Greater Manchester EUR Policy Statement on: Body Contouring GM Ref: GM011 & GM019 Version: 2.4 (6 June 2018)

Transcription

1 Greater Manchester EUR Policy Statement on: Body Contouring GM Ref: GM011 & GM019 Version: 2.4 (6 June 2018)

2 Commissioning Statement Body Contouring Policy Exclusions (Alternative commissioning arrangements apply) Fitness for Surgery Policy Inclusion Criteria Treatment/procedures undertaken as part of an externally funded trial or as a part of locally agreed contracts / or pathways of care are excluded from this policy, i.e. locally agreed pathways take precedent over this policy (the EUR Team should be informed of any local pathway for this exclusion to take effect). NOTE: All patients should be assessed as fit for surgery before going ahead with treatment, even though funding has been approved. This policy applies to adults (aged over 18 years) only. NOTE: This policy does not apply to Mastopexy / Breast Lift, which is covered in the GM Aesthetic Breast Surgery Policy or to liposuction for lipodema which is covered by the GM Other Aesthetic Surgery Policy Panniculectomy (also referred to as Apronectomy) Panniculectomy procedures are commissioned in accordance with the criteria below. Referral letters should demonstrate that the patient meets these criteria, to ensure that they can be accepted by secondary care providers. A AND B AND C The patient must have achieved a significant weight loss from a starting BMI of above 40 or above 35 with relevant and significant co-morbidities to a BMI of 28, (in accordance with Royal College of Surgeons Guidance) or below. OR Where a BMI of below 28 cannot be achieved, patients should achieve a weight loss equivalent to 75% of the excess body weight (calculated by estimating the target weight for the patient s height to give them a BMI just in the normal range and taking that from their maximum recorded weight dividing by 100 and multiplying by 75). A BMI of up to 40 can be considered here (in accordance with Royal College of Surgeons Guidance). NOTE: D does not apply in these cases. The weight loss must have been maintained for a period of 2 years. This shows a commitment to maintaining the lower weight achieved and allows any natural resolution of the excess skin to occur. Clinicians must provide the patient s peak weight and BMI and the current weight and BMI, including dates with evidence that the patient has maintained the current weight for 2 years. There is documented evidence of a severe impairment of functional activity associated with the excess skin. Examples being ambulatory restrictions, difficulty in necessary activities of daily living or in the use of orthotic and other supportive equipment. OR Documented evidence of recurrent injury to the area of excess skin. OR There is clinically documented evidence of persistent or recurrent skin conditions arising as a direct result of the panniculus (e.g. intertriginous dermatitis, panniculitis, cellulitis or skin ulcerations) that is refractory to good hygiene practice. Documented evidence includes either a record of prescriptions issued or a statement from both clinician and patient clearly setting out all selfmedication used, including when and how applied. GM Body Contouring Policy v2.4 FINAL Page 2 of 16

3 AND D AND E OR A statement from an appropriately qualified clinician that the patient is having problems associated with poorly fitting stoma bags that are likely to be resolved following surgery. The panniculus is mainly skin (in very rare cases the procedure may be considered if a clinician provides evidence of induration of the fatty tissue). The panniculus hangs below the symphysis pubis when the individual is standing normally. Funding Mechanism Monitored approval: Referrals may be made in line with the criteria without seeking funding. NOTE: These referrals may be the subject of contract challenges and/or audit of cases against commissioned criteria. Bolton CCG: Individual prior approval provided the patient meets the above criteria. Requests must be submitted with all relevant supporting evidence. Other Body Contouring Procedures Funding for procedures to remove excess skin from other areas of the body are not commissioned. Funding may be considered if there is evidence of clinical exceptional circumstances. Where clinical exceptionality is demonstrated, patients must also have achieved and maintained a massive weight loss and have significant functional impairments as described in the criteria (a-c) for Panniculectomy above. To support the decision-making process, non-identifiable photographs, preferably medical illustrations if available will be requested, but will not form the sole basis of the decision. It is not mandatory for photographs to be provided. Funding Mechanism Individual funding request (exceptional case) approval: Requests must be submitted with all relevant supporting evidence. Clinical Exceptionality Clinicians can submit an Individual Funding Request (IFR) outside of this guidance if they feel there is a good case for exceptionality. Exceptionality means a person to which the general rule is not applicable. Greater Manchester sets out the following guidance in terms of determining exceptionality; however the over-riding question which the IFR process must answer is whether each patient applying for exceptional funding has demonstrated that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by showing that s/he is: Significantly different to the general population of patients with the condition in question. and as a result of that difference They are likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. GM Body Contouring Policy v2.4 FINAL Page 3 of 16

4 Contents Commissioning Statement... 2 Policy Statement... 5 Equality & Equity Statement... 5 Governance Arrangements... 5 Aims and Objectives... 5 Rationale behind the policy statement... 6 Treatment / Procedure... 6 Epidemiology and Need... 6 Adherence to NICE Guidance... 6 Audit Requirements... 7 Date of Review... 7 Glossary... 7 References... 7 Governance Approvals... 7 Appendix 1 Evidence Review... 9 Appendix 2 Diagnostic and Procedure Codes Appendix 3 Version History GM Body Contouring Policy v2.4 FINAL Page 4 of 16

5 Policy Statement Greater Manchester Shared Services (GMSS) Effective Use of Resources (EUR) Policy Team, in conjunction with the GM EUR Steering Group, have developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester, who will commission treatments/procedures in accordance with the criteria outlined in this document. In creating this policy GMSS/GM EUR Steering Group have reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). Equality & Equity Statement GMSS/CCGs have a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act GMSS/CCGs are committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its functions, GMSS/CCGs will have due regard to the different needs of protected characteristic groups, in line with the Equality Act This document is compliant with the NHS Constitution and the Human Rights Act This applies to all activities for which they are responsible, including policy development, review and implementation. In developing policy the GMSS EUR Policy Team will ensure that equity is considered as well as equality. Equity means providing greater resource for those groups of the population with greater needs without disadvantage to any vulnerable group. The Equality Act 2010 states that we must treat disabled people as more equal than any other protected characteristic group. This is because their starting point is considered to be further back than any other group. This will be reflected in GMSS evidencing taking due regard for fair access to healthcare information, services and premises. An Equality Analysis has been carried out on the policy. For more information about the Equality Analysis, please contact policyfeedback.gmscu@nhs.net. Governance Arrangements Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association Governing Group (GMAGG) prior to formal ratification through CCG Governing Bodies. Further details of the governance arrangements can be found in the GM EUR Operational Policy. Aims and Objectives This policy document aims to ensure equity, consistency and clarity in the commissioning of treatments/procedures by CCGs in Greater Manchester by: reducing the variation in access to treatments/procedures. GM Body Contouring Policy v2.4 FINAL Page 5 of 16

6 ensuring that treatments/procedures are commissioned where there is acceptable evidence of clinical benefit and cost-effectiveness. reducing unacceptable variation in the commissioning of treatments/procedures across Greater Manchester. promoting the cost-effective use of healthcare resources. Rationale behind the policy statement The issues for which body contouring procedures are carried out are not life threating. These procedures are carried out mostly for aesthetic reasons and as such are considered low priority and are not routinely commissioned. In exceptional cases applications funding can be made via the IFR route. Treatment / Procedure Body contouring covers a variety of requests to remove redundant skin usually following major weight loss, the most commonly requested procedures are: Arm reduction and lift (Brachioplasty) is usually performed under a general anaesthetic. The surgeon makes a long incision between the elbow and axilla. Segments of skin and fat are removed and the remaining skin and tissue lifted resulting in a tight, smooth look. Thigh lift is when excess skin and fat are removed from the thighs. Liposuction may also be performed during this procedure. Sometimes a buttock lift is combined with this procedure. Surgery to improve the appearance of the abdomen: There are a number of procedures available, for example, in abdominoplasty it may involve removing excess skin and fat and tightening the abdominal muscles. Panniculectomy / apronectomy is a limited abdominoplasty procedure and is performed to remove the excess skin only. A panniculus is excess adipose tissue hanging downward from the abdomen and resembles an "apron of skin" overlying the front of the pelvic girdle. Epidemiology and Need Individuals who are obese are increasingly encouraged to lose weight either through diet and exercise (often supported by community weight loss programs) or as a result of bariatric surgery undertaken either privately or on the NHS. Rapid, marked weight loss often results in large areas of loose skin. Patients have increasing expectations that removal of this excess skin will be funded by the NHS especially if the bariatric surgery was NHS funded. Body contouring may also be requested by women who have excess abdominal skin following pregnancy or to treat excessive stretch marks. The exact number of patients with excess skin following weight loss is not known. Adherence to NICE Guidance NICE have not currently issued guidance on this treatment. The Royal College of Surgeons in association with the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) have recently produced guidance on body contouring using a NICE accredited process. Those guidelines have been taken into account in the development of this policy. GM Body Contouring Policy v2.4 FINAL Page 6 of 16

7 Audit Requirements There is currently no national database. Service providers will be expected to collect and provide audit data on request. Date of Review Three years from the date of the last review, unless new evidence or technology is available sooner. The evidence base for the policy will be reviewed and any recommendations within the policy will be checked against any new evidence. Any operational issues will also be considered at this time. All available additional data on outcomes will be included in the review and the policy updated accordingly. The policy will be continued, amended or withdrawn subject to the outcome of that review. Glossary Term Abdominoplasty / Apronectomy Bariatric Surgery Brachioplasty Intertrigo Panniculectomy The Symphysis Pubis Thigh lift Meaning Surgery to improve the appearance of the abdomen, it may involve removing excess skin and fat and tightening the abdominal muscles. Apronectomy is a reduced abdominoplasty removing only excess skin. Surgery to reduce the size of the stomach in order to promote weight loss. Arm reduction and lift. A dermatitis occurring between juxtaposed folds of skin. The dermatitis is usually caused by retention of sweat, moisture, and warmth which results in an overgrowth of normal skin microorganisms. Removal of an apron of skin panniculus (can include the removal of fat within the skin). The area of junction of the pubic bones and lies at the centre-front of the pelvic girdle. Excess skin and fat are removed from the thighs. References 1. GM EUR Operational Policy 2. The clinical effectiveness and cost effectiveness of surgery for people with morbid obesity: a systematic review and economic evaluation Health Technology Assessment 2002; Vol. 6: No Commissioning Guide: Massive Weight Loss Body Contouring, British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), Royal College of Surgeons [accessed 07/07/2014] 4. NICE CG43: Obesity prevention (Last updated: Mar 2015) Governance Approvals Name Date Approved Greater Manchester Effective Use of Resources Steering Group 17/09/2014 GM Body Contouring Policy v2.4 FINAL Page 7 of 16

8 Greater Manchester Chief Finance Officers / Greater Manchester Directors of Commissioning 15/12/2014 Greater Manchester Association Governing Group 06/01/2015 Bury Clinical Commissioning Group 04/03/2015 Bolton Clinical Commissioning Group 27/03/2015 Heywood, Middleton & Rochdale Clinical Commissioning Group 20/03/2015 Manchester Clinical Commissioning Group North: 13/01/2015 Central: 05/03/2015 South: 11/03/2015 Oldham Clinical Commissioning Group 06/01/2015 Salford Clinical Commissioning Group 06/01/2015 Stockport Clinical Commissioning Group 25/02/2015 Tameside & Glossop Clinical Commissioning Group 22/04/2015 Trafford Clinical Commissioning Group 17/03/2015 Wigan Borough Clinical Commissioning Group 04/03/2015 GM Body Contouring Policy v2.4 FINAL Page 8 of 16

9 Appendix 1 Evidence Review Body Contouring GM011 & GM019 Search Strategy The following databases are routinely searched: NICE Clinical Guidance and full website search; NHS Evidence and NICE CKS; SIGN; Cochrane; York; and the relevant Royal College and any other relevant bespoke sites. A Medline / Open Athens search is undertaken where indicated and a general google search for key terms may also be undertaken. The results from these and any other sources are included in the table below. If nothing is found on a particular website it will not appear in the table below: Database NICE (includes NHS Evidence) SIGN Cochrane York Medline / Open Athens Result Measuring Quality of Life and Patient Satisfaction After Body Contouring: A Systematic Review of Patient-Reported Outcome Measures, Patrick L. Reavey et al, Aesthetic Surgery Journal September 2011 vol. 31 no SIGN 115: Management of Obesity: A national clinical guideline Correlation of Complications of Body Contouring Surgery With Increasing Body Mass Index, Katherine Au, MD et al Aesthetic Surg J 2008;28: York Review: Panniculectomy for abdominal contouring following massive weight loss Assessing Improvement in Quality of Life and Patient Satisfaction following Body Contouring Surgery in Patients with Massive Weight Loss: A Critical Review of Outcome Measures Employed, Shehab Jabir, Plastic Surgery International Volume 2013, Article ID , 12 pages Complications in Body Contouring Procedures: An Analysis of 1,797 Patients from the ACS-NSQIP Databases, Fischer, John P. MD; Wes, Ari M. BA; Serletti, Joseph M. MD; Kovach, Stephen J. MD Other Commissioning Guide: Massive Weight Loss Body Contouring, British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), Royal College of Surgeons [accessed 07/07/2014] (Added at review: January 2016) Summary of the evidence Most of the evidence relating to these procedures was non-specific and included in reviews of obesity management. Systematic reviews of quality of outcome measures found that the papers studied did not use robust measures of outcomes and more work was needed but that overall patients appeared satisfied with the outcomes (based on low grade evidence). Studies looking at complications following these procedures found relatively high rates of complications but these were confounded by high rates of comorbidity. GM Body Contouring Policy v2.4 FINAL Page 9 of 16

10 The evidence Levels of evidence Level 1 Level 2 Level 3 Level 4 Level 5 Meta-analyses, systematic reviews of randomised controlled trials Randomised controlled trials Case-control or cohort studies Non-analytic studies e.g. case reports, case series Expert opinion 1. LEVEL 1: SYSTEMATIC REVIEW SIGN 115: Management of Obesity: A national clinical guideline Plastic Surgery No long term studies were identified on which patient groups benefit most from plastic surgery, following bariatric surgery. Quality of life outcome measures would be important to such investigations. The complication rate post abdominoplasty/panniculectomy is reported as between 25%-50% and appears to be associated with poor physical health status as assessed by the American Society of Anaesthesiologists classification system for assessment of patients prior to surgery (ASA class), history of cigarette smoking, and, in particular, higher absolute weight loss and higher maximum pre-plastic surgery BMI. 2. LEVEL 3: RETROSPECTIVE REGRESSION ANALYSIS Complications in Body Contouring Procedures: An Analysis of 1,797 Patients from the ACS-NSQIP Databases, Fischer, John P. MD; Wes, Ari M. BA; Serletti, Joseph M. MD; Kovach, Stephen J. MD AB Purpose: To examine the incidence and predictors of surgical and medical morbidity following body contouring procedures. Background: Body contouring is a rapidly emerging field in plastic surgery. This study characterizes risk factors associated with minor wound complications, major surgical morbidity, and medical complications using a large, prospective dataset. Methods: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2010 for all identifiable body contouring cases, including CPT codes brachioplasty, medial thigh lift, abdominoplasty, and suction assisted lipectomy (SAL). Multivariable logistic regression analyses were used to determine independent predictors of morbidity. Results: Seventeen hundred ninety seven patients underwent body contouring during the study period, the vast majority were female (n=1,600, 89.0%). Average BMI of patients undergoing body contouring was 31.6 kg/m2, with a total of 239 morbidly obese individuals (BMI >= 40 kg/m2). The most common area of intervention was the trunk region, with 1,652 (91.9%) patients receiving abdominal contouring and/or contouring of the hips and buttocks. Minor wound complications occurred in 114 (6.3%) individuals, while 122 (6.8%) patients suffered from a major surgical morbidity, and 40 (2.2%) experienced a medical complication. Multivariate logistic regression revealed, the presence of multiple comorbidities (OR 15.87, P=0.014), presence of a bleeding disorder (OR 20.31, P=0.026), preoperative albumin level (OR 0.14, P=0.003,), and malnutrition (OR 0.19, P=0.065), were associated with an increased odds of minor wound complications. Inpatient procedures (OR 4.64, P=0.06), and functional status (OR 9.71, P=0.011) were associated with an increased odds of major surgical morbidity. Conclusion: This study characterizes the 30-day rates of morbidity in patients undergoing body contouring procedures using a large prospective, validated national data set. These findings highlight the critical importance of careful preoperative patient evaluation, including laboratory screening, and underscore the need for detailed preoperative counselling and risk stratification. GM Body Contouring Policy v2.4 FINAL Page 10 of 16

11 3. LEVEL 1: SYSTEMATIC REVIEW Assessing Improvement in Quality of Life and Patient Satisfaction following Body Contouring Surgery in Patients with Massive Weight Loss: A Critical Review of Outcome Measures Employed, Shehab Jabir, Plastic Surgery International Volume 2013, Article ID , 12 pages Body contouring following massive weight loss is a rapidly expanding field in plastic surgery. However, healthcare payers are reluctant to fund such procedures, viewing them as purely cosmetic. This has resulted in a flurry of studies assessing quality of life (QoL) and patient satisfaction following body contouring surgery in this cohort of patients to establish an evidence base to support the idea that body contouring is as much (or even more) a functional procedure as it is cosmetic. However, the methods employed in these studies are seldomideal, and hence the conclusions are unreliable. The gold standard to assess QoL and patient satisfaction is to use patient specific psychometrically validated patient reported outcome (PRO) measures. Developing such measures consists of a three-step process which includes a review of the current literature, qualitative patient interviews to determine what patients consider the most important, and expert opinion. This study aims to appraise the currently available literature on assessment of QoL and patient satisfaction in body contouring surgery patients. 4. LEVEL 1: SYSTEMATIC REVIEW Measuring Quality of Life and Patient Satisfaction After Body Contouring: A Systematic Review of Patient-Reported Outcome Measures, Patrick L. Reavey et al, Aesthetic Surgery Journal September 2011 vol. 31 no ABSTRACT Evidence-Based Background: In both cosmetic and postbariatric body contouring populations, the primary determinants of success are patient satisfaction and quality of life (QOL). These patient-reported outcomes (PRO) are ideally measured with specially-designed, procedure- or condition-specific questionnaires. Objective: The authors identify and appraise all patient-reported outcome (PRO) measures (questionnaires) developed for patients undergoing body contouring surgery. Methods: MEDLINE, EMBASE, PsychINFO, Ebase, CINAHL, HAPI, Science Citation Index/Social Sciences Citation Index, Ovid Evidence Based Medicine databases were searched from the inception of each database through August Articles included in the study described the development and/or psychometric evaluation of a PRO measure developed for body contouring patients. Each measure was then appraised for adherence to internationally-recommended guidelines for item generation, item reduction, and psychometric evaluation. Results: The following five PRO questionnaires were identified by our search: one liposuction (the Freiburg Questionnaire on Aesthetic Dermatology and Cosmetic Surgery, FQAD), one general plastic surgery (Derriford Appearance Scale, DAS-59/24), and three breast reduction measures (the Breast Reduction Assessed Severity Scale Questionnaire, BRASSQ; Breast Related Symptoms questionnaire, BRS; and the BREAST-Q reduction module. Detailed examination of these measures revealed that the FQAD, DAS-59, and BRS are limited by both their content range and psychometric properties. The BRASSQ and BREAST-Q both have strong psychometric properties, and the BREAST-Q is unique in its inclusion of items covering specific postoperative issues such as scarring. Conclusions: While instruments are available for measuring outcomes in breast reduction patients, reliable, valid, and responsive PRO measures are lacking for the majority of body contouring procedures. To demonstrate the unique outcomes of body contouring surgery, future research to rigorously develop and validate new PRO measures in this population is necessary. 5. LEVEL N/A: HEALTH TECHNOLOGY ASSESSMENT York Review: Panniculectomy for abdominal contouring following massive weight loss Panniculectomy is a body contouring surgery that removes the large flap of subcutaneous hanging fat and redundant skin that hangs down from the abdomen and covers the pubis and groin, typically after massive weight loss. It may be performed by itself or combined with other abdominal surgeries. A large panniculus can interfere with normal activities such as walking, and lead to serious medical problems. GM Body Contouring Policy v2.4 FINAL Page 11 of 16

12 The heavy overhanging tissue can cause chronic skin inflammation under the flap, and subsequently, skin breakdown and infection. The number of panniculectomies performed in the United States is increasing with the increasing incidence of obesity and bariatric surgery. Historically, panniculectomy has been considered primarily a cosmetic procedure; however, for some patients, surgery is the only option if a large panniculus causes debilitating symptoms that do not respond to conventional medical therapy. The report may be purchased from: 6. LEVEL 3: CASE CONTORL STUDY Correlation of Complications of Body Contouring Surgery with Increasing Body Mass Index Katherine Au, MD et al Aesthetic Surg J 2008;28: Background: There have been conflicting reports regarding the incidence of postoperative complications in body contouring procedures in obese and morbidly obese patients. Our subjective impression has been that the complication rate is significantly higher for these patients than it is for other weight groups. Objective: The purpose of our study was to conduct a retrospective chart review to delineate our institution s complication rate in body contouring operations across all weight groups and to identify predictors of poor outcomes/complications that would help guide patient selection. Methods: The records of 129 patients who underwent a single body contouring procedure at The Penn State Hershey Medical Center from 1993 to 2002 were reviewed. Patients were categorized based on their body mass index into the following weight groups: ideal, overweight, obese, morbidly obese, and severely morbidly obese. The complications were grouped into minor, major, or combined (minor or major). Patients who underwent combined procedures were excluded from the study. Results: There was a statistically significant association between minor (P =.0006), major (P =.0098), and combined (P <.0001) complications and weight group. More specifically, the percentage of complications increased as weight category increased. The percentage of minor complications increased from 3.3% in the ideal weight group to 46.9% in the severely morbidly obese group. Similarly, the percentage of major complications increased from 6.6% in the ideal weight group to 43.7% in the severely morbidly obese group. Both major and minor complications saw the largest increase in complication rates between the morbidly obese and severely morbidly obese groups. Furthermore, those in the obese (odds ratio [OR] = 6.43; P =.0115), morbidly obese (OR = 5.54; P =.0237), and severely morbidly obese (OR = 19.80; P <.0001) weight groups were more likely to experience minor or major complications than those in the ideal weight group. Conclusions: This study demonstrates two points: (1) it confirms that there is a significant increase in the occurrence of complications among morbidly obese and severely morbidly obese patients undergoing a single body contouring procedure, and (2) it shows there is an increase in the occurrence of complications with worsening degree of obesity. The (post weight loss) body mass index at the time of body contouring surgery is a predictor for postoperative complications. 7. LEVEL N/A: EVIDENCE REVIEW AND EXPERT GUIDANCE Commissioning Guide: Massive Weight Loss Body Contouring, British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), Royal College of Surgeons [accessed 07/07/2014] (Added at review: January 2016) General criteria for body contouring surgery: Age over 16 years Starting BMI above 40kg/m2 or above 35kg/m2 with co-morbidities AND current BMI of less than or equal to 28.0kg/m2 AND weight stability of 12 months AND significant functional disturbance (both physical and psychological) Body contouring surgery creates large wounds. The current evidence favours this surgery when patients have 'fully deflated'. Performing BCS at higher BMI's is associated with higher risk of complications. After reviewing British Obesity & Metabolic Surgery Society (BOMSS) input the group decided to increase the BMI from 27 to 28 for reconstructive body contouring surgery. This BMI level is considered safe for surgery. GM Body Contouring Policy v2.4 FINAL Page 12 of 16

13 Exceptions to general criteria: Starting BMI above 40kg/m2 or above 35kg/m2 with co-morbidities and 75% excess body weight lost should be eligible for apronectomy only if they are unable to slim down to a BMI of 28 or less. A BMI of up to 40kg/m2 can be considered here. Weight stability of 12 months and significant functional disturbance applies here too. Exclusion criteria: Current smoker Active psychiatric or psychological condition that would benefit from diagnosis and treatment prior to referral for body contouring surgery or that would contraindicate surgery including:25 patients who have had an episode of self-harm within the last two years; patients with a previous diagnosis of body dysmorphic disorder; patients with a disproportionate view of the problem following consultation with a consultant Plastic Surgeon; patients who currently have on going alcohol or drug misuse problems. NB: General health, social and lifestyle issues should also be taken into account before offering body contouring surgery to patients. GM Body Contouring Policy v2.4 FINAL Page 13 of 16

14 Appendix 2 Diagnostic and Procedure Codes Body Contouring GM011 & GM019 (All codes have been verified by Mersey Internal Audit s Clinical Coding Academy) GM011 & GM0019: Body Contouring Policy Abdominoplasty S02.1 Abdominolipectomy S02.2 Other specified plastic excision of skin of abdominal wall S02.8 Buttock lift S03.1 Thigh lift S03.2 Excision of redundant skin or fat of arm S03.3 Unspecified plastic excision of skin of abdominal wall S02.9 Submental lipectomy S01.3 Other specified plastic excision of skin of other site S03.8 Unspecified plastic excision of skin of other site S03.9 With the following ICD-10 diagnosis code(s): Other plastic surgery for unacceptable cosmetic appearance Z41.1 GM Body Contouring Policy v2.4 FINAL Page 14 of 16

15 Appendix 3 Version History Body Contouring GM011 & GM019 The latest version of this policy can be found here: GM Body Contouring policy Version Date Summary of Changes /10/2013 Initial Draft for consideration by GM EUR Steering Group /12/2013 Definition expanded and clarified /12/2013 Criteria defined more explicitly as per request at GM EUR Steering Group on 20 November /02/2014 Criteria for Commissioning expanded upon and severe impairment of functional activity further defined, as recommended by GM EUR Steering Group on 15 January Draft policy approved by GM EUR Steering Group on 19 March /04/2014 Statement regarding treating disabled people as more equal than other protected characteristic groups added to Equality and Equity section. Ratification through CCG Governing Bodies added to Governance Arrangements /07/2014 Amendments made at the GM EUR Steering Group on 09/07/2014 following a review of the feedback from the consultation: Mandatory criteria heading inserted under section 4. Section 4 amended to reflect that panniculectomy is commissioned under specific criteria. Other body parts are not commissioned. Minimum upper BMI added to the criteria. Additional policy criteria included to reflect RCS guidance around reduction of 75% of excess body weight if patients cannot achieve the specified lower BMI. Funding mechanism changed to reflect that Panniculectomy procedures may be referred in line with the criteria monitored approval. Other body parts IFR. Referenced the RCS guidance in section 9. Of the policy /09/2014 Amendments made following discussion at GM EUR Steering Group on 17/09/2014: Removal of paragraph d) under Mandatory Criteria, Section 4 and renumbering of following paragraphs. 17/09/2014 Approved by GM EUR Steering Group subject to the above amendments /10/2014 Branding change following creation of North West CSU on 03/10/ /09/2014 Policy approved by GM EUR Steering Group required amendments have been made /03/2015 Bolton CCG adopted funding mechanism of IPA for panniculaectomy. 23/06/2015 Variance column removed and funding mechanism column added to table. Format of funding mechanism changed /01/2016 Policy reviewed by GM EUR Steering Group no material changes necessary to the policy. GM Body Contouring Policy v2.4 FINAL Page 15 of 16

16 Following paragraph added under Policy Exclusions: 'Body contouring as part of an externally funded trial or a locally agreed pathway of care is excluded from this policy' Wording for date of review changed. Evidence review updated following review /04/2016 List of diagnostic and procedure codes in relation to this policy added as Appendix 2. Policy changed to Greater Manchester Shared Services template and references to North West Commissioning Support Unit changed to Greater Manchester Shared Services /07/2016 The EUR Steering Group agreed that under Mandatory Criteria the following be added to a) bullet point 2: 'Note: d does not apply in these cases.' The group also requested that the brackets surrounding 'with relevant and significant co-morbidities be removed The group agreed that the policy would be reviewed again in 3 years unless new evidence warrants earlier review /10/2017 Criteria for Commissioning: Note added to state: 'For liposuction for lipodema, please see the GM Other Aesthetic Surgery Policy' /06/2018 Policy moved to new format and some wording rearranged and clarified. Commissioning Statement: o (Alternative commissioning arrangements apply) added after Policy Exclusions heading o Fitness for Surgery section added Appendix 2: The following OPCS-4 procedure codes added: o S01.3 Submental lipectomy o S03.8 Other specified plastic excision of skin of other site o S03.9 Unspecified plastic excision of skin of other site GM Body Contouring Policy v2.4 FINAL Page 16 of 16