clin 6 treatments not routinely funded policyv2 (2)[1]
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NAME OF DOCUMENT:
Treatments not Routinely Funded Policy
KEYWORD DESCRIPTOR:
POLICY NUMBER: CLIN 6
DATE OF ISSUE: April 2008
REVIEW DATE: April 2010
APPROVAL BODY: PCT Board
INITIATING OFFICER: Public Health Directorate
VERSION two
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Version Control Sheet
Version Date Author Status Comment
1 April 08 Public Health Final Agreed at PEC and PCT Board
2 Oct 08 Final Minor amendments to applicationform agreed at PEC 8/10/2008.Also minor amendments to thewording in relation to High CostDrugs in the sections on Scope ofPolicy, Remit of Exceptions Paneland contact details. Also revision ofmembership of High Cost DrugsPanel.
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CONTENTS
Title Page
Background 3
Rationale 3
Scope of the policy 3
Guiding principles 3
Exceptional circumstances 4
Authorisation 4
Appeals Process 5
South East Coast Health Priorities Support Unit 5
Process for Review of Policy 5
How to Use This Document 5
Application Form for Funding 6-7
Quick Look- Up Guide to Treatments/Procedures Not Routinely Funded 8-12
Appendices
Appendix I Guidance for Clinicians 13
List of Treatments/Procedures Not Routinely Funded
Section A Breast procedures 13
Section B Facial procedure 15
Section C Body contouring procedures 17
Section D Skin and subcutaneous lesions 18
Section E Urology and Gynaecology 21
Section F Ophthalmology 22
Section G ENT Procedures 23
Section H Varicose veins 27
Section I Other procedures 28
Section J Dental procedures 29
Appendix II The Varicose Vein Prioritisation Protocol 30
Appendix III Process for Treatments not Routinely Funded bySurrey PCT
32
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Background
Surrey Primary Care Trust has developed a list of treatments that will not beroutinely commissioned.
When a General Practitioners (GPs) or Consultants in provider trusts wishes torefer a patient for a treatment listed in this policy as an exceptional case thenthey must apply using the application form (see page 6).
Rationale
Surrey PCT must ensure that the resources they invest in commissioned servicesachieve the best possible health benefit for the population.
This requires careful prioritisation of investments so that the PCTs commissioningbudget is focused as far as possible on treatments and interventions which:
Are proven to be clinically effective
Provide a demonstrable health benefit
Are cost effective
Fit with other PCT policies and priorities
Have a sound ethical base
For these reasons there are certain treatments/conditions that are not routinelyfunded
Scope of the Policy
This policy covers those treatments/procedures not normally funded by thePCT.
A separate policy for the management of high cost drugs and mental health hasbeen developed by the PCT.
Guiding Principles
The PCT will consider issues of appropriateness, effectiveness and prioritywhen commissioning services.
The PCT seeks to make appropriate use of resources. In considering whethera service is appropriate, the PCTs may take account of:
The extent to which a problem in question is an illness, disease, injury orimpairment
Whether the proposed treatment represents the correct clinical strategyto address the problem
Whether the treatment to address the problem can and should be thesubject ofNHS funding
The PCT also seek to use their resources on health care that is effective. Inconsidering whether a service is appropriate, the PCTs may take account of:
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the probability and magnitude of the expected benefit from treatment;
the probability and magnitude of side effects and complications oftreatment;
the extent to which evidence of benefits, complications and side effects isscientifically and academically robust;
the extent to which there is a plausible biological basis for the benefit;
the extent to which the service is supported or otherwise by a substantialbody of expert clinical opinion
the extent to which the patient is committed to achieving the goals of thetreatment
The PCT also seeks to use its resources to address the highest priorities.Decisions by PCTs about priority are not taken in isolation, but are taken aftercomparing the costs, benefits and effectiveness of different investment options.In considering priority of services, the PCT may consider:
the net expected benefit of treatment
the nature of that treatment
the cost of the treatment
National guidance e.g. National Institute for Health and ClinicalExcellence (NICE) Guidance or National Service Frameworks
the economic threshold (e.g., cost per Quality Adjusted Life Year (QALY))used by authoritative bodies (e.g., NICE) in advising health service aboutthe use of its resources
the extent to which services are routinely commissioned by other PCT
the effect that the service will have on other services
other policies and strategies of the PCT
The list is not exhaustive. If a procedure is requested that is not identified withinthis policy, it will be considered individually following these principles. Theremay be a delay in reaching a decision when there is a need to access robustevidence of effectiveness. Such a procedure may not be funded.
Exceptional Circumstance
This policy requires each request for treatment to be considered on its individualmerits. It accepts the possibility of a case being exceptional where there may bean overriding clinical need.
Definition of exceptions: noun. A person or thing that is excepted or that doesnot follow a rule.
Definition of exceptional: adjective. Unusual or special.
General guidelines:
1 Potentially exceptional circumstances may be considered by the patientsPCT where there is evidence of significant health status impairment andinability to perform activities of daily living.
2 By definition, exceptional may not necessarily be spelt out in advance.3 The fact that a patients clinical picture matches accepted indications for
a treatment which is not normally provided is not, in itself, exceptional.
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4 The fact that a treatment is (or is likely to be) efficacious for a particularpatient is not, in itself, exceptional.
5 Consideration will be given to evidence that shows that the benefit fromthe treatment for a particular patient would be significantly greater thanwould be expected for an average patient.
6 It is for the requesting clinician (or the patient) to demonstrate why they
should be considered an exception.7 Psychological distress alone is not accepted as grounds for automatic
exception for any procedure.
Authorisation
Surrey Primary Care Trust will not fund any of the procedures within the policyunless prior written authorisation is obtained from the PCT.
Authorisation may be given for either an outpatient consultation only, in which
case further authorisation will be necessary prior to any proposed procedure, orfor the outpatient consultation plus subsequent procedure. This will depend onthe quality and specificity of information received by the PCT for consideration.Where investigations have been carried out locally we expect these to be madeavailable and used where appropriate, rather then repeated due to lack ofaccess to previous test results.
A separate document Surrey PCT Exceptions Panel Policy and Processsetsout the PCTs process for decision making.
Appeals Process
An appeal can be requested by the applicant or patient in writing. Please seeProcess for Treatments not routinely Funded by Surrey PCT in Appendix III
South East Coast Health Priorities Support Unit
This unit has establishes a Policy Review and Recommendation Process (PRRP)throughout the Strategic Health Authority area, and is designed to achieve evidence-based co-ordinated policies underpinned by sound principles and reached by a processwhich is rigorous, defensible and open to scrutiny.
Process for Review of Policy
This policy will be reviewed on an annual basis to coincide with the development ofSLAs. The review will include:
an audit of the previous years requests a review of the current list of treatments not normally funded a review of the evidence for new treatments consultation with clinicians in local partner organisations a workshop event with panel members and partner organisations to review the process
Following the review an updated policy will be circulated to all partner organisations andGP practices. A final draft of the policy will be placed on the Surrey PCT website for easeof access in line with our commitment to open and transparent communication and
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service delivery.
How to use this document
Step 1 Use the Quick Look Up in this document to identify the relevant
procedure/treatment
Step 2 Check the page number of the appendix section indicated for furtherdetail/clarification
Step 3 Where the clinician feels criteria are met, or exceptional circumstancesare present, complete the Application Form for Funding from Surrey PCTExceptions Panel(see page 6 )
Step 4 Submit the application form to the relevant contact listed at the foot of this
page.
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1. Patients Diagnosis(for which intervention is being requested)
2. Details of Intervention(for which funding is being requested)
3. Is intervention part of an ongoingtrial?
4. What treatment is the patientcurrently receiving for this condition?
5. Why do you think this patient shouldbe an exception to the treatments notroutinely funded policy?
Please outline the individual circumstancewhich you think justifies making this casean exception.
BMI must be included for all applications for breast surgery, surgery for gynaecomastia, body contouring
procedures and bariatric surgery.
APPLICATION FOR FUNDING FOR TREATMENTS NOT ROUTINELY FUNDED
This form is to be completed by the Consultant/General Practitioner when applying for
funding for clinical procedures. Please supply as much detail as possible.
PLEASE DO NOT INCLUDE THE PATIENTS NAME ON THIS FORM
Patients Date of Birth
NHS Number
BMI/Height/Weight
Consultant/GP Name/GP Practice Name
Intervention requestedCost
Provider requested
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6. What other treatments has the patienthad for the condition in the past?
7. How successful were they?
8. What are the goals and expectedoutcome from the intervention?(e.g. quality of life, life expectancy)
9. If funding can not be approved whatis the possible alternative outcome?
10. Please provide any otherinformation you think may be relevantin this case.
Photographic evidence is required tosupport applications for all external
procedures (i.e. breast surgery, facialprocedures, body contouringprocedures, skin lesions, and varicoseveins).
Signature: .Consultant/GP Name: ... (Please Print)
Please return this form toAcute Contracting Team,Surrey PCTPascal PlaceRandalls Research ParkRandalls WayLeatherheadSurreySave Haven Fax: 01372 202 690
GP Practice Stamp
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QUICK LOOK UP GUIDETHE FOLLOWING TREATMENTS ARE NOT ROUTINELY FUNDED BY SURREY PCT
OPCS code(s)Treatment/procedure
COSMETIC/PLASTIC SURGERY
The PCT does not fund treatment where the primary or principais cosmetic, i.e. to improve appearance.
Reconstruction following surgery for non-aesthetic reasons (egmajor trauma) is not affected by this policy.BREAST SURGERY
B311 Female breast reduction (reduction mammoplasty) B311 Male breast reduction for gynaecomastia
B312 Breast enlargement (augmentation mammoplasty)
B314 Revision of breast augmentation B313 Breast lift (mastopexy)
B356 Nipple eversion (for nipple inversion)
FACIAL PROCEDURESS01* Face and brow lifts C13* Surgery on upper eyelid (upper lid blepharoplasty)
C13* Surgery on lower eyelid (lower lid blepharoplasty)
E02* Surgery to reshape the nose (rhinoplasty) D033 Correction of prominent ears (pinnaplasty / otoplasty)
D062 Repair of external ear lobes (lobules)
S211/S212/S218/S219/S33* Alopecia S211/S212/S218/S219/S33* Correction of male pattern baldness
S211/S212/S218/S219/S33* Hair transplantation/hair replacement interventions
BODY CONTOURING PROCEDURESS02* Abdominoplasty/apronectomy
S03* Other skin excisions for contour e.g. buttock lift, thigh lift, arm lift S621/S622 Liposuction
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SKIN AND SUBCUTANEOUS PROCEDURESE094/S05*/S06*/S09*/S10*/S11*/Y088 Fatty lumps (lipoma)
Viral warts (outside Genito-Urinary Medicine services)
Other benign skin lesions e.g. skin tags and seborrhoeic keratoses
S601/S602, X85 Xanthalasma
Tattoo removal
Skin hypo-pigmentation Small benign acquired vascular lesions such as thread veins and spSkin resurfacing techniques such as laser, dermabrasion and chem
Botulinum toxin for the treatment of facial aging/excessive wrinkles
Hair Depilation
Treatment for excessive sweating
Scar revision
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OPCS code(s)Treatment/procedure
UROLOGY/GYNAECOLOGY
The PCT does not fund treatment where the primary or principais cosmetic, i.e. to improve appearance.
Reconstruction following surgery for non-aesthetic reasons (egmajor trauma) is not affected by this policy.
N303 Circumcision for social / religious grounds N29* Penile implants
N181/Q37* Reversal of sterilisation/vasectomy
Gender re-assignment -Female to male at University College London Hospital Male to female at Hammersmith Hospitals TrustThe PCTs do not fund any associated cosmetic procedures e.g. breaugmentation, wigs, laser therapy, brow surgery etc.
Genital surgery aimed at improving appearance
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OPCS code(s)Treatment/procedure
OPHTHAMOLOGY
The PCT does not fund treatment where the primary or principais cosmetic, i.e. to improve appearance.
Reconstruction following surgery for non-aesthetic reasons (egmajor trauma) is not affected by this policy.Laser eye surgery for myopia
Photodynamic therapy (PDT) unless fulfilling NICE criteria
OPCS code(s)Treatment/procedure
EAR NOSE AND THROAT
The PCT does not fund treatment where the primary or principais cosmetic, i.e. to improve appearance.Reconstruction following surgery for non-aesthetic reasons (egmajor trauma) is not affected by this policy.
D15.1 Grommets for persons over 19D13* Bone anchored hearing aid
D241 Cochlear implants
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OPCS code(s)Treatment/procedure
VASCULAR SURGERY
The PCT does not fund treatment where the primary or principais cosmetic, i.e. to improve appearance.
Reconstruction following surgery for non-aesthetic reasons (egmajor trauma) is not affected by this policy.
L84*/L85*/L86*/L87*/L88* Varicose Veins Class 1 and 2
OPCS code(s)Treatment/procedure
OTHERThe PCT does not fund treatment where the primary or principais cosmetic, i.e. to improve appearance.Reconstruction following surgery for non-aesthetic reasons (eg
major trauma) is not affected by this policy.X521 Hyperbaric oxygen therapy(unless decompression illness)
Weight loss interventions
Complementary/Alternative therapiesFunctional Electrical Stimulation
OPCS code(s)Treatment/procedure
DENTAL SURGERY The PCT does not fund treatment where the primary or principa
is cosmetic, i.e. to improve appearance.Reconstruction following surgery for non-aesthetic reasons (egmajor trauma) is not affected by this policy.
F08* Dental implants
F091/F092/F093 Wisdom tooth extraction that falls outside NICE criteria
F12* Apicectomy of multi rooted teethF14*/F15* Orthodontic treatment IOTN 1-3 with aesthetic component of less tha
F10 Minor Dental Extractions
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Appendix I Guidance for Clinicians
This section gives the guidance to clinical factors that the clinician will need to take into account when making the refer
It represents a guide to determine the individuals who are felt to be suitable for the intervention and are a means of eMeeting the factors listed in the guidance does not automatically entitle the patient to the procedure.
Section A
Procedure/Therapy Comments / Rationale Guidance for Clinicians RefTreatment
B311Female breastreduction (reductionmammoplasty)
The patient has a body mass
30kg/m2
The patient is suffering from nintertrigo
The wearing of a professionalrelieved the symptoms
B311Male breastreduction forgynaecomastia
Prior to surgical intervention it must be clear that there is no underlying cause
for the gynaecomastia.
This will include screening for endocrine disorders, drug related causes and
exclude male breast cancer. If there is any doubt, an urgent consultation with
an appropriate specialist must be obtained.
Most cases of gynaecomastia have no known cause especially thosepresenting in adolescence. It may be unilateral or bilateral.
Commonly gynaecomastia is seen during puberty and may correct once thepost-pubertal fat distribution is complete if the patient has a normal BMI.
Certain prescription and non-prescription drugs (including cannabis) can
result in gynaecomastia.In rare circumstances gynaecomastia may represent an underlyingendocrine condition. It is important that male breast cancer is excluded.
BMI
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B312Breast enlargement(augmentationmammoplasty)
This procedure will only be performed on an exceptional basis and shouldnot be carried out for small but normal breasts or for breast tissueinvolution (including post partum changes).For patients with asymmetry, clinicians should referral to the breast careteam, who will make an assessment and offer advice on a range ofprosthetic and other solutionsBreast implants may be associated with significant morbidity and the needfor secondary or revisional surgery (such as implant replacement) at somepoint in the future is common.Implants have a variable life span and the need for replacement or removalin the future is likely in young patients.Not all patients demonstrate improvement in psychosocial outcomemeasures following breast augmentation.
Previous mastectomy of other
Trauma to the breast during o
Congenital amastia (total failu
Endocrine abnormalities
Development asymmetry
B314Revision of breastaugmentation
If revisional surgery is being carried out for implant failure, the decision to
replace the implant(s) rather than simply remove them should be based
upon the clinical need for replacement and whether the patient meets the
policy for augmentation at the time of revision.
There may be clinical reasonsan appropriate surgical interve
B313Breast lift(mastopexy)
This procedure may be considered as part of the treatment for
breast asymmetry and reduction (see above) but will not be
funded for purely cosmetic/aesthetic purposes such as post-
lactational ptosis.
B356Nipple Eversion (fornipple inversion)
Nipple inversion may occur as a result of an underlying breast malignancy
and it is essential that this be excluded.
Idiopathic nipple inversion can often (but not always) be corrected by the
application of sustained suction. Commercially available devices may be
obtained from major chemists or online without prescription for use at home
by the patient.
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Section BFacial ProceduresOperations on congenital anomalies of the face and skull for correction of post traumatic bony and soft tissue not affected by this document
Procedure/Therapy Comments /Rationale Guidance for Clinicfor Treatment
S01* Face and brow lifts
These procedures will be considered for treatment of certain clinical
conditions
They will not be available to treat the natural processes of aging
There are many changes to the face and brow as a result of aging that may
be considered normal; however there are a number of specific conditions for
which these procedures may form part of the treatment to restore
appearance and function.
Congenital facial ab
Facial palsy (congen
As part of the treatmaffecting the facial spseudoxanthoma ela
To correct the conse
To correct deformity
C13* Surgery on uppereyelid (upper lidblepharoplasty)
This procedure will be funded to correct functional impairment (not purely for
cosmetic reasons)
The procedure will not be available to treat the natural processes ofaging
Many people acquire excess skin in the upper eyelids as part of the process of
aging and this may be considered normal. However if this starts to interfere
with vision or function of the eyelid apparatus then this can warrant treatment.
Impairment of visuacompensated state
Clinical observation discomfort, e.g. heaof day and/or evidenthrough elevation of
C13* Surgery on lowereyelid (lower lidblepharoplasty)
Excessive skin in the lower lid may cause eye bags but does not affect
function of the eyelid or vision and therefore does not need correction.
Blepharoplasty type procedures however may form part of the treatment of
disorders of the lid or overlying skin.
Correction of ectrop
removal of lesions o
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E02* Surgery to reshape thenose (rhinoplasty)
Patients with isolated airway problems (in the absence of visible nasaldeformity) may be referred initially to an ENT consultant for assessment andtreatment.
Problems caused byairway
Objective nasal defo
Correction of comple
Cleft lip and palate
D033 Correction ofprominent ears (pinnaplasty/ otoplasty)
Prominent ears may lead to significant psychosocial dysfunction for children
and adolescents and impact on the education of young children as a result of
teasing and truancy.
< 19 years of age
D062 Repair of external earlobes (lobules)
This procedure is only available on the NHS for the repair of totally split earlobes as a result of direct trauma prior to surgical correction,
Correction of split earlobes is not always successful and the earlobe is a site
where poor scar formation is a recognised risk.
S211/S212/S218/S219/S33*
Alopecia
Hair pieces and wigshair loss as a result
totalis are available S211/S212/S218/S219/S33*Correction of male patternbaldness
Many types of hair loss including male pattern baldness is a normal processfor many men at whatever age it occurs
S211/S212/S218/S219/S33*Hair transplantation/hairreplacement interventions
Hair pieces and wigshair loss as a result totalis are available
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Section CBody Contouring Procedures
Procedure/Therapy Comments /Rationale Guidance for Clinfor Treatment
S02*Abdominoplasty/apronectomy
Excessive abdominal skin folds may occur following weight loss in the
previously obese patient and can cause significant functional difficulty.
These types of procedures, which may be combined with limited liposuction,
can be used to correct scarring and other abnormalities of the anterior
abdominal wall and skin.
It is important that patients undergoing such procedures have achieved and
maintained a stable weight so that the risks of recurrent obesity are reduced.
Stable BMI betwee
Experiencing sever
Those with scarringabdominal surgery
Those who are undobesity and have e
Problems associatebags
Where it is required
correction or other
S03*Other skin excisions forcontour e.g. buttock lift, thighlift, arm lift
Whilst the patient groups seeking such procedures are similar to those
seeking abdominoplasty (see above), the functional disturbance of skin
excess in these sites tends to be less and so surgery is less likely to be
indicated except for appearance.
The PCT does not fund treatment where the primary or principal reasonfor it is cosmetic, i.e. to improve appearance
S621/S622Liposuction
The PCT does not fund treatment where the primary or principal reasonfor it is cosmetic, i.e. to improve appearance.
Liposuction may belocalised fat atroph(e.g.Multiple lipoma
Liposuction is somsurgical procedure
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Section DSkin and Subcutaneous LesionsAny patient with a skin or subcutaneous lesion that has features suspicious of malignancy, must be referred tospecialist for urgent assessment
Procedure/Therapy Comments /Rationale Guidance for Clinifor Treatment
Removal of skin lesions/S05*/S06*/S09*/S10*/S11*/Y088Medicine Services)
Patients should be
they suffer from o
Suspected mal Obstruction of o Facial disfigure Recurrent infec Function limitat Pain
Fatty lumps (lipoma)
Lipomata of any size
treatment by the NH
circumstances:There is functional i
symptomatic
The lump is rapidly g(e.g. sub-fascial, su
Viral warts (outside Genito-Urinary Clinic)
Most viral warts will clear spontaneously or following application oftopical treatments.
Painful, persistent oin the immuno-suppspecialist assessmesurgical removal ma
Other benign skin lesions e.g.skin tags and seborrhoeickeratoses
Clinically benign skin lesions should not be removed on purely cosmetic
grounds. Patients with moderate to large lesions that cause actual facial
disfigurement may benefit from surgical excision. The risks of scarringmust be balanced against the appearance of the lesion.
The decision to remove benign skin lesions from conspicuous sites is a
Some skin lesions mparticularly if large osite where they are
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balance between the appearances of the original lesion against the likely
appearance of the surgical scar.
It is therefore essential that the decision is made by a practitioner fully
familiar with the factors affecting the outcome of surgery in these sites and
that the excision is carried out by a trained practitioner using fine
instruments and sutures in an appropriate surgical setting.
Xanthelasma (yellow fattydeposits around the eyelids)
Patients with xanthelasma should always have their lipid profile checked
before referral to a specialist. Many xanthelasmata may be treated with
topical TCA or cryotherapy.
Xanthelasma (yellow fatty deposits around the eyelids) may be
associated with abnormally high cholesterol levels and this should be
tested for. They may be very unsightly and multiple and do not always
respond to medical treatments. Surgery can require blepharoplasty
type operations and/or skin grafts.
Larger lesions or thothese treatments malesion is disfiguring.
Tattoo removal
Skin hypo-pigmentation The recommended NHS suitable treatment for hypo-pigmentation iscosmetic camouflage.
Small benign acquired vascularlesions such as thread veins andspider naevi
RhinophymaThe first-line treatment of this disfiguring condition of the nasal skin ismedical.
Severe cases or thomedical treatment mor laser treatment
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Laser treatment / skin resurfacingtechniques
The refinement of laser technology has created new therapeutic optionsfor cosmetic problems ranging from insignificant blemishes and tattoosto extreme and disfiguring birth marks. Potential demand for this newservice is greater than available resources.
Botulinum toxin for thetreatment of facialaging/excessive wrinkles
Hair Depilation
Treatment for excessivesweating
Scar revision
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Section EUrology and Gynaecology
Procedure/Therapy Comments /Rationale Guidance for ClinicianTreatment
Gender re-assignment -Female to male at
University College LondonHospital Male to female atHammersmith HospitalsTrust
Gender re-assignment is a highly specialised area of clinical practice and
should only be considered, assessed for and carried out as part of a
recognised NHS programme of care. Each case should be considered onits individual merits
The PCTs do not fund any associated cosmetic procedures e.g. breastaugmentation
Lived in the acquired geyears.
Patient has gender dysp
Patient intends to live indeath.
Genital Surgery aimed atimproving appearance
Patients requiring prostheses following orchidectomy are not affected by
this policy.
N303Circumcision for social /
religious grounds
Male Circumcision
Female circumcision isprohibited by law: TheProhibition of FemaleCircumcision Act 1995
This decision is made in line with the statement on Male Circumcisionmade by the British Association of Paediatric Surgeons, The Royal Collegeof Nursing, The Royal College of Paediatrics and Child Health, The RoyalCollege of Surgeons of England and The Royal College of Anaesthetists.
The foreskin is still in the process of developing at birth and hence is oftennon-retractable up to the age of 3 years
The process of separation is spontaneous and does not requiremanipulation
By 3 years of age, 90% of boys will have a retractable foreskin
In a small proportion of boys this natural process of separation continues to
occur well into childhood.
The one absolute indicascarring of the opening retractable (pathologicabefore 5 years of age.
Recurrent, troublesomethe foreskin (balanoposindication for circumcisi
Occasionally specialist urologists may need to some rare conditions.
N29*Penile implants
N181/Q37*Reversal ofsterilisation/vasectomy
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Section FOphthalmology
Procedure/Therapy Comments /Rationale Guidance for ClinicianTreatment
Laser eye surgery formyopiaPhotodynamic therapy
(PDT)
Patients should meet th
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Section GENT Procedures
Procedure/Therapy CommentsRationale
Guidance for Clinicians RefTreatment
D15.1Grommets
Children: There is only limited evidence that grommets are an effectivetreatment in children with otitis media with effusions.
In accordance with NICE Clin2008 Surgical Management Childrenthe PCT may fund t
are likely to benefit as follows
Children who will benefit from
Children with persistent bilateEffusion) over a period of threin the better ear of 25-30 dBH1,2 and 4kHz (or equivalent davailable)should be considere
Exceptionally, health care prosurgical intervention in childrewith a hearing loss less than 2of the hearing loss on a child
educational status is judged t
Adults: The PCT mayconsidin patients for whom grommereasonable hearing acuity, bafundamental to their general h
Elderly or frail patients at risk experience social isolation as
D13*Bone anchoredhearing aid
Bone anchored hearing aids(BAHA) have been recommended for people
who cannot wear a conventional hearing aid due to infection or peoplewith a conduction hearing loss. NICE have not yet issued guidance onthe use of BAHA.Complications including osseointegration, implant removal, local infection orimplications.
As a guide the patient should
abnormalities of the middear or a chronic ear infeconventional hearing aid
have a hearing loss in booperated on and for whicare not felt to suitable
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can hear sounds well via can understand 60% or m
test, using bone conduct are able to keep the area
The following represent potenprocedure : Word recognition scores
are less than 60% patient has less than 3m patient less than 5 years patient unable to keep im patient unable to remove
processor due to lack of patient unable to accept
the side of the head
D241Cochlear implantsfor persons under18 years
Priority is given to providing single implants to more people rather thanbilateral implants to fewer people which will not be funded.
Patients (including adults) whose severe/profound hearing loss is as aconsequence of meningitis should be 'fast tracked', regardless of hearingaid use, due to the risk of cochlear ossification.
Cochlear implantation has not yet been formally reviewed by NICE todetermine cost effectiveness. Those analyses which have been conductedso far seem to demonstrate that unilateral cochlear implantation is cost-effective when judged by the standards usually applied by NICE. Cost-utility analysis shows a cost per QALY of around 18,000, lower in thosemore profoundly deaf at outset, and lower in younger age groups.
Cost utility ratio estimates for bilateral cochlear implantation fall
significantly above the 30,000 limit.
As a guide the patient should
Audiometric CriteriaHearing threshold >90dB at 2ear.
Other Criteria
Pre-lingually deafened childrethe time of surgery.
Older congenitally deaf childrhave developed good spokenacoustic hearing aids.Ideally, a minimum of 3 monthhearing aids, prior to referral f
Morphological suitability for e
Established spoken language
Willingness and commitment participation in implantation aprogramme
Physically fit for surgery and r
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Failure to develop, progress olanguage, and communicationpatients age, on a range of m
Support from parents and rele
Parents and child have realistof implantation.
Cochlear implantsfor persons over 18years
Cochlear implantation for adults is not routinely available. If a clinician orpatients believes there are exceptional reasons why their patient wouldbenefit from this intervention they may put their case forward to the SurreyPCT Exceptions Panel.
As a guide the patient should
Audiometric Criteria
Hearing threshold >90dB ave2000Hz and 4000Hz unaidedhearing ear, as measured by
Less than 50% word identificatest presented at 70dB, witho
Other Criteria
Minimum of 3 months use of oprior to referral for assessmenMorphological suitability for eEstablished spoken languageWillingness and commitment and long-term rehabilitation pPhysically fit for surgeryAppropriate support from releRealistic expectations of the o
Patients should have a li
10 years, at the time of t
Chronological age is not
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Section HVaricose Veins
Procedure/Therapy CommentsRationale
Guidance for Clinfor Treatment
L84*/L85*/L86*/L87*/L88*
Varicose Veins Class Iand II
Please see appendix section II: The Varicose Vein Prioritisation
Protocol on page 29
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Section IOther Procedures
Procedure/Therapy Comments /Rationale Guidance for ClinicTreatment
X521 Hyperbaric oxygen
therapy (HBOT) (unlessdecompression illness)
HBOT for decompression illness can carbon monoxide poisoning are notaffected by this policy.
There is insufficient evidence for the clinical effectiveness of HyperbaricOxygen Therapy (HBOT) for wound healing. Therefore it is not routinelyfunded by the PCT
Weight loss interventions
Various weight loss approaches are available within the NHS, including:dietetic and lifestyle advice, exercise prescription, drug therapy,psychotherapy.
Surrey PCT will not fund other non-NHS interventions such as weight losscamps.
Complementary/Alternative
therapies
Complementary therapies are not normally funded by Surrey PCT, with theexception of holistic care as part of ongoing treatment in certain locations.
Literature in support of homeopathy, acupuncture and other alternative
treatments is of poor quality and contains significant bias and placebo effect.Documented studies are often not randomised or blinded. Body of evidenceincluding several meta-analysis has failed to confirm any demonstrablebenefit from treatments. NICE guidance for homeopathy and acupuncturehas not been compiled.
Functional ElectricalStimulation
NICE guidance has been used to support the use of FES in certainconditions, e.g., and can be found at http://guidance.nice.org.uk/
As a guide patients suntil conservative meproven unsuccessful
NICE has issued guidsets of circumstanceincontinence.
In both cases the funconsidered by the PCguidelines.
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Section JDental Procedures
Procedure/Therapy Comments /Rationale Guidance for Clinicians RTreatment
Wisdom ToothExtraction
In accordance with NICE guidance the routine practice of prophylactic removalof pathology-free impacted third molars should be discontinued in the NHS.
Surgical removal of impacted third molars should be limited to patients withevidence of pathology.
Unrestorable caries,
Non-treatable pulpal and/o
Cellulitis, abcess and osteo
Internal/external resorption
fracture of tooth, disease o
tooth/teeth impeding surge
Reconstructive jaw surgery
in or within the field of tumo
F10 Minor DentalExtractions
F12* Apicectomy of multi rooted teeth
Dental Implants
Orthodontic treatment needs to be justified on either dental health or aesthetic
needs, there are two components to this index:-
The Dental Health Component (DHC)The Aesthetic Component (AC)
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APPENDIX II: - The Varicose Vein Prioritisation ProtocolWith thanks to Southern Derbyshire Acute Hospitals NHS Trust
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Appendix III - Process for Treatments Not Routinely Funded by Surrey Primary CareTrust
1. The Scope of the documentThis document describes the process by which applications for treatments not routinely funded bySurrey Primary Care Trust (PCT) are considered.
2. Application Process
Applications may be submitted by GPs or Consultants. Applications must be made by completingthe appropriate application form which can be found on page 6 in the Treatments not RoutinelyFunded policy document. Applications should be submitted to the Commissioning team at SurreyPCT. There will be a fortnightly meeting between Public Health and the Commissioning team to sortthrough the requests
The applications will be reviewed to ensure that they:
are appropriate
have sufficient supporting information to proceed to panel
Application forms may be returned to the referring clinician in the following circumstances:
Insufficient detail provided by referring clinician on the application form
The patients exceptional circumstances are not outlined on the application form
The application does not demonstrate that the patient meets the minimum guidance setout Treatments not Routinely Funded policy document
Incomplete / partially completed application forms
If an application form is returned and the clinician feels that they may have further relevantinformation available that has not been considered then they may re submit the case to the AcuteCommissioning team.
3. Remit of the Exceptions Panel
The remit of the Exceptions Panel will be to deal with requests for individual patients, where thetreatment falls outside the established commissioning contracts and has been determined atreatment not routinely funded.
Applications are likely to include:
Requests for treatments not included in current contracts (as detailed in this Policy)
Requests for high cost or cancer drugs
Requests for private treatment
Other exceptional circumstances
Requests for high cost will be managed centrally and overseen by the Lead PharmaceuticalCommissioning Pharmacist. Requests requiring decisions for funding of high costs drugs will bereferred to a sub-committee of the Exceptions Panel (the high cost drugs panel) comprising thefollowing:
Panel members:
Lead Pharmaceutical Commissioning Pharmacist
Public Health Representative
Commissioning Manager (Associate Director or above)
Lay representation
Surrey GP
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In attendance:
Senior Technician Pharmaceutical Commissioning (taking minutes)
Pharmaceutical Commissioning Pharmacist
Please see separate document: Funding Requests for High Cost Drugs Policy and Process, formore information
The Exceptions Panel will not have a remit to consider cases under the Continuing Care EligibilityCriteria or those falling under the Mental Health and Learning Difficulties remit, for which there areseparate processes.
Requests for dental implants and orthodontic appeals, to be considered following assessment byPCT dental advisor/or commissioned orthodontic advice as appropriate.
Requests requiring urgent consideration may be delegated to a sub-committee of the Panel,comprising of two regular Panel members. Discussion can be carried out by telephone, fax or emailif necessary, and in such circumstances a decision will be taken on a consensus view. Any suchdecisions will be reported and minuted at the next available Panel meeting.
The Public Health Directorate will play a key role in determining the clinical and cost effectivenessof the treatments requested and will supply evidence briefings for panel meeting as requested. Theevidence briefings will aim to support the decision making by providing panel members withbackground information to the treatment requested and summarising the most relevant and up todate information and guidance on effectiveness available.
The Panel will be asked to consider appropriate individual cases for consideration for funding.
The key question for the Exceptions Panel may be posed as:
On what exceptional grounds can this patient be funded when this treatment is notroutinely funded by the PCT?
Requests for funding will be considered in line with the guiding principles detailed in Surrey PCTsPolicy for Treatments Not Routinely Funded. The panel will consider issues of appropriateness,clinical and cost effectiveness and priority when commissioning services.
The Exceptions Panel will
aim to ensure consistency in decision making
deal with all patient information in confidence.
make decisions in accordance with the PCT's Policy for Treatments Not Routinely Funded
consider each request in the context of the relevant policy where this exists or as atreatment not routinely funded where there is no explicit policy
consider the request on the basis of patients exceptional circumstances.
consider clinical and cost effectiveness not approve funding where there appears to be no evidence that the clinical circumstances
of the patients case are exceptional when compared with other patients who have thesame or a substantively similar condition
4. Constitution
To be quorate each panel will be made up of at least one of each of the following:
GPPublic Health RepresentativeA lay MemberCommissioning Manager (Chair)
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The same personnel will not be present at each meeting, but will be drawn from a list of potentialpanel members, according to their availability. The Chair will remain constant, as far as isreasonably possible. Other personnel may be co-opted in as appropriate.
The final decision of the panel will be reached by group consensus. In the event of the panel beingunable to reach a group consensus the decision will be made by majority vote.
Members of the Exceptions Panel who have any personal interest with a particular patient or clinicalcondition will be excluded from the discussion of that case
5. Venue and Frequency
The Panel will meet fortnightly, but the frequency may be subject to variation over time. Dates willbe set quarterly in advance. The panel venue will be variable, within the Surrey PCT boundary.
6. Accountability
The Exceptions Panel will be a sub-committee of the Surrey Professional Executive Committee(PEC) and as such will report to the PEC quarterly.
7. Administration
Administrative support to the panel will be provided by the Acute Commissioning Team.
An agenda, anonymised application forms and the papers associated with each request will becirculated 4 working days in advance of the Panel meeting.
Clear minutes will record the outcome of the discussion on each case, which will signed off by thechair of the panel in paper form and filed for records. In addition letters to the referring clinician,informing them of the Panel decision, will be signed off by the chair of the Exceptions Panel prior tobeing sent.
The applicant (Consultant or GP) will receive a written response to their request following theExceptions Panel meeting. This will be within 22 working days of receipt of a completed applicationform by the Commissioning team. In certain circumstances delays in dealing with requests may beencountered (please see section 12). Where a delay may occur this will be conveyed to theclinician applying for the treatment.
8. Reporting, Review and Evaluation
The Exceptions Panel will review its activities and expenditure to monitor trends, policyrequirements and consistency. This information will be fed back to Exceptions Panel Members andthe PEC.
An annual review will be carried out jointly by the Commissioning and Public Health teams. This will
review the processes and policies of the Exceptions Panel to ensure they remain relevant, andreflect national policy (including NICE Guidance) where applicable.
The annual review will include:
An audit of the previous years requests
A review of the current list of treatments not normally funded
A review of evidence for new treatments
Consultation with clinicians in partner organizations
9. Appeals
Appeals must be received by the PCT within 22 working days of receipt of written notification of theExceptions Panel decision.
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Appeals can be made by the referring clinician (GP or Consultant) or patient. If the patient isundertaking the appeal it must be supported by the referring clinician.Appeals will be dealt within 22 working days of receipt a written appeal.
If the clinician or patient is unhappy with the decision made by the panel and feel that all relevantinformation was available then they may ask that the case be reconsidered. The case file will be
reviewed by the Director of Commissioning, or one of their Associate Directors (as delegated) toensure that the correct process was followed in the decision making at panel.
If the process in reaching the decision to decline funding is found to be correct it will be upheld thenthe case will go forward to the appeals panel.
If the correct process was not used by the original panel in the decision making then the case willbe resubmitted to a second Exceptions panel for reconsideration.
9.1 Appeals Panel
The purpose of the Appeals Panel is to consider appeals against decisions of the Exceptions Panel.
The Appeal panel will consist:
A Public Health representative
Director or Associate Director of Commissioning (chair)
Lay member /Non-Executive Director
A GP
Additional specialist input may be co-opted in, as appropriate to the case, and at the discretion ofthe chair. None of the above will have been involved in the original decision.
There is no right of attendance by the requesting clinician, the patient or their representative at thepanel.
The appeal panel will consider the following;
Whether the Exceptions Panel correctly followed its own procedures
Took all important facts into account
Considered the all relevant information presented
Made a decision in accordance with its remit
The outcome of the appeal panel may be
To uphold the Exceptions Panel decision
To overturn the Exceptions Panel decision
Following a decision by the Appeals Panel if dissatisfaction still persists, the patient may pursue thecase through the NHS Complaints procedure. Information concerning this can be obtained from thePCT Complaints Manager
10. Quality standards
Upon receipt of a fully completed application form cases will be logged.
The applicant (Consultant or GP) will receive a written response to their request following theExceptions Panel meeting. This will be within 22 working days of receipt of a completed applicationform by the Commissioning team.
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In certain circumstances delays in dealing with requests may be encountered (please see section12). Where a delay may occur this will be conveyed to the clinician submitting the application forfunding treatment.
11. Management Process
High Cost Drugs
Requests to be directed to the Pharmaceutical Commissioning team at Surrey PCT
Email address: [email protected]
All other Requests
The day to day initial management of cases will include:
Receipt and logging of cases
Initial management review
Information gathering
Preparation of case for panel
This will be co-ordinated by a named link.
The aim will be to identify:
Cases which require a panel decision should be referred to the Exceptions PanelCoordinator.
The Co-ordinator and/or Commissioning Team will provide an initial review of thepaperwork to ensure it is complete.
Papers for cases requiring an Exceptions Panel decision will then be distributed to Panelmembers to allow at least 4 working days prior to the Panel Meeting.
The panels decision, including the rationale for the decision will be clearly recorded in theminutes which will be signed off in paper form by the chair of the Exceptions Panel Meetingand filed for record keeping.
12. Information Gathering
When considering individual cases, the Exceptions Panel will require supporting information. Thisis likely to include:
relevant patient history
a clear description of what is being asked for and the likely outcome for this patient cost of treatment
evidence of clinical effectiveness and any relevant NICE guidance which will besupplied by the public health team
Details of why this patient is exceptional when compared with other patients who havethe same or a substantively similar condition
If the treatment is new or unusual the Commissioning team will request the Public HealthDirectorate to provide an evidence briefing for the requested treatment. If an evidence briefing on anew or unusual treatment is required from the Public Health Directorate this may take up to 10working days to enable members of the team to access information from diverse sources includingpublished research and expert opinion.
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When public health input is required and they will endeavour to obtain this information prior to thescheduled meeting date. Where information is sought from external organisations, casediscussions may be postponed if information is not available in sufficient time or in sufficient detailto enable a Panel decision to be made.
Clinical advice may be sought from PCT clinicians, local consultants and specialist commissioning
services.Where a delay may occur this will be conveyed to the clinician applying for the treatment.
13. Budget
Many requests to panel will be for cases with local providers, whereby the activity will be charged tothe relevant contract. For those cases where no contract exists, the cost will be charged to adedicated budget held by the Head of Contracting.
14. Decisions
In reaching a decision on individual funding, the Panel will apply the PCTs relevant policy (policies)The Panel will set out their decision and the reasons for it in writing to the referring clinician.