Policy for Procedures of Limited Clinical Benefit (including low priority treatments)

Transcription

1 APPENDIX 1 Policy for Procedures of Limited Clinical Benefit (including low priority treatments) Please read in conjunction with the Policy for Individual Funding for Treatments outside Commissioned Services (2012) Kernow Clinical Commissioning Group. Distribution list All GP practices Kernow Clinical Commissioning Group Acute Hospitals NHS Trust Chief Executive (Plymouth & Cornwall) Commissioning Managers for distribution to all commissioned NHS Providers A copy of this policy is also available on the website. Version: Final.ammend.KCCG Approved by: PEC/Clinical Commissioning Forum Date Approved: 5 April 2011 Review date: April

2 The Policy In order to ensure that good quality services are available to those patients with the greatest need, it is necessary to restrict the funding of procedures which have limited or no clinical benefit. These procedures may also be referred to as low priority treatments. This policy replaces the Low Priority Treatment Policy. This policy includes: - all treatment for cosmetic/aesthetic reasons in any specialty - applies to all patients, including trans-gender patients - applies to patients of all ages, including children. This policy excludes patients with suspected or diagnosed cancer NHS FUNDING WILL NOT BE PROVIDED FOR THE REVERSAL OF STERILISATION IN MALES OR FEMALES. NHS FUNDING WILL NOT BE PROVIDED FOR ANY TREATMENT REQUESTED FOR COSMETIC OR OTHER NON CLINICAL REASONS. Policy Context Primary and secondary care providers (including Independent Sector providers) should be in line with the Policy (where appropriate) Any referrals not in line with this policy should be returned to the GP with an explanatory letter. Where GPs consider necessary, individual requests not in line with the policy may be referred to the Individual Funding Request Panels. In these circumstances an Exceptional Clinical Need will be need to be demonstrated. Implementation of the policy in Primary Care is a pre-requisite to avoid inappropriate referrals with such unintended consequences as: Raising patient expectations Relying on secondary care clinicians to turn back referrals and act as gate-keepers KCCG will not pay for activity undertaken outside the policy unless there is approval through the individual funding request process or evidence of compliance as outlined within local policies. EXCEPTIONALITY Commissioning, by its very nature, focuses on the high level. However, it is recognised that every patient is an individual and that there may be particular circumstances which give grounds for funding treatment in an individual case contrary to the decision not to fund in general. In making a case for special consideration it needs to be demonstrated that: the patient is significantly different to the general population of patients with the condition in question; and the patient is likely to gain significantly more health benefit from the intervention than might be normally expected for patients with that condition. The fact that a treatment is likely to be effective for a patient is not in itself, a basis for exceptionality. 2

3 INFORMATION TO BE INCLUDED IN REQUESTS FOR FUNDING BMI The BMI and other co-morbidities for some patients will be a key consideration when making clinical decisions. Reducing the BMI in some cases may resolve the problem encountered by the patient. In addition the risks associated with surgery are known to be significantly higher in those patients with a BMI over 30. PHOTOGRAPHS Photographs have considerably assisted the Panel in helping to determine exceptionality, which may not necessarily be evident from written correspondence. If it is felt appropriate, photographs should be submitted to support applications for funding for procedures. Where possible the face should be excluded from the photograph. The photograph should be taking in a standing position, neck to hip with the arms held naturally to the side of the body. Front and side views are required for breast surgery. n the absence of a photograph a clear description of the extent of the problem will be required, including measurements. MEASUREMENTS* Requests for funding in relation to breast asymmetry correction, breast augmentation and breast reduction will require an assessment of breast size in relation to the frame. Information should also include the patient s bra size. For breast asymmetry, the disparity between the breasts will also need to be demonstrated and a clavicle to nipple distance measurement is helpful in these cases. Waist and hip measurements are also required. OTHER INFORMATION In cases where the patient is suffering from significant or persistent pain please include details of this and any medication that is being prescribed for the condition. Where the patient is under the on-going care of any psychology/psychiatric services an up-to-date report can also be submitted. However, referrals to these services should no longer be made specifically in order to support the request for funding, unless it is appropriate for the patient to receive on-going care from these services. Please include any other relevant information, including any specialist/consultant reports available where these have been obtained prior to the request for funding being made. PROCESS Each policy or position statement indicates whether the procedure is routinely funded or whether it is restricted with specified criteria. o Prior Notification Where stated, if the patient meets the criteria set out within the policy a prior notification form (attached to each policy) should be completed and sent to the address below. o Individual Funding Requests Process If the procedure is not routinely funded, a referral to secondary care services should not be made before approval is given by the Individual Funding Request Panel. 3

4 The panel, consisting of clinicians, a non executive/lay-person and a commissioning manager meet on a regular basis. For further information please refer to Policy for Individual Funding Requests outside Commissioned Services and to obtain the relevant application form please go to or contact the officer at the address below. All applications should be made in writing by the relevant clinician, in most cases this will be the patients GP as they are able to demonstrate more clearly the impact of the patient s condition on their day to day life. In some circumstances it may be relevant for another clinician to submit an application for funding approval. The panel is unable to accept requests for funding directly from the patient. Following the panel meeting, the decision will be conveyed to the requesting clinician. It is the responsibility of the requesting clinician to convey the decision of the panel to the patient in a timely manner. The patient should not be directed to the panel as it is not able to pass this information to the patient. Should a negative decision be reached, details of the Appeals and Complaints process will also be provided. Applications for consideration for funding approval should be sent to: Individual Funding Requests Office NHS Kernow Sedgemoor Centre Priory Road St Austell Cornwall PL25 5AS KCCG.IFRequests@nhs.net 4

5 Procedure Abdominoplasty/ Apronectomy (Tummy Tuck) Artificial Urinary Sphincters for post prostatectomy Assisted Conception Blepharoplasty (eyelid surgery) or Brow Lift for hooded eyelids / excess skin folds of the eyes / bulging fat pads Botox injections for Hyperhydrosis (excessive sweating) or aging skin on any OPCS code Commissioning Position Approval by S021, S022,S028, S029 M5520 C131,C132, C133, C134 C138, C139 C161, C162 C163 C164, C165 C168 See policy for Artificial Urinary Sphincters for Post-Prostatectomy Incontinence See policy for Assisted Conception Not commissioned for cosmetic reasons. See policy for Blepharoplasty To if To if To if S532 part of the body or face Breast Asymmetry Correction no code Breast Augmentation (breast implants) B312 Breast Reduction B311 Breast Prosthesis (implant) removal and replacement B303, B308, B309, B302, B314 Brow lift S014 See policy for Blepharoplasty Buttock, Arm or Thigh lift S031, S032, S033, S038, S039 Circumcision N303 See policy for Circumcision : Photographs are requested * Measurements* : Photographs are requested* Measurements* : Measurements* Photographs and a list of medication are requested To if

6 Dermabrasion of skin S091, S092, S093, S098, S099, S103, S113 Face lift S011, S012, S013, S015, S016 Gynaecomastia Surgery B311 (same as breast) (removal of male excess breast tissue) Hair Graft for Male Pattern Baldness Hallux Vagus (Bunions) surgical procedures S331, S332, S333, S338, S339 See policy for Hallux Valgus : All applications should include photographs and measurements* Please note: Only those patients with a BMI of 25 or below, and post puberty will be considered To if Referral to secondary care for homeopathy treatment Inverted nipple correction B356 Laser hair removal S606 Exclusions include recurrent pilonidal sinus and post hair bearing flap reconstructions Labiaplasty (reshaping of the P055, P056, P057 labia) Laser surgery for myopia C461 (shortsight) Laser treatment for post acne S601, S602, S069. S103, scarring S113 Liposuction (removal of excess S621, S622, S623, S628 fat tissue) Mastopexy (breast lift) B313 Myringotomy with and without Criteria Based Access grommet insertion See policy for Myringotomy D151,D158,D159, D202, D203,D208,D209, D288,D289 6

7 Orthodontics for adults F141, F142 F143, F144, F145, F148, F149, F151, F154, F155, F152, F153, F156, F157, F158, F159 Penile Prosthesis N291, N292, N298, N299 See policy for Penile Prosthesis Pinnaplasty (correction of bat D033,D031, D032,D038, Not routinely commissioned ears) D039 Removal of benign neoplasms (non cancerous lumps and bumps) surgically or by laser in primary and secondary care (including moles, naevi, cysts, seborrhoeic keratosis, lipomata, skin tags, warts, thread veins, telangiectasia, sebaceous cysts, xanthelasma, verrucas S041, S042, S043, S048, S049. S051, S052, S053. S054, S055, S058. S059 S061, S062, S063 S064 S065 S068 S069 S101 S102 S103 S104 S108 S109 S111 S112 S113 S114 S118 S119 T591 T592 T593 T594 T598 T599 T601 T602 T603 T604 T608 T609 See policy for benign skin lesions (removal of). Exclusions include: - All suspected melanoma and squamous cell cancers should be referred via the suspected cancer two week system - Diagnostic uncertainty eg suspected basal cell carcinoma Removal of Wrist Ganglion T59,60 See policy for Wrist Ganglia (removal of) : Examples of possible exceptions subject to CCG approval: Significant functional impairment Significant dental health problem : All applications should include presence or absence of antihelical fold and degree of projection (>2cm) To if To if Rhinoplasty (nose reshaping) E023, E024, E025, E026 Surgery or Shave Rhinophyma E094 Scar revision S604, Y064 Examples of possible exceptions subject to CCG approval : Facial disfigurement. Severe burns scarring. *Photographs are requested Split earlobe repair D062 Tattoo removal S603 Tonsillectomy F341,F342,F343, F344,F345,F346, See policy for Tonsillectomy Criteria Based Access 7

8 F347,F348 F349 Varicose veins procedures L841, L842, L843, L844, L845, L846, L848, L849, L851, L852, L853, L858, L859, L862, L868, L869, L871, L872, L873, L874, L875, L876, L877, L878, L879, L881, L882, L883, L889, L382, L918, L919, L932 See policy for Varicose Vein Procedures To if 8

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