CONTENTS 1 INTRODUCTION 2 2 SURGICAL RESTRICTED AND EXCLUDED PROCEDURES LIST 3 3 SECONDARY CARE FLOW CHART 5 4 INDIVIDUAL FUNDING REQUESTS 6

Transcription

1 Policy and Procedure for Individual Funding Requests (IFRs) and the management of restricted treatments and procedures concerning Clinical Commissioning Groups CONTENTS 1 INTRODUCTION 2 2 SURGICAL RESTRICTED AND EXCLUDED PROCEDURES LIST 3 3 SECONDARY CARE FLOW CHART 5 4 INDIVIDUAL FUNDING REQUESTS 6 5 PRIOR APPROVALS AND PROCEDURES 11 6 VERSION CONTROL 31 APPENDICES 1 POLICY SCOPE 34 2 PROCESS 35 3 THE IFR REFERRAL PANEL 36 4 CCG APPEALS PANELS 37 5 SOUTH CENTRAL ETHICAL FRAMEWORK 38 6 INDIVIDUAL FUNDING REQUEST (IFR) - SECONDARY CARE USE 41 7 INDIVIDUAL FUNDING REQUEST (IFR) APPLICATION PRIMARY CARE 47 8 COSMETIC/ PLASTIC SURGERY 52 9 IVF REFERRAL FORM FURTHER SUPPORTING INFORMATION OPCS CODES FOR PROCEDURES 60 Portsmouth and South Eastern Hampshire Page 1 of 72

2 1 INTRODUCTION This document sets out the Policy and Procedure with respect to treatments not routinely commissioned or restricted to clinical criteria for the following Clinical Commissioning Groups (CCGs) in Hampshire Fareham & Gosport CCG Portsmouth CCG South Eastern Hampshire CCG North Hampshire CCG (associate) West Hampshire CCG (associate) The function for addressing individual funding requests and the management of restricted treatments and procedures lies with the NHS South, Central & West Commissioning Support Unit (CSU) which acts on behalf of CCGs. These may be treatment requests or referrals made to either to an NHS provider outside the local health economy; to a provider where there is no contract in place; generally for a treatment/ procedure that is excluded or to a non-nhs provider i.e. the private sector. These referrals will, for the purposes of the Policy, be known as Individual Funding Requests (IFRs). The treatments listed in this policy are restricted either by the relevant diagnosis and/or the relevant procedure. For example a patient with a diagnosis of Hallux Valgus who has a subsequent procedure will not be routinely funded irrespective of the type of procedure a patient ultimately receives. Portsmouth and South Eastern Hampshire Page 2 of 72

3 SURGICAL RESTRICTED AND EXCLUDED PROCEDURES This list sets out those procedures requiring either an IFR or Prior Approval and from where such an application should normally come from. Where applicable discretion will be applied by the CSU team regarding the origin of the request. The referral must be clinically led. In most cases, the GP would be the appropriate clinician making the application. However, where specialist opinion is required to inform the application, we would expect the responsibility for the application to fall upon the specialist clinician. Procedure the specialties listed below are a guide only and patients may be treated under different treatment function codes ORTHOPAEDIC IFR Required Prior Approval Request normally expected from Patellar knee resurfacing as part of total knee replacement Secondary care Arthroscopic lavage and debridement with or without partial meniscectomy for osteoarthritis of knee Secondary Care or MSK community service Arthroscopic hip surgery in impingement Secondary Care or MSK community service Autologous blood injections for musculo-skeletal conditions Secondary Care Bunion (hallux valgus) surgery Secondary Care or MSK community service Carpal tunnel release Primary Care, Secondary Care or MSK community service Dupuytren s contracture surgery (palmar fasciectomy) Primary Care or MSK community service Ganglion surgery Primary Care Hip or knee replacement (primary) BMI 35+ Secondary Care or MSK community service Hip resurfacing Secondary Care or MSK community service Trigger finger surgery Primary Care or MSK service Subacromial shoulder decompression Secondary care or MSK Spinal fusion and/or discectomy in non-specific back pain Secondary Care Epidural injections in non-radicular or non-radiated pain Secondary Care Epidural injections in severe and acute radiated pain including Secondary Care sciatica and other radiculopathy Other therapeutic injections (including facet or sacro-iliac Secondary Care joint/medial branch blocks or cervical injections) Therapeutic Diagnostic Repeat interventions outside of denervation Secondary Care Radio-frequency denervation of facet joint and repeat denervations GENERAL, PLASTIC, VASCULAR AND GI SURGERY Secondary Care Abdominoplasty (cosmetic) (IFR or prior approval if after Primary Care massive weight loss) Skin reduction surgery (after massive weight loss) Primary Care Portsmouth and South Eastern Hampshire Page 3 of 72

4 Breast procedures Primary Care Chronic anal fissure in adults Secondary care Gastric fundoplication for reflux disease Secondary Care Varicose vein treatment Primary Care Cosmetic devices/ appliances e.g. silicon Primary Care cosmeses/prostheses Laser treatment Primary Care or Secondary Care (Dermatology) Benign skin lesions Primary Care Plastics procedures (facial, brow, facelift, thighs, upper arms) Primary Care OPHTHALMOLOGY Eyelid Surgery for ectopion and chalazia Primary Care Eyelid Surgery for ptosis, blepharoplasty and dermatochalasis Secondary care with visual fields test included Short sight/ long sight corrective (laser) surgery (Refractive keratoplasty) Secondary care Second eye cataract surgery Community ophthalmology or secondary care ENT Adenoidectomy in children with upper respiratory tract Secondary care infection Balloon catheter sinus dilation in chronic rhino-sinusitis Secondary care Surgery for snoring Secondary care Functional endoscopic sinus surgery Secondary care Functional nasal airway surgery Primary Care or Secondary Care (ENT) Tonsillectomy Primary Care or Secondary Care (ENT) Grommet insertion /myringotomy (adults and children) Secondary Care Pinnaplasty Primary Care GYNAECOLOGY/ UROLOGY Female cosmetic genital surgery (labiaplasty) Primary Care Female sterilisation Primary Care or Secondary Care (Gynaecology) Circumcision Primary Care or Secondary Care Hydrocele surgery Secondary care Hysterectomy for menorrhagia Secondary Care Inguinal hernia (asymptomatic) Secondary Care Pelvic organ prolapse Secondary care Reversal of sterilisation/ vasectomy Primary Care Faecal microbiota transplant (outside of use in C.difficile) Secondary care Portsmouth and South Eastern Hampshire Page 4 of 72

5 Secondary Care Flow Chart Referral Received Is the referral for a procedure/ treatment? YES NO Is an approval code included with the referral? Patient seen and assessed YES NO Does the patient require a procedure? Continue to Treat Is the procedure/ treatment restricted IFR/ PLCP? YES NO NO YES Is the referral from Primary Care? Is the procedure/ treatment restricted IFR/ PLCP? Continue with treatment NO YES NO YES Should Primary care have applied for approval? YES Secondary Care Provider to apply for approval Secondary Care Provider to apply for approval Reject referral and return to referring clinician Portsmouth and South Eastern Hampshire Page 5 of 72

6 INDIVIDUAL FUNDING REQUESTS The procedures listed below are not routinely funded. Funding may be considered in exceptional circumstances, using the criteria listed below. All requests should be in writing using the IFR funding application forms available on NHS South, Central and West CSU s website then click Hampshire. They must include: a clear description of the patient s exceptional circumstances, including overriding clinical need and expected outcome copies of any relevant correspondence supporting documentation e.g. robust evidence of clinical and cost effectiveness, consultant and other specialist assessments The specialties listed below are a guide only and patients may be treated under different treatment function codes Plastic/ cosmetic procedures surgery Procedure Guidance notes The exclusion does not apply in the following circumstances and patients may be treated without prior approval CCGs do not fund the provision of plastic/ cosmetic procedures for cosmetic reasons Clinical photography is a useful adjunct to an application compared to a written description, although this cannot be insisted upon due to the sensitivity of such requests and patient consent. Photographs are stored securely and anonymously to ensure patient confidentiality and will be returned on request. Liposuction CCGs do not routinely fund this procedure N/A Facelift (Rhytidectomy/ Surgical removal of wrinkles)/ Brow lift and Submental lipectomy Buttock lift, thigh lift, upper arm lift (brachioplasty), abdominoplasty Breast and nipple procedures CCGs do not routinely fund this procedure CCGs do not routinely fund this procedure CCGs do not routinely fund this procedure N/A N/A Reconstructive procedures following cancer treatment may go ahead as part of established pathways and must take place within one year of Portsmouth and South Eastern Hampshire Page 6 of 72

7 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure Guidance notes The exclusion does not apply in the following circumstances and patients may be treated without prior approval the last cancer treatment Pinnaplasty/meatoplasty/ plastic operations on external ear CCGs do not routinely fund this procedure N/A Female cosmetic genital surgery (labiaplasty) CCGs do not routinely fund this procedure N/A Rhinoplasty/ reconstruction of nose CCGs do not routinely fund this procedure. N.B. Functional nasal airways surgery is referenced as a separate procedure Post-surgical reconstruction procedures may go ahead as part of the pathway following trauma and must take place within 12 months of the trauma occurrence. Dermatology/ general surgery Surgical removal of skin lesions. CCGs do not routinely fund this procedure. Referrals to secondary care for skin lesions should only be made where there is suspicion of malignancy. All other referrals for benign lesions including lipomas are not routinely funded. Removal should not be offered except via prior approval where there is Obstruction of an orifice or vision Functional limitation to movement or activity Moderate to large facial lesions causing disfigurement Significant symptoms such Where there is a valid suspicion of malignancy, e.g. the patient is referred using a two-week wait referral form for suspected cancer, or the patient s consultant upgrades the referral to reflect the suspected cancer Portsmouth and South Eastern Hampshire Page 7 of 72

8 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure Guidance notes The exclusion does not apply in the following circumstances and patients may be treated without prior approval as recurrent bleeding, infection or inflammation; marked itching or severe pain failing to respond to medical or conservative management Located in an area of recurrent trauma Applications in cases which are asymptomatic but considered severely disfiguring may be made with appropriate photography to demonstrate the level of disfigurement. Please include a summary of how the patients daily function is affected against the criteria listed above. Plastic surgery Laser removal of skin and excessive hirsutism CCGs do not routinely fund this procedure. N/A Laser surgery in recurrent pilonidal sinus CCGs do not routinely fund this procedure. In line with Priorities Committee policy statement 016 (Feb 2017) Appliances and devices for cosmetic purposes (high-grade silicon cosmesis and/or prosthesis) CCGs do not routinely fund these appliances or devices. N/A Portsmouth and South Eastern Hampshire Page 8 of 72

9 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure Guidance notes The exclusion does not apply in the following circumstances and patients may be treated without prior approval Ophthalmology Short sight/long sight corrective (laser) surgery (Refractive keratoplasty) CCGs do not routinely fund this procedure N/A Dermatology Surgical shaving/ laser treatment / chemical destruction of skin CCGs do not routinely fund this procedure. N/A Urology Reversal of sterilisation/ vasectomy CCGs do not routinely fund this procedure. N/A Gastrointestinal Faecal microbiota transplants CCGs do not routinely fund this procedure Use in refractory C-difficile is routinely commissioned ENT Adenoidectomy in children with upper respiratory tract infections In line with Priorities Committee policy statement Feb 2016 CCGs do not routinely fund this procedure in isolation When offered in combination with myringotomy (grommet insertion) and/or tonsillectomy which are subject to separate prior approval arrangements Surgery for snoring CCGs do not routinely fund this procedure N/A In line with Priorities Committee policy statement Feb 2016 Balloon catheter sinus dilation for chronic rhinosinusitis CCGs do not routinely fund this procedure In line with Priorities Committee policy statement 018 (Feb 2017) Orthopaedics Autologous blood injections in MSK conditions CCGs do not routinely fund this procedure In line with Priorities Committee policy statement 024 (Dec 2017) Portsmouth and South Eastern Hampshire Page 9 of 72

10 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure Guidance notes The exclusion does not apply in the following circumstances and patients may be treated without prior approval Patellar knee resurfacing as part of total knee replacement In line with SHIP Priorities Committee policy statement 015 stating that this is low priority to support resurfacing as part of a routine total knee replacement Alternative/ complementary/ homeopathic therapies Complementary therapies/medicine CCGs do not routinely fund this N/A Mental health In patient treatment for severe chronic Fatigue/ME CCGs do not routinely fund this. N/A Non-NHS residential placements CCGs do not routinely fund this N/A Adult ADHD CCGs do not routinely fund this. N/A Portsmouth and South Eastern Hampshire Page 10 of 72

11 PRIOR APPROVALS AND PROCEDURES The procedures and conditions listed below require prior approval before treatment can commence. The following CCGs will require approval for the procedures listed below before treatment can commence. Fareham & Gosport CCG South Eastern Hampshire CCG Portsmouth CCG North Hampshire CCG (all procedures with the exception of carpal tunnel, minor skin lesions, tonsillectomies and second eye cataract surgery) West Hampshire CCG (all procedures with the exception of carpal tunnel, minor skin lesions, tonsillectomies and second eye cataract surgery) Providers will not be paid for activity that has been carried out without evidence of prior approval. Prior approval codes are valid for 12 months from date of issue. Prior approval is requested via the referring clinician from the Commissioning Support Unit at All proforma and resources can be found at the CSU s website at (then click Hampshire ) If a request is authorised a prior approval code will be issued. For associate commissioners outside of this policy, approval should be sought from either the CCG in-house service or from the CSU representing that commissioner. Portsmouth and South Eastern Hampshire Page 11 of 72

12 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) ENT/ Audiology Myringotomy/ grommet insertion for children This procedure is not routinely funded. Prior approval may be considered under the following conditions: Children with disabilities such as Downs Syndrome and Cleft Palate where the insertion of grommets is part of an established pathway of care. Children to treat a tympanic membrane retraction pocket. Children aged over 3 years old with Otitis Media with Effusion (OME) and without a second disability (such as Downs Syndrome or Cleft Palate) when: o There has been a period of watchful waiting for three months in primary care from diagnosis of OME, followed by a further period of watchful waiting for up to three months in ; secondary care; and o OME persists after the three-six months of watchful waiting; and o The child has documented speech or language delay or behavioural problems; and o The child has a documented hearing level in the better ear of 25-30dBHL or worse averaged at 0.5, 1, 2 and 4kHz (or equivalent dba where dbhl not available) Children under 3 years of age Myringotomy/ grommet insertion for adults (>18) This procedure is not routinely funded. N/A Portsmouth and South Eastern Hampshire Page 12 of 72

13 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Tonsillectomy Prior approval may be considered under the following conditions: A middle ear effusion causing measured conductive hearing loss, persisting for 3 months and resistant to medical treatments. The patient must be experiencing disability ue to deafness. The possible option of a hearing aid may be discussed, at the discretion of the clinician. Persistent Eustachian tube dysfunction resulting in pain (3 month wait not required) As one possible treatment for Meniere s disease. Severe retraction of the tympanic membrane if the clinician feels this may be reversible and reversing it may help avoid erosion of the ossicular chain or the development of cholesteatoma (3 month wait not relevant) Grommet insertion as part of a procedure for the diagnosis or management of head and neck cancer and/or its complications NB It is important that conductive unilateral hearing loss present for 4 weeks should be referred to an ENT surgeon without delay This procedure is not routinely funded. Prior approval may be considered under the following conditions: in children and adults for cases of quinsy In children and adults for cancer where patient is coded with a cancer diagnosis directly related to the procedure Portsmouth and South Eastern Hampshire Page 13 of 72

14 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) requiring hospital admission; or in children and adults in a high risk category e.g. Down s syndrome, cerebral palsy, craniofacial disorders, chronic lung disease, sickle cell disease, neuro-muscular disorders, genetic or metabolic disease, central hyperventilation syndromes; or severe halitosis due to tonsillar debris following conservative management or in children and adults with diagnosed obstructive sleep apnoea where other treatments have failed or are inappropriate; or in children and adults for tonsillitis if all of the following criteria are met: o Sore throats are due to tonsillitis and o There are 5 or more episodes of sore throat per year and o There have been symptoms for at least a year and o Episodes of sore throat are disabling and preventing normal functioning Where there is a valid suspicion of malignancy, e.g. has been referred via the two-week wait referral form. Functional nasal airway surgery (which may include septorhinoplasty) GP referrals must include the practice record detailing frequency of reported episodes and prescribing in line with the criteria above. Providers should alert commissioners/csu where this is not being included. This procedure is not routinely funded. In line with Priorities Committee policy no.23 Septorhinoplasty may be considered by prior approval from secondary care if it is deemed the most effective intervention for the patients nasal Trauma (for acute admissions identified as emergency procedures recorded under admission method 21-28) Portsmouth and South Eastern Hampshire Page 14 of 72

15 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) obstruction. The request must explain the improvement in functional outcome that is expected This procedure may be considered under the following conditions: Obstruction of one or both nostrils; and Conservative measures withouth success for > 3 months; and Overuse of nasal sprays excluded as a cause of nasal congestion or ceased prior to referral and congestion persists Nasal surgery to alleviate snoring or as a treatment for patients unhappy with the outcomes of previous surgery but without the expectation of improving a significant functional deficit is considered low priority. Surgery to address the effects of facial trauma as part of the initial care pathway for that trauma and the care for relevant cancer treatments are excluded from this policy. Functional endoscopic sinus surgery in chronic rhino-sinusitis and/or nasal polyps This procedure is not routinely funded. In line with Priorities Committee policy statement 019 (Feb 2017) Functional endoscopic sinus surgery is recommended ONLY for patients with chronic rhinosinusitis and/or nasal polyps in whom the following criteria are met: The patient has had severe and persistent symptoms despite treatment for at least twelve months AND Where there is a valid suspicion of malignancy, e.g.has been referred via the two-week wait referral form. Portsmouth and South Eastern Hampshire Page 15 of 72

16 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Symptoms on optimal medical therapy have a significant impact on the patient s quality of life AND The following medical therapies have been tried with inadequate response or are contra-indicated Regular use of saline douching and nasal steroid AND For patients with nasal polys, attempts at medical polypectomy using prednisolone or a topical steroid AND/OR For patients with chronic rhinosinusitis, an oral antibiotic + douche + topical steroids Vascular Surgery Varicose vein procedures This procedure is not routinely funded. Prior approval may be considered under the following conditions: People with a body mass index less than 32 kg/m 2 who satisfy at least one of the following criteria: o A first venous ulcer persists despite a sixmonth trial of conservative management of the ulcer o A recurrent venous ulcer o Haemorrhage from a superficial varicosity Acute admissions identified as emergency procedures recorded under admission method Reference: SHIP Priorities Committee policy statement no then click Hamsphire Gynaecology Hysterectomy in heavy menstrual bleeding/ dysmennorhea This procedure is not routinely funded. Requests for hysterectomy for heavy menstrual Hysterectomy for uterine problems amenable to Portsmouth and South Eastern Hampshire Page 16 of 72

17 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Female sterilisation bleeding or dysmenorrhoea may be considered if all the following criteria are met: Other treatments for heavy menstrual bleeding (in accordance with NICE Clinical Guideline 44 Heavy Menstrual Bleeding ) or dysmenorrhoea such as a trial of a Mirena coil have failed or are medically contraindicated; An alternative first line treatment has failed including tranexamic acid, NSAIDs, combined oral contraceptives, oral progesterone Endometrial resection/ablation has failed to relieve symptoms, or is contraindicated e.g. fibroids >3cm, abnormal uterus; There is a wish for amenorrhoea; The woman no longer wishes to retain her uterus and fertility This procedure is not routinely funded. Prior approval may be considered under the following conditions surgery and not related to heavy menstrual bleeding or dysmenorrhoea will be funded and do not require prior approval. N/A Sterilisation will not be available on nonmedical grounds unless the woman has had at least 12 months' trial using Mirena or Implanon and found it unsuitable. Where sterilisation is to take place at the time of another procedure such as caesarean section. Where there is a clinical contraindication to the use of a Mirena/Implanon. Portsmouth and South Eastern Hampshire Page 17 of 72

18 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Where there is an absolute clinical contraindication to pregnancy. These are:- o young women (under 45 years of age) undergoing endometrial ablation for heavy periods o women with severe diabetes o women with severe heart disease Pelvic organ prolapse surgery Women should be informed that vasectomy carries a lower failure rate in terms of postprocedure pregnancies and that there is less risk related to the procedure. In line with Priorities Committee policy statement 29 Surgical management will be considered by prior approval in the context of the following pathway Patients with pelvic organ prolapse up to stage 3 with bowel or micturition problems, sexual dysfunction or bothersome symptoms causing significant functional impairment should initially be treated conservatively as follows Guided pelvic floor muscle training with or without insertion of pessaries should be used for at least 3 months before surgery is considered Patients to be fully informed of potential complicaitons and adverse effects of surgery and this should be documented Oestrogen supplementation should only be Stage 4 prolapses may automatically proceed to surgery Portsmouth and South Eastern Hampshire Page 18 of 72

19 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) considered for co-existing menopausal symptoms Urology Male circumcision This procedure is not routinely funded. Prior approval may be considered under the following conditions: Patients coded with a cancer diagnosis directly related to the procedure Suspected cancer Balanitis xerotica obliterans (BXO) Congenital urological abnormality where skin grafting is required Interference with normal sexual activity Phimosis interfering with urine flow and/or recurrent urinary tract infections Recurrent paraphimosis Symptomatic or minor hypospadias Recurrent balanophosphitis resistant to antibiotics Circumcision during or after surgery for correction of penile curvature Where there is a valid suspicion of malignancy, e.g. has been referred via the two-week wait referral form Hydrocele surgery Where appropriate conservative measures e.g. topical steroids for six weeks should have been exhausted first. Paraphimosis is not a routine indication for circumcision In line with Priorities Committee policy statement 26 Prior approval will be considered under the following conditions Interventions in children should be delayed Cases of testicular torsion are a surgical emergency and should proceed directly Portsmouth and South Eastern Hampshire Page 19 of 72

20 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) until at least 2 years of age Surgical treatment should only be offered where there is significant discomfort preventing voiding, sexual function, mobility or dressing Ultrasound may be of value in initial assessment where there is diagnostic uncertainty but should not be repeated Pain management Interventional Injections for non specific spinal back/neck pain with or without radiculopathy (sciatica/brachialgia). This refers to: soft tissue/trigger point; spinal/epidural injections; facet joint and medial branch blocks; radio-frequency lesioning & denervation (NICE Guidance Nov 2016 & National Pathway of Care for Low Back and Radicular Pain 2014) Referenced Priorities Committee policy statement 020 (Feb 2017) In line with NICE Guidance [NG59], injections of therapeutic substances into the back or neck for non-specific pain will not be routinely funded and should not be routinely offered. This includes soft tissue, trigger point, facet joint and sacroiliac injections. All interventional treatments should only be offered in the context of a comprehensive multidisciplinary programme of care (MSK or Pain Management) with arrangements for ongoing assessment and following a trial of conservative treatment that shows limited evidence of response. Epidural/ transforaminal and nerve root blocks may proceed in the management of acute and severe sciatica (radiculopathy):- with the aim of avoiding surgery and do not require prior approval in this context Epidural Injections (either sacral/caudal, foraminal/root or inter-laminar) are not considered of value for patients with non-specific low back pain or on a repeat basis and will not be routinely funded. Portsmouth and South Eastern Hampshire Page 20 of 72

21 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Medial branch blockade/ facet joint injection Prior approval is required for the following interventions where the pain is considered to be arising from the structures supplied by the medial branch nerve. Medial branch blockade/ facet joint injection will only be funded As a diagnostic intervention to improve the specificity of radio-frequency lesioning where this is being considered and where all the following criteria are met:- o Failed conservative treatment including maximal oral and topical analgesia o Moderate or severe levels of pain (5 or more on visual analogue scale at time of referral) o The patient has been assessed by a clinician trained in the management, diagnosis and management of chronic pain who considers it would enable mobilisation and participation in rehabilitation o There is documented use of a standardised Pain and Quality of Life tool before and after the procedure Radiofrequency denervation will only be funded: Following a trial of treatment (medial branch block/ facet joint injection) demonstrating evidence of response >50% improvement in pain using a validated scoring tool. AND Subject to submission of patient outcome data to the National Spinal Portsmouth and South Eastern Hampshire Page 21 of 72

22 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Radiofrequency Registry Repeat denervation procedures may only be offered following a previous successful response (as above) with benefits lasting > 15 months. This should only be permitted with a minimum interval of 16 months. Interventional Surgery for non specific spinal back/neck pain with or without radiculopathy (sciatica/brachialgia). Refers to: spinal decompression, fusion & disc replacement. (NICE Guidance Nov 2016 & National Pathway of Care for Low Back and Radicular Pain 2014) Spinal Decompression will be funded for people with sciatica when non-surgical treatment has failed to improve pain or function and radiological findings are consistent with spinal or nerve root compression. This will not require prior approval Spinal Fusion will not be funded and should not be offered for people with back pain unless as part of a randomised controlled trial. It may be carried out as a component part of another definitive spinal operation such as to correct deformity, remove tumours, treat spinal fractures or as part of a primary spinal decompression as outlined above. Spinal Disc Replacement will not be funded as a treatment for low back pain. Orthopaedics/ MSK Trigger finger surgery These procedures are not routinely funded. Prior approval may be considered under the following conditions for patients diagnosed with trigger finger: who fail to respond to conservative treatment, including no response from up to two corticosteroid injections; and moderate to severe pain/locking sufficient to cause interference with hand function; and N/A Portsmouth and South Eastern Hampshire Page 22 of 72

23 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) persistent symptoms > 3 months Carpal tunnel release/ nerve entrapment at wrist These procedures are not routinely funded. In line with Priorities Committee policy statement 22 N/A Orthopaedics/ MSK Prior approval may be considered under the following conditions: In moderate symptoms i.e pins and needles in the day with occasional night symptoms (2-3 nights/ week) All conservative measures (e.g. wrist splint and a corticosteroid injection into the carpal tunnel) have failed; and There have been symptoms for longer than 6 months In severe symptoms Evidence of neurological deficit such as frequent pins and needles, numbness and permanent pain during the day, functional loss with muscle wastage and frequent nocturnal symptoms Palmar fasciectomy /Dupuytren s contracture These procedures are not routinely funded. Prior approval may be considered under the following conditions: Patient has a fixed flexion in one or more joints exceeding 25 or Patients under 45 years of age with 2 or more affected digits and fixed flexion exceeding 10 and There is functional impairment which may N/A Portsmouth and South Eastern Hampshire Page 23 of 72

24 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Treatment of bunions (hallux valgus) include safety concerns Procedures related to the treatment of this condition are not routinely funded. N/A Orthopaedics/ MSK Prior approval may be considered under the following conditions: Have been managed via MSK or podiatry services first before consideration of orthopaedic surgery and Has documented functional impairment and Inability to wear suitable footwear and Patient is fully aware of pros and cons of surgery having used patient decision aids Arthroscopic lavage and debridement with or without meniscectomy of the knee in patients over 40 with non-traumatic and persistent knee pain These procedures are not routinely funded. Prior approval may be considered under the following condition: Cases of acute traumatic knee pain will not require prior approval Where the patient has a clear history of mechanical locking. Hip resurfacing Reference SHIP Priorities Committee policy statement 010 April then click Hampshire These procedures are not routinely funded. Prior approval may be considered under the following conditions: N/A Portsmouth and South Eastern Hampshire Page 24 of 72

25 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) As an alternative to hip replacement in men younger than 55 years of age provided the risks and benefits have been explained and the patient is keen to proceed Orthopaedics/ MSK Primary hip and knee replacement in patients with a BMI above 35 Reference SHIP Policy Recommendation 105 on Metal on Metal (MOM) hip resurfacing then click Hampshire These procedures are not routinely funded for patients with a BMI above 35. Prior approval may be considered under the following conditions: In patients whose pain is so severe and/or mobility compromised that they are at risk of losing their independence and that joint replacement would relieve this risk In patients whose destruction of the joint is of a severity that delaying surgery would increase the technical difficulty of the procedure Trauma (for acute admissions identified as emergency procedures recorded under admission method 21-28) Referral should also have been made to the commissioned tier 3 obesity management programme prior to offering surgery. Arthroscopic hip surgery in impingement In line with SHIP Priorities Committee policy statement 006 Nov 2015 Portsmouth and South Eastern Hampshire Page 25 of 72

26 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Arthroscopic femero-acetabular surgery for hip impingement should be considered as a second line treatment option for patients who are symptomatic, have significant impaired activities of daily living and have undergone activity modification as part of conservative treatment. Patients with evidence of osteoarthritis in the hip joint are not suitable for arthroscopic hip impingement surgery. All arthroscopic surgery for hip impingement procedure data should be submitted to the registry set up by the British Hip Society Registry (in line with NICE guidance). Subacromial decompression of shoulder In line with SHIP Priorities Committee policy statement 014 Open subacromial decompression is not routinely funded Prior approval is required for arthroscopic subacromial decompression if all the following criteria are fulfilled Symptoms for at least 6 months Symptoms are intrusive and debilitating (e.g. waking at night, pain when putting on a coat) Patient complaint with physiotherapy intervention for at least 6 weeks There has been a positive response to a Emergency procedures recorded under admission method Portsmouth and South Eastern Hampshire Page 26 of 72

27 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) steroid injection Ophthalmology All eyelid surgery including blepharoplasty and chalazia These procedures are not routinely funded. Blepharoplasty The procedure is subject to Prior Approval and may be funded if the following conditions apply: Patient complains of interference with vision or visual field related activities such as difficulty reading or driving due to upper eye lid skin drooping, looking through the eyelids or seeing the upper eye lid skin and There is redundant skin overhanging the upper eye lid margin and resting on the eyelashes when gazing straight ahead and A visual field test by the hospital shows that eyelids impinge on visual fields reducing field to either 120 laterally and or by 40 vertically in the relaxed, non-compensated state. Fields should be assessed with the lid in its normal position and again with the lid taped up in order to demonstrate that it is the droopy lid causing the field defect. All applications should be submitted with a copy of the 120 point Humphrey screening test results. Exemptions - Upper eyelid blepharoplasty is considered medically necessary for the following indications: To repair defects predisposing to corneal or conjunctival irritation such as entropion or pseudotrichiasis. To treat periorbital sequelae of thyroid disease, nerve palsy, blepharochalasis, floppy eyelid syndrome and chronic inflammatory skin conditions To relieve symptoms of blepharospasm or significant dermatitis on the upper eyelid caused by redundant tissue. Children with Ptosis should continue to be referred as normal as the condition may cause Amblyopia. Also any rapid onset Ptosis in adults and children Portsmouth and South Eastern Hampshire Page 27 of 72

28 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Eyelid Dermatochalasis The surgical treatment of Eyelid Dermatochalasis is subject to Prior Approval and may only be funded if the patient has objective demonstration of visual field restriction within 20 degrees of fixation on visual field testing Eyelid ectropion The surgical treatment of Eyelid Ectropion is subject to Prior Approval and may only be funded if the following criteria can be met: Vision is impeded or There is exposure of the cornea (e.g. in paralytic Ectropion) and risk of keratopathy (urgent correction required). Eyelid Ptosis The surgical treatment of Eyelid Ptosis is subject to Prior Approval and will only be funded if the following criteria can be met: Patient has objective demonstration of visual field restriction within 20 degrees of fixation on visual field testing and/or There is abnormal compensatory head posture and/or There are symptoms related to ptosis e.g. headache, neck ache, back pain. Please confirm the nature of the symptoms when where there is a suspicion of a neurological problem such as Horner s Syndrome should not wait for a visual field test. Eyelid entropion procedures Patients coded with a cancer diagnosis Where there is a valid suspicion of malignancy, e.g. has been referred via the two-week wait referral form Portsmouth and South Eastern Hampshire Page 28 of 72

29 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) requesting Prior Approval. Chalazia (Meibomian cysts) These procedures are not routinely funded Prior approval will be considered under the following conditions The chalazia has been present for more than 6 months Where it is situated subcutaneously in the upper or lower eyelid Where it is causing impairment of vision Ophthalmology Second eye cataract surgery These procedures are not routinely funded. N/A Prior approval will be considered under one of the following conditions: Best corrected visual acuity worse than 6/9 in the second eye for drivers (6/12 or worse for non-drivers) Best corrected binocular visual acuity of 6/18 or worse irrespective of the visual acuity of the first eye Anisometropia +/- 2D or where symptomatic Surgery indicated for control of glaucoma or to facilitate further surgery (as determined by consultant ophthalmologist) Surgery indicated for view of diabetic retinopathy or retinal disease (where cataract impairs retinal view) Portsmouth and South Eastern Hampshire Page 29 of 72

30 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) Severe glare Patient wishes to/is required to drive and does not meet DVLA sight test requirements The cataract is preventing the management of other co-morbid eye conditions Where visual acuity is a criterion, the referring clinician should demonstrate the level via Snellen test score. General/ Plastic surgery Excision of skin following massive weight loss These procedures are not routinely funded. Removal of excess skin including abdominoplasty, mammoplasty and removal of skin folds from the inner thighs following significant weight loss may be considered under all the following conditions: N/A The patient s starting BMI before weight loss must have been no less than 45kg/m 2 (the threshold for access to bariatric surgery in HIOW) The patient s BMI must be less than 30kg/m 2. (In some patients a BMI of less than 30kg/m 2 may not be achievable, due the weight of excess skin. In these circumstances an exception to the policy may be considered, provided that the patient has lost at least 50% of their excess weight, and their clinician confirms that no further reduction in BMI will be possible without removal of excess skin) The patient s weight must have been stable for Portsmouth and South Eastern Hampshire Page 30 of 72

31 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) a minimum of 2 years There must be documented evidence of clinical pathology or disability due to the skin fold in question (e.g. recurrent infection, intertrigo, cellulites, restricted mobility, or inability to undertake physical exercise to maintain cardiovascular fitness). Purely cosmetic procedures, such as removal of surplus skin from the arms, will not be funded Treatment of chronic anal fissure in adults In line with Priorities Committee statement 25 (Dec 2017) The majority of cases will be treated in primary care and advice regarding diet and avoidance of constipation is imperative. Surgery (lateral sphincterotomy) will be considered via prior approval when the following pathway has been followed First line pharmacological therapy with GTN (glyceryl trinitrate) rectal ointment Diltiazem where GTN is not tolerated but after education on proper application of extremely small amounts Medical therapies have been tried for at least a month Injection of botulinum toxin restricted to Portsmouth and South Eastern Hampshire Page 31 of 72

32 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) one injection offered to women and anally receptive men All the above options have failed Gastroenterology Gastric fundoplication for chronic reflux oesophagitis These procedures are not routinely funded Prior approval may be considered under the following conditions: Regular, significant symptoms of gastrooesophageal reflux despite receiving at least one year of continuous pharmacological treatment up to the maximum dose licensed for reflux oesophagitis Significant volume reflux placing them at risk of aspiration Anaemia because of oesophagitis Reference: South Central Priorities Committees policy statement no 51. For all other indications, treatment is funded Infertility treatments In vitro fertilisation (including the prescriptions of infertility drugs) and ICSI (intracytoplasmic sperm injection) This treatment is not routinely funded. Prior approval may be considered in line with the SHIP Priorities Committee policy statement September 2014 where endorsed by the CCG then N/A Portsmouth and South Eastern Hampshire Page 32 of 72

33 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) click Hampshire General surgery/ hand surgery/ Treatment of asymptomatic inguinal hernias These procedures are not routinely funded. Prior approval may be considered where all the following conditions are met: History of incarceration of or real difficulty in reducing the hernia An inguinal-scrotal hernia An increase in size Pain or discomfort significantly interfering with activities of daily living directly related to the hernia N/A Treatment of ganglions These procedures are not routinely funded. N/A Prior approval may be considered where one of the following conditions are met: The ganglion is the likely cause of persistent pain, either through local effects or likely pressure on a nerve The ganglion is the cause of reduced function, perhaps through loss of range of movement or pain There is a sudden increase in size raising suspicion of an alternative diagnosis Endocrinology Flash libre glucose monitoring in diabetes In line with Priorities Committee statement 28 (Jan 2018) Flash glucose monitoring systems such as the Freestyle Libre may be recommended in patients with Type 1 diabetes or those with Type 1 or 2 diabetes who are pregnant and who fulfil one or Portsmouth and South Eastern Hampshire Page 33 of 72

34 The specialties listed below are a guide only and patients may be treated under different treatment function codes Procedure/Condition Comments/ guidance for prior approval Exclusion (may be treated without prior approval) more of the criteria below: Patients who are clinically required to undertake intensive monitoring with 8 or more finger prick blood tests daily. Those who meet the current NICE criteria for insulin pump therapy (HbA1c >69.4mmol/mol) or disabling hypoglycaemia as described in NICE TA151 where a successful trial of flash glucose monitoring may avoid the need for pump therapy Those who have recently developed impaired awareness of hypoglycaemia, when it may be used as an initial tool in its management with a review at 6 months. Frequent (>2 per year) hospital admissions with diabetic keto-acidosis or hypoglycaemia where other management plans have failed. Those requiring third parties to carry out monitoring or where conventional blood testing is not possible. This method of monitoring must not to be initiated in a primary care setting and should only be initiated or recommended by the consultant-led service Liothyronine in hypothyroidism In line with Priorities Committee statement 27 (Jan 2018) Treatment with liothyronine should not be initiated in primary care Hypothyroidism should be treated first line Portsmouth and South Eastern Hampshire Page 34 of 72