NORTH LINCOLNSHIRE CCG EVIDENCE-BASED INTERVENTIONS POLICY DOCUMENT Interventions subject to Prior Approval or an Individual Funding Request JULY 2019 (VERSION 2) NORTH LINCOLNSHIRE CCG Introduction This document outlines North Lincolnshire CCG’s clinical commissioning policy statements on interventions that are not routinely commissioned or are restricted. The objective of this policy is to support CCG decision-making on these interventions and procedures, aiming to provide a statement on interventions based on the available evidence to enable a reasoned and structured process for individual cases to be considered for funding by the CCG. This policy, in line with National terminology, classifies interventions as follows: Operational Definitions - Category 1 Interventions – Interventions that are not routinely commissioned, due to there being little evidence to support the intervention. Cases are examined on an individual basis where clinical exceptionality is considered through the Individual Funding Request (IFR) process accessed via https://ifryh.necsu.nhs.uk/ - Category 2 Interventions – Interventions are restricted and should only be performed after specific criteria are met via the Prior Approval process (VBC Checker), which enables an immediate funding decision on the intervention requested at the point of care accessed via https://vbcchecker.necsu.nhs.uk/Account/Login?ReturnUrl=%2F No Category 1 or Category 2 intervention must be undertaken before securing CCG IFR approval or Prior Approval – activity will be monitored and audits will be regularly undertaken. Please note this document is not exhaustive of all interventions not routinely commissioned or restricted by the CCG. For any medical procedure or treatment that is not routinely commissioned where there is not a specific policy statement, a request via the IFR process must still be made. North Lincolnshire CCG holds an Individual Funding Request (IFR) procedure document for people living within that CCG area, that can be accessed via https://northlincolnshireccg.nhs.uk/wp- content/uploads/2019/02/ifr-policy-and-procedures-05.09.17.pdf therefore the policies listed this document should be read alongside the relevant IFR procedure for each individual CCG. Humber CCG aligned policy statements Hull, East Riding of Yorkshire, North Lincolnshire, and North East Lincolnshire Clinical Commissioning Groups (CCGs) have worked together to align a large number of CCG clinical commissioning policy statements across the Humber area. As part of this process, some of these statements have been amended and updated as per recommendations for interventions from the NHS England National Evidence-based Interventions Programme. The Humber CCG Evidence Based Interventions Policy Document, accessed via the North Lincolnshire CCG website: https://northlincolnshireccg.nhs.uk/publications/commissioning- policies/ should be read alongside this suite of policies and in conjunction with North Lincolnshire CCG’s IFR Procedure document above. Page 1 of 67 Contents Introduction ............................................................................................................................................ 1 Colorectal Interventions ......................................................................................................................... 4 Botulinum toxin type A for Anal Fissure ............................................................................................. 4 12 week trial of Percutaneous Tibial Nerve Stimulation (PTNS) – Faecal Incontinence ..................... 4 Permanent Percutaneous Tibial Nerve Stimulation (PTNS) – Faecal Incontinence ............................ 5 Dermatology Interventions ..................................................................................................................... 6 Hair Loss Treatments .......................................................................................................................... 6 Ear, Nose and Throat Interventions ........................................................................................................ 7 Botulinum toxin type A for Spasmodic Dysphonia ............................................................................. 7 Irrigation of the external Auditory Canal ............................................................................................ 8 Endocrine Interventions.......................................................................................................................... 9 Botulinum toxin type A for Hyperhidrosis .......................................................................................... 9 Continuous Glucose Monitoring System (CGMS) ............................................................................. 10 Flash Glucose Monitoring (FGM) Systems such as Freestyle Libre® ................................................. 11 Fertility Interventions ........................................................................................................................... 12 Assisted Reproductive Techniques (ART) - Infertility ........................................................................ 12 Gynaecological Interventions ............................................................................................................... 18 Elective Caesarean Section (non-clinical reasons) ............................................................................ 18 Mental Health Interventions ................................................................................................................. 19 Referral to Specialist Chronic Fatigue Services ................................................................................. 19 Minor Surgery Procedures .................................................................................................................... 21 Eyelid Surgery - Ectropian ................................................................................................................. 21 Eyelid Surgery - Entropian ................................................................................................................. 21 Eyelid Surgery - Epithoria .................................................................................................................. 21 Neurological and Pain Interventions..................................................................................................... 22 Botulinum toxin type A for Chronic Migraine ................................................................................... 22 Extra Corporeal Shockwave Therapy (ESWT) - Ankle ....................................................................... 23 Extra Corporeal Shockwave Therapy (ESWT) - Elbow ....................................................................... 24 Extra Corporeal Shockwave Therapy (ESWT) - Heel ......................................................................... 24 Extra Corporeal Shockwave Therapy (ESWT) - Hip ........................................................................... 25 Extra Corporeal Shockwave Therapy (ESWT) - Shoulder .................................................................. 26 Referral to Goole Neuro Rehabilitation Centre ................................................................................ 27 Delta-9-Tetrahydrocannabinol and Cannabidiol Oromucosal Spray (Sativex) ................................. 28 Ophthalmology Interventions ............................................................................................................... 29 Intravitreal Therapies for Eye Disease .............................................................................................. 29 Photodynamic Therapy (PDT) – for CSR ............................................................................................ 33 Page 2 of 67 Orthopaedic Interventions .................................................................................................................... 34 Arthroscopic Lavage and Debridement ............................................................................................ 34 Facet Joint Injections ........................................................................................................................ 35 Hyaluronic Acid Injections for Musculoskeletal Joint Pain (Synvisc) ................................................ 36 Other ..................................................................................................................................................... 37 Open and Wide-Bore Magnetic Resonance Imaging (MRI) Scanning ............................................... 37 Plastic Surgery Interventions ................................................................................................................ 39 Bariatric Surgery – Referral to Tier 4 Service (Adults) ...................................................................... 39 Cleft Earlobe Surgery ........................................................................................................................ 41 Face, Neck and Brow Lifts ................................................................................................................. 42 Scar Revision and Skin Resurfacing ................................................................................................... 43 Surgical Fillers ................................................................................................................................... 44 Urological Interventions ......................................................................................................................