policy for procedures not funded - nottinghamwestccg.nhs.uk · cranial banding for positional...

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Policy for Procedures Not Funded

Document purpose

This policy lists procedures that are not funded by NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG (Greater Nottinghamshire). This policy is based on and supersedes the Nottinghamshire (less Bassetlaw) Procedures of Limited Clinical Value Policy 2015 and the East Midlands Cosmetics Policy 2015.

Version Version 1.0 Version 2 - 5/6/17 Version 3 – 11/7/17 Version 4 – 16-8-17 Version 5 – 18-08-17 Version 6 – 31-10-17

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Title Policy for Procedures Not Funded

Associated Policy

Service Restriction Policy (2017)

Nominated Lead

Director of Contract Delivery

Approval Date October 2017

Approving Committee

NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG Governing Bodies

Review Date This policy will be reviewed in 1 year or earlier if additions or changes

are required.

Groups/staff Consulted

Clinical leads across Greater Nottinghamshire CCGs

Target audience All CCG staff All providers All Clinicians

Circulation list CCG Websites All providers Primary Care Clinicians

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Associated documents

Individual Funding Requests (IFR) V2 April 2011

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Contents Purpose of the policy ............................................................................................................................4

Introduction...........................................................................................................................................4

Commissioning Principles ....................................................................................................................4

Procedures not expressly covered in this policy ...................................................................................4

Policy Exclusions..................................................................................................................................5

Exceptionality and Special Circumstances ......................................... Error! Bookmark not defined.

Implementation and Compliance ........................................................ Error! Bookmark not defined.

Statement of Cosmetic Procedures .......................................................................................................5

List of procedures covered under this policy ........................................................................................5

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Purpose of the policy The purpose of this policy is to ensure that the Greater Nottinghamshire Clinical Commissioning Groups (the Commissioners) only fund treatment for clinically effective interventions that are then delivered to the right patients. It sets out the treatments deemed to be of insufficient priority to justify funding from the available fixed budget. This policy lists a number of procedures and services that the Commissioners do not fund.

If a provider undertakes one of the procedures contained within this policy commissioners will not pay unless explicit agreement has been given by the appropriate CCG.

This policy should be read in conjunction with the Service Restriction Policy (2017). These two policies have been based on and include all the procedures that were part of the Procedures of Limited Clinical Value Policy (2015) or the East Midlands Cosmetic Policy (2015) which has now been superseded.

Approved prescribing of medicines falls outside the scope of this document and is covered in the guidelines and protocols produced by the Nottinghamshire Area Prescribing Committee. Further information can be obtained from the Pharmacy/Medicines Management Department or via www.nottsapc.nhs.uk.

Introduction This policy identifies procedures that the Greater Nottinghamshire CCGs do not fund. These procedures have either previously been identified as not routinely funded in the Procedures of Limited Clinical Value 2015, East Midlands Cosmetics Policy 2015, or are new to Greater Nottinghamshire CCGs but have been adopted where the procedures are not routinely commissioned in a number of other CCGs

Commissioning Principles Commissioning decisions are made in accordance with the general principles set out below:

Clear evidence of clinical and cost effectiveness will be sought before NHS resources are invested in the treatment

The cost of the treatment for individual patients and others within any anticipated cohort is a relevant factor.

The extent to which the individual or patient group will gain a benefit from the treatment will be considered and balanced against the benefit which could be gained by alternative investment possibilities to meet the needs of the community

The process and policies will consider all relevant national standards, take into account all proper and authoritative guidance along with due regard to the funding available for local health services.

Procedures not expressly covered in this policy

If a procedure is not covered in either this policy or the service restrictions policy and is documented on the indicative activity plan, with or without an activity value or finance value, this would indicate that both provider and commissioner recognize the activity as commissioned and therefore is chargeable.

If a procedure is not shown on the indicative activity plan and is also not covered in either this policy or the service restrictions policy this would indicate that both the provider and commissioner acknowledge that the procedure is unlikely to have been actively commissioned and on that basis the provider should seek clarification and appropriate approval before carrying out the procedure otherwise the procedure will not be funded.

http://www.nottsapc.nhs.uk/

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The above scenario would be applicable should new guidance be published by NICE or any other body suggesting that criteria for procedures or new procedures are available. Commissioners require the opportunity to ensure that a procedure is actively commissioned before funding is available.

Policy Exclusions Patients should not be referred for or undergo the procedures listed in this policy, except in the case of: Emergency, OR

A reasonable suspicion of cancer, OR

As part of reconstruction following treatment for cancer, traumatic injury or the correction of congenital malformation

The procedures covered by this policy are not commissioned unless the treatment is: post-trauma, part of reconstruction following surgery (e.g. for cancer), part of the management of a congenital abnormality which results in a serious health function deficit, or for an iatrogenic condition arising from treatment previously delivered within the NHS. The term ‘iatrogenic condition’ refers to a condition that was directly attributable to previous medical treatment. In this context, ‘iatrogenic condition’ specifically excludes known side effects of a treatment or possible complications which the patient would normally be notified about when they were informed of the benefits and risks when consenting to the original treatment.

If a patient falls within the above categories then the expectation is that the patient will receive the appropriate treatment without delay. Commissioners will require assurance and evidence that the reason for carrying out the procedure meets the above criteria but this assurance will be sought retrospectively.

The policy will be implemented across providers in primary and secondary care. It will be formally incorporated into contracts and will be subject to routine monitoring for compliance.

Statement of Cosmetic Procedures "Cosmetic" surgery means procedures to improve appearance. It is also known as "aesthetic" surgery.

This policy lists many procedures that are judged to be cosmetic and will not normally be funded by the NHS. This policy applies to cosmetic surgery irrespective of the sub specialty of the surgeon concerned, including plastic surgery, ear nose and throat surgery, oral and maxillofacial surgery, dermatology, and other surgical specialties.

List of procedures covered under this policy

Description of Procedure/Treatment Status under previous East Midlands Policies

Abdominoplasty (Apronectomy/ Panniculectomy) Previously restricted *

Acupuncture for non-specific low back pain of up

to 1 year duration

Previously restricted *

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Acupuncture for all other purposes (see above) Previously not routinely funded *

Aesthetic operations on the umbilicus Not previously within policy

Alternative therapies not explicitly listed in

this policy

Previously not routinely funded *

Alexander technique Previously not routinely funded *

Anal rectal skin tags Previously not routinely funded *

Applied kinesiology Previously not routinely funded *

Aromatherapy Previously not routinely funded *

Autogenic training Previously not routinely funded *

Autologous Chondrocyte Implantation (ACI) Previously not routinely funded *

Ayurveda Previously not routinely funded *

Back pain - Facet joint injections Previously restricted *

Benign skin lesions Previously restricted **

Brow Lift / Face lift / Ptosis surgery Previously restricted **

Body Contouring Previously not routinely funded **

Botulinum Toxin Treatment, lontophoresis or

surgical treatments for Axillary Hyperhidrosis

Previously restricted *

Botulinum Toxin treatment for wrinkles frown lines

or aging neck

Previously not routinely funded **

Brachioplasty/Upper arm lift Previously not routinely funded **

Breast Uplift Previously restricted **

Buttock Lift Previously not routinely funded *

Calf implants Not previously within policy

Cheek Implants (except in post-trauma cases

and/ or part of planned reconstruction following

surgery e.g. for cancer


Chemical peels Not previously within policy

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Chin implant (genioplasty, mentoplasty) Previously not routinely funded **

Chinese medicine Previously not routinely funded *

Chiropractic therapy Previously not routinely funded *

Cholecystectomy for asymptomatic gallstones -

Where there are no symptoms, cholecystectomy

confers no benefit to patients with asymptomatic

gallstones, even in patients with one attack of

uncomplicated gallstone pain.

Only funded for patients at risk of developing

gallbladder carcinoma or gallstone complications

– special cases process will apply


Circumcision for non-medical reasons Previously not routinely funded **

Collagen implant (except in post-trauma cases

and/ or part of planned reconstruction following

surgery e.g. for cancer


Congenital pigmented lesions on the face

(removal of)

Previously restricted**

Correction of deviated septum (see

surgical treatment of snoring)


Cranial banding for positional plagiocephaly Previously not routinely funded **

Dermabrasion of skin Not previously within policy

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Diagnostic investigations for Irritable

Bowel Syndrome (IBS)

The following tests will not be funded for

confirmation of diagnosis in adults who meet the

IBS diagnostic criteria:

Ultrasound

Rigid/flexible sigmoidoscopy

Colonoscopy; barium enema

Thyroid function test

Faecal ova and parasite test

Faecal occult blood

Hydrogen breath test


Dupuytrens Contracture;

The Commissioner does not fund

collagenase injections (Xiapex) nor does

the commissioner fund radiation therapy

for early Dupuytrens.

Previously restricted

Dilatation and Curettage (D&C) /

Hysteroscopy Including the treatment of

menorrhagia (Heavy Menstrual Bleeding)

Dilation and Curettage will not be funded in

the following circumstances:

As a diagnostic tool for heavy menstrual

bleeding.

Or as a therapeutic treatment for heavy

menstrual bleeding


Earlobe repair Previously not routinely funded **

Electrolysis Previously not routinely funded **

Environmental medicine Previously not routinely funded *

Removal of Epidermoid/Pilar (Sebaceous Cysts)

with the exception of recurrent infection and size

greater than 0.5cm diameter


Epidural injections of non-radicular pain Not previously within policy

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Epidural injections of non-specific low back pain Previously not routinely funded *

Excimer laser for Astugmatism and Xanthelasma Not previously within policy

Excimer laser for corneal erosions Not previously within policy

Excision of excessive skin from thigh, leg,

hip, buttock, arm, forearm or other areas


Extracorporeal shock-wave therapy for

planta fasciitis

Not previously within policy

Face lifts (unless part of the treatment of facial nerve

palsy/ congenital facial abnormalities/treatment of

specific facial skin condition e.g. cutis laxa,

pseudoxanthoma elasticum)


Fat Grafts Previously not routinely funded **

Forearm implants

Hair depilation (removal) for excessive hair

growth (hirsutism)


Hair transplant/ Hair graft/ Hair replacement/ Intralace

hair system for abnormal hair loss


Healing Previously not routinely funded *

Herbal medicine Previously not routinely funded *

Hip resurfacing Previously not routinely funded *

Homeopathy Previously not routinely funded *

Hydrotherapy unless part of an established

care package


Hymen reconstruction Previously not routinely funded **

Hypnosis Previously not routinely funded *

Joint revisions – including hip and knee.

The commissioner will only fund revisions

using standard prosthesis


Knee - Diagnostic Arthroscopy Previously not routinely funded *

Knee Washout Previously resitricted**

Labial reduction/ labiaplasty Previously not routinely funded **

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Laser - general Previously not routinely funded **

Laser Treatment for skin conditions causing

scarring including post acne and post traumatic

scarring


Laser Treatment for facial hyperpigmentation Previously restricted **

Laser treatment for myopia Previously not routinely funded *

Laser Treatment/ therapy/ tunable dye laser

for aesthetic reasons


Lipoma (removal of) Previously restricted **

Liposuction (Suction assisted lipectomy) (except

as part of planned reconstruction surgery for the treatment

of cancer or congenital syndrome)


Lymphoedema treatment in private specialist units NHS standard Lymphoedema

treatment funded by NHS England

Male Breast reduction Surgery for Gynaecomastia Previously restricted **

Massage


Meditation Previously not routinely funded *

Natruropathy Previously not routinely funded *

Neck Lift Previously not routinely funded **

Nipple inversion – correction of Previously not routinely funded **

Nutritional therapy Previously not routinely funded *

Osteopathy Previously not routinely funded *

Out of area or referrals to the independent sector for

Children with suspected Autism- referrals to the

independent sector or out of area will only be

considered where the child’s care has been

assessed by CAMHS or paediatric services and

where there is a recommendation by either or both

agencies that such a referral is necessary


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Out of area treatment for chronic fatigue syndrome

/ ME (local pathways in place)


Patella resurfacing Not previously within policy

Penile Implants Previously Restricted**

Phalloplasty Previously not routinely funded ** (funded by NHS England for Gender Reassignment Surgery)

Pinnaplasty (“correction” of prominent ears) Previously restricted **

Procedures related to gender reassignment not

included in the original package of care


Radiofrequency Denervation (RFD) to treat osteoidostemoma


Reflexology Previously not routinely funded *

Reiki Previously not routinely funded *

Removal of anal/ rectal skin tags Previously not routinely funded *

Removal of excess skin following weight loss

whether through surgery or natural means


Removal of Supernumerary Nipples (Polymastia) Not previously within policy

Repair of chronic clefts due to avulsion of

body piercing


Repair of chronic tear of lobe of external ear Previously not routinely funded **

Residential pain management programmes Previously not routinely funded *

Reversal of Female Sterilization Previously not routinely funded *

Reversal of Vasectomy Previously not routinely funded *

Scar Reduction including skin grafts for

scars

Previously restricted **

Septo-Rhinoplasty or Rhinoplasty Previously restricted

Shiatsu Previously not routinely funded *

Submental Lipectomy (neck lift) Previously not routinely funded **

Surgery for divarication of the abdominal rectus Not previously within policy

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Surgical procedures to correct rhinophyma

"bulbous nose" or "phymatous rosacea"


Surgical reduction of the tongue (see

surgical treatment for snoring)


Surgical treatment for myopia or short sight Previously not routinely funded *

Surgical Treatment for Snoring Previously not routinely funded *

Surgical treatment of Lipoma Previously not routinely funded **

Surgical treatment of Myopia Previously not routinely funded *

Tattoo removal Previously not routinely funded **

Therapeutic community method for treatment of Previously not routinely funded *

borderline personality disorder

Therapeutic use of ultrasound in hip and

knee osteoarthritis


Tonsillectomy as a treatment for snoring Previously not routinely funded *

Toric Intraocular Lens Implant for Astigmatism Not previously within policy

Trigger finger (non-surgical treatment is funded

by commissioners)


Vaginoplasty Previously not routinely funded **

X-ray (plain) of back for low back pain Previously not routinely funded *

* Value-based commissioning: procedures of limited clinical value. A joint commissioning

policy of clinical commissioning groups in Nottinghamshire County (excluding Bassetlaw and Nottingham City) (2015)

** East midlands commissioning policy for cosmetic procedures (2015) Version 2

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