Current Mid Essex - DOC by pengtt


									Mid Essex PCT Clinical Prioritisation Policies – Version 5

Table. List of procedures which are designated low priority for Mid Essex based on evidence of effectiveness
(Includes those treatments where a referral threshold can be set)

This list has been derived from:
1. Policy statements from other PCTs which have been based on evidence of effectiveness.
2. Restatements of policies currently in effect across Essex.
3. This version incorporates comments received from clinicians and has PCT Board approval

This list includes two categories of procedure:
               Those which, as routine are not provided by the PCT and where provision is only possible on an individual patient basis, via the
                 referral of the case by the relevant clinician to the PCT Exceptional Cases Panel. These are listed as “PARTIALLY EXCLUDED
                 PROCEDURE (PE)” In this case the criteria list form guidance to referring clinicians and the Exceptional Cases Panel on what
                 may be considered exception but the final decision rest with the Exceptional Cases Panel.
               Those which may be offered on a routine basis but only for patients who meet defined criteria. These are listed as
                 “THRESHOLD APPLIES (TA)”. The responsibility for adherence to these policies lies with the referring and accepting clinicians
                 and prior approval should be sought where this is part of the contracting arrangements.

TVPC = Thames Valley Priorities Committees
Suffolk Low Priority Procedure List
Cambridgeshire Clinical Priorities Policies
Norfolk policies
Bedfordshire and Hertfordshire policies
Essex policies

This list is subject to change in year

    Procedure and          Criteria which may be considered suitable for funding
    type of restriction
                           COSMETIC AND LIFESTYLE
    Cosmetic surgery       Referrals for plastic surgery from both primary and tertiary sources will be assessed in line with the Service Restriction Policy and the clinical
    (general principles)   evidence provided.

                           For an authorised first appointment, the Plastic Surgery Specialist to whom the referral is subsequently passed should decide whether the
                           patient would benefit from plastic surgical intervention, and if so, establish that the patient fully understands the risks a nd benefits of surgery.

                           All referrals should be assessed for both first OPD appointments and subsequent procedure appointments, in line with the policy and clinical

                           Cosmetic surgery undertaken exclusively to improve appearance should not be funded in adults, in the absence of previous trauma, disease
                           or congenital deformity.

                           Assessment of patients being considered for referral who have an underlying genetic, endocrine or psychosocial condition should have had
                           this fully investigated by a relevant specialist prior to the referral to plastic surgery being made.

                           Referrals within the NHS for the revision of treatments originally performed outside the NHS will not usually be permitted. Referrers should
                           be encouraged to re-refer to the practitioner who carried out the original treatment.

                           Surgery should be supported where a patient has been accepted onto an NHS wai ting list prior to taking up residence in Mid Essex,
                           providing the existing clinical evidence has remained the same.

                           Where a patient has previously had NHS funded treatment, procedures necessary for dealing with complications or an outcome th at,
                           because of complications or technical difficulties, has resulted in cosmetic or physical problems that, from a professional point of view, are
                           severe enough to oblige the NHS to fund corrective treatment should be supported.

                           An undesirable outcome from an aesthetic perspective and the questions of whether revision should be funded is an issue that the referrer
                           should discuss with the patient prior to referring on to plastic surgery.

                           The National Service Framework for Children (National Service Framework for Children, Young People and Maternity Services. DH October
                           2004), defines childhood as ending at 19 years. Funding for this age group should only be considered if there is a problem likely to impair
                           normal emotional development. Children under the age of five rarely e xperience teasing and referrals may reflect concerns expressed by
                           the parents rather than the child, which should be taken into consideration prior to referral. Some patients are only able to seek correction
                           surgery once they are in control of their own healthcare decisions and again should be taken into consideration prior to referral.
1   Abdominoplasty or      Abdominoplasty and apronectomy may be offered to the following groups of patients who should have achieved a stable BMI betwe en 18
    Apronectomy            and 27 Kg/m² and be suffering from sever functional problems:
    (PE)                   Those with scarring following trauma or previous abdominal surgery
                           Those who are undergoing treatment for morbid obesity and have excessive abdominal folds (generally a weight loss of 10 poi nts on the BMI
                           Previously obese patients who have achieved significant weight loss and have maintained their weight loss for at least two ye ars
                           Where it is required as part of abdominal hernia correction or other abdominal wall surgery

Procedure and         Criteria which may be considered suitable for funding
type of restriction

                      Severe Functional problems include:
                             Recurrent intertrigo beneath the skin fold
                             Experiencing severe difficulties with daily living i.e. ambulatory restrictions. These patients will need full assessment by the
                              appropriate professional e.g. OT. Prior to referral
                             Where previous post trauma or surgical scarring (usually midline vertical or multiple) leads to very poor appearance and results in
                              disabling psychological distress or risk of infection.
                             Abdominal wall prolapse with proven urinary symptoms
                             Problems associated with poorly fitting stoma bags

    Procedure and         Criteria which may be considered suitable for funding
    type of restriction
2   Other skin excision   Buttock lifts, thigh lifts and arm lifts (brachioplasty), procedures will only be funded in exceptional circumstances.
    for contour
3   Liposuction           Liposuction may be useful for contouring areas of localised fat atrophy or pathological hypertrophy e.g. multiple lipomatosis, lipodystropies.
    (PE)                  Liposuction is sometimes an adjunct to other surgical procedures. It will not be funded simply to correct the distribution o f fat.
4   Acne Vulgaris         The treatment of active acne vulgaris should be provided in primary care or through a dermatology service.
    (PE)                  Patients with severe facial post-acne scarring can benefit from resurfacing and other surgical interventions, which may be available from the
                          plastic surgery service. All resurfacing techniques, including laser, dermabrasion and chemical peels may be considered for post-traumatic
                          scarring, including post surgical and serve acne scarring once the active disease is controlled. This will need to be evalua ted as being
                          inactive by the referrer.
5   Benign Skin Lesions   Clinically benign skin lesions/conditions should not be removed/treated on purely cosmetic grounds. This will include:
    (PE and T)
                                  Benign Pigmented Moles:

                                  Comedones:

                                  Corn/Callous:

                                  Lipoma
                                   Lipoma of any size may be treated in the following circumstances:
                                         The lipoma is/are symptomatic
                                         There is a functional impairment
                                         The lipoma is rapidly growing or abnormally located e.g. sub-facial, sub-muscular

                                  Male Pattern Baldness:

                                  Hirsuitism:
                                   Facial electrolysis is a cosmetic procedure that will not be funded.

                                  Sweating/ hyperhidrosis

                                  Milia:

                                  Molluscum Contagiosum:

                                  Seborrhoeic Keratoses (Basal Cell Papillomata):

                                  Skin Tags

                                  Spider Naevus (Telangiectasia):

Procedure and         Criteria which may be considered suitable for funding
type of restriction
                              Warts
                               Most viral warts will clear spontaneously or following application of topical treatments.
                               The following warts may be referred to dermatology or genitourinary medicine:
                                      Warts on the face
                                      Warts in patients who are immunosuppressed
                                      Genital warts
                                      Painful, persistent or extensive warts, particularly in the immuno-suppressed patient, will need specialist assessment from a

                              Sebaceous cysts
                               Sebaceous cysts are always benign but some may become infected or be symptomatic. Some may require surgical excision
                               particularly if located on the face or on a site where they are subjected to trauma.
                               Indications for intervention might include:
                                     Bleeding, recurrent trauma, site or size that interferes with normal day to day activity. E.g. a naevus on the bridge of the
                                      nose that interferes with the wearing of glasses.
                                     Uncertain diagnosis
                                     Sebaceous or inclusion cysts with a past history of repeated infection.
                                     Cysts on the scalp or other body parts should be managed in the context of the minor operations/general surgery. Funding
                                      will be considered for:
                                     Treatment of diabetic injection sites
                                     Pathological lipodystrophy

                              Xanthelasma
                               Patients with xanthelasma should always have their lipid profile checked before referral to plastic surgery.
                               Many xanthelasmata may be treated with topical TCA or cryotherapy. Larger lesions or those that have not responded to these
                               treatments may benefit from surgery if the lesion is disfiguring. Clinical evidence that previous treatment has been pursued before
                               referral has been made will be required.

                              Dermatofibromas

                      These lesions may be funded in the following circumstances:

                              If a benign skin lesion has become complicated eg by infection or it is interfering with physical function and the clinician wishes to
                               refer the patient to secondary care then funding must be approved by the PCT.

                              If a benign skin lesion of the eye obscures vision or is causing a separate ocular problem then the patient can be referred to an
                               ophthalmologist for removal.

                              A patient with a skin or subcutaneous lesion that has features suspicious of malignancy must be referred to an appropriate
                               specialist for urgent assessment.

Procedure and         Criteria which may be considered suitable for funding
type of restriction
                              Patients with moderate to large lesions that cause actual facial disfigurement may benefit from surgical excision. Medical
                               photography will be required before a funding decision can be made . The risk of scarring must be balanced against the
                               appearance of the lesion.

                      Multiple neurofibromatosis will be funded for plastic surgery.

                      Port wine stains on the face will be funded for removal. Port wine stains on other parts of the body that are causing physical discomfort or
                      are resulting in tissue hypertrophy should be funded.
                      The threshold for agreeing funding will be lower in patients under the age of 19 years.

                      Treatment should be considered for other haemangiomatous or vascular lesions should be funded if:
                            There are physical problems such as bleeding or ulceration
                            The lesion is on the face and is unusually prominent and is getting bigger.

     Procedure and          Criteria which may be considered suitable for funding
     type of restriction
6    Rhinophyma             The first-line treatment of the nasal skin condition is medical. Severe cases or those that do not respond to medical treatment may be
     (PE)                   considered for surgery or laser treatment.
7    Tattoo Removal         The funding for removal of tattoos will be considered in the following circumstances:
     (PE)                            Funding should be considered for allergy to pigments
                                     Where the tattoo is the result of trauma, inflicted against the patient‟s will
                                     The patient was not found to be Fraser (formally Gillick) competent, and therefore not responsible for their actions, at the time of the
                                     Exceptions may also be made for tattoos inflicted under duress during adolescence or disturbed periods where it is considered that
                                      psychological rehabilitation, break up of family units or prolonged unemployment could be avoided, given the treatment opport unity.
                                      (Only considered in very exceptional circumstances where the tattoo causes marked limitations of psychosocial function).
                                      Psychiatric/psychological reports will need to be provided with the initial referral.
8    Scar Revision          Scars that are resulting in physical disability due to contraction, tethering or recurrent breakdown will be funded.
                            Keloid scars, due to an over vigorous reaction in a scar, is more common in certain parts of the body and in certain racial g roups.

                            Funding will be available for:
                                   Keloid scars that result in physical distress due to significant pain or pruritis
                                   Significant keloid scarring on the face

                            Funding will not be available for:
                                   Keloid scars on other parts of the body
                                   Keloid scars secondary to body piercing procedures

                            Scars secondary to trauma/accidents
                                    Scars on the face that are ragged, over 2cm in length or can otherwise be regarded, as particularly disfiguring will be funde d.
                                    Scars on the rest of the body. Scar revision for cosmetic purposes will not be funded unless the disfigurement can be regarded as
                                     particularly grave. Cases will be judged on an individual basis.
                            In both cases, medical photography will be required with the initial referral.

                            Scars as a result of self-harm
                            These are very difficult to treat and usually the only achievable outcome is to make the scars resemble trauma or burns rather than be
                            obviously due to self-harm. Treatment will only be funded when there has been a minimum period of three years where there has been no
                            self-harm and where there is a supporting report from a psychiatrist indicating that the behaviour would be unlikely to recur.
9    Face lifts and brow    These procedures will be considered for treatment of:
     lifts (Rhytidectomy)           Congenital face abnormalities
     (PE)                           Facial palsy (congenital or acquired paralysis)
                                    As part of the treatment of specific conditions affecting the facial skin e.g. cutis laxa, pseudoxanthoma elasticum, neurofib romatosis
                                    To correct the consequences of trauma
                                    To correct deformity following surgery
                                    They will not be available to treat the natural processes of ageing.
10   Blepharoplasty         Upper Lid

     Procedure and           Criteria which may be considered suitable for funding
     type of restriction
     (upper and lower lid)   This procedure will be funded to correct functional impairment (not purely for cosmetic reasons)
     (PE)                    Indications:
                                      Impairment of visual fields in the relaxed, non-compensated state. Evidence will be required that that eyelids impinge on visual
                                       fields reducing field to 120° laterally and 40° vertically
                                      Clinical observation of poor eyelid function, discomfort, e.g. headache worsening towards end of day and/or evidence of chron ic
                                       compensation through elevation of the brow

                             Lower Lid
                             This will be funded for correction of ectropion or entropian or for the removal of lesions of the eyelid skin or lid margin.
11   Rhinoplasty             Rhinoplasty should be funded for:
     (PE)                             Problems caused by obstruction of the nasal airway
                                      Objective nasal deformity caused by trauma
                                      Part of reconstructive head and neck surgery
                                      Correction of complex congenital conditions e.g.cleft lip and palate

                             Patients with isolated airway problems, in the absence of visible nasal deformity, should be referred initially to an ENT consultant for
                             assessment and treatment.
12   Pinnaplasty/            The following criteria should be met for funding to be made available:
     Otoplasty                       The patient must be between the ages of 5 and 14 years at the time of referral
                             Patients seeking pinnaplasty should be seen by a plastic surgeon and following assessment, if there is any concern, assessed by a
13   Repair of external      This will not be routinely funded other than primary suture post trauma
     ear lobes
14   Aesthetic Facial        Funding should be considered for:
     Surgery                        Anatomical abnormalities in children <19 years, likely to cause impairment of normal emotional development
     (PE)                           Pathological abnormalities
                                    Correction of post traumatic bony and soft tissue deformity of the face
15   Alopecia                Funding will be available when it is a result of previous surgery or trauma including burns
16   Male pattern            Is excluded from funding.
17   Hair transplantation    Will not be funded, regardless of gender, other than in exceptional cases, such as reconstruction of the eyebrow following cancer or trauma.
18   Hair depilation         Hair depilation will be funded for patients who:
     (PE)                            Have undergone reconstructive surgery leading to abnormally located hair-bearing skin
                                     Those with a proven underlying endocrine disturbance resulting in Hirsutism e.g. polycystic ovary syndrome
                                     Are undergoing treatment for pilonidal sinuses to reduce recurrence

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction
19   Breast Reduction      Breast reduction surgery is an effective intervention that should be funded if the following criteria are met:
                                   The patient is suffering from neck ache or backache. Clinical evidence will need to be produced that this has been investiga ted to
                                    rule out any other medical/physical problems to cause these symptoms
                                   The wearing of a professionally fitted brassiere has not relieved the symptoms
                                   Persistent intertrigo
                                   Serious functional impairment
                                   The patient has a BMI of less than 30 kg/m²
                                   (or the patient is male with hormonal or drug related breast growth)

                           Patients should have an initial assessment by the referrer prior to an appointment with a consultant plastic surgeon to ensur e that these
                           criteria are met. At, or following this assessment, there should be access to a trained bra fitter, to assess if this alone will relieve the
                           symptoms experienced by the patient. Assessment of the thorax should be performed, including the use of x-ray, scan etc.
20   Breast augmentation   Augmentation will only be performed for reconstructive purposes and will not be carried out for small but normal breasts or for breast tissue
     (PE)                  involution, including post partum changes.
21   Asymmetry             Funding will only be considered if there is gross disparity of breast cup sizes on initial consultation with the patients GP .
22   Revision of Breast    Revisional surgery is carried out for implant failure, causing proven health problems the decision to replace the implants ra ther than simply
     Augmentation          remove them should be based upon the clinical need for replacement and whether the patient meets the criteria for augmentation at the time
     (PE)                  of revision.

                           Replacement should not be funded if the original operation was done for cosmetic reasons in the private sector, although it w ould be
                           acceptable to replace implant failures with an implant purchased by the patient
23   Mastopexy (Breast     This is included as part of the treatment of breast asymmetry and reduction but not for purely cosmetic/aesthetic purposes su ch as post-
     Lift)                 lactational ptosis.
24   Nipple Inversion      Nipple inversion may occur as a result of underlying breast malignancy. If the inversion is newly developed, it requires urge nt referral and
     (PE)                  assessment.

                           Surgical correction of nipple inversion should only be available for functional reasons in a post-pubertal woman and if the inversion has not
                           been corrected by correct use of a non-invasive suction device.
25   Gynaecomastia         Surgery to correct gynaecomastia should be allowed if the patient is:
     (PE)                          Post pubertal
                                    Normal BMI < 25 Kg/m

                           True gynaecomastia that is mainly caused by an excess of glandular breast tissue will be funded if the normal medical treatments have
                           failed. Re assurance that the problem is not due to the abuse of drugs with bodybuilding.

                           Pseudo-gynaecomastia, where the enlargement of the male breast is due to an excess of adipose tissue and the BMI is outside the range of
                           a normal BMI, funding will not normally be agreed unless there is clear evidence that the problem has persisted in spite of r igorous dieting
                           and weight loss.

     Procedure and           Criteria which may be considered suitable for funding
     type of restriction
26   Reversal of male        Funding will only be considered if death of an existing child of the man has occurred, OR remarriage following death of spouse, OR loss of
     sterilization           unborn child when vasectomy had taken place during the pregnancy.
27   Reversal of female      Funding will only be considered if death of an existing child of the woman has occurred, OR remarriage following death of spouse AND
     sterilization           partner has a satisfactory sperm count
28   Treatment for           As there is currently insufficient evidence on the risks and benefits of gender reassignment this procedure should only be considered under
     gender dysphoria        exceptional circumstanced. These are some of the criteria that would be taken into account before funding the procedure.
                             Referrals should be made by a consultant psychiatrist. A written recommendation will be needed from the psychiatrist, who should have had
                             clinical responsibility for the patient for at least 6 months. Referrals should not be accepted directly from GPs or other professionals.

                             Prior to genital sex reassignment the patient will also need to be seen by a consultant urologist to identify and possibly tr eat abnormalities of
                             the genito-urinary tract. This is commonly accepted as good practice.

                             Prospective patients should be required to live and work for at least two years in the social role of the opposite sex. This is referred to as the
                             "real life" test.
29   Assisted conception     Intrauterine insemination (IUI) is considered a low priority treatment for couples who are mutually eligible for both in-vitro fertilisation (IVF)
     using IVF/ICS/IUI for   and IUI.
     infertility             One full cycle of (IVF) intracytoplasmic sperm injection (ICSI) will only be provided under the NHS to couples who satisfy th e eligibility
     (T)                     criteria. Referrals should be made to a hospital consultant with a special interest in infertility for in vestigation and then to the Isis Fertility
                             Centre if criteria are met.
                             This policy does not cover preimplantation genetic diagnosis or cryopreservation of gametes
                             and/or embryos.
                             Criteria for funding:
                             1. Ma ximum FSH level 15 U/L.
                             2. Minimum maternal age 23 years at the start of super-ovulation.
                             3. Ma ximum maternal age 39 (ie < 40) at the start of super-ovulation.
                             4. Ma ximum BMI 30 kg/m 2.
                             5. Minimum BMI 19 kg/m 2, if anovulatory.
                             6. Duration of sub-fertility: No criterion for cases with a diagnosed severe cause of infertility; 2 years for cases with unexplained or mild -
                             moderate cause of sub-fertility.
                             7. Previous IVF treatment: Ineligible if there have been 3 or more unsuccessful p revious fresh embryo cycles (either NHS or self-funded).
                             8. Smoking status. Where a couple smoke, only couples who agree to take part in a supportive programme of smoking cessation w ill be
                             accepted on the IVF treatment waiting list and should be nonsmoking at time of treatment.
                             9. Parental status Couples are ineligible if there are any children from current relationship. Priority should be given to ch ildless couples (i.e.
                             no previous children for either partner).
                             10. Previous sterilization has taken place (either partner), even if it has been reversed.
                             11. Child welfare Couples should conform to statutory „Welfare of the Child‟ requirements.
                             12. Medical conditions Treatment may be denied on other medical grounds not explicitly co vered in this document.
                             A “full cycle‟ of IVF (IVF/ICSI) includes one „fresh embryo‟ cycle (when appropriate including egg donation subject to UK availab ility of donor
                             eggs, sperm donation in the context of subfertility, or surgical sperm retrieval).

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction
30   Treatment for         Radiofrequency ablation should not be used for snoring.
     snoring               Laser treatment will only be considered for snoring in the context of treatment under specialist supervision for obstructive sleep apnoea.
31   Grommets /            A period of watchful waiting is the best management strategy for children with otitis media with effusion. Grommets should only be
     Adenoidectomy         considered for patients satisfying defined criteria.
     (T)                   Children with hearing impairment should have a period of at least 6 months of watchful waitin g from the onset of the symptoms.
                           Grommet should only be considered if
                           A - glue ear persists, and the child (3 years or over) also suffers from one of the followings:
                                1. Recurrent acute otitis media with more than 5 times per year.
                                2. Evidenced delay in speech development
                                3. Educational or behavioural problems attributable to persistent hearing impairment, with a hearing loss of at least 25dB particularly in
                                    the lower tones (low frequency loss
                                4. A second disability, such as Down‟s syndrome
                                5. Severe collapse of the eardrum

                           B.       the child has had at least 5 occurrences of acute otitis media in the last year with additional complications such as perfora tions,
                           persistent discharge, febrile convulsions, sensorineural deafness or cochlear implantation.
                           C.       for children aged 2 years, the child has:
                                   OME with prolonged effusion (6 months or longer);
                                   AND measured hearing loss;
                                   AND disability attributable to hearing loss (delay in speech development or other problems).

                           Indications 1-5 are similar to the referral guidelines outlined in „Prodigy‟.
                           Combine adenoidectomy and grommet insertion if the child has nasal symptoms on top of otitis media with effusion
32   Tonsillectomy         A period of watchful waiting is recommended prior to tonsillectomy to establish firmly the pattern of symptoms and allow the patient to
     (T)                   consider fully the implications of operation.

                           Patients   should meet all of the following criteria:
                                     sore throats are due to tonsillitis
                                     five or more episodes of sore throat per year
                                     symptoms for at least a year
                                     the episodes of sore throat are disabling and prevent normal functioning.

                           OR the patient should have:
                                  intractable cough with a high level of streptococcal antibody; OR
                                  severe halitosis which has been demonstrated to be due to tonsil crypt debris.

                           Note should also be taken of whether the frequency of episodes is increasing or decreasing.

     Procedure and          Criteria which may be considered suitable for funding
     type of restriction
                            Tonsillectomies for other indications will need to go via exceptional cases panel before surgery is undertaken including:
                                    Sleep apnoea (demonstrated by a sleep study or other accepted method of diagnosis).
                                    Significant failure to thrive in children.

                            Once a decision is made for tonsillectomy, this should be performed as soon as possible, to maximise the period of benefit be fore natural
                            resolution of symptoms might occur (without tons illectomy).
                            GENERAL SURGERY
33   Bariatric surgery      Funded patients are those who fulfill criteria for treatment under NICE guidance. Treatment will not be funded without prior approval of the
     (PE)                   Exceptional cases Panel. Treatment should be carried out in accordance with NICE guidance.

                            The NICE guidance includes the following:

                            It is recommended that patients with morbid obesity who are considering surgery to aid weight loss should discuss the treatme nt with the
                            specialist responsible for their treatment. This discussion should cover, in detail, the potential benefits, risks and complications of having
                            surgery to aid weight reduction.

                            NICE has recommended that surgery to aid weight loss should be available as a treatment option for people with morbid o besity provided
                            that they meet all of the following criteria
                                     They are aged 18 years or over
                                     They have tried all other appropriate non-surgical treatments to lose weight but have not been able to lose weight or maintain
                                      weight loss
                                     There are no specific medical or psychological reasons why they should not have this type of surgery
                                     They are generally fit enough to have an anaesthetic and surgery
                                     They should understand that they will need to be followed-up by a doctor and other healthcare professionals such as dieticians or
                                      psychologists over the long-term
                            People with morbid obesity should have surgery to aid weight loss only after they ha ve had a full assessment by the specialis t and other
                            healthcare professionals involved in their care. In addition, counselling and support should be arranged for people before and after the
                            surgery. Smoking cessation advice should be offered as necessary.
34   Varicose vein          Surgery or injection will not be performed unless the patient meets one or m ore of the following criteria:
     surgery or injection            Patient has varicose eczema which has not responded to the regular use of compression hosiery for a period of six months
     (T)                             Patient has lipodermatosclerosis or ulcer
                                     Patient has had at least two episodes of superficial thrombophlebitis
                                     Patient has had two minor episodes of bleeding from a varicosity or one major episode
                                     Patient has significant aching, discomfort or oedema in the affected leg(s) that is thought to be due to varicose veins, requ ires
                                      analgesia (in the case of aching or discomfort) and has not responded to the regular use of compression hosiery for a period of six
35   Endoscopy              Criteria for upper GI endoscopy for the investigation of dyspepsia s hould be based on NICE guidance:
     (T)                    Urgent specialist referral for endoscopic investigation is indicated for patients of any age with dyspepsia when presenting with any of the
                            · chronic gastrointestinal bleeding
                            · progressive unintentional weight loss

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction
                           · progressive difficulty swallowing
                           · persistent vomiting
                           · iron deficiency anaemia
                           · epigastric mass or suspicious barium meal.
                           Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. H owever, in
                           patients aged 55 years and older with unexplained and persistent recent onset dyspepsia alone despite treatment, an urgent referral for
                           endoscopy should be made.

                           Relevant OPCS code(s): G16, G19, G45

                           Audit note: These OPCS coded procedures will also be used for other indications, so audit of
                           implementation of guidance should be specific to dyspepsia.
36   Non-urgent elective   Elective surgery will not be carried out (unless urgent) on patients unless they have been offered and attended (or have documental refusal
     surgery for smokers   of) a course of stop smoking support (provided either by the specialist stop smoking service or in primary care)
                           Patients should be offered stop smoking support at the point of referral and in secondary care. Patients who have not achieve d smoke free
                           status are not excluded from surgery – this is down to clinical judgment of risks and benefits.
37   Spinal surgery:       Exceptional patients are those who fulfill criteria for treatment under NICE guidance.
     Endoscopic laser      The only indications for this spinal surgery to be considered are those from NICE guidance (IPG027, IPG031, IPG061, IPG088, I PG081) and
     spinal surgery,       must conform to this guidance ie should not be used without special arrangements for audit, consent and research.
     percutaneous                  IPG061 Percutaneous endoscopic laser thoracic discectomy is used to treat symptomatic thoracic disc herniation.
     intradiscal                   IPG027 Laser lumbar discectomy is considered when there is nerve compression or persistent symptoms that are unresponsive to
     electrothermal                 conservative treatment. Laser discectomy can be performed when the prolapse is contained. It is one of several minimally inva sive
     therapy                        surgical techniques, which are alternatives to open repair procedures such as open lumbar discectomy or laminectomy.
     (PE)                          IPG031 endoscopic laser foraminoplasty for chronic back and leg pain from a variety of causes.
                                   IPG088. Endoscopic division of epidural adhesions for lower back pain, particularly when radiculopathy (a disorder of the spinal
                                    nerve roots) is present.
                                   IPG081 Percutaneous intradiscal electrothermal therapy for discogenic back pain
38   Spinal surgery for    Patients will only receive non-acute spinal surgery under the following circumstances:
     non-acute lumbar
     conditions            Surgical discectomy (standard or microdiscectomy) in selected patients with sciatica secondary to disc prolapse where conservati ve
     (T)                   management for at least 4-6 weeks has failed.

                           It is recommended that Primary Care Referral for assessment for spinal surgery or other invasive intervention should only be considered if
                           radicular pain has not responded to non-invasive treatment after 4-6 weeks.

                           Fusion surgery for chronic low back pain may be considered if severe pain despite two years of an „active rehabilitation programme‟
                           (cognitive intervention combined with exercises is recommended when available).

                           + Acute conditions include back pain due to fracture, dislocation, complications of tumour or infection and/or nerve root or spinal
                           compression responsible for progressive neurological deficit.
39   Hip and knee          Patients should be referred for consideration of total joint replacement when all conservative means have failed to alleviate the patient‟s pain

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction
     replacement surgery   and disability, which should be significantly interfering with their activities of daily living and their ability to sleep. Referral should only be for
     (T)                   patients satisfying defined criteria.

                           Replacement surgery will not be performed unless all the following criteria are met:
                                   The patient is suffering from pain and disability that is sufficiently severe as to interfere with their daily life and/or ability to sleep (eg
                                    Salisbury Score 14 or an Oxford Hip and Knee Score of 60) AND
                                   The patient has used a range of conservative treatments – analgesics, NSAIDS, e xercise and physiotherapy (as appropriate) – and
                                    these have failed to alleviate the patient‟s pain AND
                                   If obese (BMI >30), the patient has undertaken a supervised weight reduction programme with the aim of reducing the BMI to be low
40   Chronic hand          GANGLION
     conditions            Cystic degeneration from joint capsule or tendon sheath. Lesions at the base of the digits are often small but very tender (seed ganglion).
     (T)                   Mucoid cysts arise at the distal interphalangeal joint and may disturb nail growth. Ganglions arising at the level of the wrist are rarely painful
                           and most will resolve spontaneously within 5 years. The recurrence rate after excision of wrist ganglia is between 10 – 45 %.
                           Conservative management is largely a matter of reassurance. When there is doubt aspiration will confirm diagnosis. After a first aspiration
                           50-80% of ganglia recur, but after a third aspiration only 20% recur.
                                   Painful seed ganglia.
                                   Mucoid cysts that are disturbing nail growth or have a tendency to discharge (risk of septic arthritis in distal inter-phalangeal joint).
                           There is no indication for the routine excision of simple wrist ganglia. These should not generally be referred.

                           CARPAL TUNNEL SYNDROME
                           Patients typically present with nocturnal dysaethesia in the hands wearing off with activity. The presence of a positive Phalen‟s (wrist flexion
                           test) or Tinel‟s sign confirms. Nerve conduction studies are NOT generally needed to confirm the diagnosis. In elderly patients the
                           condition may develop insidiously.
                           Conservative treatment may include adjustment of activities or posture, with night splintage in neutral wrist position. Non-steroidal anti-
                           inflammatory drugs and diuretics are occasionally of benefit. Steroid injections may be of value in uncomplicated cases (requires clinical
                                    Acute severe symptoms (fewer than 5% of patients) uncontrolled by conservative measures, particularly in pregnancy, significantly
                                     interfere with daily activities.
                                    Mild to moderate symptoms with failure of conservative management, (4 months)
                                    Neurological deficit ie. Sensory blunting or weakness of thenar abduction (wasting or weakness of abductor pollicis brevis).

                           DUPUYTRENS DISEASE
                           Nodular or cord-like thickening of the palmar skin. May tend to cause tethering of the digits with loss of extension range.
                                  Loss of extension in one or more joints exceeding 25 degrees.
                                  Young patients (under 45 years) with disease affecting 2 or more digits and loss of extension exceeding 10 degrees.

                           TRIGGER FINGER

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction
                           Snapping of the fingers as they are extended from a fully flexed posture, associated with a tender nodule in flexor tendon at base of finger or
                           Conservative treatment may include rest from precipitating activities, Non-steroidal anti-inflammatory drugs. Injection of hydrocortisone into
                           the tissue IN FRONT of the tendon at the level of the distal palmar crease (MCPJ) will often settle early cases (requires cli nical experience).
                                    Failure to respond to conservative treatment (max 2 injections)
                                    Fixed flexion deformity that cannot be corrected
41   Temporomandibular     This should not be routinely funded
     Joint Replacement     Indications for intervention in rare cases with prior approval.
     (PE)                  The affected patients usually have severe disease of the temporomandibular joint which may be more se rious if patients cannot open their
                           mouths adequately, as dentistry, anaesthesia and resuscitation may be severely complicated and even life -threatening. In such rare cases,
                           TMJ replacement may be considered. Contraindications are: 1) active or chronic infection; 2) patient conditions where there is insufficient
                           quantity or quality of bone to support the components; 3) systemic disease with increased susceptibility to infection; 4) patients with
                           extensive perforations in the mandibular fossa and/or bony deficiencies in the articular eminence or zygomatic arch that would severely
                           comprise support for the artificial fossa component; 5) partial TMJ joint reconstruction; 6) known allergic reaction to any m aterials used in the
                           components; 7) patients with mental or neurological conditions who are unwilling or unable to follow post-operative care instructions; 8)
                           skeletally immature patients; and 9) patients with severe hyper-functional habits (e.g. clenching, grinding etc.).
42   Drugs                 Drugs will only be funded in line with the locally agreed policy, formulary and guidelines. Updates to drug policy will be communicated to
                           clinicians directly and posted on the PCT website
43   Dental implants       Implants offer the possibility of a stable prosthesis for individuals who have suffered extensive loss of oral tissue. They can also be used to
     (T)                   provide support for fixed bridges and individual crowns.

                           The technique currently used was developed by Professor Brånemark in the late 1970s and relies on the principle of osseointegration. This
                           means that the material (titanium) of the implant is not merely tolerated by the tissues but becomes integrated within the ja w bone giving the
                           implant firm stability. The prosthesis is then attached to the implant. With earlier blade type implants results were unpredictable with the
                           possibility of the implant loosening within a few years of placement. Osseointegrated implants, however, have a much higher s uccess rate.

                           With the increasing popularity of Professor Brånemark‟s technique an increasing demand for implants is inevitable and it is important,
                           therefore, to prioritise the categories of individuals for whom implant treatment is appropriate. The vast majority of the p opulation can
                           tolerate wearing dentures and these remain a successful and well-established method of replacing missing teeth.


                           The categories of patient for whom implants should be considered are those where there is no practical alternative. The categ ories are: -
                                  Patients with maxillofacial and cranial defects. These individuals have considerable amounts of missing hard tissue and/or teeth,
                                   may be due to developmental disorders, trauma or tumours. These include: Clefts of the hard and/or soft palate, Major
                                   maxillary/mandibular resections, Extensive alveolar ridge deformities
                                  Patients with multiple congenitally missing teeth where conventional prostheses have proved to be ineffective
                                  Patients who have suffered major trauma that cannot be restored by conventional prostheses
                                  Patients with edentulous jaw(s) who: have gross atrophy of their jaw(s) with unacceptable stability or pain following the utilisation of
                                   appropriate specialist techniques in the constructions of the prosthesis or have problems in retaining a conventional prosthesis due

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction
                                     to atypical movements, such as dyskinesias and Parkinson‟s Disease.
                           Only in the most exceptional circumstances will implants be available for patients with problem dentures or who require single tooth
44   Orthodontics          Patients should be referred for orthodontic care for the following categories of need:
     (T)                            Grade 4 or 5 of the Dental Health Component of the Index of Orthodontic Treatment Need: or
                                    Grade 3 of the Dental Health Component of that index with an Aesthetic Component of 6 or above
45   Wisdom teeth          Surgical removal of impacted third molars should be limited to patients with evidence of pathology (as per NICE Guidance, TA1 , 2000):
     removal                        unrestorable caries,
     (T)                            non-treatable pulpal and/or periapical pathology,
                                    cellulitis, abcess and osteomyelitis,
                                    internal/external resorption of the tooth or adjacent teeth,
                                    fracture of tooth,
                                    disease of follicle including cyst/tumour,
                                    tooth/teeth impeding surgery or reconstructive jaw surgery,
                                    when a tooth is involved in or within the field of tumour resection.
46   Filtered/coloured     These will not be offered for specific reading difficulties
47   Photodynamic          Photodynamic therapy (PDT) should only be used in accordance with NICE guidance (TA68).
     therapy (PDT) for
     age related macular   PDT should only be considered for the treatment of wet age-related macular degeneration for individuals who have a confirmed diagnosis of
     degeneration          classic with no occult subfoveal choroidal neovascularisation (CNV) (that is, whose lesions are composed of cl assic CNV with no evidence
     (T)                   of an occult component) and best-corrected visual acuity 6/60 or better. PDT should be carried out only by retinal specialists with expertise
                           in the use of this technology.

                           PDT is not recommended for the treatment of people with predominantly classic subfoveal CNV (that is, 50% or more of the entire area of
                           the lesion is classic CNV but some occult CNV is present) associated with wet age -related macular degeneration, except as part of ongoing
                           or new clinical studies that are designed to generate robust and relevant outcome data, including data on optimum treatment regimens, long -
                           term outcomes, quality of life and costs.

48   Cataract surgery      First eye
     (T)                   Surgery will not be offered for patients with visual acuity of 6/12 or better without any other significant ophthalmic pathology unless they drive
                           or have problems with work or are unsafe because of glare

                           Second eye
                           As benefits of second eye surgery have been demonstrated patients will be offered this procedure provided they full fill the referral criteria.
                           The only exception to the above is when there is resultant anisometropia (a large refractive difference between the two eyes) , which would
                           result in poor binocular vision or even diplopia.

                           The following scoring system should be used to determine referral.

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction

                           Assessment of visual and social difficulties:

                           Visual acuity

                           Less than 6/36                                                       3
                           Less than 6/18 in both eyes                                          3
                           Less than 6/18 in poorer eye                                         2
                           Less than 6/12 in either eye                                         1
                           6/9 or better but with significant visual disturbance                1

                           All patients scoring 3 points in this section should be referred for the worst eye

                           Visual disability

                           Affected by glare                                                        2
                           Difficulty with reading                                                  1
                           Difficulty watching television                                           1
                           Difficulty performing work or hobbies                                    1

                           Social functioning (Tick ONE box only)

                           Lives independently                                                      2
                           Cares for partner                                                        2
                           Lives in sheltered accommodation                                         1
                           Lives with carer                                                         1
                           Lives in a residential or nursing home                                   1

                           Drives a car/is in paid employment                                       1
                           Mild/moderate hearing impairment                                         1
                           Severe hearing impairment (Deaf)                                         2
                           Has fallen twice or more in the last 12 months                           2
                           Total points scored:

                           Patients with a VA score of 3 or a cumulative score of 6 or more should be referred.
                           Please Note:
                           Patients with retinal pathology should be referred to a general ophthalmology clinic.
49   Laser treatment of    Not routinely funded

     Procedure and         Criteria which may be considered suitable for funding
     type of restriction
50   Circumcision          Circumcision should only be performed for the following indications:
     (T)                   1. Redundant prepuce, phimosis (inability to retract the foreskin due to a narrow prepucial ring) and paraphimosis (inability to pull forward a
                           2. Balanitis Xerotica Obliterans (chronic inflammation leading to a rigid fibrous foreskin).
                           3. Balanoposthis (recurrent bacterial infection of the prepuce).
                           There are several alternatives to treating retraction difficulties before circumcision is carried out. It is important that all those performing
                           circumcision should follow the General Medical Council (GMC) guidelines.
51   Prostatism            Investigations will not be carried out unless the patient has one of the following:
     (T)                            An international prostate symptom score of 8 or more
                                    Dysuria
                                    Post voided residual volume of >200mls
                                    More than one UTI
                                    Deranged renal function
                                    PSA greater than age adjusted normal values
52   Vasectomies under     This policy is for circumstances when vasectomy should be performed under general anaesthetic. In all other cases, referral should be made
     general anaesthetic   to local GP based services.
                           Only under the following circumstances should a vasectomy be performed under local anaesthetic. In other cases a referral sho uld be made
                           to a primary Care Provider

                                 Previous documented adverse reaction to local anaesthesia
                                 Scarring or deformity distorting the anatomy of the scrotal sac or content making identification and/or control of the sperma tic cord
                                  through the skin difficult to achieve
53   Dilletation &         D&C and hysteroscopy will only be used in line with NICE guidance (CG44, 2007):
     curettage             Patients will not receive D&C:
     (T)                           As a diagnostic tool for heavy menstrual bleeding, or
                                   As a therapeutic treatment for heavy menstrual bleeding

                           Patients will receive hysteroscopy in the investigation and management of heavy menstrual bleeding only when it is carried ou t
                                           Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive, for example, to determine
                                            the exact location of a fibroid or the exact nature of the abnormality.
                                         Where dilatation is required for non-hysteroscopic ablative procedures, hysteroscopy should be used immediately prior to
                                            the procedure to ensure correct placement of the device.
54   Hysterectomy          Hysterectomy for heavy menstrual bleeding will only be funded within NICE guidance and when:
     (T)                          Other treatments (such as a levornogestrel intrauterine system, non-steroidal anti-inflammatory agents, tranexamic acid,
                                   endometrial ablation, uterine-artery embolisation in selected cases) have failed, are not appropriate or are contra -indicated in line
                                   with NICE guidelines.

     Procedure and           Criteria which may be considered suitable for funding
     type of restriction

                             Contraindications to the levonorgestrel intrauterine system are:
                                            1. Severe anaemia, unresponsive to transfusion or other treatment, whilst a Levonorgestrel intrauterine system trial is in
                                            2. Distorted or small uterine cavity (with proven ultrasound measurements).
                                            3. Genital malignancy.
                                            4. Acti ve trophoblastic disease.
                                            5. Pelvic inflammatory disease.
                                            6. Established or marked immunosuppression.
55   Intensive inpatient     Intensive inpatient therapy will not be provided
     therapy for severe      There is limited evidence to support the use of manual lymphatic drainage and compression bandaging. Intensive, short term th erapy using
     primary                 decongestive lymphatic therapy may be beneficial when combined with long term self management. These treatments are suitable for local
     lymphoedema             outpatient provision.
56   Complementary and       Complementary and alternative therapies are a mixed group of therapies considered low priority treatments on the basis of weak evidence of
     alternative therapies   clinical effectiveness. They will only be funded under the NHS as part of an existing service where:
     (T)                     • The individual therapy used for a specific condition has been critically appraised.
                             • The training and practice of the therapist is regulated by a statutory regulatory body.
                             Complementary and alternative therapies will only be provided outside the NHS in exceptional circumstances.

                             Complementary and alternative therapies comprise a wide range of disciplines. We have adapted the classification recently used by the
                             House of Lords Select Committee, which divides these therapies into three groups:
                             Group 1 - those which are regarded as the principle disciplines:
                             1a - with statutory regulatory control - osteopathy, chiropractic
                             1b - acupuncture, herbal medicine and homeopathy.
                             Group 2 - therapies used to complement conventional medicine without embracing diagnostic skills, eg massage, aromatherapy,
                             hypnotherapy, reflexology and the Ale xander Technique.
                             Group     3a - therapies which are long established and rational in certain cultures (eg Ayurvedic medicine)
                             3b - others with no credible evidence such as crystal therapy and dowsing.

                             While some evidence of effectiveness exists for therapies in Group 1, the clinical effectiveness of the majority of these therapies has not
                             been proved with strong evidence as obtained through properly established scientific trials. Some NHS professionals use a sel ection of
                             these therapies in their practice, eg physiotherapists using manipulation or acupuncture, or GPs using homeopathy. With effective regulator y
                             mechanisms in place for individual professionals and under NHS clinical governance arrangements use of such therapies is acce ptable.


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