Policies and Application forms – Hampshire and Isle of Wight ICB

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)
Procedure that requires Prior Approval
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 there is exceptional health need for this procedure without myringotomy or tonsillectomy, 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

Proforma for CRS
Prior approval Adenoidectomy for CRS v1
Adult Mental Health IFR
Procedure Not Routinely Funded
No policy statement for these interventions.This procedure is not routinely funded.

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.CPIS.requests@nhs.net for consideration.

IFR application form
Arthroscopic hip surgery in impingement
Orthopaedics/ MSK
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
006 Arthroscopic femoro-acetabular surgery for hip impingement - November 2015

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.

Prior Approval hip arthroscopy in impingement v1 - Word format
Knee arthroscopy (in adults over 40 years old)
Orthopaedics/ MSK
Procedure that requires Prior Approval
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
Prior approval is not required for cases of traumatic knee pain.

In all other circumstances this procedure is not routinely funded and prior approval is always required from the IFR service. In the first instance, GP's to refer to the local MSK community service.

Requests are normally expected from Secondary Care or the MSK community service.

If MSK service wishes to refer to secondary care, or if a Consultant wishes to treat, they must fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

Prior Approval knee Arthroscopy (in adults over 40 years old) v4

Prior Approval Arthroscopic Surgery for Meniscal Tears v2
Assisted conception
Infertility treatments
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
002 Assisted Conception Services Policy Recommendation SHIP8 review July 2019
Covers: Hampshire and Isle of Wight ICB including Portsmouth.
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.

IVF-Referral-Form-2020

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
Policy 24 Use of AB and PRP Injections for musculoskelatal conditions v2.0
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.cpis.requests@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
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
031 Bariatric Surgery Revision v1.1
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.

Prior Approval revision bariatric v1
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
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
51 Bunions (Hallux Valgus)
This procedure is not routinely funded and in the first instance, GP's to refer to the local MSK community service.

Requests are normally expected from Secondary Care or the MSK community service.

If MSK service wishes to refer to secondary care, or if a Consultant wishes to treat, they must fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

Prior Approval Bunions (Hallux valgus) v4
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
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
22 Carpal Tunnel Syndrome reviewed November 2020
This procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Primary Care, Secondary Care or MSK service.

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

Prior Approval Carpal tunnel v5
Cataract Removal
Procedure Funded Subject to Audit
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 32 Cataract removal v3.0
For information only.
Erectile DysfunctionSHIP8 Clinical Commissioning Groups' Priorities Committee
63 Erectile Dysfunction and Penile Rehabilitation Policy FINAL v1.0
For information only.
Complementary and alternative therapy
Procedure Not Routinely Funded
Hampshire and Isle of Wight Integrated Care Board Priorities
Policy 70 Complementary and alternative therapy v2.0
For Information Only.
Complex Children IFR
Procedure Not Routinely Funded
No policy statement for these interventions.This procedure is not routinely funded.

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.CPIS.requests@nhs.net for consideration.

Complex Children IFR Form
Cosmetic interventions for adults and children
Procedure Not Routinely Funded
Hampshire and Isle of Wight Integrated Care Board Priorities
Policy 72 Cosmetic interventions for adults and children v1.1
For Information Only.
Cholecystectomy - Asymptomatic Gallstones
Procedure Not Routinely Funded
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 12 Cholecystectomy for asymptomatic gallstones v3.0
For information only.
Treatment of Chronic Anal Fissure (CAF) in Adults
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 25 Treatment of Chronic Anal Fissure (CAF) in Adults v3.0
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

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

Prior Approval Chronic Anal Fissure 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
Complex Neurological Rehabilitation for acquired brain injuryComplex Neurological Rehabilitation - Initial Referral form
Please email the completed forms to the IFR service at ifrcasemanagement@nhs.net
Continuous Glucose Monitoring for Diabetes in Adults
Procedure Funded Subject to Audit
Hampshire and Isle of Wight Integrated Care Board Priorities
Policy 7 Continuous Glucose Monitoring for Diabetes in Adults v2
Continuous Glucose monitors are commissioned for patients with diabetes who meet the criteria outlined in the policy. Prior approval is not required from the IFR service if these criteria 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.CPIS.requests@nhs.net for consideration.

IFR application form
Cryopreservation - Fertility preservation
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 30 Fertility preservation v2.0
This procedure is not routinely funded and prior approval is always required from the IFR service.
Requests are normally expected from Secondary Care.
Fertility Preservation Form
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.cpis.requests@nhs.net for consideration.
Dupuytren’s contracture / Palmar fasciectomy
Orthopaedics/ MSK
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
46 Dupuytrens Contracture HANTS
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 MSK community service.

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

Prior Approval Dupuytrens v4 - Word format
Excision of skin following massive weight loss
including abdominoplasty, mammoplasty and removal of skin folds from the inner thighs
Cosmetic/Plastic/ Aesthetic surgery
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
56 Excision of skin following massive weight loss.docx
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

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

Prior Approval Skin reduction surgery after massive weight loss v3 - Word format
Eyelid Surgery
Ophthalmology
Procedure that requires Prior Approval

Chalazia
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 54 Chalazia v2.0
Where there is a suspicion of malignancy, the patient is referred using a two-week wait referral form for suspected cancer.

In all other circumstances this procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in secondary care.

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

Eyelid Surgery Chalazia Form
Eyelid Surgery
Ophthalmology
Procedure that requires Prior Approval

Ectropion and Entropion
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 53 Ectropion and Entropion v2.0
Where there is a suspicion of malignancy, the patient is referred using a two-week wait referral form for suspected cancer.

In all other circumstances this procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in secondary care.

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

Eyelid Surgery Ectropion and Entropion Form
Eyelid Surgery
Ophthalmology
Procedure that requires Prior Approval

Ptosis and Dermatochalasis
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
52-Eyelid-surgery-for-ptosis-and-dermatochalasis
Where there is a suspicion of malignancy, the patient is referred using a two-week wait referral form for suspected cancer.

In all other circumstances this procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in secondary care.

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

Prior-Approval-Eye-Lid-Surgery-ptosis-and-dermatochalasis
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
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
45 Female Sterilisation Hants
This procedure is not routinely funded and prior approval is always required from the IFR service prior to treatment.

Requests are normally expected from Primary Care or Gynaecology Service.

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

Prior Approval Female sterilisation v4 - Word format
Skin surface Functional electrical stimulation (FES) for foot drop as a result of a condition of central neurological origin
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 5 Skin surface FES for foot drop ... central neurological origin v3.0
Prior approval must be obtained before assessment and treatment from the IFR service. Functional Electrical Stimulation may be considered as a second line treatment option for carefully selected patients with drop foot (most commonly due to multiple sclerosis or stroke).

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

Prior Approval Functional Stimulation Form
Sinus surgery for chronic rhinosinusitis
ENT/Audiology
(FESS)
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 19 Sinus surgery for chronic rhinosinusitis v3.0
Prior approval is required from the IFR service.

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

Prior Approval Sinus surgery for Chronic Rhinosinusitis
Functional nasal airways surgery (which may include septo-rhinoplasty)
ENT/ Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
23 Nasal surgery for nasal blockage and/or deformity reviewed November 2020
Emergency procedures recorded under admission 21-28 do not require prior approval.

In all other cases this procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Primary Care or ENT.

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

Prior Approval Nasal surgery for nasal blockage and/or deformity v5
Ganglion Surgery
General surgery/ hand surgery/
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
48 Ganglion excision Hants
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.

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

Prior Approval Ganglion v3 - Word format
Gastric fundoplication for chronic reflux oesophagitis
Gastroenterology
Procedure that requires Prior Approval
South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
58 Gastric Fundoplication in reflux oesophagitis.docx
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment for this indication.

Application is expected from secondary care

If the Consultant wishes to treat please fully complete the following appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

Prior Approval Gastric fundoplication for reflux oesophagitis v4 - Word format
Hydrocele
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities
Policy 26 Treatment of Hydrocele 1.0
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

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

Prior Approval Hydrocele v3
Hysterectomy and Dilation and Curettage for Heavy Menstrual Bleeding
Procedure Not Routinely Funded
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 39 Hysterectomy and D&C for HMB v2.0
This procedure is not routinely funded.

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.CPIS.requests@nhs.net for consideration.

IFR application form
Spinal Pain
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
Policy 60 Spinal pain v2.0
This procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care.

If the Consultant wishes to treat please fully complete the following appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

Prior Approval Interventions for Spinal Pain v10
Knee Pressure Offloading Devices for OAHampshire and Isle of Wight Integrated Care Board Priorities
Policy 69 Knee Pressure Offloading Devices for OA v1.0
For Information Only.
Prior Approval not required.
Keloid Scars
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities
Policy 71 Keloid Scars 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.cpis.requests@nhs.net for consideration.

Prior Approval Keloid Scars 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
Liothyronine in the treatment of Primary Hypothyroidism
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 27 Liothyronine in the treatment of primary hypothyroidism v2.0
This treatment is not routinely funded and prior approval is always required from the IFR service prior to treatment.

Applications are expected from Secondary Care.

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

Prior Approval Liothyronine Form
Lymphoedema treatments - Intensive decongestive therapy
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 4 Lymphoedema treatments v2.0
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

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

Prior Approval Lymphoedema treatments Form
Male circumcision
Urology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
43 Circumcision - November 2018
Where there is a suspicion of malignancy, the patient should be referred using the two-week wait referral form.

In all other cases this procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care and Primary Care

If the GP wishes to refer or the Consultant wishes to treat please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.
Prior Approval Male circumcision v5
- Word format
Management of Haemorrhoids
Procedure Funded Subject to Audit
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 40 Management of Haemorrhoids v2.0
For information only.
Rotator Cuff Tears
Orthopaedics/MSK
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 41 Rotator cuff tears v2.0
Prior approval is not required if the tear is caused by trauma.

For all other procedures prior approval is required. Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

Prior Approval Rotator Cuff Tears 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
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
37 Grommet insertion - adults and children Updated 2021
This procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care.

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

Prior Approval Grommets 12 years and over v5
Myringotomy/ grommet insertion for children (≥12 years of age)
ENT/Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
37 Grommet insertion - adults and children Updated 2021

Children under 3 years of age may be treated without prior approval.

This procedure is not routinely funded in all other circumstances and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care.

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

Prior Approval Grommets 3-11 years v6
Negative Pressure Wound TherapySHIP8 Clinical Commissioning Groups' Priorities Committee
61 Negative Pressure Wound Therapy
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
Pulse oximetry for the diagnosis of obstructive sleep apnoea
Procedure Funded Subject to Audit
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 34 Pulse oximetry for the diagnosis of obstructive sleep apnoea v2.0
For information only.
The Use of Partial Knee Arthroplasty in patients with OA of the kneeHampshire and Isle of Wight Integrated Care Board Priorities
Policy 3 The Use of Partial Knee Arthroplasty in Patients with OA v2.0
For information only.
Pelvic Organ Prolapse
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
29 Policy Pelvic Organ Prolapse FINAL v1.0 250820
Reviewed July 2020
This is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

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

Prior Approval Pelvic organ prolapse surgery v4 - Word format
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:
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
Procedure that requires Prior Approval
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
Emergency procedures recorded under admission 21-28 do not require prior approval.

In all other cases this procedure is not routinely funded and prior approval is always required from the IFR service. Referrals should have been made to the commissioned tier 2 or tier 3 obesity management programme prior to offering surgery.

If MSK wishes to refer to secondary care, or if a Consultant wishes to treat, please fully complete the following appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.

Prior Approval Hip or knee replacement in patients with a BMI above 35 v5


Repair of asymptomatic/minimally symptomatic inguinal hernias in men
Procedure Not Routinely Funded
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 20 Repair of asymptomatic and minimally symptomatic inguinal hernias in men v3.0
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.cpis.requests@nhs.net for consideration.

IFR application form
Reversal of female sterilisation and male sterilisation (vasectomy)
Procedure Not Routinely Funded
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 73 Reversal of female sterilisation and male steralisation v2.0
For Information Only.
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
Shoulder Radiology Guided Injections and Scans for Shoulder Pain (Ultrasound guided subacromial injections)
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
Subacromial decompression of the shoulder
Orthopaedics/ MSK
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee

14 Policy Subacromial decompression FINAL v1.0
Reviewed July 2020
This procedure is not routinely funded and prior approval is always required from the IFR service. In the first instance, GP's to refer to the local MSK community service.

Requests are normally expected from Secondary Care or the MSK community service.

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

Prior Approval subacromial shoulder decompression v1 - Word format
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
Removal of benign skin lesions
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 57 Removal of benign skin lesions v2.0
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.cpis.requests@nhs.net for consideration.
Removal-of-Benign-Skin-Lesions-Form

Tonsillectomy
ENT/ Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
36 Tonsillectomy- adults and children reviewed November 2020

Prior approval is not required for patients who have been referred via the two-week wait referral form for suspected cancer.

In all other circumstances prior approval must be obtained from the IFR service before treatment.

Requests are normally expected from Primary Care or ENT.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.ship.ifrrequests@nhs.net for consideration.
Prior Approval Tonsillectomy v7
Treatment of lower urinary tract symptoms (LUTS) as a result of benign prostatic hyperplasia (BPH)
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee

Policy 66 Treatment of lower urinary tract symptoms (LUTS) as a result of benign prostatic hyperplasia (BPH) v2.1
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Prior Approval Treatment of LUTS as a result of Benign Prostatic Hyperplasia Form
Treatments for primary focal hyperhidrosis
Procedure that requires Prior Approval
Hampshire and Isle of Wight Integrated Care Board Priorities Committee
Policy 68 Treatments for primary focal hyperhidrosis v1.0
Please fully complete the appropriate form and together with all relevant documentary proof, email it to scwcsu.cpis.requests@nhs.net for consideration.

Treatment for primary focal hyperhidrosis Form
Trigger finger surgery
Orthopaedics/ MSK
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
47 Trigger Finger Hants
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 or MSK community service.

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

Prior Approval Trigger finger surgery v3 - Word format
Varicose vein procedures
Vascular Surgery
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee

001-Varicose-veins-policy-recommendation-reviewed-Jan-2020
Emergency procedures recorded under admission 21-28 do not require prior approval.

In all other circumstances this procedure is not routinely funded and prior approval must be obtained from the IFR service before referral and treatment in secondary care.

Requests normally are expected from Primary Care.

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

Prior-Approval-Varicose-veins-v4
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.ship.ifrrequests@nhs.net for all enquiries about the policy statements or the process for considering Individual Funding Requests.

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