Guidance for Clinicians Policies Document for INTERVENTIONS NOT NORMALLY FUNDED (INNF)

Transcription

1 SOMERSET CCG INDIVIDUAL FUNDING REQUEST PANEL Guidance for Clinicians Policies Document for INTERVENTIONS NOT NORMALLY FUNDED (INNF) Applications cannot be considered from patients personally and all applications must be signed by an NHS GP or Consultant. 1. Procedures/treatments which are indicated as CBA (Criteria Based Access) will only be funded where the published criteria is met and detailed within the patient s medical records. Referrals to secondary care should clearly demonstrated how the published criteria is fulfilled. 2. Procedures/treatments which are indicated as PA (Prior Approval) will require completion of the generic RP application form and should clearly indicate how the published criteria is fulfilled. 3. Procedures/treatments which are indicated as (Individual Funding) will require completion of the generic RP application form. 4. In order for funding to be authorised for applications put forward there must be some unusual or unique clinical factor about the patient that suggests that they are exceptional as defined below: Significantly different to the general population of patients with the condition in question Likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition 5. Provided these patients receive the full support of their general practitioner, or NHS consultant, in pursuing a funding request an application may be made to the Individual Funding Request Panel for consideration. 6. For some procedures, criteria relating to BMI and smoking status have been included. These criteria have been agreed following discussions with plastic surgeons and take into account their impact on clinical outcomes including wound healing. 7. It is expected that clinicians will have ensured that the patient, on behalf of who they are forwarding the application for, is appropriately informed about the existing policies prior to an application to the RP. This will reassure the panel that the patient has a reasonable expectation of the outcome of the application and its context. 1

2 ITEM PAGE NO: PLASTIC & RECONSTRUCTIVE SURGERY 1 4 Abdominoplasty or Apronectomy Policy listed separately 2 / Blepharoplasty/Ptosis Policy listed separately Complete Blepharoplasty/Ptosis R PA Application Form 3 4 Buttock, Thigh or Arm Lift / Reduction 4a/b/c / ITEM ITEM Labiaplasty / Vaginoplasty / Hymenorrhaphy Policy listed separately and renamed Female Genitalia Surgery 5 4 Liposuction (Cosmetic) 6 / 7 / Pinnaplasty / Otoplasty Policy listed separately renamed Congenital Ear Deformity Correction Surgery Penile Implants / Prosthesis NHS England is the commissioner for this service 8 5 Rhinoplasty 9 / 10 5/6 11 / PAGE NO: Split Earlobes Policy listed separately renamed External Ear Repair Surgery of the Face (including but not restricted to facelift or brow lift) Facial Blushing, including Erythrophobia Policy - Policy listed separately BREAST PROCEDURES 12 7/8 Breast Reduction 13 8/9 Breast Augmentation 12 9/10 Breast Asymmetry 13 10/11 Breast Revision of Implants 14 11/12 Mastopexy (breast lift/repositioning of nipple) Correction of inverted nipples for cosmetic purposes 15 12/13 Gynaecomastia PAGE NO: 16 13/14 SKIN PROCEDURES General Guidance on; Removal of Benign Skin Lesions / Moles PA CBA 17 14/15 Cysts CBA Chalazions CBA 19 16/17 Ganglia Removal CBA 2

3 ITEM ITEM Removal of Lipomas Warts Telangiectasia / Thread Veins - Policy listed separately Scar Revision Policy listed separately Dermabrasion for Acne Scarring Policy listed separately Tattoo Removal - Policy listed separately PAGE NO: Removal of Port Wine Stains & Other Birthmarks Policy listed separately EAR NOSE & THROAT PROCEDURES 27 / Grommet Insertion 3-18 years - Policy listed separately PA / / Grommet Insertion Adults Policy currently under review PA Tonsillectomy CBA / / Adenoidectomy - Policy listed separately CBA 29 / Surgical Intervention for Simple Snoring - Policy listed separately 30 / Ear Wax Removal - Policy listed separately CBA PAGE NO: OTHER PROCEDURES/TREATMENTS 31 / Circumcision Policy listed separately CBA 32 18/19 Varicose Veins CBA Immunology CBA 34 / Hair Depilation - Policy listed separately 35 / 36 / 37 / Reversal of Sterilisation / Vasectomy Policy listed separately Laser Surgery to correct Visual Acuity Policy listed separately Gastro-electrical Stimulation As of 1 April 2015 all GES Paed/Adults is part of the NHS England commissioning remit Percutaneous Tibial Nerve Stimulation Treatment for Urinary Incontinence 39 21/21 Functional Electrical Stimulation (FES) Lower Limb NHS E 39 21/22 Functional Electrical Stimulation (FES) Upper Limb 3

4 40 / Botulinum Toxin hyperhidrosis - Policy listed separately Complete Botulinum Toxin R Application Form / / Cataract Policy listed separately CBA / / Open/Upright MRI - Policy listed separately Complete Open/Upright MRI R PA Application Form / / Anal Skin Tags Policy listed separately CBA / / / / Laparoscopic Ventral Rectopexy & Stapled Transanal Resection of the Rectum (STARR) Policy listed separately Interim Complex Obesity Policy as of 1 April Policy listed separately PA PA PA CBA / / Acupuncture Policy currently under review CBA / / Hernias (Adults) Policy currently under review CBA / / Hysterectomy for Menorrhagia currently under review CBA / / PLASTIC AND RECONSTRUCTIVE SURGERY Fertility Assessment and Treatment Policy Policy listed separately Guidance for Clinicians PA 1 Abdominoplasty or Apronectomy Policy listed separately 2 Blepharoplasty (repair of drooping eyelids) Policy listed separately Complete the Blepharoplasty/Ptosis R Application form V1 3 Buttock, Thigh or Arm Lift / Reduction Buttock, Thigh or Arm Lift / Reduction procedures are not available on cosmetic grounds. Cases will only be considered as a result of: post-traumatic surgery and/or thinning of skin flaps Photographic supporting evidence must be sent with the RP application form. 4a 4b 4c Labiaplasty Policy listed separately and renamed Female Genitalia Surgery Vaginoplasty - Policy listed separately and renamed Female Genitalia Surgery Hymenorrhaphy - Policy listed separately and renamed Female Genitalia Surgery 5 Liposuction (Cosmetic) 4

5 Liposuction treatment will not be considered for any of the following: The reduction and correction of symmetrically distributed fatty deposits for enhancement of appearance Limb recontouring Age, sun and cigarette-related laxity of skin giving rise to poor performance. It would be unusual for this to be requested on the basis of functional problems Patients seeking a liposuction for cosmetic reasons should be offered dietary advice when appropriate It could be considered as an exception in the management of certain conditions including Lymphedema or as part of other surgery, for example, thinning of a transplanted flap. Photographic supporting evidence must be sent with the application form 6 Pinnaplasty/Otoplasty Policy listed separately renamed Congenital Ear Deformity Correction Surgery 7 Penile implants / Prosthesis NHS England is the Commissioner for this service 8 Rhinoplasty Rhinoplasty is not routinely funded as this procedure is considered cosmetic. Consideration may be given in the following cases: as part of reconstructive head and neck surgery (including traumatic deformity) or if there is functional impairment or to correct complex congenital conditions e.g. cleft lip or palate Photographic supporting evidence will be required and must be sent with the application form. 9 Split Earlobes Policy listed separately and renamed External Ear Repair 10 Surgery of face (including but not restricted to facelift or brow lift) Surgery of the face is regarded as a procedure of low clinical priority and is therefore not routinely funded by NHS Somerset. Surgery to improve appearance alone, normal changes such as those due to aging, is not funded. Patients may be considered on an individual basis where their GP or treating consultant believes that exceptional circumstances exist. Photographic supporting evidence must be forwarded with the RP application form. GPs and Consultants must obtain approval before proceeding for the following; 5

6 as part of treatment of specific conditions affecting facial skin, e.g., neurofibromatosis to correct deformity following surgery to correct the consequences of trauma Surgery of the face is commissioned for patients where there is: AND 1. Severe deformity 2. Significant functional impairment that prevents performance of physical activities of daily living, meaning: as part of the treatment of congenital facial abnormalities for treatment of congenital or acquired facial palsy symptoms preventing the patient fulfilling vital work responsibilities symptoms preventing the patient carrying out vital domestic or carer activities AND 3. There is evidence that surgery will relieve their symptoms Patients not fulfilling the above criteria can be considered by the RP where there is: Anatomical abnormalities in children <18, likely to cause impairment of normal emotional development pathological abnormalities e.g. facial palsy, progeria or cutis laxa. Photographic supporting evidence must be forwarded with the RP application form. 11 Facial Blushing, including Erythrophobia - Policy listed separately BREAST PROCEDURES Please note: breast reconstruction following mastectomy for breast cancer should be routinely funded and is not considered an exceptional treatment. 12 Breast Reduction The following classes of patient should NOT be referred for consideration of breast reduction: patients with a BMI greater than 27 (Note 1) patients who have smoked/used nicotine replacement therapy over preceding 3-months (Note 2) patients who intend to have children and breast feed 6

7 patients who are pregnant or who have had a baby within past 12 months patients who have not yet attained full breast development patients who are under the age of 23 weight loss has been sustained for a minimum of 6 months at the current level and further weight loss is unlikely Note 1: It is recognised that not every woman s breasts reduce when they lose weight but it is felt appropriate to seek to exclude those whose problem would be addressed with weight loss by setting a BMI limit. Note 2: The restriction to non-smokers relates to associated surgical complications and problems with healing as a result of the effects of nicotine on the peripheral circulation. Applications should only be made when breast size is causing functional symptoms and should include the following information: actual breast size, assurance that the patient s breasts have been professionally measured by a reputable underwear fitter, and that the patient is wearing appropriate support underwear a detailed account of functional problems as a result of breast size including detail of any pain experienced, intetrigo, etc the patient s height, weight and BMI basic detail of breast volume reduction required, that is, ensuring volume for reduction is at least 500g each side, as equivalent to half a bag of sugar each side detail of any body disproportion (including asymmetry detail) including photographic supporting evidence (if the patient is referred to the Breast Care Nurse Service a photograph will be taken by the nurse) where the condition is affecting psychological and social well being, a detailed account of specific problems encountered, along with any previous referrals treatment and outcomes past medical history detailing all prescribed drugs and medication Evidence will need to be provided that conservative measures pursued, including corsetry advice or non-surgical referral, have failed to alleviate the symptoms: for physical symptoms such as neck or back pain all other appropriate interventions should have been tried and failed for a minimum of 6 months and should include: wearing appropriate support, NSAIDS (if not contraindicated) and exercises (as directed via physiotherapy assessment) where intractable intetrigo is the justification for referral, conservative treatment for submammary intertrigo should have been trialled for a minimum of 6 weeks and should include: appropriate hygiene, appropriate pharmacological treatment and utilisation of an appropriate support bra where psychological difficulties are cited as the justification for the proposed intervention, all efforts should have been made already to manage these problems. It is expected that appropriate interventions to improve psychological wellbeing would have been used over a period of time before surgery would ever be considered as an option. 7

8 Patients who meet the above criteria and are referred to the Individual Funding Request Panel, will be referred onto the Breast Care Nurse Team at Yeovil District Hospital for an assessment and support, prior to their case being considered by the Panel. 13 Breast Augmentation Breast augmentation surgery is not routinely funded as this procedure is considered cosmetic. These procedures are not available on cosmetic grounds. Patients must have reached physical maturity and would not normally be considered below the age of 23 years. where psychological difficulties are cited as the justification for the proposed intervention, all efforts should have been made already to manage these problems. It is expected that appropriate interventions to improve psychological wellbeing would have been used over a period of time before surgery would ever be considered as an option. PLEASE NOTE: Patients who received morbid obesity surgery and other previously obese patients who have achieved significant weight loss; These procedures are not available on cosmetic grounds Weight loss has been maintained for at least 2 years at the current level and further weight loss is unlikely The scale of the weight loss and the period for which it has been sustained must be verified in the patient s clinical record Consideration will be given to patients who present exceptional need such as: congenital absence of breasts significant developmental abnormalities reconstruction needed after surgery/trauma The following classes of patient should NOT be referred for breast augmentation: patients with a BMI less than 19 or greater than 27 patients who have smoked/used nicotine replacement therapy over preceding 3-months patients who intend to have children and breast feed patients who are pregnant or who have had a baby within past 12 months patients who have not yet attained full breast development Requests should include the following information: actual breast size, assurance that the patient s breasts have been professionally measured by a reputable underwear fitter 8

9 detail of body disproportion including photographic supporting evidence (if the patient is referred to the Breast Care Nurse Service a photograph will be taken by the nurse) detail of height, weight and BMI where the condition is affecting psychological and social well being, a detailed account of specific problems encountered, along with any previous referrals treatment and outcomes. Patients who meet the above criteria and are referred to the Individual Funding Request Panel, will be referred onto the Breast Care Nurse Team at Yeovil District Hospital for an assessment and support, prior to their case being considered by the Panel 12 Breast Asymmetry Surgery to correct breast asymmetry is not routinely funded as this procedure is considered cosmetic. The following classes of patient should NOT be referred for surgery to correct breast asymmetry: younger than 18 years of age patients who have smoked/used nicotine replacement therapy over preceding 3-months patients who intend to have children and breast feed patients who are pregnant or who have had a baby within past 12 months patients who have not yet attained full breast development. Consideration may be given where there is: a disparity of greater than 2 or more cup sizes in the lower range (size C or below) based on the smaller breast size a disparity of 3 or more cup sizes in the upper range (size D upwards) based on the smaller breast size (For cup sizes D and upwards there are intermediate sizes DD, E, EE, G, GG etc. A difference of B to D would count as 2 cup sizes; a difference of DD to F would count as 3 cup sizes). Patients must have reached physical maturity and would not normally be considered below the age of 18: where psychological difficulties are cited as the justification for the proposed intervention, all efforts should have been made already to manage these problems. It is expected that appropriate interventions to improve psychological wellbeing would have been used over a period of time before surgery would ever be considered as an option. Requests should include the following information: actual size of each breast with assurance that the patient s breasts have been professionally measured by a reputable underwear fitter detail of body disproportion including photographic supporting evidence (if the patient is referred to the Breast Care Nurse Service a photograph will be taken by the nurse) detail of height, weight and BMI (cases will not normally be considered where the BMI is less that 19 or greater than 27) 9

10 where the condition is affecting psychological and social wellbeing, a detailed account of specific problems encountered, along with any previous referrals treatment and outcomes. Patients that meet the above criteria will be referred onto the Breast Care Nurse Team at Yeovil District Hospital for an assessment and support, this would be prior to any application being considered by the Panel. 13 Revision of Breast Implants Breast implant surgery is a regarded as a procedure of low priority and is not therefore funded by NHS Somerset unless patients meet the following criteria; Insertion of breast implants: Insertion of breast implants is commissioned if one of the following indications applies: Reconstructive surgery needed following mastectomy Congenital amastia, where breast tissue is completely absent Insertion of breast implants is not otherwise commissioned Removal and replacement of breast implants: There are instances for clinical indications where breast implants will need to be removed and replaced. These include when both of the following indications are met: Original procedure was provided by the NHS (e.g. as part of treatment for breast cancer or other clinically required surgery) AND Implant is proven to be ruptured causing health problems The removal and replacement of breast implants is not otherwise commissioned. Removal of breast implants: This includes breast implants which were originally privately funded by the patient. The removal of breast implants, both unilaterally and bilaterally, is commissioned where there is a clinical reason requiring removal, such as the implant is proven to be ruptured. The replacement of privately funded breast implants, either unilaterally or bilaterally, where removal is required is not commissioned by NHS Somerset. 10

11 14 Mastopexy (breast lift/repositioning of nipple) Correction of inverted nipples for cosmetic purposes Mastopexy is regarded as a procedure of a low clinical priority. Breast ptosis (droopiness) is inevitable in most women and is normal with the passage of age and after pregnancy. Mastopexy is not available on cosmetic grounds. Surgery to improve appearance alone is not routinely commissioned. Mastopexy is commissioned if a necessary part of the treatment of breast asymmetry or in breast reduction, in patients meeting criteria for access to these procedures. Corrective surgery for inverted nipples is not routinely available, GPs should be aware that there are now well proven non-operative ways of correcting inverted nipples by devices which can be obtained relatively cheaply commercially and are suitable for simple lack of nipple protrusion. Surgery may be funded if there is a co-existing clinical reason such as chronic infection. Please Note: Patients must have completed puberty. Therefore surgery is not normally commissioned for people below the age of 18 years. Note: any acquired nipple inversion should be assessed to rule out carcinoma of the breast. 15 Gynaecomastia Breast reduction for gynaecomastia is funded on a restricted basis only. GPs and Consultants must obtain approval before proceeding. Surgery is not normally commissioned to improve appearance alone in benign gynaecomastia. Requests for breast reduction for gynaecomastia will be considered when all of the points below are met: the patient has reached physical maturity, surgery is not normally commissioned for people below the age of 18 years have a BMI of 27 or below have not smoked/used nicotine replacement therapy over preceding 3-months there has been insufficient response to reassurance and where normal medical treatments or management with exclusion of causative pointers have failed confirmation that the problem is not due to a medical condition or from drug side effects Pseudo-gynaecomastia (when the proposed volume of reduction is greater than 200g per site or for gross asymmetry) cases will not be approved unless there is clear evidence that the problem has persisted in spite of rigorous dieting and weight loss and the BMI has remained below 27 for at least 6-months photographic supporting evidence must be sent with the RP application patient experiences persistent pain 11

12 Cancers are diagnosed in about 1% of cases of gynaecomastia1. Where history or physical examination raises suspicion of cancer, urgent referral for further investigation should be made. Background to condition: Gynaecomastia is common and usually temporary in neonates and adolescent boys. In later life, prevalence rises with increasing age. It is thought to occur in about 30% of men. Gynaecomastia is enlargement of breast tissue in men where there is >2cm palpable, firm, subareolar gland and ductal tissue (not fat) reflecting an increased ratio of oestrogen to testosterone. There are many causes: it can be normal, a side effect of medication or a sign of diseases that affect hormonal balance. It is a common feature of obesity. Treatments for painful or embarrassing gynaecomastia include an anti-oestrogen, such as tamoxifen, or surgery (liposuction or ammoplasty). Physiological gynaecomastia requires no treatment unless accompanied by pain or significant embarrassment i.e. sufficient to cause functional problems. Withdrawing an offending drug or treating an underlying disorder may be sufficient, especially if gynaecomastia is relatively recent. SKIN PROCEDURES 16 General Guidance on Removal of benign skin lesions or moles The surgical removal, laser treatment, or cryotherapy of a benign asymptomatic skin lesion is regarded as a procedure of low clinical priority. These procedures are therefore not routinely funded by the NHS Somerset. Surgery to improve appearance alone is not provided for normal changes such as those due to aging. This policy includes: benign pigmented naevi (moles) chalazion see information section 18 cherry angiomas or Campbell de Morgan spots dermatofibromas (skin growths) ganglion removal see information section 19 lipomas (lipomata) (fat deposits underneath the skin) see information section 20 molluscum contagiosum port wine stains see information section 26 sebaceous cysts (pilar and epidermoid cysts) see information section 17 seborrhoeic keratoses (benign skin growths, basal cell papillomas, warts) skin tags (Anal Skin Tag Removal see separate policy listed) spider naevi thread veins warts, plantar warts see information section 21 12

13 xanthelasmas (cholesterol deposits underneath the skin) The removal of benign skin lesions in secondary care is therefore funded on a restricted basis only. The vast majority of skin lesions are of no great consequence but some in certain places are a cause for concern and may be referred on to secondary care. If referring to secondary care ensure the referral indicates how the patient fulfils any of the criteria (below) and that there is supporting clinical evidence that the patient fulfils any of the following criteria: 1. Rapid growth or other features suspicious of dysplasia/malignancy 2. Obstruction of an orifice or vision 3. Lesions on the face (not scalp or neck) where the extent and size of the lesion can be regarded as disfigurement (minimum greater than 1cm in diameter) 4. Site or size that interferes with normal day to day activity, for example, a naevus on the bridge of the nose that interferes with the wearing of glasses Removal of all other benign skin lesions is considered a low priority procedure. Prior approval is therefore required for those that fail to meet the above criteria. Completion of an RP application form is required and a photograph of the area. Limited provision for excision of lesions through GPwSI services and secondary care continues to be available to patients where clinically appropriate, in circumstances whereby the practice does not have the competency to undertake such procedures as part of the Minor Surgery Enhanced Service. Please note: viral warts should be treated in Primary Care, typically with topical salicylic acid; treatment of viral warts on the margins of the eyelids is problematic and these should be referred to an Ophthalmic Plastic Surgeon (or if not available an Ophthalmic surgeon) for treatment. 17 Cysts (Sebaceous cysts are now known as epidermal or pilar cysts. Trichilemmel cysts are a type of pilar cyst ) Cysts will usually grow slowly and only need removal if causing symptoms. Epidermal and pilar cysts which are less than 5mm in diameter and/or give no trouble can be left alone. Corticosteroid injections. GPs may inject an inflamed, but uninfected, epidermoid cyst with a corticosteroid to help reduce the inflammation Requests for the removal of sebaceous cysts should only be considered where there has been more than one episode of infection. The vast majority of sebaceous cysts are of no great consequence but some in certain places are a cause for concern and may be referred to secondary care. Surgery to improve appearance alone is not funded. If referring to secondary care ensure the referral indicates how the patient fulfils any of the criteria (below) and that there is supporting clinical evidence that the patient fulfils any of the following criteria; 13

14 1. Uncertainty on whether the lesion may be malignant in nature 2. More than one episode of infection 3. Genital and umbilical lesions sometimes extending into the pelvis or below the midline fascia, which may not be apparent until they are being removed. 4. Obstruction of an orifice 5. Lesions on the face (not scalp or neck) and greater than 1cm diameter where the extent and size of the lesion can be regarded as disfigurement 6. Lesions which cause functional impairment which prevents the individual from fulfilling work/study/carer or domestic responsibilities 7. Lesions over the skull which can have an intracranial or intraosseous connection - Features suggestive of intracranial or intraosseous extension include the following: Present since birth or appearance in early childhood (although small lesions may remain unnoticed until adulthood) Bruits, pulsation or fluctuation in size with straining or crying Fixation to underlying tissue, fluid-filled consistency, or ability to transilluminate Location along the nasal, forehead, or scalp midline, or along cranial suture lines Dimple or unusual overlying hair growth pattern History of cranial trauma or surgery Family history of neural developmental anomalies, neurological symptoms or history of meningitis. Removal of cysts is considered a low priority procedure. Prior approval is therefore required for those that fail to meet the above criteria. Completion of an RP application form is required and a photograph of the area. Limited provision for excision of lesions through GPwSI services and secondary care continues to be available to patients where clinically appropriate, in circumstances whereby the practice does not have the competency to undertake such procedures as part of the Minor Surgery Enhanced Service. 18 Chalazion Chalazia are benign, granulomatous lesions caused by blockage of the Meibomian gland duct, which will normally resolve within 6 months with conservative management in primary care. Removal of Chalazia is regarded as a procedure of low clinical priority and is subject to the criteria below. If patient s fulfil the criteria below approval is not required from RP, please indicate clearly on the referral to the secondary care how the patient fulfils the criteria and that there is clinical evidence to support this: Present continuously for more than six months, verified in clinical notes or Present on the upper eyelid, and interferes significantly with vision or Source of regular infection (2 times within six month time frame) requiring medical 14

15 treatment or The site of the lesion or lashes renders the condition as requiring specialist intervention within the acute trust A chalazion that keeps coming back should be biopsied to rule out malignancy, therefore use the appropriate referral route for suspected malignancy in this instance. 19 Ganglion Removal Ganglion removal is not routinely commissioned. If patient fulfil the criteria below and evidence is within the medical records funding approval is not required. Please ensure the referral to secondary care indicates how the patient fulfils the criteria (below) and forward the supporting evidence. The ganglion has resulted in functional impairment which prevents the individual from fulfilling work/study/carer or domestic responsibilities or The individual is experiencing considerable pain as a result of the ganglions size or position or Where there is doubt about the diagnosis (with or without pain) If a patient doesn t fulfil the above criteria but there is exceptionality that can be demonstrated an RP application form must be completed. Photographic supporting evidence must be included with the application form. 20 Removal of Lipomas (Lipomata) Lipomas should normally be managed in the context of the local general surgical services. Multiple lipomas or those presenting particular technical difficulties may be considered if there are exceptional reasons for their removal. An RP application form must be completed and photographic supporting evidence must be included with the application form. Lipomas that are under 5cms, without other clinical symptoms, should be observed only using soft tissue sarcoma guidelines (SIGN 2003) Severely functionally/disabling and/or subject to repeated trauma due to size/position Lipomas located on the body that are over 5cms in diameter, or in a sub-fascial position, which have also shown rapid growth and/or are painful can be referred to an appropriate surgical clinic for removal if clinically appropriate

16 Warts - These are self-limiting viral infections that can be managed in Primary Care 22 Telangectasia/Thread Veins Policy listed separately 23 Scar Revision Policy listed separately 24 Dermabrasion for Acne scarring Policy listed separately 25 Tattoo Removal Policy listed separately 26 Removal of Port Wine Stains and Other Birthmarks Policy listed separately EAR NOSE AND THROAT PROCEDURES 27 Grommet Insertion 3-18 years Policy listed separately Secondary Care to request Prior Approval 28 Tonsillectomy If patients fulfil the following criteria RP approval is not required. The referral to secondary care must indicates how the patient fulfils the criteria and the evidence is recorded in the medical notes. Suspected/diagnosed malignancy of the tonsils Recurrent sore throat where the following documented evidence applies: 7 or more episodes in the last year OR 5 or more episodes in each of the last two years OR 3 or more episodes in each of the last 3 years AND There has been significant severe impact on quality of life indicated by documented evidence of absence from work/school. OR 16

17 2 or more episodes of tonsillitis or peritonsillar abscess (quinsy) requiring admission to hospital. OR Tonsillitis exacerbating disease such as febrile convulsions, guttate psoriasis, glomerulonephritis or rheumatic fever. NHS Somerset RP will consider funding for tonsillectomy in sleep apnoea syndrome for children when one or more of the following apply: A positive sleep study or A significant impact on quality of life demonstrated or A strong clinical history suggestive of sleep apnoea Note: The case is much more likely to be approved where there is supporting evidence such as sleep studies, growth charts, letters from GPs and letters from employer/school. If a general practitioner feels that a patient may have other exceptional circumstances then an application to the Individual Funding Request Panel must be made. 29 Surgical Intervention for Simple Snoring Policy listed separately 30 Ear Wax Removal - Policy listed separately OTHER PROCEDURES/TREATMENTS 31 Circumcision Policy listed separately 32 Varicose Veins Patients with varicose veins should not be referred to secondary care except where there are any complications listed below. If patients fulfil the criteria below no prior approval is required from RP. Please ensure that the referral to secondary care indicates how the patient fulfils the criteria and there is clinical evidence within the medical records: a documented history of recurrent superficial thrombophlebitis or a single episode of ascending (migratory) thrombophlebitis spontaneous bleeding (not including spontaneous bruising) severe trophic skin changes lipodermatosclerosis, atrophie blanche 17

18 extreme Varicose eczema associated with varicose veins venous leg ulceration with evidence of varicose veins If a general practitioner feels that a patient has other exceptional circumstances then these patients must be referred to the RP for consideration of funding by completing the RP application form along with the evidence of exceptionality. Additional information Management of patients with significant symptoms (pain, swelling, ache) adversely affecting daily activities in the presence of varicose veins These patients may have symptoms that relate to their varicose veins and in order to clarify whether or not venous disease is responsible for their symptoms, we would recommend that in patients with a full complement of peripheral pulses (i.e. no evidence of arterial disease) a trial of below knee or full length (as appropriate) Class II graduated compression hosiery should be tried. Hosiery should be worn during the daytime and removed prior to going to bed. Patients who notice no significant improvement in symptoms after a 6 week trial of compression hosiery are unlikely to benefit from varicose vein surgery. Patients not suitable for referral to vascular surgical clinics for NHS treatment Patients with no symptoms or skin changes associated with venous disease Patients whose concerns are cosmetic including Telangectasia and reticular veins Patients with mild symptoms including itch, ache, mild swelling, minor changes of skin eczema and haemosiderosis 33 Immunology Allergy Testing NHS Somerset CCG referrals to an NHS Immunologist within secondary care for simple allergies, does not require funding authorisation from the Somerset CCG R panel. Please note that recommended treatment following an assessment within secondary care which is not routinely commissioned or is not normally funded within NHS guidance/criteria would require completion of generic RP application form for consideration of funding. 34 Hair Depilation - Policy listed separately 35 Reversal of Sterilisation / Vasectomy Policy listed separately 36 Laser Surgery to correct visual acuity Policy listed separately 37 Gastro-electrical Stimulation As of 1 April 2015 all GES Paed/Adults is part of the NHS England commissioning remit 18

19 38 Percutaneous Tibial Nerve Stimulation Treatment for Urinary Incontinence Percutaneous Tibial Nerve Stimulation (PTNS) treatment for Urinary Incontinence is regarded as a procedure of low clinical priority. This procedure is therefore not routinely funded by NHS Somerset. There is currently insufficient evidence of clinical and cost effectiveness of this treatment. 39 Functional Electrical Stimulation (FES) Lower Limb Functional Electrical Stimulation (FES) is an evidence-based, intervention recommended by the National Institute for Health and Care Excellence (NICE PG278). FES is a means of producing useful movement in partially paralysed muscles. The intervention is commonly used as a practical assistive device to assist daily mobility for people who have dropped foot due to upper motor neurone neurological conditions such as stroke, brain injury, spinal cord injury and multiple sclerosis. Somerset FES Service - Outpatient referrals for lower limb All patients currently not receiving lower limb FES therapy can be referred by their GP or Medical Consultant through the patient s local ILT Team Referral criteria 1. All patients must be aged 18 and over 2. Cause and functional deficit a. Neurological deficit due to an upper motor neurone lesion An upper motor neurone lesion is defined as one that occurs in the brain or spinal cord at or above the level of T12 Upper motor neurone lesions that may benefit form FES are stroke, multiple sclerosis, incomplete spinal cord injury at T12 or above, cerebral palsy, familial / hereditary spastic paraparesis, head injury and Parkinson's disease Referrals outside of local pathway for FES for Lower Limb Prior approval is required for funding authorisation for a referral outside of the local pathway for an assessment of FES for lower limb dropped foot due. PA should be sought by completion of the generic RP application form. Criteria: 19

20 3. All patients must be aged 18 and over 4. Cause and functional deficit a Neurological deficit due to an upper motor neurone lesion An upper motor neurone lesion is defined as one that occurs in the brain or spinal cord at or above the level of T12 Upper motor neurone lesions that may benefit form FES are stroke, multiple sclerosis, incomplete spinal cord injury at T12 or above, cerebral palsy, familial / hereditary spastic paraparesis, head injury and Parkinson's disease FES FOR UPPER LIMB IS NOT ROUTINELY COMMISSIONED Funding authorisation should be sought by completion of a generic RP application form for consideration by the R Panel. Please ensure the following is provided with the application form; Clinical evidence to support the treatment requested Evidence of exceptionality Associated costs 40 Botulinum Toxin Treatment Policy Listed Separately 20