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Home , Anal sphincterotomy, Preputioplasty, Rhinectomy, Septoplasty, Strictureplasty, Tendon transfer

UNION MEDICAL BENEFITS SOCIETY LTD

APPROVED SURGICAL PROCEDURES

The following list of surgical procedures should be read in conjunction with your policy document. If you are intending to have one of the listed procedures, please call our surgical team on 0800 600 666 so we can guide you through the prior approval process. If a surgical procedure is not listed below, it will not be covered unless UniMed decides, in its sole discretion, to offer cover.

CARDIAC GENERAL • Pericardiotomy Breast • Pericardiocentesis • Breast Cyst Aspiration or Needle Biopsy • Drainage of Pericaridal Effusion • Breast Biopsy • Coronary Artery Bypass (using vein or artery) • Core Biopsy of Breast • Open Repair of Atrial Septal Defect (ASD) • Excision Accessary Breast Tissue • Valvuloplasty • Mastectomy • Aortic/ Mitral Valve Replacement via Sternotomy • Sentinel Node Biopsy with/without Axillary Dissection • Pulmonary Valve Replacement via Sternotomy • Breast Microdochotomy • Tricuspid Valve Replacement via Sternotomy • Balloon Valvuloplasty – Mitral/ Aortic Reconstruction Post Mastectomy • Pacemaker – Initial Implantation (Excluding the Cost • Breast/ Nipple Reconstruction of the Pacemaker) • Nipple Areolar Tattoo • Removal of Sternal Wire • Maze Arrhythmia Surgery Gastrointestinal • Removal & Rewiring of Sternal Wire • • Maze Arrhythmia Surgery (Standalone procedure) • Simple Repair of Anal Fistula – Special approval only • Maze Procedure – Thoracoscopic • Anal Fistula Repair with Mucosal Advancement Flap • Bentall’s Procedure (includes Aortic Valve Replacement) • Insertion of Seton Tube • Open Ascending Aortic Aneurysm Repair (Suprarenal) • Anal Dilatation • Abdominal or Pleural Tap Interventional Cardiology • Haemorrhoidectomy • Percutaneous Repair of Atrial Septal Defect • Haemorrhoidal Artery Ligation (HAL) • Percutaneous Repair of Patent Foramen Ovale (PFO) • Injection/ Banding of Haemorrhoids • EP Studies – Cardiac Electrophysiology • Excision of Anal Skin Tag • Radio Frequency Ablation (RFA) (PVI)– Special approval only • Excision of Pilonidal Sinus • Angioplasty DES • with/ without Biopsy • Sigmoidoscopy And Anal Fistula Cardiac Imaging • Diagnostic – Gastrointestinal • Cardiac Angiography with OCT • Biopsy of Internal Mass or Tumour (standalone) • Cardiac Angiography with Intravascular Ultrasound of Cardiac • Freeing of Abdominal Adhesions Vessels (IVUS) • Botulinum toxin injection for anal fissure • CT Coronary Angiography (CTCA) – Special approval only • Appendicectomy • Cardiac Angiography with Fractional Flow Reserve (FFR) • Reversal of Hartmann’s procedure • Coronary Angiogram • Sphincteroplasty • Coronary Angioplasty • Rectosigmoidectomy with Formation of Stoma (Hartmann’s Resection) • Hemicolectomy – With Formation of Stoma • Hemicolectomy – With Anastomosis

UniMed Approved Surgical Procedures 2016.V2/2 PAGE 1 • Transverse with Anastomosis • Supraomohyoid Gland Dissection • Sigmoidcolectomy With Anastomosis • Radical Neck Dissection • Sigmoidcolectomy With Formation of Stoma • Parotidectomy • Colectomy – Total with Ileo-Rectal Anastomosis • Parathyroidectomy • Laparoscopic Colectomy – Total with Ileo-Rectal Anastomosis • Excision of Submandibular Gland • Open Proctocolectomy with Anastomosis • Excision of Thyroglossal Cyst or Fistula • Proctocolectomy with Ileoanal Pouch and Loop • Thyroplasty • – Formation/ closure • Total Thyroid Lobectomy • Ileostomy Formation/ closure • Thyroidectomy • Ileostomy Revision • Thyroidectomy Including Parathyroid Transplant • Creation of or • Tongue – Partial Removal, Hemi-Glossectomy • Gastrojejunstomy or Roux-en Y Anastomosis • Salivary Gland – Intraoral Removal of Duct Calculus • Colotomy – For Polyp or of Colon For Polyp • Insertion of Oesaphageal Stent Lymph Nodes • • Sentinel Node Biopsy • Total Gastrectomy and Oesaphogectomy By Abdominal • Excision of a Single Lymph Node (not elsewhere classified) Transthoracic Mobilisation • Simple Lymph Node Dissection of Neck • E.R.C.P. • Superficial Axillary Lymph Node Dissection • Sphincterotomy Or Stenting • Radical Node Dissection – Axilla • Toupet Fundoplication • Superficial Inguinal Node Dissection • Dilation of Oesophagus • Neck Dissection • Needle Biopsy of (separate procedure) • Radical Inguinofemoral Node Dissection of Groin • • Radical Pelvic Node Dissection • Repair of of Oddi • Laparoscopic Pelvic Node Dissection • Repair of Pancreatic Duct Sphincter • Pelvic Node Dissection including Para-Aortic Nodes for • Choledocho-jejunostomy or choledoco-duodenostomy Staging • Small • Laparoscopic Small Bowel Resection • Biopsy of Liver • Repair of Umbilical Hernia • Hepatic Cryotherapy • Hernia – Femoral or Inguinal Repair • Liver Lobectomy • Herniotomy • • Hernia-other • Radiofrequency Ablation of the Liver • Small Bowel Skin and Superficial Structures • Oesophagectomy • Abscess – Small, or Cellulitis Requiring Incision and Drainage • Oesophagus – Hellers Operation with Local Anaesthetic • – Total Excision Of, Or Pancreatico-Duodenectomy • Abscess – Large, or extensive Cellulitis Requiring Incision or • Whipples Procedure Drainage • Transanal Excision of Rectal Tumour • Debridement of infected wound/fistula/sinus • Transanal Endoscopic Microsurgery (TEM) • Fine Need Aspiration • Resection of • Removal of Foreign Body (simple) • Prolapse of Rectum – Rectopexy • Excision of Ganglion • Prolapse of Rectum – Excision of Rectal Mucosa (including • Aspiration/ drainage of Haematoma Sigmoidoscopy) • Skin Lesion Excision with Closure • Dynamic Graciloplasty • Mohs Micrographic Surgery and associated surgical closure • Splenectomy • Gastrointestinal Veins • Examination of Colon up to Splenic Flexure (Short • Varicose Veins with Biopsy) • Endo Venous Ablation of Varicose Veins • Colonoscopy with Biopsy with/without Dilatation • Ultrasound Guided Sclerotherapy – Varicose Veins • Colonoscopy with Removal of Polyps • Varicose Veins Surgery • Gastroscopy (with biopsy) • Oesophageal Dilatation with Gastroscopy / Chest • Mucosal Resection • Lung, Lobectomy • Endoscopy Argon Plasma Coagulation • Lung Biopsy / Exploration • • , Chest Biopsy • Operative Cholangiogram • • Laparoscopic Cholecystectomy • Thorascopic Stapling Bullae • Nissen Repair or Wrap • Excision Thymoma With Sternotomy • Laparoscopic Cholecystectomy Converted to Open • Chest Biopsy, Needle • Choledochotomy • Mediastinal Mass Biopsy/ Excision • Hiatus • Mediastinotomy or for Staging • Laparoscopic Hiatus Hernia Repair • Lung Lobectomy • Sacral Nerve Stimulation – Special approval only • Lung, Sleeve Lobectomy • Head and Neck • Transcervical Thymectomy • Branchial Fistula • Lung Biopsy – Wedge Resection • Sublingual gland excision • Thoracic Lymph Node Dissection in association • Simple Lymph Node Dissection of Neck with another procedure

PAGE 2 UniMed Approved Surgical Procedures 2016.V2/2 Miscellaneous • Omentectomy • Insertion/ removal of Port-A-Cath • Oophorectomy • Central Vein Catheterisation • Salpingectomy • Examination Under Anaesthetic • Ovarian Cystectomy • P.C.O.S. Laparoscopic Drilling of Ovaries GYNAECOLOGY • Division of Adhesions to Ovaries Vulva • Biopsy of Ovary • Bartholins Cyst / Abscess Surgery • Salpingectomy • Separation of Labial Fusion • Laparotomy • Fenton’s Procedure • Salpingo Or Salpingolysis • Simple Excision Vulval Lesion – (including excision varicocele) • Salpingostomy • Vulva – Radical Excision Of, With Glands • Laparoscopic Diathermy • Simple Vulvectomy • Endometriosis Surgery • Multiple Vulval Biopsy Clinic Procedure Vagina • Cryotherapy/Cautery of Cervix • Revision of Episiotomy Scar (not cosmetic) • Colposcopy with Biopsy • Minor Revision Mesh Repair • Incision of Hymen • Colporrhaphy • Vulvoscopy with or without Biopsy • Repair of Enterocele • Insertion/ Removal of Intra-uterine Device • Repair of Vaginal Vault (including Sacrospinous Fixation) – Special approval only • Sacrocolpopexy, Levatorplasty INTERVENTIONAL RADIOLOGY • Repair of vaginal Fistula • Excision of Vaginal Lesion • Fine Needle Aspiration Under Ultrasound • Sacrocolporectopexy • Ultrasound Breast Cyst Aspiration • Pelvic Floor Repair • Core Biopsy With Ultrasound • Vaginal reconstruction disease related • CT Guided Biopsy/ Drainage • Vaginoplasty • Trans Perineal Biopsy • Laser division of vaginal band – Special approval only • Chemical Sympathectomy • Intradiscal/Verteb.Inject Cervix • Fluoroscopy (In Conjunction with Surgical Procedure) • Cervix – or Reconstruction Vaginal Approach • CT Guided Injection • Cervix – Biopsy • Stereotactic Mammotome Breast Biopsy • Cervix – Cauterisation • X-Ray or Ultrasound Guided Injection • Cervical Polypectomy • Brachytherapy Grid Guided • Lletz Loop • Embolisation of Renal Artery • Cone Biopsy • Embolisation of Varicocele • MRI Breast Biopsy Uterus • Embolisation of Fibroid • Drainage of Pelvic Abscess Via Fornices • Biopsy/ Cone Biopsy of Cervix NEUROSURGERY • Removal of Polyp – Uterus/ Cervix • Craniotomy and Excision of Tumour – Supratentorial • Endometrial Biopsy (Pipelle) • Endoscopic Transsphenoidal Excision of Pituitary Adenoma • Laparoscopic Uterine Nerve Ablation • Repair of Encephalocele • Hysteroscopy D&C • Removal of Spinal Intradural Lesion – Cervical • Removal of Submucous Fibroid – Special approval only • Percutaneous Balloon Compression of Trigeminal Nerve/ • Removal of Endometrial Polyp Ganglion • Insert Intrauterine Device • Burr Hole for Biopsy of Intracranial Lesion • Hysterectomy • Burr Hole Stereotactic Biopsy for Intracranial Lesion • Endometrial Ablation / Resection • Craniotomy For Clipping Of Intracranial Aneurysm • Omentectomy +/- Nodes • Craniotomy For Removal Of Vascular Malformation/ • Pelvic Repair Cavernoma • Wertheim Hysterectomy • Craniotomy/Craniectomy For Resection Of Supratentorial • Myomectomy Tumour • Excision Pelvic Lymph Nodes • Resection Of Skull Base Tumour (Complex) • Radical Dissection for Debulking incl. Pelvic & Paraaortic • Microvascular Decompression Of Cranial Nerve (Ie Trigeminal Lymphadenectomy Neuralgia/Hemifacial Spasm) • Colporrhaphy with/without vault repair • Retromastoid Or Translabyrinthine Resection Of Vestibular • Repair of Enterocele Schwannoma (Acoustic) • Vaginal Anterior Mesh Repair • Craniotomy/Craniectomy For Resection Of Infratentorial • Salpingo-Opherectomy Tumour • Transsphenoidal Resection Of Pituitary Tumour/Lesion (open Fallopian Tubes – Ovaries or endoscopic - two surgeons may be required) • Laparoscopic Sterilisation (NB Loyalty Benefit) • Craniotomy/Craniectomy For Repair Of Encephalocoel/Csf • Laparoscopy with D&C Leak/Skull Base Defect • Resection Ovarian/Tubal-Intr-abdominal/ Retroperitoneal • Burrhole Or Stereotactic Biopsy Of Intracranial Lesion/ Malignancy,Radical Dissection for Debulking Drainage Of Subdural Collection • Excision open intra abdominal or retroperitoneal tumours or • Removal Of Spinal Tumour/Lesion (Extradural) cysts • Removal Of Spinal Tumour/Lesion (Intradural, Extramedullary)

UniMed Approved Surgical Procedures 2016.V2/2 PAGE 3 • Removal Of Spinal Tumour/Lesion (Intramedullary) Corneal Surgery • 14 Foramen Magnum Decompression For Chiari • Anterior Stromal Puncture Malformation/Syringomyelia • Excision of Conjunctival Lesion with Cryotherapy • Ventriculoperitoneal Shunt For Hydrocephalus • Cornea Or Sclera – Removal of Foreign Body • Lumboperitoneal Shunt For Hydrocephalus • Keratectomy • Percutaneous Rhizotomy For Trigeminal Neuralgia • Penetrating Keratoplasty • Endovascular Occlusion Of Intracranial Aneursym/ • Descemet’s Stripping Endothelial Automated Keratoplasty Malformation • Rebubble Following Corneal Endothelial Transplantation • / For Release Of Tethered Cord • Deep Anterior Lamellar Kertatoplasty (DALK) • Phototherapeutic Keratectomy – Special approval only Donor Tissue – Preparation Charge • Intrastomal Corneal Ring Segment Implantation for • Cornea – Intact Button Kertaconus • Cornea – Pre-cut • Corneal Surgery • Sclera – Whole • Corneal Collagen Cross-Linking with Riboflavin (CX-L) • Amniotic Membrane – Piece – Special approval only • Graft • Retinal (Non-Invasive) • Transpupillary Thermotherapy (TTT) OPHTHAMOLOGY • Retinal Cryotherapy Lacrimal • Lacrimal Syringing with/without Probing Retinal (Non-Invasive) • Punctoplasty • Photocoagulation of Retina • Lacrimal Intubation • Pan Retinal Laser • Dacryocystorhinostomy Vitreo-Retinal Surgery Lids and Adnexa • Repair of Detached Retina • Excision of Xanthelasma • Repair With Scleral Buckle • Tarsal Cyst (Chalazion) Removal • Pneumatic Retinopexy • Removal of One or More Eyelashes for Trichiasis • Vitrectomy • Entropion or Ectropion Repair • Retinal Detachment Repair • Eyelid Surgery (other than Blepharoplasty or Ptosis Correction) • Macular Hole Surgery • Upper Eyelid Recession Surgery • Removal Of Silicone Oil • Ophthalmic Skin Grafts • Macular Hole Eye Surgery • Macular Epiretinal Membrane Peel Strabismus Surgery • Strabismus Surgery Orbit • Orbital exenteration Extraocular Operations on Globe • Sub Tenon’s Capsule Injection • Excision of Pterygium • Evisceration of Globe • Conjunctival Graft • Enucleation Of Eye • Pingueculum Excision • Orbitotomy • Orbital Decompression Cataract ORAL AND MAXILLOFACIAL (SUBJECT TO BENEFIT) • Lens Extraction • Secondary IOL Implant (Standard Monofocal Only) • Bone Graft • IOL Implant with Anterior Vitrectomy • Biopsy – Incisional/ Excisional (Oral Surg) (Standard Monofocal Only) • Biopsy – Needle • Extracapsular Cataract Extraction with Insertion of Artifical • Cyst Enucleation Lens (Standard Monofocal Only) • Cyst – Soft Tissue – Excision • Phacoemulsification Cataract Extraction with Insertion of • Infection – Drain Abscess – Cellulitis Intro/ Extra Oral Artificial Lens (Standard Monofocal Only) • Excision Ranula – Sub-Lingual Gland • Phacoemulsificiation Cataract Extraction with Insertion of • Tumour Excision Artificial Lens (Standard Monofocal Only) (includes Axial • Wisdom tooth extraction – unerupted or impacted only Length Ultrasonography) ORTHOPAEDIC SURGERY • Cataract Extraction with Intro-Ocular Lens with Anterior Vitrectomy (Standard Monofocal Only) Ankle / Foot • Cataract Extraction with Intro-Ocular Lens with • Repair of Foot (Flexor or Extensor) Trabeculectomy (Standard Monofocal Only) • Repair Ruptured Achilles Tendon • Yag Laser Capsulotomy • Achilles Tendon Reconstruction (, Percutaneous, Achilles Tendon) Glaucoma • Achilles – Elongation • Bleb Needling/ Revision • Incision of Tendon Sheath • Trabeculectomy • Tendon Reconstruction – Ankle • Drainage (Glaucoma), Molteno Drain Or Similar Procedure • Gastrocnemius Slide – • Iridectomy Or Iridotomy • Neurectomy of Leg / Foot • Iridoplasty • Ingrown Toenail – Radical Excision / Wedge Resection • Laser Trabeculoplasty • Amputation of Toe – MTP/ IP • – Ankle • – Ankle • Tarsal Tunnel Release

PAGE 4 UniMed Approved Surgical Procedures 2016.V2/2 • Ankle Ligament Reconstruction • Revision • – Ankle • • Ankle Triple Arthrodesis • Hip • Subtalar Arthrodesis • – Distal Femur • Tarsometatarsal Arthrodesis • Hip – Closed Reduction • Talo-Navicular Arthrodesis • Removal Of Intramedullary Rod • Hind Foot Correction • Femur – Slipped Epiphysis – Pinning • Soft Tissue Correction Of Foot • Femur Osteotomy • Bone Correction – Tarsectomy Triple • Open Hip Joint Biopsy • Complex Midfoot Correction • Hallux Valgus Knee • Arthrodesis • Amputation – Above or Below Knee • Hallux Rigidus • Manipulation of Knee Joint • Hammer Toe Repair • Knee Arthrotomy • Tenotomy – Toe • Repair Collateral Ligament – Knee • Correction of Hallux Valgus By Osteotomy • of Knee • Osteotomy – Lesser Metatarsal • Open Cruciate Ligament Repair and/or Reconstruction • • Repair of Patella Tendon with/ without Graft • Patella of the Knee Elbow • Arthroscopy Knee • Tendon Transfer – Elbow • Meniscectomy • Transposition of Ulnar Nerve • Chondroplasty of Knee With or Without Microfracture • Ulnar Nerve Release – Elbow • Debridement of Knee Joint • Cubital Tunnel release • Arthroscopic Cruciate Ligament Repair And/Or Reconstruction • Epicondylitis Release (Epicondylitis Debridement) • Patellectomy • Posterior Inerosseous Nerve Release • Patella Arthroplasty • Elbow Replacement Arthroplasty • Patello-Femoral Resurfacing • Supracondylar Osteotomy • Repair Recurrent Dislocating Patella • Arthrotomy and Removal Of Loose Bodies – Elbow • Knee – Osteotomy • Arthrotomy – Elbow • Knee Joint Resurfacing • Arthroscopy – Elbow • Arthrodesis of Knee • Release of Elbow Contracture • Revision • Radial Head Excision • Partial/ Total Knee Replacement

General Lower Leg • Tenotomy • Repair of Leg Flexor/ Extensor Tendon with/ without Graft • Decompression (Compartment Syndrome) • Tendon Lengthening • Nerve Graft • Foot or Ankle Tendon Transfer • Acute Osteomyelitis – Drainage Small/ Large Bone • Osteotomy – Proximal Tibial • Sub-Acute or Chronic Osteomyelitis – Exploration • Excision Bursa Nervous System • Bone Graft • Suture of Nerve Requiring Extensive Mobilisation • • Primary Suture Nerves • Excision of Intramuscular Tumour or Cyst • Suture of Major Peripheral Nerves – Arm/Leg • Excision Exostosis • Suture of Digital Nerve – Hand/Foot • Excision of Nail and Nail Matrix, Partial or Complete • Secondary Repair of Nerve • Debridement of Digital Joint • Excision of Neuroma • Osteotomy of Digit • Lateral Popliteal Nerve Decompression • Manipulation of Joint • Excision of Neuroma – Major Peripheral Nerves • Neurofasciotomy • Intra-Spinal Injection • Soft Tissue Injection • Peripheral Nerve Block • Joint Injection • Epidural Injection Anaesthetic – Lumbar/Caudal • Removal of Sesamoid Bone • IV Guanethidine Block or Similar • Subcutaneous Tenotomy • Coeliac Plexus Block • Debridement of Tendon • Nerve Root Injection(Trans-Foraminal) • Excision Bone Tumour • Stellate Ganglion Block • Removal of Metal • Open Neurolysis of Peripheral Nerve, Not Elsewhere Classified

Hip / Upper Leg Shoulder • Hip or Thigh Tendon Repair or Reconstruction • Biceps Tendon Release Or Tenodesis • Neurectomy of Leg Nerve • Removal of Calcareous Deposits from the Shoulder • Decompression Fasciotomy – Thigh / Knee • Acromionectomy • Surgical Dislocation Including Chondroplasty, Labral or • Capsular Repair – • Rotator Cuff Repair • Hip Arthroscopy • Stabilisation of Shoulder • Ganz Osteotomy • Decompression • Hip Arthrotomy • Subacromial Decompression of Shoulder • Bone Graft To Femur • Excision Outer End of Clavicle • Total Hip • Open Reduction Fracture of Clavicle

UniMed Approved Surgical Procedures 2016.V2/2 PAGE 5 • Arthroscopy –Shoulder • Dupuytren’s Contracture – Palmar Fasciectomy with Z-plasty, • Arthrodesis of Shoulder other Local Tissue Rearrangement or Skin Graft • Hemi Replacement of Shoulder • Dupuytren’s Contracture Partial Palmar Fasciectomy, Release • Total 1/2/3 Digits + Z-plasty/Local Tissue Rearrangement/Skin Graft • Revision Shoulder Replacement • Volkmann’s Contracture • Shoulder Excision Arthroplasty • Amputation – Finger Or Thumb, any Joint • Acromioclavicular (AC) Joint – Reduction and Repair • Wrist Osteotomy – Unilateral • Manipulation of Shoulder Joint • Arthrodesis – Wrist With/ Without Bone Graft • Repair of Recurrent Shoulder Dislocation • Proximal Row Carpectomy Removal of • Wrist Arthroscopy with Additional Procedure Spine • Total Replacement – Wrist Joint • Medial Branch Block • Replacement – Interphalangeal Joint • Facet Joint Injection • Replacement MCP or CMC Joint • Intr-Discal Injection • Fusion – Thumb • Discography • Fusion – MCP Joint • Fusion – IP Joint with/without Graft Spine (Cervical) • Fusion – CMC Joint to Thumb With Bone Graft • Anterior Cervical Fusion • Fusion – CMC Joint to Digits With Graft • Anterior Cervical Fusion Including Foramen Decompression • Replacement Arthroplasty in Thumb – Carpal Bones • Total Cervical Disc Arthroplasty • Bone Graft – Metecarpals Or Phalanx • Anterior Cervical Fusion • Wrist/Hand • Posterior Cervical Fusion • Carpal Tunnel Release • Anterior Cervical • Posterior Cervical Decompression(including Laminectomy or OTOLARYNGOLOGY if required) Throat • Cervical 1 Level • Tongue – Partial Removal, Hemi-Glossectomy • Biopsy of Tongue Spine (Thoracic) • Excision of Tongue Lesion • Transthoracic Fusion With or Without Instrumentation • Partial Pharyngectomy • Posterior Thoracic Fusion With or Without Instrumentation • Fixation Mandibular reconstruction plate • Thoracic Discectomy • Mandibulectomy • Condylectomy Spine (Lumbar) • Coronoidectomy • Sacroiliac Joint Injection • Tracheostomy • Lumbar Discectomy • Floor of mouth Excision • Anterior Lumbar Interbody Fusion(including Discectomy) • Throat • Anterior Endoscopic Lumbar Fusion • Adenotonsillectomy • Posterior / Posterolateral Lumbar Fusion With/ Without • Tonsillectomy Instrumentation • Adenoidectomy • Posterior / Posterolateral Lumbar Fusion Including PLIF With Instrumentation Hypopharynx and Larynx • Posterior Lumbar Interbody Fusion (PLIF) With • Pharyngoscopy With/ without Biopsy Instrumentation (including Discectomy) • Excision of Malignant Tumour of Upper Aerodigestive Tract • Lateral Lumbar Interbody Fusion (LLIF) (including Discectomy) • Removal of Pharyngeal Pouch • Lumbar Corpectomy • Excision and Stapling Hypopharyngeal Diverticulum, • Lumbar Spinal Stenosis Decompression Cricopharyngeal • Posterior / Posterolateral Instrumented Lumbar Fusion and • – with or without Biopsy Decompression • Microlaryngoscopy with or without Biopsy • • Total • Dohlman’s Procedure Wrist / Hand • Primary Repair of Flexor Tendon – Hand , Bronchi and Oesophagus • Repair of Wrist or Forearm Flexor Tendon • – Fibreoptic • Secondary Repair Flexor Tendon – Hand (With or Without • Oesophagoscopy – with/ without Biopsy Graft) • Pan-Endoscopy – Including Laryngoscopy, Pharyngoscopy, • Ligament Repair of Hand/Wrist Oesophagoscopy & E.U.A Nasopharynx • Extensor Tendon Repair – Hand/ Finger • Tracheal resection • Tenolysis Extensor Tendon – Hand/Finger • Tenolysis Flexor Tendon – Finger/Palm Ears • Tenolysis Flexor or Extensor Tendon – Wrist / Forearm • Lateral temporal bone resection • Repair of Mallet Finger • Foreign Body Ear – Surgical Removal • Repair of Wrist or Forearm Extensor Tendon • Removal Solitary Osteoma Ear Canal • Tendon Transfer – Opponensplasty • Removal of Multiple Exostoses – Ear Canal • Tendon Transfer – Hand/ Palm • Meatoplasty • Tenotomy – Hand/Finger (eg for Trigger Finger) • Myringotomy • Synovectomy – MCP Joint • Grommet Insertion • Dupuytren’s Contracture – Closed (Subcutaneous) Palmar • Removal of Grommets Fasciotomy • Tympanotomy • Dupuytren’s Contracture – Open Partial Palmar Fasciotomy • Tympanoplasty (Myringoplasty Postaural or Endaural)

PAGE 6 UniMed Approved Surgical Procedures 2016.V2/2 • Ossiculoplasty PLASTIC • Stapedectomy • Repair of Perilymph Fistula • Apocrinectomy • Cortical Mastoidectomy • Reconstruction following Major Head & Neck Surgery • Atticotomy • Reconstructions Other than Breast, Skin, Head/Neck • Cortical Mastoidectomy TESTS (SUBJECT TO POLICY BENEFIT) • Modified Radical Mastoidectomy or Combined Approached Tympanoplasty (CAT) Cardiac Tests • Cochlear Implant Surgery (Excluding the Cost of the • Resting ECG Appliance) • Ambulatory NIBP • Exercise ECG & Paranasal Sinuses • Echocardiogram • Bilateral Antral Lavage • Stress Echocardiogram • Nasal Polyptectomy • Dobutamine Stress Echo/Transoesophageal Echo • Transnasal Ethmoidectomy • Holter Monitoring • Endoscopic Maxillary Antrostomy • Radical Antrostomy (Caldwell Luc) Diagnostic Tests • Endoscopic Powered Turbinoplasty • Endometrial Biopsy (Pipelle) • Sinoscopy • Bone Marrow Aspiration • Endoscopic Sinus Surgery • Full Urodynamic Assessment (some plans) • External/ Radical Fronto-Ethomoidectomy • Ultrasound of Eye • Cautery of Septum Or Turbinates • Corneal Topography • Trimming Of Turbinates • Visual Evoked Potential • • Optical Coherence Tomography • Crural J flap • Glaucoma Detection Scan • Conchal Graft • Heidelberg Retinal Tomography • • Gastroscopy • Excision Maxillary Tuberosity • Colonoscopy • Maxillectomy • Screening Colonoscopy or Gastroscopy • External Ethmoidectomy • Oesophageal Manometry Test • Inferior Craniofacial Resection • Oesophageal 24hr ph Monitoring • Nasendoscopy • Anorectal Physiology Study • Examination of Nasopharynx with or without Biopsy • Gastric Empty Study • Nose and Paranasal Sinuses • Wireless – Special approval only • Endoscopic Modified Lothrop • Balloon • BRAVO ph Monitoring System PERIPHERAL VASCULAR SURGERY UROLOGY • Cervical Rib Excision • Aorto-Iliac Endarterectomy Kidney • Aortoiliac or Aortofemoral Bifurcation Graft (Occlusive Disease) • Biopsy of Kidney – Ultrasound Guided • Carotid Endarterectomy – Patch Closure • Nephrectomy • Carotid Sinus Denervation • Adreanalectomy • Carotid Subclavian Graft • Nephroureterectomy • Brachial Artery Bypass • Laparoscopic Renal Cryotherapy • Transaxillary Sympathectomy • Pyelolithotomy • Endoscopic Thoracic Sympathectomy (ETS) • Nephrolithotomy • Cross-Over Graft (Fem-Fem) • Nephrostomy • Femoro Popliteal Embolectomy • Percutaneous Nephroscopy and Lithotomy • Femoral Endarterectomy with Patch Closure • Pyeloplasty • Femoral Distal Above/ Below Knee Graft • Endopyelotomy – Retrograde/ Antegrade • Temporal Artery Biopsy • Extracorporeal Shockwave • Common Femoral Endarterectomy/Profundoplasty+- Femoral • Radiofrequency Ablation of Kidney to treat Renal Tumour Angioplasty • Abdominal Aortic Aneurysm Replacement / Repair Renal • Renal Visceral Artery Aneurysm Repair • Laparoscopic renal cryotherapy – Special approval only • Common Femoral Endarterectomy with Angioplasty +/- • Ureter stenting of the Aorto-iliac segment or Superficial Femoral • Insertion of Double J Stent Artery • Ureteroscopy • Endoluminal Stent Graft Repair to Femoral/Iliac Artery • Reimplantation Ureter • Illio-Femoral Bypass Graft • Ureterolithotomy • Peripheral Vascular Surgery • Ureterolysis • Non-Cardiac Angiogram • Reduction Ureteroplasty And Reimplant • Aortogram • Hepatic Arteriogram, Lumbar Arteriogram, Renal Angiogram Bladder • Renal Artery Angioplasty • Colposuspension • Non-Cardiac Angioplasty • Cystoscopy and urethroscopy • • Cystoscopy – With Biopsy, Ureteric Catheterisation, Urethral Dilatation, Removal Stent, Or Other Minor Procedure • Flexible Cystourethroscopy

UniMed Approved Surgical Procedures 2016.V2/2 PAGE 7 • Cystoscopy and Transrectal Ultrasound and Biopsy (TRUS) • TVT Sling Revision • Cystourethroscopy – With Bladder Neck Incision or Major • Implantation Artificial Urinary Sphincter Visual Urethrotomy • Male Sling Operation • Retrograde Pyelogram • Transurethral Resection Bladder Tumour Urethra • Cystoscopy – Removal Ureteric Calculus or Foreign Body • Excision or Cauterisation of Caruncle • Cystoscopic Destruction and Removal Bladder Calculus / • Periurethral Injection for Incontinence Litholopaxy • • Incision of Bladder Neck • Urethroplasty • Percutaneous Suprapubic Catheterisation of the Bladder • Meatoplasty (Urethra) • Cystectomy • Urethral Calculus • Radical Cystoprostratectomy • Urethrotomy - Internal • Bladder – Repair of Rupture • Urethral Diverticulum • Bladder Tumours, Suprapubic Diathermy Of • Cystoscopic Destruction and Removal Bladder Calculus Scrotum • Laser Resection of Bladder Tumour • Orchidopexy • Cystolithotomy • Varicocele Repair • Diverticulum of Bladder, Excision Or Obliteration Of • Excision of Epididymal Cyst Spermatocele, or Epididymectomy • Cystoplasty • Hydrocele Repair • Colposuspension • Testicular Biopsy • Ventro-Suspension • Undescended Testis – Laparoscopy For • Partial Cystectomy • Simple/ Radical Orchidectomy • Percutaneous Suprapubic Catheterisation of the Bladder Prostate • (Medical not Religious) • Open Enucleation Prostate • Preputioplasty • Prostate – Biopsy • Dorsal Slit • Prostate • Penile Biopsy • with/ without Node Dissection • Penis – Amputation • Perineal Prostatectomy/ Brachytherapy/ Cryotherapy • Clinical Procedures • Transurethral Resection of Prostate (TURP) • Catheterisation with/ without Instillation Drugs • Enucleation of Prostate • Urethral Dilatation • Laser Prostatectomy • Cystoscopy with Urodynamic Assessment • Diathermy Minor Genital Skin Lesion Excision Incontinence • Transrectal Ultrasound and Biopsy of Prostate • Pubo-Vaginal Sling Operation for Incontinence with or • (NB: Loyalty Benefit) without Cystoscopy

PAGE 8 UniMed Approved Surgical Procedures 2016.V2/2