CLIN 6 Treatments Not Routinely Funded PolicyV2 (2)[1]

8/14/2019 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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Treatments not Routinely Funded Policy review date April 2010 version 2 Page 2 of 38

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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UROLOGY/GYNAECOLOGY


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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OPHTHAMOLOGY


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


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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VASCULAR SURGERY


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


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


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.


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.


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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Treatments not Routinely Funded Policy review date April 2010 version 2 Page 33 of38

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.

Documents

CLIN 6 Treatments Not Routinely Funded PolicyV2 (2)[1]