Policies & Funding Information – Berkshire West

Cosmetic, Other Surgeries, Devices, Screening, 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 a secure NHS.net account to BerksWest.IFRrequests@nhs.net for consideration.

INTERVENTIONPOLICY STATEMENTPROCESS PATHWAY
Acupuncture for managing low back pain with or without sciatica
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
This procedure is not routinely funded and funding approval must always be obtained from the IFR service prior to referral and treatment.

For these cases a strong case on grounds of an exceptional health need must be provided. The GP must fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Acupuncture
Procedure Not Routinely Funded
Berkshire Priorites Committee
17 Acupuncture
This procedure is not routinely funded. If there is excepitional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Adenoidectomy
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC20 Surgical management of otitis media with effusion in children (under the age of 12 years) - Sept 2015

This procedure is funded subject to audit. Please refer your patient directly by the e-Referral Service if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Adenoidectomy with Grommets Application Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.

Patient Decision Aid is available at http://sdm.rightcare.nhs.uk/pda/glue-ear/
ADHD Treatment Pathway for Adults with Attention Deficit Hyperactivity Disorder
Procedure Not Routinely Funded
MOBBB
16 Treatment Pathway for Adults with Attention Deficit Hyperactivity Disorder (ADHD)
Outside of the local service this is a procedure not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Aesthetic/Cosmetic Breast Surgery including:
- breast augmentation, revision of breast agumentation, breast asymmetry, breast mastopexy - breast lift, mammoplasty,reconstruction/revision of breast (not including post breast cancer), inverted nipple, corrective surgery to nipple, removal of supernumerary nipples
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the Breast Surgery Form
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.netfor consideration.
Aesthetic/Cosmetic Breast Surgery:
- Breast implant removal and replacement
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the Breast Implant Removal and Replacement Form
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.netfor consideration.
Aesthetic/Cosmetic Breast Surgery:
- female breast reduction, reduction mammoplasty
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the
Aesthetic Breast Reduction Form - Female
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.netfor consideration.
Aesthetic/Cosmetic Breast Surgery:
- male breast reduction for gynaecomastia
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the Breast Reduction Form - Male
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.netfor consideration.
Aesthetic/Cosmetic Procedures:

Eyelid surgery (blepharoplasty) including blepharoptosis(an abnormal low-lying upper eyelid margin) and dermatochalasis (skin redundancy of the upper lid) / ptosis of eyelid

Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the appropriate checklist:
Aesthetic/ Cosmetic Surgery Form - Adult
Aesthetic/Cosmetic Surgery Form - Child
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net
Aesthetic/Cosmetic Procedures
including:
abdominoplasty, apronectomy, (tummy tucks), reconstruction/revision of body (excess skin removal for all areas, reconstruction/revision of body (excess skin removal all areas) post bariatric surgery/ weight loss,
body contouring procedures (buttock, thigh, calf implants, arm lifts), plastic operations on the umbilicus, brachioplasty (arm lifts), liposuction, facial procedures including eye bags, facelift (rhytidectomy/ surgical removal of wrinkles)/ brow lift and submental lipectomy, botox for cosmetic reasons, pinnaplasty for adults and children (bat ears), rhinoplasty (cosmetic nose surgery), reconstruction/ revision of nose surgery, rhinophyma and correction surgery, reconstruction /revision of external ear, split earlobes, meatoplasty/plastic operations on external ear (lobe repair)
acne vulgaris, rosacea, irregularities of aesthetic significance,
excision of skin tag of anus (not including fistula's),
excision of sweat bearing glands,
revision of keloid and hypertrophic scars, skin graft for scars,
laser treatment, excessive hirsutism,
minor skin procedures (not including BCC and SCC),
asesthetic/cosmetic genital surgery (male or female), clitoroplasty, labiaplasty, vaginoplasty, hymenopathy,
penile prothesis / enlargement,
repair of traumatic /chronic clefts due to avulsion of body piercing,
tattoo removal,
skin resurfacing (dermabrasion, laser and chemical peels),
correction of Alopecia (hair loss including Intralace), correction of male pattern baldness, hair transplantation, hair grafting, intralace
treatments for hirsutism/ hair depilation,
electrolysis for hair removal,
appliances and devices for cosmetic purposes (high-grade silicon cosmesis and/or prosthesis)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the appropriate checklist:
Aesthetic/ Cosmetic Surgery Form - Adult
Aesthetic/Cosmetic Surgery Form - Child
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net
Aesthetic/Cosmetic Procedures
including:
Removal of lipomata, seborrhoeic keratoses (benign skin growths, verrucas, warts), chalazia (meibomian cysts), spider naevi (moles),port wine stains, sebaceous cysts (pilar and epidermoid cysts), lesions, HHT, telangiectasia, xanthelasmas, (excluding ?histology ie cancer)
laser removal of skin lesions, haemangioma, congenital naevi,
Excluding BCC and SCC
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the appropriate checklist:
Lesion Form
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration
Anal Irrigation Systems for the Management of Faecal Incontinence/Constipation
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC3a policy recommendation Anal Irrigation Systems for the Management of Faecal Incontinence/Constipation (with flow chart)
This is a procedure that requires prior approval. Please complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Arthroscopic lavage and debridement for patients with osteoarthritis of the knee
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC6 policy recommendation Arthroscopy lavage and debridement for patients with osteoarthritis of the knee - 2014
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Assisted Conception Services (including IVF/ICSI)
Procedure that requires Prior Approval
TV 11g
11g Assisted Reproduction services for infertile couples - 2013
Appendix to Policy Statement 11g
Summary of the rationale behind departing from NICE guidelines
Patients/couples requesting specialist infertility treatment and meeting the eligibility criteria must be referred for specialist infertility treatment(s) by a NHS Consultant Gynaecologist.
Please complete the following Referral Form - Nov 2013
and submit it to the tertiary provider of the patient’s choice.
There are currently four designated (approved) specialist fertility centres in the Thames Valley:
BMI Healthcare Chiltern (Bucks)
Oxford Fertility Unit
Care Northampton
Nuffield Woking
If the patient meets the criteria the referring gynaecologist should apply to the provider unit of the patient's choice.
If the patients/couples do not meet the criteria then the form should be completed detailing how the couple are clinically exceptional. Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net

Patient leaflet - Assisted Reproduction Policy - Nov 2013

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.

Consultants must ensure that funding is in place prior to treatment.
Autologous Cartilage Transplantation
Excluded Specialised : NHS England
NHS EnglandFollow the appropriate pathway. For further information contact NHS England
Bespoke orthopaedic prostheses
Excluded Specialised : NHS England
NHS England
For further information contact NHS England
Biological Mesh
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC14 Biological Mesh -Sept 2015
This is a procedure that requires prior approval. Please complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Bone Anchored Hearing Aids
Excluded Specialised : NHS England
National Policy
NHS England
Bone anchored hearing aids - April 2013
For further information contact NHS England
Botulinum Toxin A (Botox) - Chronic Anal Fissure
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Sept 2015
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Botulinum Toxin A (Botox) - Long term Bell's Palsy
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Sept 2015
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Botulinum Toxin A (Botox) - Sialorrhoea (Severe drooling)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Sept 2015
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Botulinum Toxin A (Botox) for chronic headaches (excluding migraines)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Sept 2015
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

TA 260
Botulinum Toxin Type A for the prevention of headaches in adults with chronic migraine
Botulinum Toxin A (Botox) in the management of severe hyperhidrosis
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC25 Hyperhidrosis (excessive sweating) – Botulinum Toxin A and Endoscopic Thoracic Sympathectomy - Sept 2015
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Botulinum toxin Type A (Botox) - Overactive Bladder
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Sept 2015
This is a procedure that requires prior approval. Please complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Botulinum toxin Type A (Botox) - Spasticity
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Sept 2015
This is a procedure that requires prior approval. Please complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Carotid Endarterectomy and Endovascular Stent
Excluded Specialised : NHS England
National Policy
NHS England
Complex Endovascular Stent Grafts in Abdominal Aortic Aneuruysm - April 2013
For further information contact NHS England
Carpal Tunnel Syndrome
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC19 Carpal tunnel syndrome - Sept 2015
This is a procedure that requires prior approval. Please complete the following Carpal Tunnel Application Form email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

Patient Decision Aid is available at http://sdm.rightcare.nhs.uk/pda/carpal-tunnel-syndrome/
Cataract removal in adults (including second eye cataract surgery)
Procedure Funded Subject to Audit
Berkshire West
04 Cataract removal in adults - threshold for surgery
This procedure is funded subject to audit. Please refer your patient directly by the e-Referral Service if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Cataract Form
Email the fully completed form to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.
Cerebellar Stimulator Implants
Excluded Specialised : NHS England
National Policy
NHS England
Cerebellar Stimulator Implants - April 2013
For further information contact NHS England
Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis (ME) in patient stay
Procedure Not Routinely Funded
South Central Priorities Committee
130 Chronic Fatigue Syndrome/Myalgic Encephalomyelitis
Follow the appropriate pathway and refer patients to the local Clinical Health Psychology Services, NHS Berkshire Health NHS Foundation Trust

Inpatient stay is a procedure not routinely funded. If there is exceptional health need please fully complete the following Exceptional Health Need Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Closure of patent foramen ovale for migraine (PFO)
Excluded Specialised : NHS England
National Policy
NHS England
Patent Foramen Ovale PFO Closure - April 2013

For further information contact NHS England
Cochlear Implants
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Complex Neurological Rehabilitation for acquired brain injury not including injury due to stroke
Procedure that requires Prior Approval
Rehabilitation Categories:
Rehabilitation Categories
This is a procedure that requires prior approval.

Please complete all the following forms:
1 Complex Neurological Rehabilitation Needs
2 The Rehabilitation Complexity Scale - Trauma (RSCE-Trauma)
3 Complex Neurological Rehabilitation Referral
Complex Neurological Rehabilitation - referral forms
Please email the completed forms to the IFR Service at BerksWest.IFRrequests@nhs.net
Contribution to Reimbursement of Expenses for Living Donors (Renal Transplantation)
Excluded Specialised : NHS England
National Policy
NHS England
Reimbursement of Expenses for Living Kidney Donors - April 2013
For further information contact NHS England
Coronary Artery Stents
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Corticosteroid injections for lateral elbow tendiopathy (tennis elbow)
Procedure Not Routinely Funded
MOBBB
65 Corticosteroid injections for lateral elbow tendinopathy
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Corticosteroid injections for patellar tendiopathy (jumper's knee)
Procedure Not Routinely Funded
MOBBB
66 Cortiscosteroid injections for patellar
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Cryopreservation - preservation of fertility (Male and Female)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC17 Policy for the preservation of fertility - July 2015

This is a procedure that requires prior approval. Please complete the following Cryopreservation Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Cryotherapy (salvage) for recurrent prostate cancer
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Cryotherapy for localised Prostate cancer
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Deep Brain Stimulation for Parkinson’s Disease
Excluded Specialised : NHS England
National Policy
NHS England
Deep Brain Stimulation in movement disorders - April 2013
For further information contact NHS England
Deep Brain Stimulation for primary dystonia and essential tremor
Excluded Specialised : NHS England
National Policy
NHS England
Deep Brain Stimulation in movement disorders - April 2013
For further information contact NHS England
Deep Brain Stimulation including other interventions
Excluded Specialised : NHS England
National Policy
NHS England
Deep Brian Stimulation for Indications except movement disorders - April 2013
For further information contact NHS England
Dental Implants
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Dilatation and curettage (D&C) for abnormal bleeding
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC29 Dilatation and curettage (D&C) for abnormal uterine bleeding - Oct 2015
This is a procedure that is not routinely funded.If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Disc replacement surgery for low back pain with or without sciatica
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Dupuytren’s Contracture
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC18 Dupuytrens contracture - October 2017
NEW


This is a procedure that requires prior approval. Please complete the following:
Dupuytrens Form
Email the completed form with supporting clinical information to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Eflornithine for facial hirsutism (Vaniqa© Cream)
Procedure Not Routinely Funded
BPC 88
88 Eflornithine for facial hirsutism
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 an exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the appropriate checklist:
Aesthetic/ Cosmetic Surgery Form - Adult
Aesthetic/Cosmetic Surgery Form - Child
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net
Elective Endovascular repair infrarenal abdominal aortic aneurysms
Excluded Specialised : NHS England
National Policy
NHS England
Complex Endovascular Stent Grafts in Abdominal Aortic Aneuruysm - April 2013
For further information contact NHS England
Eligibility for NHS transport for patients in non-emergency situationsBerkshire
68 Eligibility for NHS Transport for patient's in non-emergency situations


Policy for information.
Endoprosthetic replacement for benign bone tumours
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Endoscopic Thoracic Sympathectomy for Facial Blushing and/or sweating
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC25 Hyperhidrosis (excessive sweating) – Botulinum Toxin A and Endoscopic Thoracic Sympathectomy - Sept 2015
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Epidural injections for acute and severe sciatica - Diagnostic
Procedure Not Routinely Funded


Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
This procedure is not routinely funded and prior approval is always required from the IFR service.

For these cases a strong case on grounds of an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

Epidural injections for neurogenic claudication in people who have central spinal canal stenosis are not normally funded.
Epidural injections for acute and severe sciatica - Therapeutic
Procedure that requires Prior Approval

Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
This procedure always requires prior approval from the IFR service.

Please fully complete the following:
Low Back Pain Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

Epidural injections for neurogenic claudication in people who have central spinal canal stenosis are not normally funded.
Erectile Dysfunction treatments
Including: Alprostadil cream, Erectile pumps/devices and psychosexual interventions
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC34 Erectile Dysfunction - updated July 2017
These procedures not routinely funded. If there is exceptional health need please fully complete the following Exceptional Health Need Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Erectile Dysfunction treatments - Including: the drugs sildenafil, vardenafil and tadalafil and avanafil and prostaglandin E1 intracavernosal injections and intraurethral instillations
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC34 Erectile Dysfunction - updated July 2017
Prior approval is not required where the patient meets the criteria in full for the listed drugs.

If the patient does not meet fully the policy criteria complete the following:
Exceptional Health Need Application Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.

This intervention will be audited as per the contract audit process.
Excess Treatment Costs (ETCs) for non-commercial clinical trials
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC37 Excess Treatment Costs (ETCs) for non-commercial clinical trials - April 2016
This procedure is not routinely funded. If there is exceptional health need please fully complete the following Exceptional Health Need Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Facet Joint & Medial Branch Block for chronic neck pain - Diagnostic
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC56 Facet joint injections and medial branch blocks for chronic neck pain - May 2017
NEW

This procedure is not routinely funded. If there is exceptional health need please fully complete the following:
Facet Joint Injection for Neck Pain Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

Facet Joint & Medial Branch Block for chronic neck pain - Therapeutic
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC56 Facet joint injections and medial branch blocks for chronic neck pain - May 2017
NEW

This procedure is not routinely funded. If there is exceptional health need please fully complete the following:
Facet Joint Injection for Neck Pain Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

Facet Joint & Medial Branch Block for low back pain - Diagnostic
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW

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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

Facet Joint & Medial Branch Block for low back pain - Therapeutic
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW

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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Female sterilisation
Procedure that requires Prior Approval
Referral criteria
Female Sterilisation
This is a procedure that requires prior approval. Please complete the following
Female Sterilisation Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Femoro-acetabular (Hip) Impingement (Arthroscopic and open Approaches) – Surgical Treatment - Hip Impingement surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC33 Surgical treatment of femoro acetabular hip impingement (FAI) (open or arthroscopic) - March 2016

Prior approval is always required from the IFR service before referral and treatment. Please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

In reference to TVPC33 Policy statement for Hip Impingement Surgery and prior approval process agreed providers and referral contacts are:
Frimley Health NHS Foundation Trust Hospitals (Frimley Park, Heatherwood and Wexham Park Hospitals): Mr Jonathan Hull and Mr Sebastian Sturridge
Royal Berkshire NHS Foundation Trust, Reading: Mr Tom Pollard and Mr Tony Andrade
Nuffield Orthopaedic Centre, Oxford: Mr Sion Glyn-Jones
Buckinghshire Healthcare NHS Trust: Mr Gurdeep Biring
Basingstoke and North Hampshire Hospital: None
Fenestrated endovascular stent-grafts for abdominal aortic aneurysms
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Functional Electrical Stimulation (FES) for upper and lower limb dysfunction of central neurological origin
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC62 Functional Electrical Stimulation (FES) for Upper and Lower Limb Dysfunction of Central Neurological Origin - October 2017
NEW


This procedure is not routinely funded. If there is exceptional health need please fully complete the following:
Exceptional Health Need Application Form
and email it with any supporting documents to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Gallstones (treatment of patients with previously symptomatic gallstones who are now free of symptoms)
Procedure Funded Subject to Audit
MOBBB
48 Treatment of patients with previously symptomatic gallstones who are now free of symptoms
This procedure is funded subject to audit. Please refer your patient directly by the e-Referral Service if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Gallstones Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.
Gamma Knife Surgery for Trigeminal Neuralgia
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Ganglion cysts (including Ganglion of the wrist)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC15 Ganglion cysts - Sept 2015

All ganglion surgery is a procedure not routinely funded. If there is exceptional health need please fully complete the following Ganglion Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Gender Reassignment surgery for the treatment of Gender Dysphoria
Excluded Specialised : NHS England
National Policy
NHS England
Interim Gender Dysphoria Protocol and Service Guidelines 2013/14

Thames Valley Priorities Committee Commissioning Statement
TVPC2 policy recommendation treatments for Gender Dysphoria - 2014

This is a procedure commissioned by NHS England.

Patients should be referred to a specialist centre in line with the NHS England National Policy and Thames Valley policy recommendations.

TVPC2 GP referral information for Gender Dysphoria Services October 2014
Hallux Valgus (Bunions)
Procedure that requires Prior Approval
04 Hallux Valgus - Bunions This is a procedure that requires prior approval. Please complete the following
Bunion Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Hemicraniectomy for malignant middle cerebral artery infarction
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Hernia (abdominal/ventral)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - February 2017
NEW
This is a procedure that requires prior approval. Please complete the following:
Hernia Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Hernia (Epigastric)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - February 2017
NEW
This is a procedure that requires prior approval. Please complete the following:
Hernia Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Hernia (Femoral, Spigelian or Inguino-scrotal)
Prior Approval not required
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - February 2017
NEW
This procedure is funded subject to audit.

Please refer your patient directly for surgical opinion for patients with the following conditions where prior approval for surgery is not required:
- diagnosis of femoral hernia
- diagnosis of Spigelian hernia, following ultrasound confirmation
- diagnosis of an inguino-scrotal hernia
Hernia (Incisional)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - February 2017
NEW
This is a procedure that requires prior approval. Please complete the following:

Hernia Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Hernia (lnguinal)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - February 2017
NEW
This is a procedure that requires prior approval. Please complete the following:
Hernia Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Patient Decision Aid is available at https://www.evidence.nhs.uk/Inguinal hernia decision aid for Ingunial Hernia.

Hernia (Umbilical, Para-umbilical)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - February 2017
NEW
This is a procedure that requires prior approval. Please complete the following:

Hernia Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
High-intensity focused ultrasound for colorectal liver metastases
Excluded Specialised : NHS England
MOBBB
231 SCP High-intensity focused ultrasound for colerectal liver metastases
For further information contact NHS England
Hip and Knee Replacement Surgery - follow-up appointments
Procedure that requires Prior Approval
Thames Valley Priorities Committee Policy Statement
TVPC8 policy recommendation Routine follow-up Knee replacement surgery - 2014
Prior approval is required for further appointments following the initial routine follow-up appointment. Please complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Hip Joint Revision Surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement (Policy)
42 Referral for hip replacement revision surgery - March 2011
Thames Valley Priorities Committee Commissioning Policy Statement (Procedure)
TVPC55 Hip and knee replacement; first revision (second procedure) INTERIM STATEMENT - April 2017
NEW
Prior approval is always required from the IFR service.

Please fully complete the following:
Primary Hip or Knee Replacement Revision Surgery Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Hip Prostheses
NICE TA 304
NEW
NICE TA 304 states that prostheses for total hip replacement and resurfacing arthroplasty are recommended as treatment options for people with end-stage arthritis of the hip only if the prostheses have rates (or projected rates) of revision of 5% or less at 10 years. This recommendation supersedes the previous prosthesis policy discussing the types of prosthesis used in THR.
Hip Resurfacing for Advanced Arthropathy NICE TA 304
NEW
NICE Technology Appraisal 304 (2014) has superseded the previous Hip Resurfacing for Advanced Arthropathy policy.
Homeopathy - Complementary therapy
Procedure Not Routinely Funded
Berkshire Priorities Committee
10 Homeopathy
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Hysterectomy for heavy menstrual bleeding and/or dysmenorrhoea - indications for surgery (excluding cancer)
Procedure that requires Prior Approval
Berkshire West
03 Hysterectomy for heavy menstrual bleeding and/or dysmenorrhoea - indications for surgery (excluding cancer)
This is a procedure that requires prior approval. Please complete the following Hysterectomy Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Impacted Third Molars - Wisdom Teeth
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Implantable Cardioverter Defibrillator devices for non-ischaemic cardiomyopathy
Excluded Specialised : NHS England
NHS England
For further information contact NHS England
Inpatient pain management programmes for adults with chronic pain
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Interventions for delayed non-union fracture: Low-intensity Pulsed Ultrasound (marketed in the UK as the Exogen® system) and teriparatide
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC10 policy recommendation interventions for non-union fracture: Low-intensity Pulsed Ultrasound (marketed in the UK as the Exogen® system) and teriparatide
This procedure is not routinely funded. If there is exceptional health need please fully complete the following Exceptional Health Need Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Intracranial Aneurysms – treatment of incidentally discovered IAs
Excluded Specialised : NHS England
National Policy
NHS England
Flow Diverting Device for Intracranial Aneurysms - April 2013

For further information contact NHS England
Intrathecal Baclofen pumps for severe spascity
Excluded Specialised : NHS England
National Policy
NHS England
Intrathecal Baclofen - April 2013
For further information contact NHS England
Ketone TestingThames Valley Priorities Committee Commissioning
Care and Care Pathway
TVPC13 Ketone Testing - Sept 2015
Please follow the recommended policy.
Knee Joint Revision Surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement (Policy)
TVPC9 policy recommendation Knee replacement revision surgery - October 2014
Thames Valley Priorities Committee Commissioning Policy Statement (Process)
TVPC55 Hip and knee replacement; first revision (second procedure) INTERIM STATEMENT - April 2017
NEW
Prior approval is always required from the IFR service.

Please fully complete the following:
Primary Hip or Knee Replacement Revision Surgery Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Laparoscopic surgery for colorectal cancer
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Lung resection for metastases
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Male Circumcision
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC63 Male Circumcision - October 2017
NEW
This procedure is a procedure which requires prior approval. Please fully complete the following Male Circumcision Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Managing the boundaries of NHS and privately funded healthcare
- NHS v Private Funding
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC35 Managing the boundaries of NHS and privately funded healthcare - April 2016
There is no obligation for the GP to prescribe treatment recommended by a private practitioner if it is contrary to local agreement or outside normal clinical practice.

The NHS will not normally fund treatments that have been recommended by a private practitioner if that treatment is not normally commissioned within the local area.

The fact that a patient can demonstrate they have benefited from the private treatment does not necessarily provide grounds for continuing the treatment in the NHS as an exception.

Patients who commence care privately can request that further treatment be provided within the NHS. Their clinical needs should be reassessed for NHS treatment within the same regime of priorities applicable to NHS patients with the same condition. Prior approval will be required from the IFR service if it is a restricted procedure. Please use the appropriate application form for the specific intervention required.

The CCG will not be responsible for retrospective funding of earlier treatment where patients who have received private treatment then transfer to the NHS.
Melatonin treatment in children
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC54 Melatonin treatment in children - April 2017
NEW
This is funded subject to audit where the patient fully meets the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Exceptional Health Need Application Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.
Microwave ablation for lung metastases
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Multiple Chemical Sensitivity (MCS) and Clinical Ecology/ Environmental Medicine
Procedure Not Routinely Funded
Berkshire Priorities Committee
36 Multiple Chemical Sensitivity (MCS) and Clinical Ecology Environmental Medicine
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Myringotomy and Grommets for otitis media with effusion
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC20 Surgical management of otitis media with effusion in children (under the age of 12 years) - Sept 2015
This procedure is funded subject to audit. Please refer your patient directly by the e-Referral Service if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Adenoidectomy with Grommets Application Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.

Patient Decision Aid is available at http://sdm.rightcare.nhs.uk/pda/glue-ear/
Neurosurgery for cerebral metastases
Excluded Specialised : NHS England
National Policy
NHS England
Stereotactic radiosurgery - radiotherapy for cerebral metastases - April 2013
For further information contact NHS England
Non pharmacological services for dementia patients
Procedure Not Routinely Funded
MOBBB
63 Non pharmacological services for dementia patients
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Open magnetic resonance imaging (MRI) scans
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC53 Open magnetic resonance imaging (MRI) scans and standing / upright MRI scans
NEW
This is a procedure which always requires prior approval from the IFR service. If the GP / Clinician wishes to treat, approval from the IFR service must be obtained. Please fully complete the following:
MRI Scan Form
or provide detailed clinic letter(s) which clearly state how the patient meets the criteria for consideration.

Please email the completed form/letters to the IFR Service for consideration at BerksWest.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Orthodontics
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Orthognathic surgery
Excluded Specialised : NHS England
NHS England
Interim Clinical Commissioning Policy: Orthognathic surgery - November 2013
For further information contact NHS England
Osteopathy and Chiropractic
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Patella resurfacing as part of total knee replacement (TKR)
Procedure Not Routinely Funded
Berkshire West Clinical Commissioning Groups Commissioning Policy Statement
Berkshire West CCGs policy patella resurfacing with total knee replacement (TKR) - June 2016
NEW

This procedure is not routinely funded and prior approval is always required from the IFR service. It is expected that these patients will have been referred, assessed and treated for their painful knee.

If a Consultant wishes to treat, they must apply by fully completing the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Pectus anomaly surgery (pectus excavatum / pectus carinatum)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC26 Pectus anomaly surgery - Oct 2015
This procedure is not routinely funded. If there is exceptional health need and the patient meets the criteria for treatment, please complete fully the appropriate checklist:
Aesthetic/Cosmetic Surgery Form
Aesthetic/Cosmetic Surgery - Child - Form
Please email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net
Penile Rehabilitation following prostate surgery
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC40 Penile Rehabilitation following prostate surgery - May 2016

This procedure is not routinely funded. If there is exceptional health need please fully complete the following Exceptional Health Need Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Percutaneous pulmonary valve implantation
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Polysomnography in the investigation of children with sleep-related disorders
Excluded Specialised : NHS England
NHS England

For further information contact NHS England
Preimplant genetic diagnosis (PGD)
Excluded Specialised : NHS England
National Policy
NHS England
Pre-implantation Genetic Diagnosis(PGD) - April 2013

For further information contact NHS England
Primary Hip Joint Replacement
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC49 Patients with osteoarthritis (OA); primary hip and knee replacement
NEW
This procedure is funded subject to audit. Please refer your patient directly by Electronic Referral System if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Primary Hip and Knee Replacement Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration

Example of Shared Decision making process - SDM - osteoarthritis of the hip
Please note in order to be valid the form must be signed by the patient.
The Arthritis Care Certificate can only be obtained from Arthritis Care.
Primary Knee Joint Replacement
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC49 Patients with osteoarthritis (OA); primary hip and knee replacement
NEW
This procedure is funded subject to audit. Please refer your patient directly by the Electronic Referral System if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Primary Hip and Knee Replacement Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.

Example of Shared Decision making process - SDM - osteoarthritis of the knee
Please note in order to be valid the form must be signed by the patient.
The Arthritis Care Certificate can only be obtained from Arthritis Care.

Proton Pump Inhibitors in the treatment of dyspepsiaBPC
21 Use of Proton Pump Inhibitors in the treatment of dyspepsia BW
Policy for information only.
Radiofrequency Ablation and Cryotherapy for Renal Tumours
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Radiofrequency denervation for chronic low back pain
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
This is a procedure that always requires prior approval from the IFR service.

Please fully complete the following:
Low Back Pain Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Radiofrequency denervation of sacroiliac joint pain
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Reversal of female sterilisation
Procedure Not Routinely Funded
14 Reversal of sterilisation and reversal of vasectomy


This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Reversal of vasectomy or secondary care referral
Procedure Not Routinely Funded
14 Reversal of sterilisation and reversal of vasectomyThis procedure is not routinely funded and prior approval is always required from the IFR service. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need email a detailed letter clearly demonstrating the clincial case to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Robotic-assisted laparoscopic radical prostatectomy
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Sacral Nerve Stimulation in faecal incontinence
Excluded Specialised : NHS England
National Policy
NHS England
Sacral nerve stimulation SNS for faecal incontinence in Adults - April 2013
For further information contact NHS England
Selective Dorsal Rhizotomy
Excluded Specialised : NHS England
National Policy
NHS England
Selective dorsal rhizotomy
For further information contact NHS England
Sequential Cochlear implants in profoundly deaf children
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Settings for alcohol detoxificationPublic HealthPublic Health
Severe and complex obesity
- Eligibility for bariatric surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC39 Severe and complex obesity - Eligibility for bariatric surgery - interim policy - May 2016
Weight Management
Services including Bariatric Surgery

Please note information concerning Tier 1, Tier 2 and Tier 3 services as bariatric surgery is not offered outside of the MDT Tier 3 pathway. Application will be normally be expected from the Tier 3 MDT/Consultants.

Tiers 1-4
Tier 1 and 2 Primary Healthcare
Tier 3 accessed by referral from GP/ Primary Healthcare

In addition to offering a programme of care, Tier 3 services will select and refer patients for consideration for bariatric surgery. Some Tier 3 providers are listed below.
Tier 4 - Complex and Specialised Obesity Surgery

Tier 3 providers include:
Royal Berkshire NHS Foundation Trust
Patient Leaflet What to expect in a weight management clinic
Berkshire Health Care NHS Foundation Trust
Patient Leaflet Weight No Longer
Ashford & St Peter's Hospitals
Patient Leaflet Frequently asked questions Tier 3
Luton & Dunstable University Hospitals
Patient Leaflet The Weigh to go

Eligibility for Bariatric Surgery includes:
- Patients considered morbidly obese. Adults with a BMI of 40kg/m2 or more, or between 35kg/m2 and 40kg/m2 or greater in the presence of other significant diseases.
- Screening of co-morbidities and the detection of other significant diseases by MDT led processes prior to entering the surgical pathway.
- Morbid/severe obesity present for at least 5 years.
- Patient have recently received and complied with a local specialist obesity service weight loss programme (non-surgical Tiers 3/4). This will have been for the duration of 12-24 months. For patients with a BMI>50 attending a specialist bariatric service, this period may include the stabilisation and assessment period prior to bariatric surgery. The minimum acceptable period is 6 months.
- The specialist obesity weight loss programme and MDT (Tier 3/4)assesses evidence that all suitable non-invasive options have been explored and trialled

Tier 3 services will select and refer appropriate patients for consideration for bariatric surgery
Severe and complex obesity
- Tier 1, Tier 2 and Tier 3
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC39 Severe and complex obesity - Eligibility for bariatric surgery - interim policy - May 2016
Weight Management
Services Tier 1, Tier 2 and Tier 3

Prior approval is required from the IFR service for referral to Tier 3 services. Please fully complete the following form
Weight management-Form
and email it with any supporting information to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.

Tiers 1-4
Tier 1 and 2 Primary Healthcare
Tier 3 accessed by referral from GP/ Primary Healthcare

In addition to offering a programme of care, Tier 3 services will select and refer patients for consideration for bariatric surgery. Some Tier 3 providers are listed below.
Tier 4 - Complex and Specialised Obesity Surgery

Tier 3 providers include:
Royal Berkshire NHS Foundation Trust
Patient Leaflet What to expect in a weight management clinic
Berkshire Health Care NHS Foundation Trust
Patient Leaflet Weight No Longer
Ashford & St Peter's Hospitals
Patient Leaflet Frequently asked questions Tier 3
Luton & Dunstable University Hospitals
Patient Leaflet The Weigh to go

Eligibility for Bariatric Surgery includes:
- Patients considered morbidly obese. Adults with a BMI of 40kg/m2 or more, or between 35kg/m2 and 40kg/m2 or greater in the presence of other significant diseases.
- Screening of co-morbidities and the detection of other significant diseases by MDT led processes prior to entering the surgical pathway.
- Morbid/severe obesity present for at least 5 years.
- Patient have recently received and complied with a local specialist obesity service weight loss programme (non-surgical Tiers 3/4). This will have been for the duration of 12-24 months. For patients with a BMI>50 attending a specialist bariatric service, this period may include the stabilisation and assessment period prior to bariatric surgery. The minimum acceptable period is 6 months.
- The specialist obesity weight loss programme and MDT (Tier 3/4)assesses evidence that all suitable non-invasive options have been explored and trialled

Tier 3 services will select and refer appropriate patients for consideration for bariatric surgery
Short Burst Oxygen Therapy (SBOT) for the relief of episodic breathlessness
Procedure Funded and Subject to Audit
BPC
133 Short Burst Oxygen Therapy for the relief of breathlessness
This intervention is funded subject to audit where the criteria are met in full. Please refer your patient to the Specialist Respiratory Service.

If after assessment the criteria are not met in full but the Specialist Respiratory Service wishes to treat, they must apply for prior approval by fully completing the following:
General Funding Form
or sending detailed clinic letter(s) to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Short sight/long sight corrective (laser) surgery (Refractive keratoplasty)
Procedure Not Routinely Funded
This procedure in not routinely funded.

Cases will only be considered where laser or operative correction is the only treatment available to restore reasonable visual acuity /or where there are substantial other medical reasons that make correction by external visual aids inappropriate.

This 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 also be provided. Please fully complete the General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Silicon Cosmesis for Prosthetic Limbs
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Speech and Language Therapy in Parkinson's Disease
Procedure Not Routinely Funded
MOBBB
89 Speech and language therapy in Parkinson's Disease
This procedure is not routinely funded. If there is exceptional health need please fully complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Spinal Cord Stimulation for ischaemic pain
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Spinal Cord Stimulation in neuropathic pain
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Spinal decompression for sciatica (including laminectomy, foraminotomy, undercutting facetectomy and discectomy)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
This is a procedure that always requires prior approval from the IFR service.

Please fully complete the following:
Low Back Pain Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Spinal fusion for people with low back pain
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW

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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Spinal injections for managing low back pain including: facet joint injections, medial branch blocks, intradiscal injections, prolotherapy (proliferation therapy or regeneration injection therapy) and trigger point injections
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Spinal manipulation for the treatment of chronic, non-specific low back pain
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - April 2017
NEW
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 an exceptional health need must be provided. Please fully complete the following form and clearly detail the exceptionality:
Low Back Pain Form
Email the completed form to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Spinal Surgery (Specialist surgery not listed here)
Excluded Specialised : NHS England
NHS England
For further information contact NHS England
Standing and Upright Magnetic resonance imaging (MRI) scans
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC53 Open magnetic resonance imaging (MRI) scans and standing / upright MRI scans
NEW

This procedure is not routinely funded and prior approval is always required for the IFR service. If there is exceptional health need please fully complete the following and indicating the exceptional health need:
MRI Scan Form
or provide detailed clinic letter(s) which clearly state how the policy criteria are met and the exceptional health need
Please email the completed form/letters to the IFR Service for consideration at BerksWest.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Subacromial decompression of the shoulder
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC50 Subacromial decompression of the shoulder - February 2017
NEW

Prior approval is always required from the IFR service before referral and treatment except for RED FLAG symptoms as stated on the policy. Please fully complete the following:
Subacromial decompression of the shoulder Form
and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Surgery in the management of chronic rhinosinusitis(CRS) and nasal polyposis(NP) (FESS)
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC21 Rhinosinusitis - Sept 2015
This procedure is funded subject to audit. Please refer your patient directly by the e-Referral Service if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Rhinosinusitis Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.
Surgical resection and percutaneous ablation for colorectal liver metastases
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Temporomandibular Joint Replacement
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Tonsillectomy
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC22 Tonsillectomy for recurrent tonsillitis and obstructive sleep apnoea in children and adults - Sept 2015
This procedure is funded subject to audit. Please refer your patient directly by the e-Referral Service if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
Tonsillectomy Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.

Patient Decision Aid is available at http://sdm.rightcare.nhs.uk/pda/recurrent-sore-throat/
Trans-cranial Doppler Ultrasonography with frequent transfusion to prevent stroke in children with sickle cell
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Transcatheter Aortic Valve implantation for aortic stenosis
Excluded Specialised : NHS England
National Policy
NHS England
Transcatheter Aortic Valve Implantation (TAVI) for Aortic Stenosis - April 2013
For further information contact NHS England
Trigger Finger (Stenosing Tenosynovitis,Stenosing Tenovaginosis)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC23 Trigger finger - Sept 2015

This is a procedure that requires prior approval. Please complete the following Trigger Finger Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Ultrasound guided injections for hip pain (trochanteric bursitis and osteoarthritis of the hip)
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC32 Ultrasound guided injections for hip pain (trochanteric bursitis and osteoarthritis of the hip) - March 2016
This procedure is funded subject to audit. Please refer your patient directly if they fully meet the criteria outlined in the policy.

If the patient does not meet fully the policy criteria complete the following:
General Funding Form
Email the fully completed form and any supporting evidence to the IFR service at BerksWest.IFRrequests@nhs.net for consideration.
Uterine Artery Embolisation of Fibroids
Procedure that requires Prior Approval
Berkshire
59 Uterine Artery Embolisation of Fibroids
This is a procedure that requires prior approval. Please complete the following General Funding Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Vagus Nerve Stimulation (VNS) for other indications
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Vagus Nerve Stimulation (VNS) for refractory epilepsy in children and adults
Excluded Specialised : NHS England
NHS EnglandFor further information contact NHS England
Varicose Veins
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC1 policy recommendation for Inteventional Procedures for Varicose Veins
This is a procedure that requires prior approval. Please complete the following Varicose Veins Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Vasectomy Services - Male Sterilisation
Procedure Not Routinely Funded

Berkshire West Clinical Commissioning Groups Commissioning Policy Statement
Berkshire West CCGs policy Vasectomy (male sterilisation) - October 2016
NEW
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 an exceptional health need must be provided.

If there is an exceptional health need please email a detailed letter clearly demonstrating the clinical case to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.
Vertebroplasty and KyphoplastyNICE TA 279 If the patient does not meet in full the NICE TA prior approval is always required from the IFR service before referral and treatment. Please fully complete the Exceptional Health Need Application Form and email it to the IFR Service at BerksWest.IFRrequests@nhs.net for consideration.

 

 

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