Clinical policy review (3)

This is a new policy.

Diastasis recti is a separation of the abdominal muscle. Diastasis recti surgery is a 'muscle repair' surgical procedure to repair the separation of the rectus abdominis (“six-pack”) muscles. An Abdominoplasty (tummy tuck) is a type of surgery performed to tighten loose muscles and to remove fat and excess loose skin from the abdomen.

The proposed policy states that abdominoplasty for the correction of diastasis recti is not routinely funded.

View proposed Abdominoplasty for Diastasis recti policy

Is there a proposed change?

This is a new policy for Dudley, Sandwell, Walsall and Wolverhampton.

This is a harmonised policy.

The proposed policy states that ‘blind’ dilation and curettage as a sole diagnostic tool will not be funded. Diagnostic sampling of the lining of the uterus is expected to be carried out as part of another procedure where the uterus is visualised. It is not expected that clinicians will seek to carry out this procedure in isolation.

View the proposed Blind Dilation and Curettage (D&C) as a diagnostic tool for Menorrhagia policy

Is there a proposed change?

There is no change for Dudley, Sandwell, Walsall or Wolverhampton.

This is a harmonised policy.

The proposed policy states that complementary and alternative medicines are not funded on the grounds that they are experimental or unproven. 

View the proposed Complementary and alternative therapies policy

Is there a proposed change?

There is no change for Dudley, Sandwell and Wolverhampton. This is a new policy in Walsall.

This is a harmonised policy, and a new policy for Dudley and Wolverhampton

The proposed policy states it is restricted to conditions which cause respiratory muscle weakness or upper airway functional impairment (unable to cough or clear secretions effectively).

View the proposed Cough Assist Machines [Mechanical Insufflator-Exsufflator (MI-E)] policy

Is there a proposed change?

There is no change for Sandwell and Walsall. This is a new policy for Dudley and Wolverhampton with increased access.

This is a new policy for Sandwell, Walsall and Wolverhampton

The proposed policy states doppler velocimetry in antenatal care is not routinely commissioned for low-risk pregnancies but it is commissioned for high-risk pregnancies.

View the proposed Doppler velocimetry in antenatal care policy

Is there a proposed change?

There is no change for Dudley. This is a new policy for Sandwell, Walsall and Wolverhampton.

This is a new policy.

The proposed policy states that endoscopic radiofrequency ablation for Gastro Oesophageal Reflux Disease (GORD) is not commissioned on the grounds that the treatment is considered unproven.

View the proposed Endoscopic Radiofrequency Ablation for Gastro Oesophageal Reflux Disease (GORD) policy

Is there a proposed change?

This is a new policy for Dudley, Sandwell and Walsall and there is no change for Wolverhampton.

This is a harmonised policy and a new policy for Wolverhampton.

The proposed policy states that the procedure is considered unproven and experimental, and is therefore not funded.

View the proposed Extracorporeal shockwave therapy for Musculoskeletal (MSK) indications and soft tissue injuries policy

Is there a proposed change?

There is no change for Dudley, Sandwell and Walsall. This is a new policy for Wolverhampton.

This is a harmonised policy.

Blepharoplasty is a procedure which reshapes eyelids. Common indications are to restore full vision where the eye is obstructed incoming light to the eye or to restore the normal position of the eyelashes.

The proposed policy states:

• Blepharoplasty will be funded for:
  • Ectropion (where the eyelid turns outwards from the eyeball).
  • Entropion (where the eyelid turns inwards leaves the eyelashes scratching the surface of the eye).
  • Any medical condition that results in impairment of vision in the relaxed, non-compensated state as determined by the Visual field test reducing visual field to 120 degrees laterally and/or more than 40 degrees reduction vertically.
  • Congenital drooping of the eye which might be impacting on visual development of the child.
• Blepharoplasty will not be funded for cosmetic reasons or for psychological distress.

​​​​​​​Chalazia (meibomian cysts) are benign lesions on the eyelids due to blockage and swelling of an oil gland that normally change size over a few weeks. Many but not all resolve within six months with regular application of warm compresses and massage.

• Surgical removal of chalazia if one of the following clinical circumstances have been met:
  • Has been present for more than 6 months and has been managed conservatively with warm compresses, lid cleaning and massage for 4 weeks.
  • Interferes significantly with vision.
  • Interferes with the protection of the eye by the eyelid due to altered lid closure or lid anatomy.
  • Is a source of infection that has required medical attention twice or more within a six-month time frame.
  • Is a source of infection causing an abscess which requires drainage.
  • Cancer is suspected e.g. madarosis/recurrence/other suspicious features in which case the lesion should be removed and sent for histology as for all suspicious lesions.
  • Removal of cysts will not be funded for cosmetic reasons or psychological distress.
• Surgical removal of other eyelid lesions is commissioned if one of the following clinical circumstances have been met:
  • Interferes significantly with vision.
  • Interferes with the protection of the eye by the eyelid due to altered lid closure or lid anatomy.
  • Is a source of infection that has required medical attention twice or more within a six-month time frame.
  • Is a source of infection causing an abscess which requires drainage.
  • Cancer is suspected e.g. madarosis/recurrence/other suspicious features in which case the lesion should be removed and sent for histology as for all suspicious lesions.
  • Removal of lesions will not be funded for cosmetic reasons or psychological distress.

View the proposed Eyelid surgery policy

Is there a proposed change?

There is no change for Dudley, Sandwell, Walsall and Wolverhampton - the information within the policy is clearer and more concise.

This is a harmonised policy.

Grommets are tiny plastic tubes, inserted into the eardrum to relieve glue ear. Glue ear is a common childhood condition where the middle ear becomes filled with fluid, causing issues with hearing, pain and infections. An adenoidectomy is an operation to remove enlarged adenoids. Adenoids are small lumps of tissues at the back of the throat behind the nose. They are part of the immune system and help fight infection.

The proposed policy states:

Children only

• Insertion of grommet (grommet/T-tube) for otitis media with effusion (OME) will only be funded if the following criteria are met:
  • The child should be 12 years and under, and
  • there has been persistent bilateral otitis media with effusion over a period of 3 months, and
  • the hearing level in the better ear is of at least 25 dBHL or worse averaged at 0.5, 1, 2 and 4 kHz (or equivalent dBA where dBHL not available).

• Exceptionally, healthcare professionals should consider surgical intervention in children with persistent bilateral OME with a hearing loss less than 25-30dBHL where the impact of the hearing loss on a child’s developmental, social or educational status is judged to be significant, or
• Where there is clinical and tympanographic evidence of persistent glue ear and where the impact of the hearing loss on a child’s developmental, social, or educational status is judged to be significant.

• Adjuvant adenoidectomy in conjunction with the insertion of grommets for the treatment of otitis media with effusion will only be funded if the following criteria are met:
  • The child has persistent and / or frequent nasal obstruction which is contributed to by adenoidal hypertrophy (enlargement)
  • The child is undergoing surgery for re-insertion of grommets due to recurrence of previously surgically treated otitis media with effusion
  • The child is undergoing grommet surgery for treatment of recurrent acute otitis media.

• Children with Down’s Syndrome and Cleft Palate will be funded when recommended by the specialist multidisciplinary team in line with NICE guidance.

Children and adults

• Surgery will be funded for the following:
  • Recurrent acute otitis media
  • To deliver medication directly to the middle ear

Adults only

• Surgery will be funded for the following:
  • Severe retraction of the tympanic membrane with risk of developing cholesteatoma or erosion of the ossicular chain
• Surgery will not be funded for the following:
  • To treat Meniere’s disease on the grounds it is still experimental.

View the proposed Grommets - Aural ventilation tube insertion (with or without adenoidectomy) policy

Is there a proposed change?

There is an age critieria addition for Walsall and Wolverhampton and a new criteria added for adjuvant adenoidectomy which increases access for Dudley, Sandwell, Walsall and Wolverhampton.

This is a harmonised policy.

The proposed policy states that hysteroscopy for Heavy Menstrual Bleeding (HMB) is commissioned in line with NICE’s Clinical Guidance 88: Heavy menstrual bleeding: assessment and management

As a first line diagnostic test in the following clinical circumstances:

• The patient has suspected submucosal fibroids or polyps or endometrial pathology, and
• The patient has one of the following symptoms:
  • persistent intermenstrual bleeding, or
  • are at high risk of serious endometrial pathology.

As a second line test when an ultrasound scan has provided inconclusive results.

View the proposed Hysteroscopy for Heavy Menstrual Bleeding (HMB) policy

Is there a proposed change?

There is no change for Sandwell, an increased access in Dudley, Walsall and Wolverhampton for first line use in specific clinical circumstances and no change for second line use in Dudley, Sandwell, Walsall and Wolverhampton.

This is a new policy.

The proposed policy states that intramedullary distraction for lower limb lengthening is not routinely commissioned as it is an unproven treatment.

View the proposed Intramedullary distraction for lower limb lengthening policy

Is there a proposed change?

There is no change for Wolverhampton. This is a new policy for Dudley, Sandwell and Walsall.

This is a new policy for Dudley, Walsall and Wolverhampton.

Definitions:

• Liposuction is surgical technique using suction to remove fat from certain areas of the body.
• Lipoedema is a long-term condition where an unusual build-up of fat in the legs, thighs and buttocks, and sometimes in the arms, occurs which makes them increase in size.
• Lymphoedema is a long-term (chronic) condition which causes swelling in the body's tissues due to fluid retention. It can affect any part of the body; however, it usually develops in the arms or legs when the lymphatic system doesn't work properly. 
• Lipohypertrophy is a lump of fatty tissue under the skin caused by repeat injections in the same place.

The proposed policy states that liposuction for lipoedema is not routinely commissioned on the grounds that at present it is unproven. Liposuction for lipohypertrophy is not routinely commissioned. Liposuction for cosmetic or aesthetic reasons is not routinely commissioned. Liposuction for lymphoedema is routinely commissioned when conservative treatment has failed and is assessed by a specialist lymphoedema multidisciplinary team as part of a lymphoedema service pathway

View the proposed Liposuction policy

Is there a proposed change?

• There is no change for Sandwell.
• There is no change for liposuction for cosmetic reasons in Dudley, Sandwell, Walsall and Wolverhampton - it is not routinely commissioned.
• There is a new policy for Dudley, Walsall and Wolverhampton stating liposuction for lipoedema is not routinely commissioned.
• There is a new policy with specific criteria for lymphoedema in Dudley, Walsall and Wolverhampton.
• There is a new policy for Dudley, Walsall and Wolverhampton stating liposuction for lipohypertrophy is not routinely commissioned.

This is a harmonised policy.

The proposed policy states that photorefractive (laser) surgery for the correction of refractive errors of the eye is not routinely commissioned.

View the proposed Photorefractive (laser) surgery for the correction of refractive errors of the eye policy

Is there a proposed change?

There is no change for Dudley, Sandwell, Walsall and Wolverhampton.

This is a harmonised policy.

The proposed policy states:

• The ICB will fund a deep skin biopsy if there is doubt about the lesion in order to identify lipomas or any of its variants, such as a hibernoma.
• The ICB will fund removal of lipomas associated with genetic syndromes and adiposis dolorosa when recommended by a tertiary specialist multi-disciplinary team. Treatment should be carried out by surgeons with experience in treating these more complex conditions.
• The ICB will fund the removal of the lipoma if the patient meets the following criteria:
  • The patient has an angiolipoma that is giving rise to pressure pain not managed by conservative management, or
  • The patient has a lipoma which is causing either a physical impairment for the patient (interfering with a nerve or tendon or bowel movement) or difficulty in sleeping, or
  • The patient has a lipoma on the face or neck which has become infected.

Lipomas on other areas of the body should be referred back to primary care as agreed locally.

View the proposed Removal of lipomas policy

Is there a proposed change?

There are changes which widen access for all Places; Dudley, Sandwell, Walsall and Wolverhampton, for the removal of lipomas associated with genetic syndromes and a new criteria for management of angiolipom, as well as removal if it causes physical impairment (wording changed from functional). In addition, removal from the face or neck which has become infected is also a new criteria for Wolverhampton.

This is a harmonised policy.

The proposed policy states:

• Routinely commissioned for the correction of complex congenital conditions.
• These procedures are routinely commissioned when:
  • the patient has obstruction of one or both nostrils (NOTE: If the patient has a grossly deviated septum causing complete blockage of one nostril then the two bullet points below do not apply), and
  • tried conservative measures without success, e.g. medication to treat allergic rhinitis, and
  • the overuse of nasal sprays has been excluded as a cause of the nasal congestions or has been treated prior to referral and the nasal congestion persists.
• Cosmetic and aesthetic (psychological) indications are not routinely commissioned.

View the proposed Rhinoplasty policy

Is there a proposed change?

There is no criteria change for Dudley, Sandwell, Walsall and Wolverhampton; it remains not routinely commissioned for cosmetic reasons and Wolverhampton access has increased by removing the percentage of functional airway obstruction.

This is a harmonised policy.

The proposed policy states:

• Rhytidectomy is routinely commissioned for:  
  • Congenital facial abnormalities (asymmetrical and symmetrical)
  • Facial Palsy (congenital or acquired paralysis)
  • As part of treatment of specific conditions affecting the facial skin; for example, cutis laxa, pseudoxanthoma elasticum, neurofibromatosis.
  • Facial deformities arising from trauma.
• Rhytidectomy is not routinely commissioned for cosmetic or aesthetic (psychological) indications.

View the proposed Rhytidectomy (Face or brow lift) policy

Is there a proposed change?

There is no change for Dudley, Sandwell and Walsall. There is a new criteria for Wolverhampton.

This is a harmonised policy.

The proposed policy states:

• Standard conservative management of rosacea is routinely commissioned.
• Surgical excision or shaving of disfigurement from rosacea (e.g. rhinophyma, scarring and telangiectasias) is not routinely funded .
• Laser therapy or laser resurfacing is not routinely funded.

View the proposed Rosacea policy

Is there a proposed change?

There is clarification of criteria for conditions that are not routinely commissioned including laser treatment, laser resurfacing and surgery:

• There is no change for Dudley, Sandwell and Walsall regarding surgical treatment
• Laser treatment is not funded in Dudley, Sandwell and Walsall
• There is no change for Wolverhampton regarding laser treatment
• Surgical treatment is not funded in Wolverhampton.

This is a harmonised policy.

The proposed policy states:

• The ICB will not fund surgical excision of ganglion cysts unless one of the following are present:
  • The ganglion is causing pressure on a nerve, giving rise to pain, numbness or tingling (includes carpal tunnel syndrome).
  • The ganglion Interferes with the movement of the tendon resulting in reduced function of the hand.
  • The ganglion causes hand ischaemia due to compression of a blood vessel.
  • The cyst results in frequent discharge of fluid (mucous cysts).
  • The cyst results in deformity of the nail (mucous cysts).
• Treatment for a recurrence will not be automatically funded. Funding will be provided on the same basis as for primary treatment.

View the proposed Surgery removal of Ganglion cyst policy

Is there a proposed change?

There is no change to the criteria for Dudley and Walsall and increased access for Sandwell and Wolverhampton.

This is a new policy.

The proposed policy states:

• Treatment for port wine lesions on the face will be funded for individuals 18 years and under.
• Treatment for port wine lesions will be funded if the Port Wine Stain is causing complications in terms of function of underlying or adjacent structures, infections or bleeding.

View the proposed Treatment for port wine stain including laser therapy policy

Is there a proposed change?

There is a new criteria for Dudley, Sandwell, Walsall and Wolverhampton; this is new policy for Dudley and Walsall and it was previously not routinely commissioned for Sandwell and Wolverhampton.