morecambe Bay Clinical Commissioning Group GP Quick reference guide to Commissioning Policies This document contains policy statements from the following commissioning policies: No. General policy for Individual Request (IFR) Decision Making 18 Lumbar Spine Procedures Considering Applications for Exceptionality to Commissioning Policies 19 Cosmetic Procedures 21 Grommets Complementary and Alternative Therapies (V1) 27 8 Reversal of Sterilisation in Males and Females Male Circumcision (V1.1) Photorefractive Laser Surgery for the correction of refractive error Tonsillectomy / Adeno-Tonsillectomy (V1.1) Policy for Elective Endoscopic Procedures on the Knee Joint Cavity (Knee Arthroscopy) (V1.1) Carpal Tunnel (V1.1) Trigger Finger (V1.1) 33 Interim Assisted Conception Interventions Policy A revised version of this policy is under development and is expected to be available in Link to current version: No.33 - Interim Assisted Conception Policy 17 Excision of Uterus A revised version of this policy is under development and is expected to be available in Link to current version: No.17 - Excision of Uterus Policy 40 Rehabilitation after damage to the Facial Nerve (V1) The full policies are available at: Page 1 of 17

2 Summary of changes made to this GP Quick Reference Guide Date From To Version Version Summary of Change to this guide 1/3/ Complementary & Alternative Therapies 1/3/ Rehabilitation after Damage to the Facial Nerve New hyper-link added to Policy No. 6 following new version being uploaded to website, plus section 1 (policy criteria) added to this document. New policy No. 40 added to this Quick reference guide and hyperlink added to website. 1/3/ An appendix (1) has been added to each of the following policies to summarise the OPCS and ICD codes that will be used for monitoring purposes. This is an administrative only change. 1/5/ Dilatation and Curettage and Hysterscopy 1/5/ Dilatation and Curettage Policy Number 11 Male Circumcision (V1 replaced by V1.1) Policy Number 19 Tonsillectomy / Adeno Tonsillectomy (V1 replaced by V1.1) Policy Number 27 Elective Endoscopic Procedures on the Knee Joint (V1 replaced by V1.1) Policy Number 29 Surgical Treatment of Carpal Tunnel Syndrome (V1 replaced by V1.1) Policy Number 32 Surgical release of Trigger Finger (V1 replaced by V1.1) This policy has been replaced by policy numbers 41 Dilatation and Curettage and policy number 42 Hysterscopy. New policy developed to replace policy number 20 Dilatation and Curettage and Hysteroscopy Action ed by: JM JM JM JM JM 1/5/ Hysteroscopy New policy developed to replace policy number 20 Dilatation and Curettage and Hysteroscopy JM 1/7/ (Pan Lancs) Cosmetic Procedures New Lancashire Wide Cosmetics Policy developed to replace the following policy refs: Policy number 5: Cosmetic Procedures JM Policy number 22: Tattoo removal Policy number 23: Interventions for hair depilation Policy number 24: Interventions for correcting hair loss Policy number 25: Interventions to remove benign skin lesions Policy number 34: Abdominoplasty and body contouring Policy number 35: Reduction mammoplasty Policy number 36: Augmentation mammoplasty breast enlargement Policy number 37: Breast implant removal and replacement Policy number 38: Mastopexy breast lift Policy number 39: Surgical correction of breast nipple inversion Page 2 of 17

3 2 3 5 General policy for Individual Request (IFR) Decision Making Considering Applications for Exceptionality to Commissioning Policies Cosmetic Procedures Link to full policy: No.2 Pan Lancs - General Policy for IFR request decision making Link to full policy: No.3 Pan Lancs - considering-applications-for-exceptionality-to-commissioning-policies Link to full policy: No.5 Pan Lancs - Cosmetic Procedure Policy 2 Policy 2.1 The CCG will not routinely commission any treatments or procedures that have the primary purpose of changing the appearance of a part of the body. The following procedures have been categorised as either not routinely funded or restricted. An explanation of these definitions are as follows: Not routinely funded: These treatments are considered to be cosmetic and will only be provided if funding is approved on an exceptional case basis following the submission of an Individual Funding Request (IFR). Restricted: The CCG will fund these treatments/procedures to treat the conditions set out below, provided the patient meets the intervention specific policy criteria at sections In all other circumstances these interventions are considered to be cosmetic Breast Reduction: Restricted The CCG will commission breast reduction surgery in the following circumstances: a) at least 500 grams of breast tissue will be removed during the procedure. AND b) the patient has maintained a stable BMI of no more than 27.5kg/m 2 during the previous 24-month period. AND EITHER: c) There is inflammation and/or infection of the skin folds (intertrigo) with breakdown of the integrity of the skin. This will be demonstrated by evidence of cellulitis, skin ulceration, abscesses, lymphedema, skin necrosis or equivalent that has been persistent for at least six months despite compliance with nonsurgical treatment (e.g. meticulous skin Page 3 of 17

4 hygiene; dressings; clothing that minimizes skin fold contact; topical antifungal agents, antibiotics or corticosteroids as clinically appropriate); ALL OF THE FOLLOWING d) i) The patient has persistent neck, shoulder or back pain which is disabling and meets the requirements of Appendix 2 of the Statement of Principles ii) The pain has not been relieved by a course of physiotherapy and analgesia iii) A physiotherapy report is provided that describes the treatments that have been tried and failed and the report confirms that the pain is attributable to the size of the breasts iv) The patient s physical symptoms persist despite the wearing of a professionally fitted bra v) The specialist clinical opinion is that the proposed procedure will substantially reduce the pain. Mastopexy will be commissioned when this is required as part of the planned approach for a patient who fulfils the above policy criteria for breast reduction and the intention is to undertake the procedure concurrently Breast Augmentation: Not routinely funded Mastopexy: Not routinely funded Surgical correction of breast asymmetry: Not routinely funded Surgical correction of gynaecomastia: Not routinely funded Breast implant removal: Restricted The CCG will commission the removal of breast implants under the following circumstances: a) the implant was manufactured by Poly Implant Prothese (PIP) between 2001 and 2010 and the requirements of any relevant Department of Health guidance in force at the time of the request are met. b) there is evidence that the implants have ruptured c) there is evidence of capsular contracture and the patient is experiencing significant pain. d) there is evidence, not available at the time of the implantation, that there is an increased risk of developing breast cancer (either as a result of an emerging family history, or as a result of a malignant diagnosis in the contralateral breast) and the implant is impairing mammography. Page 4 of 17

5 e) the contralateral breast implant satisfies one of the above criteria, is being removed, and the patient is requesting bilateral removal Breast implant replacement: Restricted The CCG will commission the supply and insertion of a replacement breast implant under the following circumstances: a) the original implant was supplied and inserted by the NHS; AND b) the removal of the implant is in accordance with this policy; AND c) the replacement can be carried out as part of the same procedure as the removal of the previous implant. When the CCG funds a replacement implant it is the expectation that the surgeon will explain the implications and risks in relation to breast screening and clinical detection of breast cancer and will record in the notes that the patient is aware of such risks and takes responsibility for them Surgical correction of inverted nipples: Not routinely funded Liposuction: Not routinely funded Abdominoplasty/Apronectomy: Restricted. The CCG will commission Abdominoplasty/Apronectomy in the following circumstances: - a) The patient has maintained a stable BMI measurement of no more than 27 kg/m 2 during the previous 24 month period AND b) There is inflammation and/or infection of the skin folds (intertrigo) with breakdown of the integrity of the skin This will be demonstrated by evidence of cellulitis, skin ulceration, abscesses, lymphedema, skin necrosis or equivalent that has been persistent for at least six months despite compliance with nonsurgical treatment (e.g. meticulous skin hygiene; dressings; clothing that minimizes skin fold contact; topical antifungal agents, antibiotics or corticosteroids as clinically appropriate). Page 5 of 17

6 d) The patient is experiencing problems associated with poorly fitting stoma bags Removal of excess skin (eg brachioplasty, thigh lift): Not routinely funded Rhinoplasty: Restricted The CCG will commission rhinoplasties in the following circumstances: - To correct obstruction of the nasal airway Pinnaplasty: Not routinely funded Blepharoplasty: Restricted The CCG will commission blepharoplasty in the following circumstance: a) The patient has excess of loose skin around the eyes which (with robust clinical evidence) is impairing vision within 30 degrees of the line of sight. b) The patient has dermatochalasis (loose skin around the eyes) resulting in or ore more of the following symptoms AND the symptoms have failed to respond to conservative treatment: bi) Frequent headaches attributable to frontalis overaction bii) Lateral wick syndrome biii) Lash ptosis causing visual problems biv) Ocular surface disease which is causing pain or discomfort (eg due to entropion) Face or brow lift: Restricted Face or Brow lifts will not be performed to correct the natural process of aging. The CCG will commission face or brow lifts in the following circumstances: a) For congenital facial abnormalities b) Facial Palsy (congenital or acquired paralysis) c) As part of the treatment for specific conditions affecting the facial skin e.g. cutis laxa, pseudoxanthoma elasticum, or neurofibromatosis d) To correct the consequences of trauma Page 6 of 17

7 e) To correct deformity following surgery f) The patient has brow ptosis which (with robust clinical evidence) is impairing vision within 30 degrees of the line of sight Correction of Split Ear Lobes: Restricted. The CCG will commission the correction of split ear lobes in the following circumstance: ai) The repair of a complete, unilateral traumatic tear caused by an accidental force or assault. The CCG will not commission the correction of split ear lobes in the following circumstances: aii) the repair of deficits caused by the use of stretching devices intended to produce a large hole in the ear lobe. b) The repair of deficits caused by continual wearing of heavy ear jewellery that were clearly causing gradual damage progressing to split ear lobes Surgical Correction of Hair Loss: Not routinely funded Provision of wigs: Restricted The CCG will commission wigs and prostheses for the correction of hair loss in the following circumstances: a) As part of cancer or trauma pathways. Funding will normally be provided for one device per patient and replacements will be offered not more frequently than once every three years and then will be subject to assessment of continuing need Removal of excess hair: Not routinely funded Tattoo Removal: Not routinely funded Removal of skin lesions: Restricted Removal methods included in this policy section include: - Surgical excision - Cauterisation - Cryosurgery - Cryotherapy - Electrodessication and curettage - Keratolysis - Chemical peeling - Laser destruction - Dermabrasion Page 7 of 17

8 Skin lesions covered by this section of the policy include but are not limited to: - Lipomata - Epidermoid Cyst - Sebaceous Cyst - Pilar Cyst - Xantheslasmata - Seborrhoeic Keratoses - Dermatofibromata - Milia - Skin tags - Warts- excluding genital warts - Veruccas - Naevi - Vascular naevi (haemangioma, port wine stain, spider naevus,telangiectasia) - Dermal neurofibromas - Molluscum contagiosum lesions - Scars, Keloid Scars - Stretch marks The CCG will commission the removal of skin lesions in the following circumstances: a) When the purpose of the treatment is to exclude or treat malignancy; b) When the lesion is causing frequent, recurrent bleeding; c) There is well documented evidence of significant pain that is present all or most of the time, is preventing usual activities and other causes for the pain or discomfort have been excluded. d) e) There is well documented evidence of recurrent, clinically significant infections within the last twelve months, requiring treatment with antibiotics (or formal incision and drainage in the case of sebaceous cysts). AND f) The clinical opinion is that the benefit of the procedure in terms of symptom resolution outweighs the risk of harm (scarring) Surgical repair of divarication of recti: Not routinely funded Correction of pectus excavatum: Not routinely funded Cosmetic genital surgery: Not routinely funded 6 Complementary and Link to full policy: No.6 Complementary and Alternative Therapies V1 Page 8 of 17

9 Alternative Therapies 1.1 The CCG will only commission complementary and alternative therapies where there is clear evidence of effectiveness and when they are carried out by an agreed NHS provider as part of an existing NHS pathway of care (e.g. as part of a package of end of life care or pain management) or when exceptionality has been demonstrated in accordance with section 8 below. 1.2 The CCG will not commission complementary and alternative therapies as stand alone treatments either within or outside of the NHS. 8 Reversal of Sterilisation in Males and Females 7.1 The CCG will not commission procedures for the reversal of male or female sterilisation. Link to current full policy: No.8 Reversal of sterilisation in males and females 11 Male Circumcision Link to full policy: No.11 Male Circumcision (V1.1) 8.1 The CCG will commission male circumcision when one or more of the following criteria are satisfied (Ref 4): Congenital abnormalities with functional impairment Distal scarring of the preputial orifice Painful erections secondary to a tight foreskin Recurrent bouts of infection (Balanitis / Balanoposthitis) Redundant prepuce, phimosis (inability to retract the foreskin due to a narrow prepucial ring) sufficient to cause ballooning of the foreskin on micturition; and paraphimosis (inability to pull forward a retracted foreskin) Lichen sclerosus (balanitis xerotica obliterans) -chronic inflammation leading to a rigid fibrous foreskin Pain on intercourse secondary to a tight foreskin (Phimosis) Page 9 of 17

10 8.1.8 Traumatic injury Potentially malignant lesions of the prepuce, or those causing diagnostic uncertainty Exceptionality has been demonstrated in accordance with section 9 below. 12 Photorefractive Laser Surgery for the correction of refractive error 8.2 The CCG will not commission male circumcision for non-therapeutic purposes such as cultural, religious or cosmetic reasons (Ref 5) 7.1 The Commissioning Organisation will not normally commission photorefractive surgery for corrective refractive error. Link to full existing policy: No.12 - Photorefractive Laser Surgery Policy 17 Excision of Uterus A revised version of this policy is under development and will be available in early Link to current full policy: No.17 - Excision of Uterus Policy 18 Lumbar Spine Procedures Link to full policy: No.18 - Lumbar Spine Procedure Policy 5.1 The purpose of eligibility criteria is to make the limits on NHS-funded low priority procedures or treatments fair, transparent and explicit to patients, GPs, other clinicians and other providers and commissioners. The eligibility criteria for Lumbar spine procedures is as follows: Consider MRI if one of these diagnoses is suspected: o Spinal malignancy o Infection o Fracture o Cauda equina syndrome o Ankylosing spondylitis or another inflammatory disorder NICE Guideline 88 recommends the following treatment options prior to referral: Advice and education Drug treatments Structured Exercise programme Manual therapy Acupuncture Page 10 of 17

11 All options as per Map of Medicine low back pain and chronic low back pain have been tried and failed, or the condition of the patient has deteriorated or no improvement has been seen. Paragraph 6.2 provides further detail as to what interventions must not be offered at the first instance including relevant NICE guidance. 5.2 Patients who do not meet the eligibility criteria set out above for each procedure or treatment will not be offered NHS funding by NHS North Lancashire. If they, or their clinician believe that their case merits funding on the grounds of exceptionality they can submit a request to the CCG accompanied by the appropriate evidence for each procedure or treatment. The request will then be considered by the CCG Commissioning Panel. 6 Guidance 6.1 Detailed documentation of the criteria that are fulfilled is mandatory in the referral letter. Clinically inappropriate referrals should be returned to the GP. This policy refers to management of non-specific low back pain only. Clinical assessment should exclude people with signs and symptoms suggestive of spinal malignancy, infection, fracture, cauda equina syndrome, ankylosing spondylitis or another inflammatory disorder. 6.2 Assessment and imaging Do not offer X-ray of the lumbar spine The following treatments should not be offered for the early management of persistent non-specific low back pain. SSRIs (Selective serotonin reuptake inhibitor) for treating pain Injections of therapeutic substances into the back Laser therapy Interferential therapy Therapeutic Ultrasound TENS (Transcutaneous Electrical Nerve Simulation) Lumbar supports Traction The following referrals should not be offered for the early management of persistent non-specific low back pain. Radiofrequency facet joint denervation IDET (Intra Discal Electro Thermal Annuloplasty) PIRFT (Percutaneous Intradiscal Radiofrequency Thermocoagulation) 6.3 NICE guidance strongly indicates to not offer injections of therapeutic substances into the back for non-specific low back pain. 6.4 The clinician responsible for the patient s treatment is to demonstrate appropriate use of Map of Medicine with regards to the pathway of care. Page 11 of 17

12 19 Tonsillectomy/Aden o-tonsillectomy Link to full policy: No.19 - Tonsillectomy/Adeno-Tonsillectomy (V1.1) The CCG will commission tonsillectomy as part of the investigation and management of malignancy or suspected malignancy without a need for prior approval for funding. The CCG will commission tonsillectomy/adeno-tonsillectomy, subject to the judgement of the clinician responsible for managing the patient s condition, when the SIGN 1 criteria are met, as follows: The patient has a sore throat due to acute tonsillitis. AND The episodes of sore throat are disabling and prevent normal functioning AND ONE OF THE FOLLOWING: The patient has had seven or more well documented, clinically significant, adequately treated sore throats in the preceding year The patient has had five or more such episodes in each of the preceding two years The patient has had three or more such episodes in each of the preceding three years. The CCG will also commission tonsillectomy for patients with a confirmed diagnosis of obstructive sleep apnoea who are either: Aged under 16 2 Aged 16 or over 3 when there is advice from a centre with expertise in sleep apnoea that CPAP has failed to control symptoms and tonsillectomy is the preferred clinical strategy. The CCG will also commission tonsillectomy after a clinical consideration and assessment, where there has been more than one Peri-Tonsillar Abscess (Quinsy) 2. Page 12 of 17

13 21 Grommets Link to full policy: No.21 - Grommets Policy 7.1 The Commissioning Organisation will only commission grommets if the patient has OME1 and the following criteria are met, as per NICE guidance (CG60): (a) The patient is under 12 years of age AND (b) There has been a three month documented period of active observation from diagnosis of OME in primary care; AND one of the following: (c) Diagnosis of persistent bilateral OME documented over a period of 3 months with a hearing level in the better ear of dbhl or worse (results of formal testing should be included in the referral letter) (d) Exceptionally, diagnosis of persistent bilateral OME with a hearing loss less than dbhl where the impact of the hearing loss on a child s developmental, social or educational status is judged to be significant (results of formal testing should be included in the referral letter). 7.2 Adjuvant adenoidectomy is not recommended in the absence of persistent and/or frequent upper respiratory tract symptoms. 7.3 Specific criteria apply for the management of OME in children with Down s Syndrome and for children with Cleft Palate and should be managed as per NICE guidance, CG Policy for Elective Endoscopic Procedures on the Knee Joint Cavity (Knee Arthroscopy) Link to full policy: 8.1 No.27 - Elective Endoscopic Procedures on the Knee Joint Cavity (V1.1) The commissioning organisation commissions endoscopic procedures on the knee joint cavity in the following circumstances: Where an MRI scan has shown evidence of mechanical damage to the ligaments and /or cartilage. Where the patient has a locked knee (mechanical block to extension) There is a palpable loose body or a loose body seen on x-ray which is considered to be causing symptoms of pain and disability. Page 13 of 17

14 haemarthrosis or osteochondral injury on x-ray. Where the procedure is to undertake a lateral release in patients with patellofemoral pain syndrome where there is lateral facet overload and when x-ray/mri is carried out prior to consideration of arthroscopy. Where the MRI scan is inconclusive or contraindicated, it will be for the specialist to make a clinical judgement on whether an arthroscopy is required, based on the patients history and findings. AND The documented specialist clinical opinion is that the benefit of the procedure outweighs the risk of harm. This includes those patients for whom an MRI scan is contraindicated. 8.2 The commissioning organisation does not commission endoscopic procedures on the knee joint cavity in the following circumstances: Where the procedure is to undertake a washout or debridement of an osteoarthritic knee in the absence of mechanical locking Where the procedure is undertaken to treat chondral defects by re-establishing the articular surface of the knee joint e.g. autologous cartilage implantation, marrow stimulation techniques including abrasion arthroplasty, drilling and micro fracture and mosaicplasty/osteochondral transplantation Endoscopic plica resection for the second line treatment of patients with plica syndrome in whom conservative management has failed. 29 Carpal Tunnel To determine the diagnosis of knee symptoms in the absence of a prior MRI scan, except where an MRI scan is contraindicated. Link to full policy: No.29 - Carpal Tunnel (V1.1) The CCG will commission surgical release of the carpal tunnel if all the following criteria are met: The patient is not pregnant, or is at least 12 weeks post-partum. The patient s symptoms have not resolved despite 3 months of conservative treatment, including activity modification, wrist splinting and, a single steroid injection 9. Page 14 of 17

15 The patient has sleep disturbance and/or limited ability to undertake activities of daily living due to symptom severity. The diagnosis of carpal tunnel syndrome has been confirmed, either clinically by scored questionnaire or by nerve conduction studies if not possible by examination. The documented specialist opinion is that the likely benefit from surgery outweighs the risk of harm for the patient. 8.2 The CCG recognises that the type of surgical procedure undertaken (endoscopic or open surgery) will depend both on clinical factors (including the presence of swelling over the carpal tunnel) and the experience of the surgeon. 32 Trigger Finger 8.3 In severe progressive carpal tunnel syndrome, the CCG will commission surgical release of carpal tunnel syndrome if the documented specialist opinion is that surgery is needed promptly to prevent irreversible median nerve/muscle damage. Link to full policy: No.32 - Surgical release of Trigger Finger (V1.1) The CCG will commission the surgical release of trigger finger when one or more of the following criteria are satisfied: Patient has failed to respond to a single injection of steroid and local anaesthetic or it is contraindicated Triggering has recurred after injection treatment Patient has fixed deformity that cannot be corrected 8.2 If the policy criteria are met the CCG recognises that the type of surgical procedure (percutaneous release or open surgery) will depend on the individual patient factors including the site of the tenosynovitis (e.g. open surgery may be preferable for thumbs and cases involving the proximal interphalangeal joint Interim Assisted Conception Interventions Policy A revised version of this policy is under development and is expected to be available in The following is a link to the CCGs current version: No.33 - Interim Assisted Conception Policy Page 15 of 17

16 40 Rehabilitation after damage to the facial nerve Link to full policy: No.40 - Rehabilitation after damage to facial nerve (V1) 1.1 The CCG will commission physical therapy rehabilitation (consisting of tailored facial exercises only) for facial nerve damage in the following circumstances: Criterion A: Cases reported with a House Brackmann grade of four or above or of a grade three but with weakness of eyelid closure such that cornea damage is likely AND; Criterion B: In cases reported as House Brackmann grade six, the facial nerve is confirmed as intact by electromyography (EMG) AND; Criterion C: Where Bell s palsy is the cause, the condition has been present for a minimum of 12 months. Or, when exceptionality has been demonstrated in accordance with section 8 below. 41 (Pan Lancs) Dilatation and Curettage Link to full policy: Policy No.41 - Pan Lancs - Dilatation and Curettage 1 Policy Criteria 1.1 The CCG will commission Dilatation and Curettage (D&C) in the following circumstance: - For patients requiring evacuation of retained products of conception (ERCP). 1.2 The CCG will not commission Dilatation and Curettage (D&C) in the following circumstances: - As a diagnostic tool for HMB. - As a therapeutic treatment for HMB. Page 16 of 17

17 42 (Pan Lancs) Hysterscopy Link to full policy: Policy No Pan Lancs - Hysterscopy 1 Policy Criteria 1.1 The CCG will commission hysteroscopy in the following circumstances: when ultrasound results are inconclusive, for example to determine the exact location of a fibroid or the exact nature of the abnormality. where dilatation is required for non-hysteroscopic ablative procedures, hysteroscopy should be used immediately prior to the procedure to ensure correct placement of the device The CCG will not commission hysteroscopy in the following circumstances: as a first line diagnostic tool for identifying structural abnormalities in patients with HMB. Page 17 of 17