Appendix 1- Clinical Thresholds and IFR Panel Referral Process GP reviews patient against clinical criteria Patient does not meet clinical criteria * Patient does not meet clinical criteria but GP refers for exceptionality Patient meets clinical criteria for non-routinely commissioned procedure GP refers for advice from Secondary Care Procedure refused on NHS GP provides feedback Refer to IFR Panel * GP refers to Secondary Care with completed PLCV check-list & referral letter Consultant reviews patient against clinical criteria * IFR Panel approve procedure IFR Panel does not approve procedure and patient notified Care Agreement that Patient meets clinical criteria , procedure is carried out Patient does not meet clinical criteria and is discharged to GP with a care plan GP refers to Secondary Care with IFR Approval Patient does not meet clinical criteria , consultant applies to IFR panel for approval on grounds of exceptionality IFR panel approve and the procedure is carried out* IFR panel don’t approve, letter to the patient and discharge (if appropriate) *
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring Custom Made Prosthetic Limbs Custom Made Prosthesis Limbs Routinely Commissioned NHS Products The CCG will only fund prosthetic limbs which are available on the NHS. Dental F08 F11.5 CZ02 S CZ02 T CZ02 W CZ02 Y Dental Implants Not Routinely Commissioned (orthodontics and oral surgery) Contract monitoring SLAM Dental Wisdom Removal Routinely Commissioned for patients meeting the NICE criteria. NICE TAG001 Routine monitoring Updated Nov 2011 ENT D15 Myringotomy /Grommets Routinely Commissioned meeting Criteria Funding for grommets for children with persistent otitis media with effusion will be considered for the following indications: Otitis media with effusion has persisted for a three month period of watchful waiting after diagnosis in primary care and the child suffers from one of the following: -at least five recurrences of acute otitis media requiring medical assessment and/or treatment in the previous year. - hearing loss of at least 25dB, particularly in the lower tones with either delay in speech development or educational/behavioural problems attributable to the hearing loss. -a second significant health problem or Contract monitoring SLAM But diagnosis code not E081, E201, E291, F34 or D191
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring November 2013  Gastroentero logy G802 FZ15Z Wireless Capsule Enteroscopy for Investigation of the Small Bowel Not Routinely Commissioned from DBHFT This investigation is commissioned by the CCG at STHT. NICE IPG 101 Contract monitoring SLAM Updated Nov 2011 General Surgery Varicose Veins Routinely Commissioned meeting Criteria Patients with bleeding varicose veins do not need prior approval and can be referred to a vascular service immediately. Conservative management should be the first line of treatment and applications will not normally be accepted for patients whose BMI is over 30. Interventional treatment of varicose will only be commissioned for patients aged 18 and over when any of the following criteria apply: skin changes secondary to chronic venous insufficiency, for example pigmentation or venous eczema. at two episodes of superficial thrombophlebitis. active or healed venous leg ulcers. a previous episode of bleeding from the varicosity. Contract monitoring SLAM B
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring Ophthalmolo gy C46.1 Laser surgery for Short Sight Not Routinely Commissioned Contract monitoring SLAM Orthodontics F14 F15 treatment Routinely Commissioned for patients meeting criteria. An Index of Orthodontic Treatment Need of 3.6 or above. Only patients under the age of 18 years are eligible for routine NHS orthodontic treatment. These criteria may be waived where the consultant clinician considers that there are exceptional or mitigating circumstances and prior approval has been sought from the CCG Contract monitoring SLAM Paediatrics Cranial banding for positional plageocephaly Not Routinely Commissioned. Cranial Banding will not be routinely commissioned. The available evidence does not show cranial banding as a treatment for brachycephaly and positional plagiocephaly to be effective. Updated July 2015 Plastic and Cosmetic surgery S01 Facelift Facelift procedures and Botulinum toxin will not be routinely commissioned by the NHS for cosmetic reasons Cases may be considered on an exceptional basis, for example in the presence of an anatomical abnormality or a pathological feature which significantly affects appearance. Policy for specialist plastic surgery procedures Contract monitoring SLAM
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring exceptional basis, for example where the patient: has an underlying skin condition, for example cutis laxa or has lost a considerable amount of weight resulting in severe mechanical problems affecting activities of daily living and has a normal BMI in the range18.5 - 25 for a minimum of 2 years Plastic and S010. Resurfacing Not Routinely Commissioned Policy for specialist plastic surgery Contract Cosmetic 3 procedures e.g. procedures monitoring surgery S011. Chemical peels SLAM 3 to face Updated July 2015 Plastic and Cosmetic surgery B30 B31.2 Breast Augmentation Breast augmentation will not be routinely commissioned by the NHS for cosmetic reasons, for example for normal breasts or for breast tissue involution (including post- partum changes). Breast augmentation may rarely be considered on an exceptional basis, for example where the patient: has a complete absence of breast tissue either unilaterally or bilaterally or has suffered trauma to the breast during or after development and Policy for specialist plastic surgery procedures Contract monitoring SLAM
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring treatments. Updated July 2015 Plastic and Cosmetic surgery C13 Blepharoplasty Blepharoplasty will not be routinely commissioned by the NHS for cosmetic reasons. may be considered on an exceptional basis when there is excess skin or ptosis of the upper eyelid which is confirmed to obscure vision. Policy for specialist plastic surgery procedures Contract monitoring SLAM Plastic and Cosmetic surgery D06.2 Otoplasty Earlobe repair in the absence of traumatic injury Not Routinely Commissioned Policy for specialist plastic surgery procedures Contract monitoring SLAM Updated July 2015 Plastic and Cosmetic surgery D03 Pinnaplasty Not Routinely Commissioned Surgical correction of prominent ears will not be routinely commissioned by the NHS for cosmetic reasons. may be considered on an exceptional basis, for example where the patient: is aged 5-19 at the time of referral and the child (not the parents alone) expresses concern and has very significant ear deformity or asymmetry Policy for specialist plastic surgery procedures Contract monitoring SLAM National supporting evidence NHS England Interim Commissioning Polic
Speciality code HRG Procedure Commissioning Position Evidence Base Monitoring Updated July 2015 Plastic and Cosmetic surgery E02 Not Routinely Rhinoplasty will not be routinely commissioned by the NHS for cosmetic reasons. Cases may be considered on an exceptional basis, for example in the presence of severe functional problems. Post traumatic airway obstruction or septal deviation does not need funding approval. Policy for specialist plastic surgery procedures Contract monitoring SLAM Updated July 2015 Plastic and Cosmetic surgery Not Routinely Surgical/laser treatment of rhinophyma will not be routinely commissioned by the NHS for cosmetic reasons. Cases may be considered on an individual basis, for example where the patient has functional problems and where conventional medical treatments have been ineffective. Policy for specialist plastic surgery procedures Contract monitoring SLAM Updated July 2015 Plastic and Cosmetic surgery Revision of Surgical Scars Routinely Commissioned Revision surgery for scars will not be routinely commissioned by the NHS for cosmetic reasons. Cases may be considered on an exceptional basis, for example where the patient: Policy for specialist plastic surgery procedures Contract monitoring SLAM
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring Updated July 2015 Plastic and Cosmetic surgery P05.5 P05.6 P05.7 Reduction of labia minora Not Routinely Commissioned Policy for specialist plastic surgery procedures Contract monitoring SLAM Plastic and Cosmetic surgery N29 Phallaplasty Not Routinely Commissioned Policy for specialist plastic surgery procedures Contract monitoring SLAM Updated July 2015 Plastic and Cosmetic surgery S62.1 (head and neck) S62.2 (other) Liposuction Not Routinely Commissioned Liposuction will not be routinely commissioned by the NHS for cosmetic reasons. Cases may be considered on an exceptional basis, for example where the patient has significant lipodystrophy. . Policy for specialist plastic surgery procedures Contract monitoring SLAM Pain A70 SNS for pain Prior Approval Required. SNS for Pain will be commissioned in accordance with the NICE TAG 159 and the European Consensus on Neuromodulation of pain1998. NICE TAG 159 NHS Doncaster Commissioning policy Contract monitoring SLAM
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring Trauma & Hip Arthroscopy for hip impingement Not routinely commissioned Arthroscopic femoro-acetabular surgery for hip impingement syndrome should only be used with “special arrangements for consent and for audit or research” There are no East Midlands Units currently offering this service and the arrangements for consent or research at Coventry, the sole provider are unclear at present. Current evidence on safety and efficacy does not appear adequate to recommend hip arthroscopy for other indications, treatments or diagnoses. NICE Interventional Procedure Guidance 213 Trauma & Orthopaedic s X334 SA26 A Autologous Cartilage transplantation Not routinely commissioned ACI is not recommended for treating knee problems caused by damaged articular cartilage, unless it is used in studies that are designed to produce good quality information about the results of the procedure. These results should include measuring any improvement in patients’ quality of life and the benefits and risks of ACI over a long period of time, NICE TAG89 Contract monitoring SLAM Updated Nov 2011 Trauma & Orthopaedic V25 V26 Lumbar Spine procedures Not Routinely Commissioned Contract monitoring s V33 Lumbar spine procedures are not routinely SLAM V34 commissioned for non-specific back V382- pain. 4 V393- 5 V433 V473
Appendix 3 List of Treatments and Services (post February 2017) Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring Updated January 2017 Dermatology Adults & Benign Skin lesions Minor surgery: Seborrhoeic warts Molluscum contagiosum Spider angiomas (thread veins) Cherry angiomas or Campbell de Morgan Skin Tags and papillomas Naevi (moles) and other benign haemangiomas Xanthelasma Lipomas Sebaceous Cysts Port Wine stains DCCG will only offer funding if one or more of the eligibility criteria has been met. Diagnostic uncertainty exists following Telederm report The lesion is painful or impairs function and warrants removal, but it be unsafe to do so in primary care/community setting, for example because of large size (>10mm), location (e.g. face or breast) or bleeding risk. Removal would not be purely cosmetic. warts in the immunosuppressed. Patient scores >20 in Dermatology Life Quality Index administered during a consultation with the GP or other healthcare professional. *NICE recommend GPs use the following checklist, with major features scoring 2 and minor features scoring 1. A score of 3 indicated high suspicion of malignancy. If there is a strong clinical suspicion, the patient may be referred on the basis of one feature alone. Major features Minor features Change in size Diameter > 7mm Irregular in Inflammation Irregular in colour 10968/29814/29814.pdf (p35) Kerr OA, Tidman MJ, Walker JJ et al. The profile of dermatological problems in primary care. Clin Exp Dermatol. 2010; (4):380-3 surgery-in-primary-care George S, Pockney P, Primrose J et al. A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC Health Technology Assessment 2008;12(23):iiiiv, ix-38. Mazzotti E, Barbaranelli C, Picardi A et al. Psychometric properties of the Dermatology Life Quality Index (DLQI) in 900 Italian patients with psoriasis.Acta Derm Venereol 2005;85(5):409-13 dlqi/qu ality-dlqi.html Contract monitoring SLAM
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring Oozing Change in sensation Updated January 2017 General Surgery Adults only Cholecystectomy The CCG will only support the funding of cholecystectomy in incidental gallstones if one or more of the following criteria are met: High risk of gall bladder cancer, e.g. gall bladder polyps ≥1cm, porcelain gall bladder, strong family history (parent, child or sibling with gallbladder cancer). Transplant recipient (pre or post transplant). Diagnosis of chronic haemolytic syndrome by a secondary care specialist. Increased risk of complications from gallstones, e.g. presence of stones in the common bile duct, stones smaller Sanders G, Kingsnorth AN. Gallstones. BMJ. 2007;335:295-9. Sakorafas GH, Milingos D, Peros G. Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci. 2007;52:1313-25. Updated January 2017 General Surgery Adults only Interventional treatment for Haemorrhoids Interventional treatment for Haemorrhoids will be considered only if one of the following criteria are met: Symptomatic 3rd and 4th degree haemorrhoids Recurrent 2nd degree haemorrhoids with failed conservative treatment Persistent pain or bleeding *Conservative measures = high fibre diet, exercise, weight loss and topical preparations, followed by non-surgical ablative/fixative interventions and rubber band ligation. Documentation of dates and 1.Davies RJ. Haemorrhoids. BMJ Clinical Evidence. April 2006. Available at: b/conditions/dsd/0415/0415.jsp 2.Brisinda G. How to treat haemorrhoids. BMJ 2000; 321: 582-3
Speciality OPCS code HRG Procedure Commissioning Position Evidence Base Monitoring referred to secondary care due to the increased risk of incarceration/strangulation Umbilical/Paraumbilical and midline ventral hernias: Surgical treatment should only be offered when one of the following criteria is met: pain/discomfort interfering with Activities of Daily Living OR Increase in size month on month OR to avoid incarceration or strangulation of bowel where hernia is > 2cm Incisional: Surgical treatment should only be offered when of the following criteria are met: Pain/discomfort interfering with Activities of Living management of groin hernia in primary care—a systematic review. Family Practice, 2000;17(5), 442-447. GP notebook: Paraumbilical hernias. Available from: age.cfm?ID=- 1811546097&linkID=17862&cook=n (accessed 2016) Friedrich M. Müller Riemenschneider F. Roll S. Kulp W. Vauth C. Greiner W & von der Schulenburg JM. Health Technology Assessment of laparoscopic compared to conventional surgery with and without mesh for incisional hernia repair regarding safety, efficacy and cost- effectiveness. GMS health technology assessment. 2008;4. Dabbas. Frequency of abdominal wall hernias: is classical teaching out of date. JRSM Short Reports: 2011;2/5. Fitzgibbons. Watchful waiting versus repair of inguial hernia in minimally symptomatic men, a randomised controlled trial. JAMA: 2006;295, 285- 292 Purkayastha S. Chow A, Anthanasiou T, Tekkis P P & Darzi A. Ingunal hernias. Clinical evidence, 2008;0412, 1462-3846 Rosenberg J. Bisgaard T. Kehlet H. Wara P. Asmussen T. Juul P & Bay-