Microsoft word - polcm002

South East London
Exceptional Treatments Commissioning
Issued: March 2009
Issue No: 2
BPCT Document No: POL CM002
This Policy has been produced by the South East London Exceptional Treatments
Strategy and Policy Group. Contact [email protected] for updates or

South East London
Exceptional Treatments Commissioning (ETC) Policy
Exceptional treatments (ETAs) are those interventions that are not covered by the existing
service agreements or that may not be provided because of lack of evidence of clinical
The six PCTs in the South East London Sector have been working together on developing a
joint process for dealing with ETAs. There are a number of reasons for a sector-wide process
for dealing with ETAs.
Limited Resources
There will always be competing calls for limited resources and therefore a need for a clearly
defined and co-ordinated approach to ensure that the resources are used in an equitable and
effective way and that clear, consistent and fair procedures are in place.
Local Variations
Local variations in resource allocation (postcode prescribing) are clearly undesirable, but there
has been very little debate at national level on the process of setting priorities for funding. The
National Institute for Clinical Excellence (NICE) has been established to provide guidelines on
the implementation and introduction of new drugs and technologies. However, for a majority
of requests for funding that are submitted to the PCTs, no guidelines are available. The PCTs
are therefore obliged to consider treatments and interventions in the absence of any
recommendations from NICE. Development of a joint process across the Sector will clearly
be beneficial in terms of reducing the variations between the PCTs.
Joint working will avoid duplication of work and efforts across the PCTs. It will also maximize
the use of expertise and skills across the Sector, building upon previous experience. This
joint process will also enhance joint working and communication between the PCTs.

This policy will be reviewed and updated annually.
The treatments and interventions listed in Section 1 of this document will not
receive funding from the Care Trust / PCT unless they have been reviewed by the
relevant ETA group and prior funding agreed.
Those listed in Section 2 will not require prior agreement, however they must be
notified to the Care Trust / PCT along with information about details of how the
access criteria were met. These referrals will be monitored and audited regularly.





All patients requiring a consultant opinion for diagnostic or symptomatic advice should
continue to be referred by General Practitioners e.g. skin lesions that may be

Separate guidance exists for dental & orthodontic referrals and for
interventions requiring new and/or high cost drugs.
Procedures in Section 1 will still require prior approval through the ‘Exceptional Treatments Arrangements Process’ even if the restricted access criteria outlined are

General Remarks
Cosmetic procedures are generally effective but they are considered to be of low priority by local commissioners and will only be purchased in exceptional circumstances. To qualify under the Exceptional Treatments Policy the patient should be over the age of 21 and have a severe physical disfigurement with a long standing reactive psychiatric disorder that would be improved by the cosmetic surgery. The psychiatric problem should clearly be caused by the relevant physical problem. A psychiatric opinion undertaken by an NHS Consultant Psychiatrist / Clinical Director of the specialty should be provided, confirming that the problem is still ongoing despite being appropriately addressed by a psychiatric or psychological intervention. The psychiatrist should also confirm that the cosmetic procedure would improve the patient’s underlying psychiatric condition. NHS Mental Health Trusts will not accept referrals for assessment purely for cosmetic surgery. The referral has to be for assessment and appropriate treatment of a psychiatric condition. Individual Procedures
Detailed exceptions to the general restriction on cosmetic surgery are listed here: Blepharoplasty (Eyelid Reduction)
OPCS 4 Procedure codes C131 132 133 134 138 139 This procedure is not available on cosmetic grounds. An exception may be made if the upper eyelid skin interferes with t he visual field or if there is evidence that eyelids impinge on visual fields reducing field to 120˚ laterally and 40˚ vertically. Cosmetic Breast Surgery
OPCS 4 Procedure codes B301 302 303 308 309 311 312 313 314 318 319 356 This does not refer to breast reconstruction following treatment for cancer. Breast Augmentation
This procedure is not available on cosmetic grounds. An exception may be made for congenital absence or gross asymmetry (difference in size minimum 2 cup sizes). Breast Reduction
This procedure is not available on cosmetic grounds. An exception may be made for true virginal hyperplasia when the proposed volume of reduction is greater than 500g preside, gross asymmetry or if the patient has at least one of the following: • unresponsive to treatment for ulceration of the shoulder from the bra straps • unresponsive to treatment for Intertigo between the breasts and the chest wall • lordotic posture (curvature of the spine) • ulnar pain from the thoracic nerve root compression The patient must also meet the following criteria: • waist to hip ratio of 0.85 or less for women (0.94 for men) Mastopexy (relocating the nipple and improving the shape of the breast
This procedure is not available on cosmetic grounds. Breast ptosis is inevitable in most women due to a combination of maturity, gravity and pregnancy/lactation. An exception may be made in gross cases when a nipple areola lies below the infra-mammary fold. Revision Mammoplasty
This procedure is not available on cosmetic grounds unless the original procedure was performed locally on the NHS because of health reasons, and the patient now has a gross deformity. Breast Implants
Breast implants and instant replacements are not available on the NHS. Ruptured breast implants, however, will be removed on the NHS if they are considered to be of danger to the patient. Replacement implants must not be inserted as part of the same procedure even if the patient wishes to self-fund this part of the treatment. Gynaecomastia
This procedure is not available on cosmetic grounds. Correction of Congenital Nipple Inversion
This procedure is not available on cosmetic grounds. Nipple inversion is a common condition which responds well to conservative treatment, e.g. use of Niplette device. Body Contouring (Abdominoplasty or Tummy Tuck, Thigh Lift and Buttock Lift,
Excision of Redundant Skin or Fat Liposuction)

OPCS 4 Procedure codes S021 022 028 029 031032 033 038 039
These procedures are not available on cosmetic grounds. An exception may be made
for post-traumatic surgery for contouring at diabetes injection sites or for lymphoedema.
Cases following a major weight loss may be considered on an individual basis.
Dermabrasion (Chemical Peel)
OPCS 4 Procedure codes S601 602 This procedure is not available for skin rejuvenation. It does have a place in the treatment of severe scarring following acne or sometimes following trauma. Face or Brow Lift
OPCS 4 Procedure codes S011 012 014 This procedure is not available on cosmetic grounds. An exception may be made for the treatment of facial palsy. Male Pattern Baldness (Hair Grafting and Flaps with or without Tissue Expansion)
OPCS 4 Procedure codes S331 332 333 338 339 This procedure is not available on cosmetic grounds. Baldness is a natural condition. Pinnaplasty (Correction of prominent or Bat Ears)
This procedure is not available on cosmetic grounds to adults. An exception may be made for children under the age of 18 at the time of referral for significant prominent or bat ears. Repair of Lobe of External Ear
OPCS 4 Procedure codes d031 032 034 038 039 This procedure is not available on cosmetic grounds. Rhinoplasty (Reshaping of the Nose)
OPCS 4 Procedure codes e021 022 023 024 025 026 028 029 This procedure is not available on cosmetic grounds. An exception may be made when there is breathing difficulty or occasionally following trauma (if the referral is made less than 6 months after the injury occurred). Scar Revision
OPCS 4 Procedure codes S604 This procedure is not available on cosmetic grounds. An exception may be made with certain scars, eg those which interfere with function following burns or for treatment of Keloid and post-surgical scarring. Tattoo Removal
This procedure is not available on cosmetic grounds. Removal of Birthmarks
OPCS 4 Procedure codes S038 039 041 042 043 048 049 051 052 053 054 055 058
059 061 062 063 064 065 068 069 081 082 083 088 089 091 092 093 098 099 101 102
103 104 108 109 111 112 113 114 118 119
ICD 10 diagnostic code Q82.5 Available for children up to the age of 18 for permanent large or prominent lesions on face or neck. Other Benign Skin Lesions
OPCS 4 Procedure codes S038 039 041 042 043 048 049 051 052 053 054 055 058 059 061 062 063 064 065 068 069 081 082 083 088 089 091 092 093 098 099 101 102 103 104 108 109 111 112 113 114 118 119 ICD 10 diagnostic codes D17 170 171 172 173 Other benign skin lesions eg skin tags, fibroepithelial polyps, dermatofibromata, seborrhoeic warts will not be removed on cosmetic grounds. However, if symptomatic and inflamed at the time of consultation, removal will be considered. ICD 10 diagnostic codes D23 230 231 232 233 234 235 236 237 239 Epidermoid (Sebaceous) cysts are always benign and are not removed in the Dermatology Department. Some may become infected and symptomatic and referral to General Surgeons is indicated in these cases. Viral Warts and Molluscum Contagiosum in Children under 16 Years of Age
ICD 10 diagnostic codes B07 These are self-limiting viral infections. Warts are appropriately treated in Primary Care by topical Keratolytics. Cryotherapy is too painful and no other treatment is offered in Secondary Care for either condition. Viral Warts in Adults
ICD 10 diagnostic codes B08.1
A recent systematic review has shown that properly compliant treatment with
Keratolytics is as effective as Cryotherapy.

General Remarks
Circumcision is an effective operative procedure with a range of medical indications. Some
circumcisions are also requested for social, cultural or religious reasons, these procedures will
not be funded on the NHS.
Medical Indications
Circumcisions should continue to be performed for medical indications only • phimosis seriously interfering with urine flow and/or associated with recurrent infections • suspected cancer or balanitis xerotica obliterans • congenital urological abnormalities when skin is required for grafting • interference with normal sexual activity in adult males




• Osteopathy remains a low priority treatment due to the limited evidence of clinical • Future referral for osteopathy is not available on the NHS. Acupuncture
• Acupuncture remains a low priority treatment due to the limited evidence of clinical
• Future referrals for acupuncture should be made in exceptional circumstances only for cases of dental pain and nausea and vomiting and shall be agreed by the local Exceptional Treatment Groups. Homeopathy
• Homeopathy should remain a low priority treatment due to the limited evidence of clinical
• South London PCTs that hold contracts with the Royal London Homeopathic Trust may wish to consider terminating these with a view to honouring payment for existing patients currently being treated and patients currently on the waiting list • Future referrals for homeopathy should be made in exceptional circumstances only and shall be agreed by the local Exceptional Treatment Groups. All Other Complementary Therapies
The PCTs will not purchase these services in the Acute Sector.
OPCS 4 Procedure codes Q291 292 298 299 N181
The decision to be sterilized is taken by mature adults on the understanding that it is an
irreversible contraceptive choice. Therefore, any reversal or subsequent fertility treatment
should be the responsibility of the individual and will not be funded by the PCT. Any requests
with possible exceptions may be referred to the Exceptional Treatments Arrangement process
for consideration. There should be no live children from either of the partners.
♦ The woman should not be older than 35 years ♦ The procedure should be done in a Regional Centre by a surgeon performing sufficient procedures to report a success rate of over 50% ♦ The reversal of vasectomy should not be performed more than 10 years after the original ♦ The female partner should not be more than 36 years old FUNCTIONAL ELECTRICAL STIMULATION
There is uncertainty about clinical effectiveness of this procedure and it will not be commissioned on a routine basis. SECTION 2 – PROCEDURES NOT REQUIRING PRIOR AGREEMENT
The following procedures do not require prior agreement providing the restricted access criteria are met. An audit of these procedures will be undertaken routinely. EXCISION OF OTHER SKIN LESIONS
General Remarks
If a GP or consultant is concerned that any skin lesion may be malignant the patient should continue to be referred and treated promptly. The general remarks about other cosmetic procedures also apply to the excision of benign skin lesions. Some benign skin lesions will continue to be excised in the acute sector for differential diagnosis. Some GPs also offer these procedures as part of their general practice, although not all patients currently have access to these services. Pigmented Lesions
ICD 10 diagnostic codes L81 810 811 812 813 814 815 816 817 818 819 Removal of obviously clinically benign moles is not available on cosmetic grounds. In most cases the distinction between suspicious and purely benign moles is clear cut but suspicious pigmented lesions should always be subjected to excision biopsy. Tunable Dye Laser
ICD 10 diagnostic codes Q82.5
This treatment is offered for the removal of vascular birthmarks (port wine stains) often present on the neck and face and is the only successful treatment for this type of birthmark. The criteria for patients requiring this type of treatment will be: • On the face or neck above the collar line in children up to the age of 18 years Patients above the age of 18 years will be considered on an individual basis taking into account psychological and psychiatric effects of the birthmarks on the patient. Referrals should be made on a tertiary basis usually by a Consultant Dermatologist. 2.2 VARICOSE
OPCS 4 Procedure codes L85.1 85.2 85.3 85.8 85.9 86.186.8 86.9 87.1 87.2 87.3 87.4 87.5 87.6 87.8 87.9 General Remarks
Scope for prevention of varicose veins is limited. Although treatment for varicose veins is generally effective, recurrence is estimated at around 50% within five years. Surgical treatment of asymptomatic or mild varicose veins is not recommended in the Department of Health’s Healthcare Needs Assessment document, accessible at In view of the lack of evidence for any prophylactic benefit of varicose vein surgery, high rates of recurrence and the current financial situation, treatment of moderate varicose veins is also considered to be a low priority. Most patients can be managed in primary care. Surgical treatment of asymptomatic, mild and moderate varicose veins will therefore only be purchased in individual exceptional circumstances. In patients in whom varicosities are present or suspected, referral to a specialist service is advised as described in the table below. they are bleeding from a varicosity that has eroded the skin they have bled from a varicosity and are at risk of bleeding again they have an ulcer which is progressive and/or painful despite treatment taken from National Institute for Clinical Excellence “Referral Advice – a guide to appropriate referral from general to specialist services” NICE, London, 2001. Conservative management of varicose veins, as detailed in the Department of Health funded Healthcare Needs Assessment should continue to be offered to all appropriate patients. Asymptomatic and Mild Varicose Veins
Surgical treatment of asymptomatic and mild varicose veins will not be available routinely. Asymptomatic varicose veins are those which present as a few isolated, raised, palpable veins which are not associated with any pain or discomfort or any skin changes. The main problems with asymptomatic varicose veins are likely to be cosmetic anxiety. Mild varicose veins are associated with moderate ankle swelling, feelings of heaviness, pain and other discomfort, with local or generalised dilation of subcutaneous veins. Generally, only the superficial veins are involved. Moderate Varicose Veins
Surgical treatment of moderate varicose veins will not be available routinely. Moderate varicose veins are associated with the symptoms described above for mild varicose veins with prominent local or generalized dilation of subcutaneous veins. Moderate varicose veins are more likely to be associated with skin changes but not actual ulceration or pre-ulcerative changes. Severe Varicose Veins
Treatment for severe varicose veins is available routinely if: • associated with obvious skin changes including lipodermatosclerosis, moderate to severe oedema (itching is insufficient for referral) • intractable ulceration secondary to venous stasis • more than one episode of minor haemorrhage from a ruptured superficial or significant haemorrhage from a ruptured superficial varicosity, eg if serious enough to consider transfusion • Chronic venous insufficiency assessed by hospital consultant Severe varicose veins are those associated with chronic leg pain, ulcerative and pre-ulcerative skin conditions, liposclerosis, varicose eczema, history of phlebitis or haemorrhage and there is generally deep venous incompetence or obstruction. Treatment should be in line with the recommendations of the NHS R & D Health Technology Assessment 2006; 10 (13), (Michaels J.A. et al)


Infertility is a condition that requires investigation, management and treatment in accordance
with national guidance. As part of the provision of prevention, treatment and care
Commissioners are committed to ensuring that access to NHS fertility services is provided fairly
and consistently.
Initial Assessment
It will be the responsibility of the General Practitioners to initially assess that the person meets
the local PCT’s criteria for treatment for NHS funded cycles. Further support and advice is
available from the Pharmaceutical advisor, Public Health Department and Directorate of
Strategy (Commissioning) in implementing this guidance.
Referral to Hospital
Assisted conception services are provided by agreed providers. The units must comply with
HFEA regulations and follow appropriate protocols. Couples must take up the offer of ICSI/IVF
within 3 months or risk being removed from the NHS waiting list.
Prescribing of medication
♦ The clinical prescribing of all drugs will be the responsibility of the providing Trust or the
♦ If a patient has started a privately funded cycle, the PCT will not fund the provision of prescribed drugs, which forms part of that treatment.
Timescale for treatment
Couples must be made aware at the time of being placed on the waiting list of the likely waiting
time and the treatment for which the PCT will pay.

All couples must be registered with a General Practitioner within the boundaries of the PCT or
Care Trust and be eligible for NHS treatment. Patients whose sperm or eggs have been stored
prior to chemotherapy or radiotherapy will be entitled to NHS funded infertility treatment
provided they meet the eligibility criteria.
The criteria for GP referrals for investigation and management of infertility should be in
accordance with the following:
♦ Couples should be living together and in a stable relationship.
ƒ The female partner must be aged between 23 and 39 years old (up to 39 years and 364 ƒ Couples who have been diagnosed as having male factor or female factor problems have had unexplained infertility for at least 3 years, taking into consideration both age and waiting list times. ƒ Persons aged under 23 years old will be considered for treatment where medical investigations have confirmed that conception is impossible without fertility treatment, e.g. following unsuccessful fallopian tube surgery. ƒ At present, couples will be offered one NHS funded IVF cycle or up to 3 IUI cycles, but
not both (for local agreement). The female partners must not have had more than 3
previous IVF attempts. Any previous cycles of IVF/ICSI/IUI at any other hospitals
funded by the NHS (including private) will count towards the one cycle for eligible
women. Patients are ineligible for further treatment if there have been three or more
unsuccessful fresh embryo cycles (either NHS or privately funded).
ƒ Women will be only be considered for treatment if their BMI is between 19 and 30. Ladies with the BMI>30 should be referred to the appropriate obesity management pathway. ƒ Couples should be non-smoking at the time of treatment. Couples who smoke should ƒ IVF can not be used as a substitute for reversal of sterilisation. ƒ There are no problems with signing a form concerning the welfare of the child. ƒ There must be no other medical problems making the chance of success less than ƒ This service will be only be available at agreed providers and will include all clinically ƒ Fertility treatment will only be offered to couples where the following two criteria are a) where there are no living children in the current relationship b) where neither partner has children from previous relationships. Where the eligibility criteria are not met but clinicians feel there are exceptional reasons, a case should be referred to the Exceptional Treatment Arrangements Panel for consideration. Definition of one full cycle (NICE guidance, DOH gateway ref. 10321):
'Embryos not transferred during a stimulated in vitro fertilisation treatment cycle may be suitable for freezing. If two or more embryos are frozen then they should be transferred before the next stimulated treatment cycle because this will minimise ovulation induction and egg collection, both of which carry risks for the woman and use more resources'. The 'full cycle' of IVF is therefore regarded as the fresh cycle plus the transfer of frozen embryos where this is possible. The PCTs will fund up to 2 frozen embryos per patient for 2 years. This will include the cost of freezing and storage. For unsuccessful patients, i.e those not resulting in a live birth, the PCT will also fund the transfer of frozen embryos. The age of mother at the time that the embryos are frozen is required to be within the age limits set out in the policy. This does not apply to the age at transfer. Egg Donation
This is a form of infertility treatment when a woman offers to donate her eggs, usually following a process of drug induced ovarian stimulation. The eggs are harvested from the ovaries and used by the donor. A variation known as “egg sharing” is described as a situation where a woman undergoing normal IVF treatment offers to share her eggs (sometimes in order to reduce the cost of her own treatment). The Human Fertilisation and Embryology Authority (HFEA), the regulatory and licensing body for both NHS and private providers of fertility treatments, have set out standards on the practice of egg sharing which are enshrined in law. There are however some ethical issues facing donors and recipients that need to be considered: Screening of eggs for genetic disease or infection A child’s right to seek information about their origin Even though there is no policy on Egg Donation/Sharing, the PCT has funded such requests in instances when the donor is known to the recipient.
HIV and Other Viral Infections (Sperm Washing)
King’s College Hospital and Chelsea and Westminster Healthcare NHS Trust treat patients with known viral infection, offer specialist advice to HIV infected individuals and have developed special treatment programs for men and women who are infected. DILATION AND CURETTAGE
OPCS 4 Procedure codes Q101 102 103 108 109
Effective Health Care Bulletin 9 has recommended that diagnostic Dilation and Curettage
(D&C) should hot be performed on women aged under 40 since the risks of anaesthesia,
uterine perforation and cervical laceration outweigh the minimal potential benefit.
Newer methods of endometrial sampling appear to be at least as accurate as D&C with high levels of acceptability and lower complication rates. For women with dysfunctional uterine bleeding, a range of medical interventions is available (e.g. mefenamic acid with norethisterone etc). HYSTERECTOMY FOR HEAVY MENSTRUAL-BLEEDING
HRG C57 C58
OPCS 4 Q071 Q072 Q073 Q074 Q075 Q078 Q079 Q081 Q082 Q083 Q088 Q089
Hysterectomy is an appropriate treatment for certain conditions such as malignancy. Its effectiveness in conditions such as heavy menstrual bleeding and fibroids where there are a number of treatment options is lesss clear cut. Funding for hysterectomy for heavy menstrual-bleeding and fibroids will be approved only when: There has been a prior trial with a LNG-IUS (levonorgestrel intra-uterine system) intra-uterine device (unless contraindicated) or other hormonal treatments in line with NICE guidance, which has not successfully relieved symptoms AND Other treatments (such as NSAIDs, Tranexamic Acid, Endometrial ablation, uterine-artery embolisation) have failed, are not appropriate or are contra-indicated in line with NICE guidelines. Contraindications to LNG-IUS are: • Severe anaemia, unresponsive to transfusion or other treatment whilst a LNG-IUS • Distorted or small uterine cavity (with proven ultrasound measurements) • Established or marked immunosuppression • In relation to a fibroid uterus above 12 weeks size, the LNG IUS or ablation • For those who for ethical reasons cannot accept the use of Mirena®, they should have tried at least two of the alternative treatments (NSAIDs, Tranexamic Acid, Endometrial ablation, uterine-artery embolisation). • The Mirena® device has been shown to be effective in the treatment of heavy • It is considerably cheaper than performing a hysterectomy, even if required for many A number of effective conservative treatments are available as second line treatment after failure of
Mirena or where Mirena is contra-indicated.
Implantable Cardiac Defibrillators (ICDs) are recommended for patients in the following
Secondary prevention that is, for patients who present, in the absence of a treatable cause,
with one of the following:
ƒ having survived a cardiac arrest due to either ventricular tachycardia (VT) or ventricular ƒ spontaneous sustained VT causing syncope or significant haemodynamic compromise ƒ sustained VT without syncope or cardiac arrest, and who have an associated reduction in ejection fraction (LVEF of less than 35%) (no worse than class III of the New York Heart Association functional classification of heart failure). Primary prevention that is, for patients who have: (i) a history of previous (more than 4 weeks) myocardial infarction (MI) and: either
ƒ left ventricular dysfunction with an LVEF of less than 35% (no worse than class III of the
New York Heart Association functional classification of heart failure) ƒ and non-sustained VT on Holter (24-hour electrocardiogram [ECG]) monitoring, and
ƒ inducible VT on electrophysiological (EP) testing
ƒ left ventricular dysfunction with an LVEF of less than 30% (no worse than class III of the New York Heart Association functional classification of heart failure) and
ƒ QRS duration of equal to or more than 120 milliseconds a familial cardiac condition with a high risk of sudden death, including long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome or arrhythmogenic right ventricular dysplasia (ARVD), or have undergone surgical repair of congenital heart disease.

OPCS 4 Procedure codes D241 242 This procedure is available at specialist centres only and is offered to both adults and children. The service requires considerable pre-operative counseling and assessment and post-operative support from speech therapy services. It is proposed that children up to the age of 18 should have first priority on the allocation of scarce funding. In accordance with their protocols, referrals will be on a tertiary basis from a consultant audiological physician or ENT surgeon. The criteria for patient selection as recommended by NICE TA 166, January 2009: A cochlear implant in one ear is recommended as a possible option for everyone with severe to profound deafness if they do not get enough benefit from hearing aids after trying them for 3 months. Cochlear implants in both ears are recommended for the following groups with severe to profound deafness only if they do not get enough benefit from hearing aids after trying them for 3 months and the implants are placed during the same operation: • adults who are blind or have other disabilities which mean that they depend upon The cochlear implant team should carry out an assessment to find out if an implant would help before they consider a cochlear implant. They should take into account any disabilities or difficulties in communicating, which might mean that the usual hearing tests are not suitable. In such cases they should consider other methods for testing hearing. A later operation to place a cochlear implant in the second ear is only recommended for the following groups if they already had a cochlear implant in the other ear when the guidance was issued: • adults who are blind or have other disabilities which mean that they depend upon In all cases, if more than one type of cochlear implant is suitable, the least expensive should be used. Costs should include the cost of the implant and the support package, and how reliable the system is. When an implant is placed in a second ear during the same operation the cost for the second implant should include currently available discounts on list prices of FILTERED / COLOURED LENSES
These are not offered for specific reading difficulties. TREATMENT OF GENDER DYSPHORIA
Patients should be treated in line with local draft guidance available on this issue, giving information on the ‘core’ and ‘non-core’ interventions associated with this condition. National guidance from the Royal College of Psychiatrists is also in preparation. . Treatment can be undertaken through a specialist unit following referral by a local consultant psychiatrist. Treatment is covered by specialist commissioning arrangements. PHOTODYNAMIC THERAPY (AGREED PATHWAY WITH KINGS COLLEGE HOSPITAL)
• PDT should only be used for confirmed diagnosis of classic with no occult subfoveal choroidal neovascularisation (CNV) (as determined by fluorescein angiography) • Patients with predominantly classic CNV with VA 6/60 or better may be considered by the consultant to be entered into a research programme to determine the effectiveness of treatment for the condition • Referral for PDT should be made if vision of affected eye 6/60 or better • Referral made if there is history of distortion (usually less than 6 months) • Fundal appearance suggestive of choroidal neovascularisation • Referrals should include patient details and telephone number, patient’s refraction and visual acuity, which eye is affected and duration in weeks and optometrists name and address COMMON HAND CONDITIONS
OPCS 4 Procedure codes T59 T60 ICD 10 diagnostic code M67 Cystic degeneration from joint capsule or tendon sheath. Lesions at the base of the digits are often small but very tender (Seed Ganglion). 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%. Refer: o Painful seed ganglia o Mucoid cysts that are disturbing nail growth or have a tendency to discharge (risk of septic arthritis in distal interphalangeal joint) There is no indication for the routine excision of simple wrist ganglia. These should not generally be referred. ♦ Carpal Tunnel Syndrome
OPCS 4 Procedure codes T52.1 T52.2 ICD 10 diagnostic code G56 Patients typically present with nocturnal dysaesthesia in the hands wear 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 experience). Refer: o Acute severe symptoms (fewer than 5% of patients) uncontrolled by conservative measures, particularly pregnancy o Mild to moderate symptoms with failure of conservative management (4 months) o Neurological deficit ie sensory blunting or weakness of thenar abduction (APB) ♦ Dupuytren’s Disease
ICD 10 diagnostic code M72 Nodular or cord-like thickening of the palmar skin. May tend to cause tethering of the digits with loss of extension range. Refer: o Loss of extension in one or more joints exceeding 25 degrees o Young patients (under 45 years) with disease affecting 2 or more digits and loss ♦ Trigger Finger
ICD 10 diagnostic code M20 M65.3 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 thumb. Conservative treatment may include rest from precipitating activities or NSAIDs. 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 clinical experience). Refer: o Failure to respond to conservative treatment (maximum 2 injections) o Fixed flexion deformity that cannot be corrected 2.12 TONSILLECTOMY
HRG C57 C58 OPCS4 E201 E208 E209 F341 F342 F344 F345 F346 F348 F349 F361 F368 F369 Tonsillectomy will not be funded except in cases of suspected malignancy or significant severe impact on quality of life indicated by: • 5 or more episodes of sore throat per year • the episodes of sore throat are disabling and prevent normal functioning • documented evidence of absence from school or attendance at GP or other health care setting. • Tonsillectomy offers relatively small clinical-benefit, measured best in terms of time taken away from school. The benefit in the year after the operation is roughly 2.8 days less taken away from school. • Tonsillectomy carries a risk of mortality estimated to lie between 1 in 8,000 and 1 2.13 GROMMETS
OPCS 4 Procedure code D15 ICD 10 diagnostic code H65 PCTs will fund insertion of grommets (ventilation tubes) in • Children with persistent bilateral Otitis media with effusion (OME) documented over a period of 3 months with a hearing level in the better ear of 25-30 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz (or equivalent dBA where dBHL not available) • Children with persistent bilateral OME with a hearing loss less than of 25-30 d BHL where the impact of the hearing loss on the child's developmental, social or educational status is judged to be significant (e.g. documented absence from school) • Children with Down's syndrome or cleft palate if this is considered clinically appropriate by a multidisciplinary team of professionals with expertise in assessing and treating such children see NICE guidance on surgical management of OME ADENOIDECTOMY FOR OTITIS MEDIA IN CHILDREN
Adenoidectomy combined with grommets may be considered in children who fulfil the criteria for grommets (see grommets section 2.13 of ETA). S:\Pub\NADA ETA\SE Sector ETA\SEL ETA Comm Policy\2009\SE COMMISSIONING ETA POLICY 2009-10 Final.doc


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