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
Version Control Sheet
Version Date
1 April 08
2 Oct 08
Treatments not Routinely Funded Policy review date April 2010 version 2
Author Status Comment
Public Health Final Agreed at PEC and PCT Board
Final Minor amendments to application
form agreed at PEC 8/10/2008.
Also minor amendments to the
wording in relation to High Cost
Drugs in the sections on Scope of
Policy, Remit of Exceptions Panel
and contact details. Also revision of
membership of High Cost Drugs
Panel.
Page 2 of 38
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 by

32
Surrey PCT

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 3 of 38
Background

Surrey Primary Care Trust has developed a list of treatments that will not be
routinely commissioned.

When a General Practitioners (GPs) or Consultants in provider trusts wishes to

refer a patient for a treatment listed in this policy as an exceptional case then
they must apply using the application form (see page 6).

Rationale

Surrey PCT must ensure that the resources they invest in commissioned services
achieve the best possible health benefit for the population.

This requires careful prioritisation of investments so that the PCT’s commissioning

budget 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 routinely
funded

Scope of the Policy

This policy covers those treatments/procedures not normally funded by the

PCT.

A separate policy for the management of high cost drugs and mental health has
been developed by the PCT.

Guiding Principles

The PCT will consider issues of appropriateness, effectiveness and priority

when commissioning services.

The PCT seeks to make appropriate use of resources. In considering whether

a service is appropriate, the PCTs may take account of:

• The extent to which a problem in question is an illness, disease, injury or

impairment
• Whether the proposed treatment represents the correct clinical strategy
to address the problem
• Whether the treatment to address the problem can and should be the
subject of
NHS funding

The PCT also seek to use their resources on health care that is effective. In
considering whether a service is appropriate, the PCTs may take account of:

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 4 of 38
 • the probability and magnitude of the expected benefit from treatment;
• the probability and magnitude of side effects and complications of
treatment;
• the extent to which evidence of benefits, complications and side effects is
scientifically 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 substantial
body of expert clinical opinion
• the extent to which the patient is committed to achieving the goals of the
treatment

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 after
comparing 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 Clinical
Excellence (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 about
the 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 within
this policy, it will be considered individually following these principles. There
may be a delay in reaching a decision when there is a need to access robust
evidence of effectiveness. Such a procedure may not be funded.

Exceptional Circumstance

This policy requires each request for treatment to be considered on its individual
merits. It accepts the possibility of a case being exceptional where there may be
an overriding clinical need.

Definition of “exceptions”: noun. A person or thing that is excepted or that does

not follow a rule.

Definition of “exceptional”: adjective. Unusual or special.

General guidelines:

1 Potentially exceptional circumstances may be considered by the patient’s

PCT where there is evidence of significant health status impairment and
inability to perform activities of daily living.
2 By definition, ‘exceptional’ may not necessarily be spelt out in advance.
3 The fact that a patient’s clinical picture matches accepted indications for
a treatment which is not normally provided is not, in itself, exceptional.

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 5 of 38
4 The fact that a treatment is (or is likely to be) efficacious for a particular
patient is not, in itself, exceptional.
5 Consideration will be given to evidence that shows that the benefit from
the treatment for a particular patient would be significantly greater than
would 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 policy
unless 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, or
for the outpatient consultation plus subsequent procedure. This will depend on
the quality and specificity of information received by the PCT for consideration.
Where investigations have been carried out locally we expect these to be made
available and used where appropriate, rather then repeated due to lack of
access to previous test results.

A separate document Surrey PCT Exceptions Panel – Policy and Process sets
out the PCT’s process for decision making.

Appeals Process

An appeal can be requested by the applicant or patient in writing. Please see

Process 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 process
which 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 of
SLA’s. The review will include:

ƒ an audit of the previous years requests

ƒ a review of the current list of treatments not normally funded
ƒ a review of the evidence for new treatments
ƒ consultation with clinicians in local partner organisations
ƒ 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 and
GP practices. A final draft of the policy will be placed on the Surrey PCT website for ease
of access in line with our commitment to open and transparent communication and

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 6 of 38
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 further
detail/clarification

Step 3 Where the clinician feels criteria are met, or exceptional circumstances
are present, complete the Application Form for Funding from Surrey PCT
Exceptions Panel
(see page 6 )

Step 4 Submit the application form to the relevant contact listed at the foot of this
page.

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 7 of 38
 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 requested
Cost
Provider requested

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 ongoing

trial?

4. What treatment is the patient

currently receiving for this condition?

5. Why do you think this patient should

be an exception to the treatments not
routinely funded policy?

Please outline the individual circumstance

which you think justifies making this case
an exception.

∗
BMI must be included for all applications for breast surgery, surgery for gynaecomastia, body contouring
procedures and bariatric surgery.

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 8 of 38
6. What other treatments has the patient
had for the condition in the past?

7. How successful were they?

8. What are the goals and expected

outcome from the intervention?
(e.g. quality of life, life expectancy)

9. If funding can not be approved what

is the possible alternative outcome?

10. Please provide any other

information you think may be relevant
in this case.

Photographic evidence is required to

support applications for all external
procedures (i.e. breast surgery, facial
procedures, body contouring
procedures, skin lesions, and varicose
veins).

Signature: ………………………….Consultant/GP Name: …….…………………….. (Please Print)

Please return this form to GP Practice Stamp

Acute Contracting Team,
Surrey PCT
Pascal Place
Randalls Research Park
Randalls Way
Leatherhead
Surrey
Save Haven Fax: 01372 202 690

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 9 of 38
QUICK LOOK UP GUIDE
THE FOLLOWING TREATMENTS ARE NOT ROUTINELY FUNDED BY SURREY PCT

OPCS code(s) Appendix

Treatment/procedure Page

The PCT does not fund treatment where the primary or principal reason for it
is cosmetic, i.e. to improve appearance.
COSMETIC/PLASTIC SURGERY
Reconstruction following surgery for non-aesthetic reasons (eg cancer or
major trauma) is not affected by this policy.
BREAST SURGERY 13
B311 Female breast reduction (reduction mammoplasty) 13
B311 Male breast reduction for gynaecomastia 14
B312 Breast enlargement (augmentation mammoplasty) 14
B314 Revision of breast augmentation 14
B313 Breast lift (mastopexy) 14
B356 Nipple eversion (for nipple inversion) 14

FACIAL PROCEDURES
S01* Face and brow lifts 15
C13* Surgery on upper eyelid (upper lid blepharoplasty) 15
C13* Surgery on lower eyelid (lower lid blepharoplasty) 15
E02* Surgery to reshape the nose (rhinoplasty) 16
D033 Correction of prominent ears (pinnaplasty / otoplasty) 16
D062 Repair of external ear lobes (lobules) 16
S211/S212/S218/S219/S33* Alopecia 16
S211/S212/S218/S219/S33* Correction of male pattern baldness 16
S211/S212/S218/S219/S33* Hair transplantation/hair replacement interventions 16

BODY CONTOURING PROCEDURES

S02* Abdominoplasty/apronectomy 17
S03* Other skin excisions for contour e.g. buttock lift, thigh lift, arm lift 17
S621/S622 Liposuction 17

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 10 of 38
 SKIN AND SUBCUTANEOUS PROCEDURES
E094/S05*/S06*/S09*/S10*/S11*/Y088 Fatty lumps (lipoma) 18
Viral warts (outside Genito-Urinary Medicine services) 18
Other benign skin lesions e.g. skin tags and seborrhoeic keratoses 19
S601/S602, X85 Xanthalasma 19
Tattoo removal 19
Skin hypo-pigmentation 19
Small benign acquired vascular lesions such as thread veins and spider naevi 20
Skin “resurfacing” techniques such as laser, dermabrasion and chemical peels 20
Botulinum toxin for the treatment of facial aging/excessive wrinkles 20
Hair Depilation 20
Treatment for excessive sweating 20
Scar revision 20

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 11 of 38
 OPCS code(s) Appendix
Treatment/procedure Page

The PCT does not fund treatment where the primary or principal reason for it
is cosmetic, i.e. to improve appearance.
UROLOGY/GYNAECOLOGY
Reconstruction following surgery for non-aesthetic reasons (eg cancer or
major trauma) is not affected by this policy.
N303 Circumcision for social / religious grounds 20
N29* Penile implants
N181/Q37* Reversal of sterilisation/vasectomy 20
Gender re-assignment - 20
Female to male at University College London Hospital –
Male to female at Hammersmith Hospitals Trust
The PCTs do not fund any associated cosmetic procedures e.g. breast
augmentation, wigs, laser therapy, brow surgery etc.
Genital surgery aimed at improving appearance 20

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 12 of 38
 OPCS code(s) Appendix
Treatment/procedure Page

The PCT does not fund treatment where the primary or principal reason for it
is cosmetic, i.e. to improve appearance.
OPHTHAMOLOGY Reconstruction following surgery for non-aesthetic reasons (eg cancer or
major trauma) is not affected by this policy.
Laser eye surgery for myopia 22
Photodynamic therapy (PDT) – unless fulfilling NICE criteria 22

OPCS code(s) Appendix

Treatment/procedure Page

The PCT does not fund treatment where the primary or principal reason for it
is cosmetic, i.e. to improve appearance.
EAR NOSE AND THROAT Reconstruction following surgery for non-aesthetic reasons (eg cancer or
major trauma) is not affected by this policy.
D15.1 Grommets for persons over 19 23
D13* Bone anchored hearing aid 23
D241 Cochlear implants 24

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 13 of 38
 OPCS code(s) Appendix
Treatment/procedure Page

The PCT does not fund treatment where the primary or principal reason for it
is cosmetic, i.e. to improve appearance.
VASCULAR SURGERY Reconstruction following surgery for non-aesthetic reasons (eg cancer or
major trauma) is not affected by this policy.
L84*/L85*/L86*/L87*/L88* Varicose Veins Class 1 and 2 26

OPCS code(s) Appendix

Treatment/procedure Page

The PCT does not fund treatment where the primary or principal reason for it
OTHER is cosmetic, i.e. to improve appearance.
Reconstruction following surgery for non-aesthetic reasons (eg cancer or
major trauma) is not affected by this policy.
X521 Hyperbaric oxygen therapy(unless decompression illness) 26
Weight loss interventions 26
Complementary/Alternative therapies 26
Functional Electrical Stimulation 26

OPCS code(s) Appendix

Treatment/procedure Page

DENTAL SURGERY The PCT does not fund treatment where the primary or principal reason for it
is cosmetic, i.e. to improve appearance.
Reconstruction following surgery for non-aesthetic reasons (eg cancer or
major trauma) is not affected by this policy.
F08* Dental implants 28
F091/F092/F093 Wisdom tooth extraction that falls outside NICE criteria 28
F12* Apicectomy of multi rooted teeth 28
F14*/F15* Orthodontic treatment IOTN 1-3 with aesthetic component of less than 6 28
F10 Minor Dental Extractions 28

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 14 of 38
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 referral to the Exceptions Panel.

It represents a guide to determine the individuals who are felt to be suitable for the intervention and are a means of ensuring that the procedure is indicated.
Meeting the factors listed in the guidance does not automatically entitle the patient to the procedure.

Section A

Procedure/Therapy Comments / Rationale Guidance for Clinicians Referring Individuals for

Treatment
The patient has a body mass index (BMI) of less than
2
30kg/m
B311
Female breast The patient is suffering from neck ache, backache and/or
reduction (reduction intertrigo
mammoplasty)
The wearing of a professionally fitted brassiere has not
relieved the symptoms

Prior to surgical intervention it must be clear that there is no underlying cause

for the gynaecomastia. BMI <25

Age 19 years or over

This will include screening for endocrine disorders, drug related causes and
exclude male breast cancer. If there is any doubt, an urgent consultation with Male breast cancer and underlying endocrine disorder
an appropriate specialist must be obtained. excluded

Most cases of gynaecomastia have no known cause especially those Surgical intervention recommended by consultant
B311
presenting in adolescence. It may be unilateral or bilateral. breast/plastic surgeon
Male breast
reduction for
Commonly gynaecomastia is seen during puberty and may correct once the
gynaecomastia
post-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 underlying
endocrine condition. It is important that male breast cancer is excluded.

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 15 of 38
 This procedure will only be performed on an exceptional basis and should Previous mastectomy of other excisional breast surgery
not be carried out for “small” but normal breasts or for breast tissue
involution (including post partum changes). Trauma to the breast during or after development
For patients with asymmetry, clinicians should referral to the breast care
team, who will make an assessment and offer advice on a range of Congenital amastia (total failure of breast development)
B312
prosthetic and other solutions
Breast enlargement
Breast implants may be associated with significant morbidity and the need Endocrine abnormalities
(augmentation
for secondary or revisional surgery (such as implant replacement) at some
mammoplasty)
point in the future is common. Development asymmetry
Implants have a variable life span and the need for replacement or removal
in the future is likely in young patients.
Not all patients demonstrate improvement in psychosocial outcome
measures following breast augmentation.
If revisional surgery is being carried out for implant failure, the decision to There may be clinical reasons why removal of the implant is
B314 replace the implant(s) rather than simply remove them should be based an appropriate surgical intervention.
Revision of breast upon the clinical need for replacement and whether the patient meets the
augmentation policy for augmentation at the time of revision.

This procedure may be considered as part of the treatment for

B313 breast asymmetry and reduction (see above) but will not be
Breast lift funded for purely cosmetic/aesthetic purposes such as post-
(mastopexy) lactational ptosis.

Nipple inversion may occur as a result of an underlying breast malignancy

and it is essential that this be excluded.

B356
Idiopathic nipple inversion can often (but not always) be corrected by the
Nipple Eversion (for
nipple inversion) application of sustained suction. Commercially available devices may be
obtained from major chemists or online without prescription for use at home
by the patient.

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 16 of 38
Section B
Facial Procedures
Operations on congenital anomalies of the face and skull for correction of post traumatic bony and soft tissue deformity of the face are
not affected by this document
Procedure/Therapy
S01* Face and brow lifts
C13* Surgery on upper
eyelid (upper lid
blepharoplasty)
C13* Surgery on lower
eyelid (lower lid
blepharoplasty)
Treatments not Routinely Funded Policy review date April 2010 version 2
Comments /Rationale
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.
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 of
aging
Many people acquire excess skin in the upper eyelids as part of the process of through elevation of the brow
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.
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.
Page 17 of 38
Guidance for Clinicians Referring Individuals
for Treatment
Congenital facial abnormalities
Facial palsy (congenital or acquired paralysis)
As part of the treatment of specific conditions
affecting the facial skin e.g. cutis laxa,
pseudoxanthoma elasticum, neurofibromatosis
To correct the consequences of trauma
To correct deformity following surgery
Impairment of visual fields in the relaxed, non-
compensated state
Clinical observation of poor eyelid function,
discomfort, e.g. headache worsening towards end
of day and/or evidence of chronic compensation
Correction of ectropion or entropion or for the
removal of lesions of the eyelid skin or lid margin.

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
Treatments not Routinely Funded Policy review date April 2010 version 2
Problems caused by obstruction of the nasal
airway
Patients with isolated airway problems (in the absence of visible nasal Objective nasal deformity caused by trauma
deformity) may be referred initially to an ENT consultant for assessment and
treatment. Correction of complex congenital conditions e.g.
Cleft lip and palate
Prominent ears may lead to significant psychosocial dysfunction for children < 19 years of age
and adolescents and impact on the education of young children as a result of
teasing and truancy.
This procedure is only available on the NHS for the repair of totally split ear
lobes 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.
Hair pieces and wigs for patients experiencing total
hair loss as a result of chemotherapy, or alopecia
totalis are available within local NHS Trusts
Many types of hair loss including “male pattern” baldness is a normal process
for many men at whatever age it occurs
Hair pieces and wigs for patients experiencing total
hair loss as a result of chemotherapy, or alopecia
totalis are available within local NHS Trusts
Page 18 of 38
Section C
Body Contouring Procedures

Procedure/Therapy Comments /Rationale Guidance for Clinicians Referring Individuals

for Treatment
2
Stable BMI between 18 and 27 Kg/m > 2 yrs

Experiencing severe difficulties with daily living

Excessive abdominal skin folds may occur following weight loss in the
Those with scarring following trauma or previous
previously obese patient and can cause significant functional difficulty. abdominal surgery.
These types of procedures, which may be combined with limited liposuction,
S02*
can be used to correct scarring and other abnormalities of the anterior Those who are undergoing treatment for morbid
Abdominoplasty/apronectomy
abdominal wall and skin. obesity and have excessive abdominal skin folds.

Problems associated with poorly fitting stoma

It is important that patients undergoing such procedures have achieved and
bags
maintained a stable weight so that the risks of recurrent obesity are reduced.
Where it is required as part of abdominal hernia
correction or other abdominal wall surgery

S03*
Other skin excisions for
contour e.g. buttock lift, thigh
lift, 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 reason
for it is cosmetic, i.e. to improve appearance

Liposuction may be useful for contouring areas of

localised fat atrophy or pathological hypertrophy
S621/S622 The PCT does not fund treatment where the primary or principal reason (e.g.Multiple lipomatosis, lipodystrophies).
Liposuction for it is cosmetic, i.e. to improve appearance.
Liposuction is sometimes an adjunct to other
surgical procedures.

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 19 of 38
Section D
Skin and Subcutaneous Lesions
Any patient with a skin or subcutaneous lesion that has features suspicious of malignancy, must be referred to an appropriate
specialist for urgent assessment
Procedure/Therapy
Removal of skin lesions
/S05*/S06*/S09*/S10*/S11*/Y088
Medicine Services)
Fatty lumps (lipoma)
Viral warts (outside Genito-
Urinary Clinic)
Other benign skin lesions e.g.
skin tags and seborrhoeic
keratoses
Treatments not Routinely Funded Policy review date April 2010 version 2
Comments /Rationale
Most viral warts will clear spontaneously or following application of
topical treatments.
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 scarring
must be balanced against the appearance of the lesion.
The decision to remove benign skin lesions from conspicuous sites is a
Page 20 of 38
Guidance for Clinicians Referring Individuals
for Treatment
Patients should be treated if it is clear that
they suffer from one of the following:
ƒ Suspected malignancy
ƒ Obstruction of orifice or vision
ƒ Facial disfigurement
ƒ Recurrent infection
ƒ Function limitation on movement or activity
ƒ Pain
Lipomata of any size may be considered for
treatment by the NHS in the following
circumstances:
There is functional impairment or the lipoma is
symptomatic
The lump is rapidly growing or abnormally located
(e.g. sub-fascial, submuscular).
Painful, persistent or extensive warts (particularly
in the immuno-suppressed patient) may need
specialist assessment, for a small proportion
surgical removal may be appropriate.
Some skin lesions may require surgical excision
particularly if large or located on the face or on a
site where they are subjected to trauma.

Xanthelasma (yellow fatty
deposits around the eyelids)
Tattoo removal
Skin hypo-pigmentation
Small benign acquired vascular
lesions such as thread veins and
spider naevi
Rhinophyma
Treatments not Routinely Funded Policy review date April 2010 version 2
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.
Larger lesions or those that have not responded to
Patients with xanthelasma should always have their lipid profile checked
these treatments may benefit from surgery if the
before referral to a specialist. Many xanthelasmata may be treated with
lesion is disfiguring.
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.
The recommended NHS suitable treatment for hypo-pigmentation is
cosmetic camouflage.
The first-line treatment of this disfiguring condition of the nasal skin is Severe cases or those that do not respond to
medical. medical treatment may be considered for surgery
or laser treatment
Page 21 of 38
 The refinement of laser technology has created new therapeutic options
Laser treatment / skin resurfacing
for cosmetic problems ranging from insignificant blemishes and tattoos
techniques
to extreme and disfiguring birth marks. Potential demand for this new
service is greater than available resources.
Botulinum toxin for the
treatment of facial
aging/excessive wrinkles

Hair Depilation

Treatment for excessive

sweating

Scar revision

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 22 of 38
Section E
Urology and Gynaecology
Procedure/Therapy
Gender re-assignment -
Female to male at
University College London
Hospital –
Male to female at
Hammersmith Hospitals
Trust
Genital Surgery aimed at
improving appearance
N303
Circumcision for social /
religious grounds
Male Circumcision
Female circumcision is
prohibited by law: The
Prohibition of Female
Circumcision Act 1995
N29*
Penile implants
N181/Q37*
Reversal of
sterilisation/vasectomy
Treatments not Routinely Funded Policy review date April 2010 version 2
Comments /Rationale
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 on
its individual merits
The PCTs do not fund any associated cosmetic procedures e.g. breast
augmentation
Patients requiring prostheses following orchidectomy are not affected by
this policy.
This decision is made in line with the statement on Male Circumcision
made by the British Association of Paediatric Surgeons, The Royal College
of Nursing, The Royal College of Paediatrics and Child Health, The Royal
College of Surgeons of England and The Royal College of Anaesthetists.
The foreskin is still in the process of developing at birth and hence is often
non-retractable up to the age of 3 years
The process of separation is spontaneous and does not require
manipulation
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.
Page 23 of 38
Guidance for Clinicians Referring Individuals for
Treatment
Lived in the acquired gender throughout the preceding
years.
Patient has gender dysphoria.
Patient intends to live in the acquired gender until
death.
The one absolute indication for circumcision is
scarring of the opening of the foreskin making it non-
retractable (pathological phimosis). This is unusual
before 5 years of age.
Recurrent, troublesome episodes of infection beneath
the foreskin (balanoposthitis) are an occasional
indication for circumcision.
Occasionally specialist paediatric surgeons or
urologists may need to perform a circumcision for
some rare conditions.
Section F
Ophthalmology

Procedure/Therapy Comments /Rationale Guidance for Clinicians Referring Individuals for

Treatment
Laser eye surgery for
myopia
Photodynamic therapy Patients should meet the NICE Guidance
(PDT)

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 24 of 38
Section G
ENT Procedures

Procedure/Therapy Comments Guidance for Clinicians Referring Individuals for

Rationale Treatment
In accordance with NICE Clinical Guidance 60 Issues in Feb
2008 Surgical Management of Otitis Media with Effusion in
Children the PCT may fund this procedure in children who
are likely to benefit as follows:-

‘Children who will benefit from Surgical Intervention

Children with persistent bilateral OME (Otitis Media with

Effusion) over a period of three months with a hearing level
in the better ear of 25-30 dBHL or worse averaged at 0.5,
1,2 and 4kHz (or equivalent dBA where dBHL not
available)should be considered for surgery.

Exceptionally, health care professionals should consider

Children: There is only limited evidence that grommets are an effective
D15.1 surgical intervention in children with persistent bilateral OME
treatment in children with otitis media with effusions.
Grommets with a hearing loss less than 25-30 dBHL where the impact
of the hearing loss on a child’s development, social or
educational status is judged to be significant.’

Adults: The PCT may consider funding grommet insertion

in patients for whom grommets are inserted to maintain a
reasonable hearing acuity, balance mechanism or are
fundamental to their general health and wellbeing.

Elderly or frail patients at risk of falling, those likely to

experience social isolation as a result of deafness.

As a guide the patient should be shown to have:

Bone anchored hearing aids (BAHA) have been recommended for people
who cannot wear a conventional hearing aid due to infection or people ƒ abnormalities of the middle, outer or external parts the
D13*
with a conduction hearing loss. NICE have not yet issued guidance on ear or a chronic ear infection, which makes wearing a
Bone anchored
the use of BAHA. conventional hearing aid difficult or impossible
hearing aid
Complications including osseointegration, implant removal, local infection or ƒ have a hearing loss in both ears that cannot be
implications. operated on and for which conventional hearing aids
are not felt to suitable

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 25 of 38

Priority is given to providing single implants to more people rather than
bilateral implants to fewer people which will not be funded.
Patients (including adults) whose severe/profound hearing loss is as a
consequence of meningitis should be 'fast tracked', regardless of hearing
aid use, due to the risk of cochlear ossification.
D241
Cochlear implants Cochlear implantation has not yet been formally reviewed by NICE to
for persons under determine cost effectiveness. Those analyses which have been conducted
18 years so 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 those
more 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.
Treatments not Routinely Funded Policy review date April 2010 version 2
ƒ can hear sounds well via bone conduction
ƒ can understand 60% or more of speech on a standard
test, using bone conduction
ƒ are able to keep the area around the fixture clean
The following represent potential contraindications to the
procedure :
ƒ Word recognition scores with the use of amplification
are less than 60%
ƒ patient has less than 3mm of one at the implant site
ƒ patient less than 5 years old
ƒ patient unable to keep implant site clean
ƒ patient unable to remove or attach the external
processor due to lack of manual dexterity
ƒ patient unable to accept the abutment protrudes from
the side of the head
As a guide the patient should be shown to have:
Audiometric Criteria
Hearing threshold >90dB at 2 and 4kHz in the better hearing
ear.
Other Criteria
Pre-lingually deafened children should be <5 years old at
the time of surgery.
Older congenitally deaf children will be considered if they
have developed good spoken language skills through use of
acoustic hearing aids.
Ideally, a minimum of 3 months use of optimal digital
hearing aids, prior to referral for assessment.
Morphological suitability for electrode placement
Established spoken language base
Willingness and commitment from parents and child to
participation in implantation and long-term rehabilitation
programme
Physically fit for surgery and rehabilitation
Page 26 of 38
 Failure to develop, progress or maintain auditory, speech,
language, and communication skills appropriate to the
patient’s age, on a range of multi-disciplinary assessments.

Support from parents and relevant local services

Parents and child have realistic expectations of the outcome

of implantation.

Cochlear implants Cochlear implantation for adults is not routinely available. If a clinician or As a guide the patient should be shown to have:
for persons over 18 patients believes there are ‘exceptional’ reasons why their patient would
years benefit from this intervention they may put their case forward to the Surrey Audiometric Criteria
PCT Exceptions Panel.
Hearing threshold >90dB average at 500Hz, 1000Hz,
2000Hz and 4000Hz unaided at 2 and 4kHz in the better
hearing ear, as measured by an experienced audiologist.

Less than 50% word identification using the BKB sentence

test presented at 70dB, without lip-reading.

Other Criteria
Minimum of 3 months use of optimal digital hearing aids,
prior to referral for assessment.
Morphological suitability for electrode placement
Established spoken language base, with intelligible speech.
Willingness and commitment to participation in implantation
and long-term rehabilitation programme
Physically fit for surgery
Appropriate support from relevant local services
Realistic expectations of the outcome
Patients should have a life-expectancy of at least
10 years, at the time of transplantation. (NB
Chronological age is not in itself a criterion.)

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Section H
Varicose Veins

Procedure/Therapy Comments Guidance for Clinicians Referring Individuals

Rationale for Treatment

L84*/L85*/L86*/L87*/L88*
Please see appendix section II: The Varicose Vein Prioritisation
Varicose Veins Class I Protocol on page 29
and II

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Section I
Other Procedures
Procedure/Therapy
X521 Hyperbaric oxygen
therapy (HBOT) (unless
decompression illness)
Weight loss interventions
Complementary/Alternative
therapies
Functional Electrical
Stimulation
Treatments not Routinely Funded Policy review date April 2010 version 2
Comments /Rationale Guidance for Clinicians Referring Individuals for
Treatment
HBOT for decompression illness can carbon monoxide poisoning are not
affected by this policy.
There is insufficient evidence for the clinical effectiveness of Hyperbaric
Oxygen Therapy (HBOT) for wound healing. Therefore it is not routinely
funded by the PCT
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 loss
camps.
Complementary therapies are not normally funded by Surrey PCT, with the
exception 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 evidence
including several meta-analysis has failed to confirm any demonstrable
benefit from treatments. NICE guidance for homeopathy and acupuncture
has not been compiled.
As a guide patients should not be referred for FES
until conservative methods have been tried and
proven unsuccessful
NICE has issued guidance of the use of FES in two
NICE guidance has been used to support the use of FES in certain
sets of circumstances faecal and urinary
conditions, e.g., and can be found at http://guidance.nice.org.uk/
incontinence.
In both cases the funding of a FES may be
considered by the PCT, in accordance with NICE
guidelines.
Page 29 of 38
Section J
Dental Procedures

Procedure/Therapy Comments /Rationale Guidance for Clinicians Referring Individuals for

Treatment
Wisdom Tooth In accordance with NICE guidance the routine practice of prophylactic removal Unrestorable caries,
Extraction of pathology-free impacted third molars should be discontinued in the NHS.
Non-treatable pulpal and/or periapical pathology
Surgical removal of impacted third molars should be limited to patients with
evidence of pathology.
Cellulitis, abcess and osteomyeltis,

Internal/external resorption of the tooth or adjacent teeth,

fracture of tooth, disease of follicle including cyst/tumour,
tooth/teeth impeding surgery

Reconstructive jaw surgery, and when a tooth is involved

in or within the field of tumour resection.

F10 Minor Dental

Extractions

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)

Treatments not Routinely Funded Policy review date April 2010 version 2 Page 30 of 38
APPENDIX II: - The Varicose Vein Prioritisation Protocol
With thanks to Southern Derbyshire Acute Hospitals NHS Trust

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Treatments not Routinely Funded Policy review date April 2010 version 2 Page 32 of 38
Appendix III - Process for Treatments Not Routinely Funded by Surrey Primary Care
Trust

1. The Scope of the document

This document describes the process by which applications for treatments not routinely funded by
Surrey Primary Care Trust (PCT) are considered.

2. Application Process

Applications may be submitted by GPs or Consultants. Applications must be made by completing

the appropriate application form which can be found on page 6 in the Treatments not Routinely
Funded policy document. Applications should be submitted to the Commissioning team at Surrey
PCT. There will be a fortnightly meeting between Public Health and the Commissioning team to sort
through 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 set
out 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 relevant
information available that has not been considered then they may re submit the case to the Acute
Commissioning team.

3. Remit of the Exceptions Panel

The remit of the Exceptions Panel will be to deal with requests for individual patients, where the
treatment falls outside the established commissioning contracts and has been determined a
treatment ‘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 Pharmaceutical
Commissioning Pharmacist. Requests requiring decisions for funding of high costs drugs will be
referred to a sub-committee of the Exceptions Panel (the high cost drugs panel) comprising the
following:

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, for
more information

The Exceptions Panel will not have a remit to consider cases under the Continuing Care Eligibility
Criteria or those falling under the Mental Health and Learning Difficulties remit, for which there are
separate processes.

Requests for dental implants and orthodontic appeals, to be considered following assessment by
PCT 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 email
if necessary, and in such circumstances a decision will be taken on a consensus view. Any such
decisions 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 effectiveness
of the treatments requested and will supply evidence briefings for panel meeting as requested. The
evidence briefings will aim to support the decision making by providing panel members with
background information to the treatment requested and summarising the most relevant and up to
date 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 not
routinely funded by the PCT?”

Requests for funding will be considered in line with the guiding principles detailed in Surrey PCT’s
Policy 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 a
“treatment 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 patient’s case are exceptional when compared with other patients who have the
same 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:

GP
Public Health Representative
A lay Member
Commissioning Manager (Chair)

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The same personnel will not be present at each meeting, but will be drawn from a list of potential
panel members, according to their availability. The Chair will remain constant, as far as is
reasonably 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 being
unable 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 clinical
condition 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 will
be 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 be
circulated 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 the
chair 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 to
being sent.

The applicant (Consultant or GP) will receive a written response to their request following the
Exceptions Panel meeting. This will be within 22 working days of receipt of a completed application
form by the Commissioning team. In certain circumstances delays in dealing with requests may be
encountered (please see section 12). Where a delay may occur this will be conveyed to the
clinician applying for the treatment.

8. Reporting, Review and Evaluation

The Exceptions Panel will review its activities and expenditure to monitor trends, policy
requirements and consistency. This information will be fed back to Exceptions Panel Members and
the 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, and
reflect national policy (including NICE Guidance) where applicable.

The annual review will include:

• An audit of the previous year’s 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 the
Exceptions Panel decision.

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Appeals can be made by the referring clinician (GP or Consultant) or patient. If the patient is
undertaking 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 relevant
information 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) to
ensure 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 then
the 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 will
be 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 of
the 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 the
panel.

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 the
case through the NHS Complaints procedure. Information concerning this can be obtained from the
PCT 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 the
Exceptions Panel meeting. This will be within 22 working days of receipt of a completed application
form by the Commissioning team.

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In certain circumstances delays in dealing with requests may be encountered (please see section
12). Where a delay may occur this will be conveyed to the clinician submitting the application for
funding treatment.

11. Management Process

High Cost Drugs

Requests to be directed to the Pharmaceutical Commissioning team at Surrey PCT

Email address: highcost.drugs@nhs.net

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 Panel
Coordinator.

• The Co-ordinator and/or Commissioning Team will provide an initial review of the
paperwork to ensure it is complete.

• Papers for cases requiring an Exceptions Panel decision will then be distributed to Panel
members to allow at least 4 working days prior to the Panel Meeting.

• The panel’s decision, including the rationale for the decision will be clearly recorded in the
minutes which will be signed off in paper form by the chair of the Exceptions Panel Meeting
and filed for record keeping.

12. Information Gathering

When considering individual cases, the Exceptions Panel will require supporting information. This
is 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 be
supplied by the public health team
• Details of why this patient is exceptional when compared with other patients who have
the same or a substantively similar condition

If the treatment is new or unusual the Commissioning team will request the Public Health
Directorate to provide an evidence briefing for the requested treatment. If an evidence briefing on a
new or unusual treatment is required from the Public Health Directorate this may take up to 10
working days to enable members of the team to access information from diverse sources including
published research and expert opinion.

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When public health input is required and they will endeavour to obtain this information prior to the
scheduled meeting date. Where information is sought from external organisations, case
discussions may be postponed if information is not available in sufficient time or in sufficient detail
to 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 to
the relevant contract. For those cases where no contract exists, the cost will be charged to a
dedicated budget held by the Head of Contracting.

14. Decisions

In reaching a decision on individual funding, the Panel will apply the PCT’s relevant policy (policies)
The Panel will set out their decision and the reasons for it in writing to the referring clinician.

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