Policies and Application forms – North East Hants & Farnham

Procedure that requires Prior Approval  – Prior approval is not required for any of these policies for patients registered in the North East Hampshire & Farnham locality, as there are no prior approval arrangements currently in place. The exception to this is Assisted Conception, which does still require prior approval.  The clinicians still must ensure the criteria for the below policies are met before proceeding with treatment.

Procedure Not Routinely Funded – Cases that are not routinely funded will require an Individual Funding Request (IFR) funding application to be submitted.  A fully completed IFR form with supporting clinical detail should be submitted, and cases will be considered on the grounds of exceptionality.

Cosmetic, Other Surgeries, Devices, Screening and Diagnostics and Other Therapies
Information and forms can be found by using the search facility on the right of the table below (just above Process Pathway). Type a word associated with the intervention you require and a limited list of policies and forms to be displayed. For example Assisted Conception would be displayed if any of the following is typed Assisted, Conception, IVF.

Fully completed application forms should be saved locally and sent from an NHS.net email account (or other email account which meets the secure email standard and is DCB1596 accredited) to scwcsu.cpis.requests@nhs.net for consideration.

INTERVENTIONPOLICY STATEMENT
(CURRENT POLICY, REFERRAL GUIDELINES)
PROCESS PATHWAY
(PATHWAY FOR TREATMENT AND APPROPRIATE FORMS)
Adenoidectomy
ENT
Procedure Not Routinely Funded

Adenoidectomy for children with chronic rhinosinusitis (CRS)
No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee

008 Adenoidectomy revised March 2020
This procedure is not routinely funded except when offered in combination with Myringotomy (grommet insertion) and /or Tonsillectomy which require prior approval.

If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Appliances and devices for cosmetic purposes (high-grade silicon cosmeses and /or prostheses)
Plastic surgery
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Appliances and devices for cosmetic purposes (high-grade silicon cosmesis and /or prosthesis
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.
IFR application form
Arthroscopic hip surgery in impingement
Orthopaedics/ MSK

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
006 Arthroscopic femoro-acetabular surgery for hip impingement - November 2015

If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Knee arthroscopy (in adults over 40 years old)
Orthopaedics/ MSK

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
010 The place of arthroscopy in knee pain without true locking in adults over 40 years old - revised July 2018


55 Arthroscopic Surgery for Meniscal Tears reviewed 2021
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.
IFR application form
Assisted conception
Infertility treatments
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Group's Priorities Committee

002-Assisted-Conception-Services-Policy-Recommendation-SHIP8-review-July-2019

Covering North East Hants & Farnham within NHS Frimley ICB
Excluding GP Practices - Downing Street Surgery, River Wey Medical Practice, Farnham Dene Medical Practice, Holly Tree Surgery and The Ferns Medical Practice
This procedures is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.


NEHF-ICB-IVF-Referral-Form-2020 - check list of eligibility form - Word format for patients registered with North East Hants & Farnham within NHS Frimley ICB.

Please note: Immigration health surcharge; removal of assisted conception services (Legislation.gov.uk)
Amendments to the NHS (Charges to Overseas Visitors) Regulations 2015 were introduced into Parliament on 19 July 2017. As a result, from 21 August 2017, assisted conception services will no longer be included in the scope of services available for free for those who pay the immigration health surcharge. It is therefore important that to ensure potential users of these services are aware of the changes.
Assisted conception
Infertility treatments
Procedure that requires Prior Approval
Assisted Conception Policy Feb-2012
Covering only Farnham GP Practices - Downing Street Surgery, River Wey Medical Practice, Farnham Dene Medical Practice, Holly Tree Surgery and The Ferns Medical Practice

Please note this policy is an inherited policy, and is currently in the process of being aligned across Frimley ICB.
This procedures is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IVF-Referral-Form-Farnham-pts-2020- check list of eligibility form - Word format for patients registered with a Farnham GP Surgery

Please note: Immigration health surcharge; removal of assisted conception services (Legislation.gov.uk)
Amendments to the NHS (Charges to Overseas Visitors) Regulations 2015 were introduced into Parliament on 19 July 2017. As a result, from 21 August 2017, assisted conception services will no longer be included in the scope of services available for free for those who pay the immigration health surcharge. It is therefore important that to ensure potential users of these services are aware of the changes.
Autologous Blood Injections for Musculoskeletal Conditions

Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Group's Priorities
024 Use of Autologous Blood Injections for Musculoskeletal Conditions - December 2017
This procedure is not routinely funded and prior approval is always required from the IFR service Prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need, please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Balloon catheter sinus dilation for chronic rhinosinusitis
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
018 Balloon Catheter Sinus Dilation for Chronic Rhinosinusitis - v1.0
This procedure is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Bariatric SurgerySHIP8 Clinical Commissioning Groups' Priorities Committee
013 Bariatric Surgery June 2016 reviewed Jan 2020
For information only.
Bariatric Surgery Revision
No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
031 Bariatric Surgery Revision v1.1
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form

Low Intensity Pulsed Ultrasound (Exogen) in delayed and non union fractures

Procedure Not Routinely Funded
South Central Priorities Committee
(Southampton, Hampshire, Isle of Wight and Portsmouth PCTs)
65 Exogen policy FINAL v1.0 250820
This procedure is not routinely funded and prior approval is always required from the IFR service.

If there is exceptional health need for this procedure please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Bunions (hallux valgus)
Orthopaedics/ MSK

No prior approval arrangements for this procedure
IFR Policies and Procedure extract:
51 Bunions (Hallux Valgus)
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Bursledon House - Assessment and admission for in-patient treatment
Children’s Services
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Assessment and admission to Bursledon House in Southampton for in-patient treatment
This treatment is not routinely funded and prior approval is always required from the IFR service.

If there is exceptional health need please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Carpal tunnel release/nerve entrapment at wrist
Orthopaedics/MSK

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
22 Carpal Tunnel Syndrome reviewed November 2020
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Cataract RemovalSHIP8 Clinical Commissioning Groups' Priorities Committee
32 Cataract Removal - April 2018
For information only.
Erectile DysfunctionSHIP8 Clinical Commissioning Groups' Priorities Committee
63 Erectile Dysfunction and Penile Rehabilitation Policy FINAL v1.0
For information only.
Cholecystectomy - Asymptomatic GallstonesSHIP8 Clinical Commissioning Groups' Priorities Committee
012 Cholecystectomy for patients with asymptomatic gallstones - April 2018
For information only.
Chronic Anal Fissure (CAF) in Adults

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
025 Treatment of Chronic Anal Fissure (CAF) in Adults - December 2017
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Chronic Fatigue Syndrome(CFS)/ Myalgic Encephalomyelitis(ME) - inpatient treatment
Mental health
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
In patient treatment for severe chronic Fatigue/ME in patient treatment
This treatment is not routinely funded. Severe cases require prior approval from the IFR service prior to referral and treatment but Mild-to-Moderate cases are available within the commissioned outpatient service run by South Coast Fatigue.

For severe cases a strong case on grounds of exceptional health need must be provided. If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Complementary therapies/medicine
Alternative/
complementary/ homeopathic therapies
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Complementary therapies/medicine
This treatment is not routinely funded as a separate procedure but can be used without prior approval when included as an adjunct to usual therapy e.g. acupuncture within physiotherapy or pain management services. Not funded as a separate procedure

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Continuous glucose monitoring (CGM) for adults with Type 1 Diabetes Mellitus
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
007 Continuous Glucose Monitoring (CGM) for adults with Type 1 Diabetes Mellitus - February 2016
This treatment is not routinely funded for patients requiring Continuous Glucose Monitoring (CGM) without the use of pump therapy.

Applications are expected from Secondary Care/Diabetes Specialists.

For these cases a strong case on grounds of exceptional health need must be provided. If there is exceptional health need, please complete fully the following form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Cryopreservation - preservation of fertility (Male and Female)
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
30 Cryopreservation options for patients about to start NHS treatment which might impair their future fertility - April 2018
This procedure is not routinely funded and prior approval is always required from the IFR service.

Requests are normally expected from Secondary Care.
Prior Approval Cryopreservation v1
If Secondary Care/Consultant wishes to treat, they must provide details of the diagnosis, prospective treatment and evidence of how this may impair future fertility. Please email this to scwcsu.ship.ifrrequests@nhs.net for consideration.
Dupuytren’s contracture / Palmar fasciectomy
Orthopaedics/ MSK

No prior approval arrangements for this procedure
IFR Policies and Procedure extract:
46 Dupuytrens Contracture HANTS
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Excision of skin following massive weight loss
including abdominoplasty, mammoplasty and removal of skin folds from the inner thighs
Cosmetic/Plastic/ Aesthetic surgery

No prior approval arrangements for this procedure
IFR Policies and Procedure extract:
56 Excision of skin following massive weight loss.docx
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Eyelid Surgery
Ophthalmology
including Blepharoplasty, Chalazia (meibomian cysts), Ectropion/ Entropion, Ptosis & Dermatochalasis


No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee

54 Chalazia

53 Entropion and Ectropion

52 Eyelid surgery for ptosis and dermatochalasis
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Faecal microbiota transplants

- Recurrent or refractory C. difficile infection up to a maximum of two transplants
Procedure Funded Subject to Audit

- For all other indications
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
017 Faecal Microbiota Transplants - February 2017
Faecal Microbiota Transplants are commissioned for recurrent or refractory C. difficile infection up to a maximum of two transplants. Prior approval is not required from the IFR service if the policy criteria outlined in the policy are met.

All other indications are not routinely funded and prior approval is always required from the IFR service. If the Consultant wishes to treat outside of policy please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Foetal Alcohol Spectrum DisorderSHIP8 Clinical Commissioning Groups' Priorities Committee
62 Foetal Alcohol Spectrum Disorders
This procedure is not routinely funded and prior approval is always required from the IFR service.

If there is exceptional health need for this procedure please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR form for primary care - Word format
IFR form secondary care - Word format
Female sterilisation
Gynaecology

No prior approval arrangements for this procedure
IFR Policies and Procedure extract:
45 Female Sterilisation Hants
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
'Flash' Glucose Monitoring in Diabetes
SHIP8 Clinical Commissioning Groups' Priorities Committee
028 'Flash' Glucose monitoring in Diabetes - January 2018
For notification only.

Providers are expected to keep a record of all patients set up with a Flash glucose monitor in line with the criteria and this should be reported with CCG medicines management teams.
Functional electrical stimulation (FES) in drop foot
Other services

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
005 Functional electrical stimulation in the management of drop foot of central neurological origin (specifically post stroke and multiple sclerosis) - July 2015
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Functional endoscopic sinus surgery
ENT/Audiology

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
019 Functional endoscopic sinus surgery for chronic rhinosinusitis and nasal polyps - February 2017
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Functional nasal airways surgery (which may include septo-rhinoplasty)
ENT/Audiology

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
Nasal surgery for nasal blockage and/or deformity reviewed November 2020
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Ganglion Surgery
General surgery/Hand surgery

No prior approval arrangements for this procedure
IFR Policies and Procedure extract:
48 Ganglion excision Hants
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Gastric fundoplication for chronic reflux oesophagitis
Gastroenterology

No prior approval arrangements for this procedure
South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
58 Gastric Fundoplication in reflux oesophagitis.docx
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Hydrocele
No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities
Policy 26 Treatment of Hydrocele 1.0
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Hysterectomy in heavy menstrual bleeding/dysmennorhea (menorrhagia)
Gynaecology

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
39 Hysterectomy for heavy and/or painful menstrual bleeding - September 2018
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Inguinal hernia - Asymptomatic
General surgery/hand surgery

No prior approval arrangements for this procedure
South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
148 Repair of asymptomatic inguinal hernias in adults - February 2013
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Spinal Pain
No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
Policy 60 Spinal pain v2.0
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Laser therapy for recurrent pilonidal sinus
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
016 Laser Therapy for Recurrent Pilonidal Sinus updated June 2020
This procedure is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Laser treatment
including
Removal of skin
Excessive hirsutism
Surgical shaving
Chemical destruction of skin
Plastic surgery
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Laser removal of skin and excessive hirsutism
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Liothyronine in the treatment of Primary Hypothyroidism

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
027 Liothyronine in the treatment of Primary Hypothyroidism - January 2018
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Lymphoedema - Intensive decongestive therapy
Other services

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
004 Treatments for patients with lymphoedema - June 2015
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Male circumcision
Urology

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
43 Circumcision - November 2018
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Management of Haemorrhoids
No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
40 Management of Haemorrhoids - September 2018
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Management of rotator cuff tears and rotator cuff syndrome
Orthopaedics/MSK

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
41 Management of rotator cuff tears and rotator cuff syndrome - September 2018
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Microsuction for the removal of ear wax in adults of 16 yeasrs and over.SHIP8 Clinical Commissioning Groups' Priorities Committee
33 Microsuction for the removal of ear wax in adults of 16 years and over - June 2018
For information only.
Myringotomy/grommet insertion for adults
ENT/Audiology

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
37 Grommet insertion - adults and children Updated 2021
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Myringotomy/grommet insertion for children (≥12 years of age)
ENT/Audiology

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
37 Grommet insertion - adults and children Updated 2021

If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Negative Pressure Wound TherapySHIP8 Clinical Commissioning Groups' Priorities Committee
61 Negative Pressure Wound Therapy
For information only
Non-Alcoholic Fatty Liver DiseaseSHIP8 Clinical Commissioning Groups' Priorities Committee
38 Non-Alcoholic Fatty Liver Disease - July 2018
For information only.
Non-NHS residential placements
Mental health
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Non-NHS residential placements
This treatment is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Obstructive Sleep Apnoes - Diagnosis using Pulse Oximetry SHIP8 Clinical Commissioning Groups' Priorities Committee
34 Pulse Oximetry for the diagnosis of Obstructive Sleep Apnoea - June 2018
For information only.
Partial Knee Arthroplasty inpatients with Osteoarthritis of the kneeSHIP8 Clinical Commissioning Groups' Priorities Committee
003 The Use of Partial Knee Arthroplasty in patients with Osteoarthritis of Knee - April 2015
For information only.
Pelvic Organ Prolapse
No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
29 Policy Pelvic Organ Prolapse FINAL v1.0 250820
Reviewed July 2020
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Erectile Dysfunction and Penile Rehabilitation following radical prostatectomy
Procedure Not Routinely Funded
South Central Priorities Committee
(Southampton, Hampshire, Isle of Wight and Portsmouth PCTs)
63 Erectile Dysfunction and Penile Rehabilitation Policy FINAL v1.0

Policy update July 2020 amalgamated with updated policy, Treatments for erectile dysfunction (March 2020) and replaced policy recommendation 137.
For information only.
Managed by NHS England & Improvement.
Plastic/Cosmetic procedures
including:
Abdominoplasty
Buttock lift, thigh lift, upper arm lift (brachioplasty)
Facelift
Female cosmetic genital surgery (labiaplasty)
Implant removal and replacement
Liposuction
Pinnaplasty/meatoplasty/plastic operations on external ear
Rhinoplasty/reconstruction of nose
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Plastic/cosmetic procedures surgery

South Central Priorities Committee
(Southampton, Hampshire, Isle of Wight and Portsmouth PCTs)
121 - Aesthetic surgery in children - Dec 2011

Guidance Notes
Policy and Procedure for Individual Funding Requests - Appendix 6
These procedures are not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Plastic/Cosmetic procedures
including:
Breast and nipple procedures
Breast augmentation
Breast reduction
Gynaecomastia
Implant removal and replacement
Mastopexy
Procedure Not Routinely Funded
IFR Policies and Procedure Statement: Appendix 1 -
Breast and nipple procedures

South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
15 Cosmetic breast surgery - Sept 2008

Guidance Notes
Policy and Procedure for Individual Funding Requests - Appendix 6
Reconstructive procedures may go ahead as part of established pathways and must take place within one year of the last cancer treatment.

Outside of the above exclusion these procedures are not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Primary hip and knee replacement in patients with a BMI above 35
Orthopaedics/MSK

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Policy Statement 50
Policy 50 Primary joint replacement for hip and knee osteoarthritis for patients with a body mass index of 35 and above v1.1
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Primary hip or knee replacement surgery - routine follow-up
Orthopaedics
Procedure Not Routinely Funded
South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
110 Routine follow up after primary hip or knee replacement surgery - August 2011
Following the initial routine follow-up appointment, further follow-up appointments are not normally funded and will be challenged via the contract.
IFR application form


Reversal of sterilisation/ vasectomy
Urology
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Reversal of sterilisation/ vasectomy
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care
If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form


Revision of Knee Replacement
Orthopaedics/MSK
Procedure Funded Subject to Audit
SHIP8 Clinical Commissioning Groups' Priorities Committee
44 Revision of Knee Replacement - November 2018
For information only.

SativexSHIP8 Clinical Commissioning Groups' Priorities Committee
64 Sativex
For information only
Second eye cataract surgery
Ophthalmology
Procedure Funded Subject to Audit
IFR Policies and Procedure extract:
Second eye cataract surgery
NHS Portsmouth, NHS Farenham & Gosport, NHS South East Hampshire CCGs
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in secondary care.

Requests are normally expected from Primary care or community optometry services. Requests from secondary care ophthalmology should only involve patients on long-term follow-up or listed for bilateral two-stage procedures.

Please complete the following form and submit with the relevant documentary evidence to scwcsu.ship.ifrrequests@nhs.net for consideration.

Cataract Surgery in Second Eye Form - Word format
Shoulder Radiology Guided Injections and Scans for Shoulder Pain
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
067 Shoulder Radiology Guided Injections and Scans for Shoulder Pain 1.1
This procedure is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Short sight/long sight corrective (laser) surgery (Refractive keratoplasty)
Ophthalmology
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Short sight/long sight corrective (laser) surgery (Refractive keratoplasty)
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Secondary care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Subacromial decompression of the shoulder
Orthopaedics/MSK

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee

14 Policy Subacromial decompression FINAL v1.0
Reviewed July 2020
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Surgery for snoring
ENT
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
009 Treatments for people who snore - February 2016
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form
Surgical removal of skin lesions and Lipoma
Dermatology/general surgery
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
57 Removal of benign skin lesions final.docx
If there is a suspicion of malignancy, the patient should be referred using the two-week wait referral form for suspected cancer or via the local BCC fast track pathway. Where the treatment is for Hidradenitis suppurutiva then prior approval is not required.

Outside of the above exclusion this procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Primary Care.

If there is exceptional health need send all relevant documentary proof to scwcsu.ship.ifrrequests@nhs.net for consideration.

Prior Approval removal of benign skin lesions v2 - Word format
Tonsillectomy
ENT/ Audiology

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
36 Tonsillectomy- adults and children reviewed November 2020

If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Treatment of LUTS as a result of Benign Prostatic Hyperplasia
Orthopaedics/MSK

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee
66 Treatment of LUTS as a result of Benign Prostatic Hyperplasia (2020)
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Trigger finger surgery
Orthopaedics/MSK

No prior approval arrangements for this procedure
IFR Policies and Procedure extract:
47 Trigger Finger Hants
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Varicose vein procedures
Vascular Surgery

No prior approval arrangements for this procedure
SHIP8 Clinical Commissioning Groups' Priorities Committee

001 Varicose veins policy recommendation reviewed Jan 2020
If the patient does not meet the criteria but there is exceptional health need for this procedure, please complete the form together with all relevant documentary proof, email it to scwcsu.CPIS.requests@nhs.net for consideration.

IFR application form
Dilation and curettage in heavy menstrual bleeding
Gynaecology
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
49 Dilation and curettage in HMB Hants
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

IFR application form

For more information
Please email the IFR service at scwcsu.cpis.requests@nhs.net for all enquiries about the policy statements or the process for considering Individual Funding Requests.

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