Policies & Funding Information – Buckinghamshire

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 Bucks.IFRrequests@nhs.net for consideration.

INTERVENTIONPOLICY STATEMENTPROCESS PATHWAY
Acetylcholinesterase Inhibitors for the treatment of Lewy Body Dementia and Parkinson's Disease Dementia
Procedure Not Routinely Funded
BMKPC
66 Acetylcholinesterase Inhibitors for Lewy Body and Parkinson's Disease Dementia - January 2008
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Acupuncture and manual therapies for the treatment of chronic, non-specific 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 - June 2017
This procedure in not routinely funded in secondary care.

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly state the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Adalimumab and Infliximab (dose escalation) in patients with severe active fistulating Crohn's Disease
Procedure Not Routinely Funded
MOBBB
60 Dose escalation therapy with infliximab and adalimumab in people with active fistulising Crohn's disease - November 2011

TA 187
TA187 Infliximab (review) and adalimumab for the treatment of Crohn's disease
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Adalimumab and Infliximab (dose escalation) in patients with severe active fistulating Crohn's Disease - Adults patients (18 or older)MOBBB
61 Dose escalation therapy with infliximab and adalimumab in adult patients with severe Crohn's disease - December 2011

TA 187
TA187 Infliximab (review) and adalimumab for the treatment of Crohn's disease
Where the patient fully meets the criteria outlined in the policy for Adalimumab then prior approval is not required. These cases may be audited.

Dose escalation therapy with infliximab is not routinely funded.
For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Adalimumab and Infliximab (dose escalation) in patients with severe active fistulating Crohn's Disease - (those 6-17 years old)MOBBB
62 Dose escalation therapy with infliximab and adalimumab in people aged 6-17 years with severe active Crohn's disease - December 2011

TA 187
TA187 Infliximab (review) and adalimumab for the treatment of Crohn's disease
Where the patient fully meets the criteria outlined in the policy for Adalimumab then prior approval is not required. These cases may be audited.

Dose escalation therapy with infliximab is not routinely funded.
For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Adenoidectomy
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC20 Surgical management of otitis media with effusion in children (under the age of 12 years) - Nov 2015

Adenoidectomy is of limited clinical effectiveness and will not be routinely funded. Refer to the above policy if Grommets and Adenoidectomy for Children is required.
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Adenoidectomy with Grommets Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.

Patient Decision Aid is available at https://www.england.nhs.uk/rightcare/shared-decision-making/ for Glue Ear.
ADHD Treatment Pathway for Adults with Attention Deficit Hyperactivity Disorder
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC71 Treatment pathway for adults with attention deficit hyperactivity disorder (ADHD) - March 2018
NEW
This procedure is funded subject to audit. Please refer your patient direct by Electronic Referral System if they fully meet the criteria outlined in the policy.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at
and email it to the IFR service at Bucks.IFRrequests@nhs.net for consideration.
Consultants must ensure that funding is in place prior to treatment.
Adhesive Capsulitis (Frozen Shoulder)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC74 Adhesive Capsulitis (Frozen Shoulder) - March 2018
NEW
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Adhesive Capsulitis Form
or providing detailed clinic letters which clearly indicate how the policy criteria are met. Please email the letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Aesthetic/Cosmetic Breast Surgery
- breast augmentation, revision of breast augmentation, 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
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 following form:
Breast Surgery Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria for consideration and the exceptional health need.
Please email the completed form to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 following:
Breast Implant Removal and Replacement Form
or provide detailed clinic letters which clearly state how the patient meets the criteria for consideration and the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 following:
Aesthetic Breast Reduction Surgery Form - Female
or provide detailed clinic letters which clearly indicate how the patient meets the criteria for consideration and the exceptional health need.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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
Aesthetic Breast Reduction Form - Male
or provide detailed clinic letter(s) which clearly indicate how the patient meets the criteria for consideration and the exceptional health need.
Please email the form/letters to the IFR service at
Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Aesthetic/Cosmetic Procedures
Benign skin lesions and lipomata including:
Acne vulgaris, Dermatofibromas (skin growths), Naevi (benign pigmented naevi, epidermal, haemangioma, moles, spider, congenital and port-wine, Onychomycosis (fungal nail infections), Rhinophyma, Rosacea, Scars including keloid (removal and revision), Sebaceous cysts (pilar and epidermoid cysts), Seborrhoeic keratosis (benign skin growths, basal cell papilloma, senile warts), Skin tags, Tattoo (removal or revision), Telangiectasia (HHT, spider veins and thread veins), Vitiligo, Warts (plantar including verrucae, filiform and common), Xanthelasmas (cholesterol deposits underneath the skin) (excluding ?histology ie cancer), Lipoma and Lipomata (fat deposits underneath the skin)
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 exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the following:
Lesion Form
or provide detailed clinic letters which clearly state how the patient meets the criteria for consideration and the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Aesthetic/Cosmetic Procedures
Excess skin removal and body contouring including but not limited to:
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
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 following:
Excess Skin Removal Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria for consideration and the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Aesthetic/Cosmetic Procedures
Eyelid surgery (blepharoplasty) including:
blepharoptosis (an abnormal low-lying upper eyelid margin) and dermatochalasis (skin redundancy of the upper lid), chalazion (meibomian cyst)
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 exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the following:
Eyelid Surgery Form
or provide detailed clinic letters which clearly state how the patient meets the criteria for consideration and the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Aesthetic/Cosmetic Procedures
Nose reshaping including:
Rhinoplasty / Septorhinoplasty (cosmetic nose surgery),
Reconstruction/revision of nose surgery
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 exceptional health need must be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the following:
Nose Surgery Form
or provide detailed clinic letters which clearly state how the patient meets the criteria for consideration and the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Aesthetic/Cosmetic Procedures
Other procedures including:
botox for cosmetic reasons, pinnaplasty for adults and children (bat ears), reconstruction /revision of external ear, split earlobes, meatoplasty/plastic operations on external ear (lobe repair)
irregularities of aesthetic significance,
excision of skin tag of anus (not including fistula's),
excision of sweat bearing glands,
laser treatment, excessive hirsutism,
minor skin procedures (not including BCC and SCC),
aesthetic/cosmetic genital surgery (male or female), clitoroplasty, labiaplasty, vaginoplasty, hymenopathy,
penile prosthesis / enlargement,
repair of traumatic /chronic clefts due to avulsion of body piercing,
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 following:
Aesthetic/Cosmetic Surgery Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria for consideration and the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Anal Irrigation Systems for the Management of Faecal Incontinence/ConstipationThames Valley Priorities Committee Commissioning Policy Statement
TVPC3a policy recommendation Anal Irrigation Systems for the Management of Faecal Incontinence/Constipation - October 2014
Please follow the recommended care pathway.
Anti-VEGFs for sight-threatening eye conditions other than 'wet' age related macular degeneration
Procedure Not Routinely Funded
BMKPC
52b Anti-VEGFs for sight-threatening eye conditions other than wet age related macular degeneration - August 2009
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Arthroscopic Lavage and Debridement for Patients with Osteoarthritis of the knee
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC6 Arthroscopic lavage and debridement for patients with osteoarthritis of the knee - Nov 2015
This procedure in not routinely funded in secondary care

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following
General Funding Form
or provide detailed clinic letters which clearly indicates the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Assisted Conception Services (including IVF/ICSI)
Procedure that requires Prior Approval
TV 11g
11g Assisted reproduction services for infertile couples - November 2013, updated November 2017
NEW
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 Assisted Reproduction Services Form
and submit it to the tertiary provider of the patient’s choice.
Currently designated (approved) specialist fertility centres in the Thames Valley are:
Oxford Fertility Unit
Care Northampton
Nuffield Woking

If the patients/couples do not meet the criteria then the Assisted Reproduction Services Form should be completed detailing how the couple are clinically exceptional. Please email the completed form to the IFR service at Bucks.IFRrequests@nhs.net for consideration

Patient leaflet - Assisted Reproduction Policy - Nov 2013

Consultants must ensure that funding is in place prior to treatment.

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.
Atomoxetine in Adults with Attention Deficit Hyperactivity Disorder (ADHD)MOBBB
15 Atomoxetine in Adult with ADHD - July 2010
Where the patient fully meets the criteria outlined in the policy for Adalimumab then prior approval is not required. These cases may be audited.
Autologous blood injections and platelet rich plasma injections
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC57 Autologous blood injections and platelet rich plasma injections - June 2017
This is a procedure of Low Priority. If there is an exceptional health need please complete fully the following:
Exceptional Circumstances Submission Form
and email it to the IFR service at Bucks.IFRrequests@nhs.net for consideration.
Biologic therapies for ulcerative colitis in adults (18 years and over)Thames Valley Priorities Committee Commissioning Policy Statement
TVPC43 Use of biological therapies for ulcerative colitis - 18 year and over - May 2017
Prior approval is not required where the patient meets the criteria in full.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Biologic therapy for psoriasis - Sequential use of a third or subsequent biologicThames Valley Priorities Committee Commissioning Policy Statement
TVPC44 Sequential use of a third or subsequent biologic therapy for psoriasis - May 2017
Prior approval is not required where the patient meets the criteria in full.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Biologic therapy in Ophthalmology - Sequential useThames Valley Priorities Committee Commissioning Policy Statement
TVPC45 Sequential use of biologic therapy in ophthalmology - May 2017
Prior approval is not required where the patient meets the criteria in full.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Biologic therapy in Psoriatic Arthritis - Sequential useThames Valley Priorities Committee Commissioning Policy Statement
TVPC46 Sequential use of biologics in psoriatic arthritis - May 2017
Prior approval is not required where the patient meets the criteria in full.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Biologic therapy in Rheumatoid Arthritis - Sequential useThames Valley Priorities Committee Commissioning Policy Statement
TVPC51 Sequential use of biologics therapy in Rheumatoid Arthritis - June 2017
Prior approval is not required where the patient meets the criteria in full.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Biological Mesh
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC14 Biological Mesh - Nov 2015
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provided detailed clinic letters which clearly indicate policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Bone Anchored Hearing Aids
National Policy
NHS England
Bone anchored hearing aids - April 2013
For further information contact NHS England
Botulinum toxin Type A (Botox) for chronic headache (excluding migraines)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Nov 2015
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 also be provided. Please fully complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria is met.
Please email the completed form/ letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.

For information TA 260
Botulinum Toxin Type A for the prevention of headaches in adults with chronic migraine
Botulinum toxin Type A (Botox) for cosmetic reasons - hyperhidrosis
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC25 Hyperhidrosis (excessive sweating) - Botulinum Toxin A and Endoscopic Thoracic Sympathectomy - Nov 2015
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.
For these cases a strong case on grounds of exceptional health need must also be provided. Please complete fully the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Breast prosthesis removal and replacement - PIP Implants
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW

Interim policy on PIP implants March 2012 - Buckinghamshire
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

For these cases a strong case on grounds of exceptional health need must also be provided. Please complete the following form.
Interim PIP Implant Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Cannabinoids in the Management of Multiple Sclerosis and Chronic Pain
Procedure Not Routinely Funded
BMKPC
94 Cannabinoids in the Management of Multiple Sclerosis and Chronic Pain - March 2009
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Carotid Endarterectomy and Endovascular Stent
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 - Nov 2015
In the first instance GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Carpal Tunnel Syndrome Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.

Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.

Patient Decision Aid is available at https://www.england.nhs.uk/rightcare/shared-decision-making/
Cataract removal in adults (including second eye cataract surgery)
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC60 Cataract Removal in Adults - Threshold for Surgery - July 2017
NEW
This procedure is funded subject to audit. Please refer your patient direct by Electronic Referral System if they fully meet the criteria outlined in the policy.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Cataract Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.

Patient leafletCataract treatment
Chronic Anal Fissure
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Nov 2015
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must also be provided. Please complete fully the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis (ME)
Procedure Not Routinely Funded
BMKPC 76
76 - Chronic Fatigue Syndrome Myalgic Encephalomyelitis
Local referral for CBT would be appropriate in the first instance.
Inpatient stay 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 also be provided. Please fully complete the following:
General Funding Form
or provide detailed clinical letters which clearly indicate the exceptional health need and how the policy is met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Closure of patent foramen ovale for migraine (PFO)
National Policy
NHS England
Patent Foramen Ovale PFO Closure

For further information contact NHS England
Co-careldopa intestinal gel (Duodopa®) for advanced Parkinson's disease
Procedure Not Routinely Funded
BMKPC
78 Co-careldopa intestinal gel (Duodopa®) for advance Parkinson's disease - July 2008
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Complementary and Alternative Therapies including:
Acupuncture, Body Massage, Functional Therapy Sessions, Homeopathy, Hypnosis, Movement Therapy, Osteopathy, Chiropractic, Relaxation Therapy Sessions
Procedure Not Routinely Funded
Complementary and Alternative TherapiesThese 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 also be provided. Please fully complete the following:
General Funding Form
or provide detailed clinical letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Contribution to Reimbursement of Expenses for Living Donors (Renal Transplantation)National Policy
NHS England
Reimbursement of Expenses for Living Kidney Donors
For further information contact NHS England
Correction of Ptosis
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC16 Aesthetic treatments for adults and children - Updated August 2017
NEW
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Eyelid Surgery Form
or provide detailed clinic letters which clearly indicate the health need and how the policy criteria are met.
Please email the completed form to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Corticosteroid injections for lateral elbow tendinopathy (tennis elbow)
Procedure Not Routinely Funded
MOBBB 65
65 MOBBB - Corticosteroid injections for Elbow
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 also be provided. Please fully complete the following:
Exceptional Circumstances Submission Form
or provide detailed clinical letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Corticosteroid injections for patellar tendinopathy (jumper’s knee)
Procedure Not Routinely Funded
MOBBB 66
66 MOBBB - Corticosteroid injections for patellar
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 also be provided. Please fully complete the following:
Exceptional Circumstances Submission Form
or provide detailed clinical letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - Nov 2015
The NHS Fertility Service or the Consultant wishing to treat, should check with our referral triage service that the patient is eligible by fully completing the following:
Preservation of Fertility Form
or provide detailed clinical letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Cryotherapy (salvage) for recurrent prostate cancer
NHS England
For further information contact NHS England
Cryotherapy for localised prostate cancer
NHS EnglandFor further information contact NHS England
Da Vinci Robotic Prostatectomy
NHS EnglandFor further information contact NHS England
Deep Brain Stimulation for Parkinson’s DiseaseNational Policy
NHS England
Deep Brain Stimulation DBS in movement disorders
For further information contact NHS England
Deep Brain Stimulation for primary dystonia and essential tremor
National Policy
NHS England
Deep Brain Stimulation DBS in movement disorders
For further information contact NHS England
Deep Brain Stimulation including other interventions
National Policy
NHS England
Deep Brian Stimulation for Indications except movement disorders
For further information contact NHS England
Defarasirox in the management of iron overload
Procedure Not Routinely Funded
BMKPC
56 Deferasirox in the management of iron overload - October 2007
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Dental Implants
NHS England
For further information contact NHS England
Dilatation and curettage (D&C) for abnormal uterine bleeding
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC29 Dilatation and curettage (D&C) for abnormal uterine bleeding - April 2018
NEW

Medicines & Healthcare product Regulatory Agency (MHRA)
9 February 2018 – New temporary safety measures introduced for Esmya following reports of serious liver injury in women using the medicine for uterine fibroids.
Esmya (ulipristal acetate) for uterine fibroids: monitor liver function in current and recent users; do not initiate treatment in new users or those between treatment courses.
MHRA Safety Alert - 9 February 2018
NEW

This procedure is not routinely funded.

Patients are to be referred to the local Intermediate Gynaecological Service for assessment and counselling.

If the Gynaecological Service wishes to refer to secondary care, or if a Consultant wishes to treat, they must have prior approval from the IFR service before referral and treatment. Please fully complete the following:
General Funding Form
or provide detailed clinical letters which clearly indicate the health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - June 2017
This procedure is not routinely funded.

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly state the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Donepezil, galantamine, rivastigmine and memantine for the treatement of Alzheimer's diseaseBMKPC
63 Donepezil, galantamine, rivastigmine and memantine for Alzheimer's disease - December 2007
Where the patient fully meets the criteria outlined in the policy for Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease then prior approval is not required. These cases may be audited.

If the criteria are not met but the consultant wishes to treat then prior approval will be required. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Dupuytren’s Contracture
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC18 Dupuytrens contracture - October 2017
In the first instance GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk/

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Dupuytrens Form
or provide detailed clinic letters which clearly indicate the health need and how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Ectropion and Entropion - indications for surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC70 Ectropion and entropion - indications for surgery - March 2018
NEW
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Eyelid Surgery Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Eflornithine for facial hirsutism (Vaniqa© Cream)
Procedure Not Routinely Funded
BMKPC 4
4 Eflornithine for facial hirsutism
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 following:
General Funding Form
or provide detailed clinic letters which clearly outline the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Elective Endovascular repair infrarenal abdominal aortic aneurysms
National Policy
NHS England
Complex Endovascular Stent Grafts in Abdominal Aortic Aneuruysm - April 2013
For further information contact NHS England
Electrical stimulation (including Functional Electrical Stimulation - FES) for Upper and Lower Limb Dysfunction
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 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 also be provided. Please complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Eligibility for NHS transport for patients in non-emergency situationsBMKPC 50
50 Eligibility for NHS transport for Patients in Non-Emergency Situations - Buckinghamshire
As per the policy
Endoscopic thoracic sympathectomy for excessive sweating and/or facial blushing
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC25 Hyperhidrosis (excessive sweating) - Botulinum Toxin A and Endoscopic Thoracic Sympathectomy - Nov 2015

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 also be provided. Please complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Epidural injections for managing low back pain with or without sciatica - Diagnostic
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - June 2017
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly state the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Epidural injections for neurogenic claudication in people who have central spinal canal stenosis are not normally funded.

Consultants must ensure that funding is in place prior to treatment.
Epidural injections for managing low back pain with or without sciatica - Therapeutic
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - June 2017
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly state the how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Epidural injections for neurogenic claudication in people who have central spinal canal stenosis are not normally funded.

Consultants must ensure that funding is in place prior to treatment.
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
Prior approval is not required where the patient meets the criteria in full for the listed drugs.

This intervention will be audited as per the contract audit process.

If the patient does not meet the criteria and there is a strong case on grounds of an exceptional health need please fully complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need. Email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Erectile Dysfunction treatments
Including: the drugs sildenafil, vardenafil, 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.

This intervention will be audited as per the contract audit process.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - August 2016
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 an exceptional health need must also be provided. Please fully complete the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment
Facet Joint Injections & 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 - June 2017
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 also be provided. Please fully complete the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Facet Joint Injections & 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 - June 2017
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 also be provided. Please fully complete the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Facet Joint Injections & Medial Branch Blocks 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 - June 2017
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 also be provided. Please fully complete the following:
Facet Joint Injection for Neck Pain Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Facet Joint Injections & Medial Branch Blocks 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 - June 2017
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 also be provided. Please fully complete the following:
Facet Joint Injection for Neck Pain Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Female Sterilisation
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC68 Female Sterilisation - April 2018
NEW
Female sterilisation is not normally funded. If there are exceptional circumstances these must be clearly detailed when applying for consideration.

Please complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptionality.
Please email the form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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) - Feb 2016
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria. Email the completed form /letters to the referral triage service at Bucks.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
Buckinghamshire Healthcare NHS Trust: Mr Gurdeep Biring
Basingstoke and North Hampshire Hospital: None

Consultants must ensure that funding is in place prior to treatment
Filtered and Coloured Lenses
Procedure Not Routinely Funded
BMKPC TBC
27 Filtered and Coloured Lenses - July 2006
These are not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Flash Glucose Monitoring System (Freestyle Libre®)Thames Valley Priorities Committee Commissioning Policy Statement
TVPC73 Flash Glucose Monitoring System (Freestyle Libre®) - March 2018
Prior approval is not required where the patient meets the criteria in full and will be managed through the Buckinghamshire formulary traffic light system.
Functional Electrical Stimulation (FES) in Drop Foot of Central 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 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 also be provided. Please fully complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Gallstones (treatment of patients with previously symptomatic gallstones who are now free of symptoms)
Procedure Funded Subject to Audit
MOBBB 48
48 Gallstones
This procedure is funded subject to audit. Please refer your patient directly by the Electronic Referral System if they fully meet the criteria outline in the policy.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Ganglion (including Ganglion of the wrist)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC15 Ganglion cysts - Nov 2015
This procedure is not routinely funded in secondary care.

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
Ganglion Form
or providing detailed clinic letters which clearly indicate the exceptional health need and how the criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Gender Reassignment surgery for the treatment of Gender DysphoriaNational Policy
NHS England
Interim Gender Dysphoria Protocol and Service Guidelines 2013/14

Thames Valley Priorities Committee Commissioning Statement
TVPC2 policy recommendation Gender Dysphoria October 2014
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
Grazax® allergy vaccine for seasonal rhinitis
Procedure Not Routinely Funded
BMKPC 49
49 Grazax® allergy vaccine for moderate to severe seasonal rhinitis - April 2007
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Haemorrhoids
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC72 Management of Haemorrhoids - March 2018
NEW
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Haemorrhoids Form
or providing detailed clinic letters which clearly indicate how the policy criteria are met. Please email the letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Hallux Valgus (Bunions) - Surgery for painful big toe
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC47 Surgery for painful big toe (bunion) - May 2017
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must please check with our referral triage service that the patient is eligible by fully completing the following:
Bunion Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Hemicraniectomy for malignant middle cerebral artery infarctionMOBBB 75
75 Hemicraniectomy for middle cerebral artery infarction
Follow the appropriate pathway.
Hernia (Abdominal/Ventral)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - May 2017
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Hernia Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria.
Email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Hernia (Epigastric)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - May 2017
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Hernia Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria.
Email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Hernia (Femoral, Spigelian or Inguino-scrotal)
Prior Approval not required
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - May 2017
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 - May 2017
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Hernia Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria.
Email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Hernia (Inguinal)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - May 2017
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Hernia Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria.
Email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Patient Decision Aid is available at:
https://www.england.nhs.uk/rightcare/useful-links/shared-decision-making/

Consultants must ensure that funding is in place prior to treatment.
Hernia (Umbilical)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC48 Elective surgical hernia repair in adults - May 2017
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Hernia Form
or provide detailed clinic letters which clearly indicate how the patient meets the criteria.
Email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
High-intensity focused ultrasound for colorectal liver metastasesNHS England
MOBBB 76 High-intensity focused ultrasound for colorectal liver metastases for information only.
For further information contact NHS England
Hip and Knee Replacement Surgery - follow up appointments
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC8 Routine follow-up after primary hip and knee joint replacement surgery - Nov 2015
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Hip joint revision surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC55 Primary hip and knee replacement revision surgery - March 2017, updated January 2018
NEW
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk/

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Primary Hip or Knee Replacement Revision Surgery Form
or providing detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Hip Resurfacing for Advanced Arthropathy NICE TA 304
NEW
NICE Technology Appraisal 304 (2014) has superseded the previous Hip Resurfacing for Advanced Arthropathy policy.
Hysterectomy
Procedure that requires Prior Approval

Thames Valley Priorities Committee Commissioning Policy Statement
TVPC58 Hysterectomy - indications for surgery - April 2018
NEW

Medicines & Healthcare product Regulatory Agency (MHRA)
9 February 2018 – New temporary safety measures introduced for Esmya following reports of serious liver injury in women using the medicine for uterine fibroids.
Esmya (ulipristal acetate) for uterine fibroids: monitor liver function in current and recent users; do not initiate treatment in new users or those between treatment courses.NEW
MHRA Safety Alert - 9 February 2018
NEW
Patients are to be referred to the local Gynaecological Service for assessment and counselling.
If the Gynaecological Service wishes to refer to secondary care, or a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible before referral and treatment. Please fully complete the following:
Hysterectomy Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Impacted Third Molars - Wisdom teeth
NHS EnglandFor further information contact NHS England
Implantable Cardioverter Defibrillator devices for non-ischaemic cardiomyopathy
NHS England
For further information contact NHS England
Implementation of NICE Interventional Procedures Guidance (IPGs), Medical Technologies Guidance (MTGs) and Diagnostic Technologies Guidance (DTGs)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC41 Implementation of NICE IPGs, MTGs and DTG's - August 2016
Inpatient pain management programmes for adults with chronic pain
NHS England
For further information contact NHS England
Intracranial Aneurysms – treatment of incidentally discovered IAs
National Policy
NHS England
Flow Diverting Device for Intracranial Aneurysms - April 2013
For further information contact NHS England
Intrathecal Baclofen pumps for severe spascityNational Policy
NHS England
Intrathecal Baclofen
For further information contact NHS England
Intravenous versus oral steroids for exacerbations of multiple scleroisisMOBBB
67 MOBBB Intravenous versus oral steroids for exacerbations of multiple sclerosis - January 2012
Ketone TestingThames Valley Priorities Committee Commissioning Policy Statement and Care Pathway
TVPC13 Ketone Testing - Nov 2015
Please follow the recommended care pathway.
Knee joint revision surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC55 Primary hip and knee replacement revision surgery - March 2017, updated January 2018
NEW
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk/

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Primary Hip or Knee Replacement Revision Surgery Form
or providing detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Laparoscopic fundoplication for chronic reflux oesophagitis
(funding for use in any other circumstance is Low Priority)
Procedure that requires Prior Approval
BMKPC 109
109 - Laparoscopic fundoplication for chronic reflux oesophagitis
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Long term Bell's Palsey
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Nov 2015
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must also be provided. Please complete fully the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Low-intensity pulsed ultrasound (LIPUS, marketed in the UK as the Exogen system) for delayed non-union fracture
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC10 Interventions for non-union fracture: Low-intensity Pulsed Ultrasound (marketed in the UK as the Exogen© system) and teriparatide - Nov 2015
This procedure is not routinely funded and prior approval is always required from the IF service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must also be provided. If there is an exceptional health need, please complete fully the following form:
General Funding Form
and email the form to the IFR service at Bucks.IFRrequests@nhs.net for consideration.
Lower Urinary Tract Symptoms - Highly specialist adult urinary and gynaecological surgery
NHS England
For further information contact NHS England
Lower Urinary Tract Symptoms in Men
If the patient meets the criteria direct referral into secondary care is appropriate. Please complete the following form:
GP Referral -LUTS in Men referral proforma for GPs
Consultant Referral -LUTS in Men referral proforma for Specialists
Patient leafletLower Urinary Tract Symptoms in Men
Male Circumcision and revision surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC63 Male Circumcision - October 2017
NEW
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Male Circumcision Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - August 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.
Manipulation of temporomandibular joint together with intra-articular injection of steroids under general anaesthesia
Procedure Not Routinely Funded
This procedure in not routinely funded.

Manipulation of the temporomandibular joint together with the intra-articular injection of steroids under general anaesthesia is not recommended as a first line treatment and should be considered as a second line treatment in exceptional circumstances.

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
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment
Melatonin treatment in children
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC54 Melatonin treatment in children - June 2017
Prior approval is not required where the patient meets the criteria in full.

This intervention will be audited as per the contract audit process.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Methylphenidate and atomoxetine in attention deficit hyperactivity disorder (ADHD) in children and adolescentsMOBBB
14 Methylphenidate and atomoxetine in Children and adolescents with ADHD - July 2010
Where the patient fully meets the criteria outlined in the policy then prior approval is not required. These cases may be audited.

If the criteria are not met but the consultant wishes to treat then prior approval will be required. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Myringotomy and Grommets for otitis media with effusion
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC20 Surgical management of otitis media with effusion in children (under the age of 12 years) - Nov 2015
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Adenoidectomy with Grommets Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.

Patient Decision Aid is available at https://www.england.nhs.uk/rightcare/shared-decision-making/ for Glue Ear.
Neurosurgery for cerebral metastasesNational Policy
NHS England
Stereotactic radiosurgery - radiotherapy for cerebral metastases - April 2013
For further information contact NHS England
NHS prescribing following private consultationThames Valley Priorities Committee Commissioning Policy Statement
TVPC36 NHS Prescribing following private consultation - August 2016
NICE 'Do Not Do' recommendationsThames Valley Priorities Committee Commissioning Policy Statement
TVPC66 NICE identified interventions which should be discontinued or not used routinely due to lack of evidence of benefit - NICE 'Do Not Do' recommendations - March 2018
NEW
NICE ‘Do Not Do’ recommendations and the use of any intervention included in the NICE Savings and Productivity database as ‘Do Not Do’ is not normally funded. Exceptions to this may be stated in individual TVPC commissioning policy statements.
Non pharmacological services for dementia patient
Procedure Not Routinely Funded
MOBBB 63
63 Non-pharmacological services for dementia patients
Outside the normal pathway 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 also be provided. Please complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - June 2017
If the GP / Clinician wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing 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 referral triage service at Bucks.IFRrequests@nhs.net.

Consultants must ensure that funding is in place prior to treatment.
Orthodontics
NHS EnglandFor further information contact NHS England
Orthognathic surgeryNHS England
Interim Clinical Commissioning Policy: Orthognathic surgery - November 2013
For further information contact NHS England
Overactive Bladder
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Nov 2015
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the form/letters to the referral triage service Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Patella resurfacing as part of total knee replacement (TKR)
Procedure Not Routinely Funded
Buckinghamshire Clinical Commissioning Groups Policy Statement
Buckinghamshire CCGs policy patella resurfacing as part of total knee replacement (TKR) - October 2016
This procedure in not routinely funded and prior approval is always required from the IFR service prior referral and treatment in secondary care.

It is expected that these patients will have been referred, assessed and treated for their painful knee by the local MusIC service. Therefore funding applications must be sent in by a Consultant.

If a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicates the exceptional health need and how the policy criteria are met.

Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.
Consultants must ensure that funding is in place prior to treatment.
Pectus anomaly surgery - pectus excavatum, pectus carinatum and pectus arcuatum
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC26 Pectus anomaly surgery - Nov 2015
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 also be provided. If there is exceptional health need and the patient meets the criteria for consideration, please complete fully the following:
Aesthetic/Cosmetic Surgery Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the criteria for consideration have been met.
Please email the completed form to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Penile Rehabilitation following prostate surgery
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC40 Penile Rehabilitation following prostate surgery - August 2016
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 following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Percutaneous pulmonary valve implantationNHS England
For further information contact NHS England
Pharmacological treatments for the secondary prevention of osteoporotic fragility fractures in menMOBBB
82 Pharmacological treatments for the secondary prevention of osteoporotic fragility fractures in men - Sept 2012
Where the patient fully meets the criteria outlined in the policy then prior approval is not required. These cases may be audited.

If the criteria are not met but the consultant wishes to treat then prior approval will be required. If there is exceptional health need please complete fully the following form:
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Photodynamic Therapy for Age-related Macular DegnerationBMKPC
33 Photodynamic therapy (PDT) for age-related macular degeneration - July 2006
Polysomnography in the investigation of children with sleep-related disorders
NHS England


For further information contact NHS England
Preimplant genetic diagnosis (PGD)
National Policy
NHS England
Pre-implantation Genetic Diagnosis(PGD)

For further information contact NHS England
Primary Hip Joint Replacement
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC49 Patients with osteoarthritis (OA); primary hip and knee replacement - May 2017 updated Oct 2018
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk/

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Primary Hip and Knee Replacement Form
or providing detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Patient Decision Aid is available at:
https://www.england.nhs.uk/rightcare/useful-links/shared-decision-making/

Consultants must ensure that funding is in place prior to treatment.
Primary Knee Joint Replacement
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC49 Patients with osteoarthritis (OA); primary hip and knee replacement - May 2017 updated Oct 2018
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk/

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Primary Hip and Knee Replacement Form
or providing detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Patient Decision Aid is available at:
https://www.england.nhs.uk/rightcare/useful-links/shared-decision-making/

Consultants must ensure that funding is in place prior to treatment.
Radiofrequency Ablation and Cryotherapy for Renal TumoursNHS England
For 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 - June 2017
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly state the health need and how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - June 2017
This procedure is not routinely funded.

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly state the exceptional health need and how the policy criteria are met.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Research trials and NHS Funding
- Excess treatment costs
- Post-trial treatments
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC38 Research trials and NHS funding - Excess treatment costs - post-trial treatments - August 2016
These are not routinely funded and prior approval must always be obtained
Reversal of Female Sterilisation
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC69 Reversal of female sterilisation and reversal of male sterilisation (vasectomy) - March 2018
NEW
Reversal of sterilisation is not normally funded. If there are exceptional circumstances these must be clearly detailed when applying for consideration.
Please email the request to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Reversal of Male Sterilisation (vasetcomy)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC69 Reversal of female sterilisation and reversal of male sterilisation (vasectomy) - March 2018
NEW
Reversal of sterilisation is not normally funded. If there are exceptional circumstances these must be clearly detailed when applying for consideration.
Please email request to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Robotic-assisted laparoscopic radical prostatectomy
NHS England
For further information contact NHS England
Sacral Nerve Stimulation in faecal incontinence
National Policy
NHS England
Sacral nerve stimulation SNS for faecal incontinence in Adults
For further information contact NHS England
Selective Dorsal Rhizotomy (SDR)National Policy
NHS England
Selective dorsal rhizotomy
For further information contact NHS England
Sequential Cochlear implants in profoundly deaf children
NHS England
For further information contact NHS England
Serum P1NP measurement in the management of osteoporosis
Procedure Not Routinely Funded
BMKPC
69 Serum P1NP measurement in the management of osteoporosis - February 2008
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - August 2016
Weight Management
Tier 3

For Tier 3 all Buckinghamshire CCG patients should be referred by their GP in the first instance to Weigh Forward Bucks (WFB) at enquiries@oxfordhealth.nhs.uk

In exceptional circumstances where referral to another provider is required, prior approval must be obtained from the IFR service.
Please fully complete the following:
Weight Management Form
and email it with any supporting information to the IFR service at Bucks.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 to their GP for onward consideration for Bariatric Surgery at Tier 4.
Some Tier 3/4 providers are listed below.
Tier 4 - Complex and Specialised Obesity Surgery

Tier 3 providers include:
Luton & Dunstable University Hospitals
Patient Leaflet The Weigh to go
Royal Berkshire NHS Foundation Trust
Patient Leaflet What to expect in a weight management clinic
Oxford Health NHS Foundation Trust
Patient Leaflet Weight Forward
Ashford & St Peter's Hospitals
Patient Leaflet Frequently asked questions Tier 3

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 4 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 - August 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 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 to their GP for onward consideration for Bariatric Surgery at Tier 4.
Some Tier 3/4 providers are listed below.
Tier 4 - Complex and Specialised Obesity Surgery

Tier 3 providers include:
Luton & Dunstable University Hospitals
Patient Leaflet The Weigh to go
Royal Berkshire NHS Foundation Trust
Patient Leaflet What to expect in a weight management clinic
Oxford Health NHS Foundation Trust
Patient Leaflet Weight Forward
Ashford & St Peter's Hospitals
Patient Leaflet Frequently asked questions Tier 3

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.
Bariatric Surgery - Tier 4
Email the completed form with any supporting documents to Bucks.IFRrequests@nhs.net for consideration.
Short burst oxygen therapy for the relief of breathlessness
Procedure Funded and Subject to Audit
BMKPC 77
77 Short Burst Oxygen Treatment
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).
Please email the completed form/letters to the referral service at Bucks.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 following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Sialorrhoea (Severe Drooling)
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC12 Botulinum Toxin A - Nov 2015
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 also be provided. Please fully complete the following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria is met.
Please email the completed form/ letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Snoring and Obstructive Sleep Apnoea / Hypopnoea Syndrome (OSAHS) in adults
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC61 Snoring and Obstructive Sleep Apnoea / Hypopnoea Syndrome (OSAHS) in adults - July 2017
NEW
Prior to referral and treatment please check with our referral triage service that the patient is eligible by by fully completing the following:
Snoring and OSAHS Form - Adult
or providing detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.

Link to STOP-Bang Questionnaire http://www.stopbang.ca/osa/screening.php
Spinal Cord Stimulation for ischaemic pain
NHS England
For further information contact NHS England
Spinal Cord Stimulation for neuropathic pain
NHS England
For further information contact NHS England
Spinal decompression for sciatica (including laminectomy, undercutting facetectomy and disectomy)
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - June 2017
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly state the health need and how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - June 2017
This procedure is not routinely funded.

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.
Spinal injections for managing low back pain including: facet joint, medial branch blocks, intradiscal injections, prolotherapy (proliferation therapy or regenerative 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 - June 2017
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 also be provided. Please fully complete the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - June 2017
This procedure is not routinely funded in secondary care.

In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must they apply for prior approval by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - June 2017
This is a procedure is not routinely funded and prior approval is always required from the IFR service. If there is exceptional health need please fully complete the following and indicate the exceptional health need.

If the GP / Clinician wishes to treat, and there is a strong case on the grounds of exceptional health need, 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 and the exceptional health need.

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

Consultants must ensure that funding is in place prior to treatment.
Subacromial decompression for shoulder impingement
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC50 Subacromial decompression for shoulder impingement - Updated March 2018
NEW
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Subacromial Decompression of the Shoulder Form
or provide detailed clinic letters which clearly state the exceptional health need and how the policy criteria are met.

This is not required in the case of RED FLAG symptoms as described on the policy.

Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Surgery in the management of chronic rhinosinusitis(CRS) and nasal polyposis(NP)
Procedure Funded Subject to Audit
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC21 Rhinosinusitis - Nov 2015
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 criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Surgical techniques for the treatment of oesophagael stricture
Procedure Not Routinely Funded
BMPKC 63
63 Surgical techniques for the treatment of oesophageal stricture
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 following:
General Funding Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Temporomandibular Joint Replacement
NHS EnglandFor further information contact NHS England
Terbinafine (and other antifungal prepartaions) for fungal infections
Procedure Not Routinely Funded
BMKPC 2
2 Terbinafine (& other antifungal preparations) for Fungal Infections - October 2004
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Testosterone Patch for Female Hypoactive Sexual Desire Disorder (HSDD)
Procedure Not Routinely Funded
BMKPC
59 Testosterone Patch (Intrinsa®) for Female Hypoactive Sexual Desire Disorder - December 2007
This is not routinely funded.

For these requests a strong case on grounds of exceptional health need must be provided. If there is exceptional health need please complete fully the following form :
Exceptional Circumstances Submission Form
Please email the completed application to Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Tonsillectomy
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC22 Tonsillectomy for surgical management of recurrent tonsillitis and obstructive sleep apnoea in children and adults - Nov 2015
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Tonsillectomy Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Transcatheter Aortic Valve implantation for aortic stenosis
National Policy
NHS England
Transcatheter Aortic Valve Implantation (TAVI) for Aortic Stenosis
For further information contact NHS England
Transforaminal Epidural Injections for Sciatica - Diagnostic
Procedure Not Routinely Funded
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - June 2017
This procedure is not routinely funded and prior approval is always required from the IFR service before referral and treatment.
In the first instance GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must apply for prior approval by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly indicate the exceptional health need.
Please email the completed form/letters to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Transforaminal Epidural Injections for Sciatica - Therapeutic
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC52 Management of low back pain and sciatica - June 2017
In the first instance GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wishes to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Low Back Pain and Sciatica Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Trigger Finger Surgery
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC23 Trigger finger - Nov 2015
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

If the MusIC service wish to refer to secondary care, or if a Consultant wishes to treat, they must check with our referral triage service that the patient is eligible by fully completing the following:
Trigger Finger Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
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 - Feb 2016
In the first instance, GP's refer to the local MusIC service for assessment and treatment http://www.buckinghamshire-music.nhs.uk

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

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Varicose Veins
Procedure that requires Prior Approval
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC1 policy recommendation interventional procedures for Varicose Veins - October 2014
Prior to referral and treatment please check with our referral triage service that the patient is eligible by fully completing the following:
Varicose Veins Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Vasectomy - Male Sterilisation
Procedure Not Routinely Funded
Primary Care Referral
Thames Valley Priorities Committee Commissioning Policy Statement
TVPC4 Policy Recommendation Male sterilisation - Vasectomy Services - May 2014
Please refer your patient for local anaesthetic vasectomy in primary care to Thames Valley Vasectomy Services. Please complete the following form and send it directly to Thames Valley Vasectomy Services tvvs.admin@nhs.net for consideration.

Vasectomy referral form - Word Format
Vasectomy referral form - EWDT

This procedure is not routinely funded in secondary care. For these cases a strong case on grounds of exceptional helath need must be provided. Prior to treatment or to referral into secondary care for vasectomy please check with our referral triage service that the patient is eligible.

If treatment in secondary care is required please provide detailed clinic letters which clearly indicate how the policy criteria are met and why the patient cannot be treated within primary care.
Please email the letter to the referral triage service at Bucks.IFRrequests@nhs.net for consideration.

Vasectomy reversal is not routinely funded and prior approval is always required from the IFR service providing a strong case on the grounds of exceptional health.
Please email the letter to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Vertebroplasty and Kyphoplasty NICE 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 following
Exceptional Circumstances Submission Form
or provide detailed clinic letters which clearly indicate the exceptional health need and how the policy criteria are met.
Please email the completed form/letter to the IFR service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.
Verteporfin and photodynamic therapy in Chronic Central Serous Chorioretinopathy and Idiopathic Polypoidal Choroidal Vasculopathy Thames Valley Priorities Committee Commissioning Policy Statement
TVPC42 Verteporfin and photodynamic therapy in Chronic Central Serous Chorioretinopathy and Idiopathic Polypoidal Choroidal Vasculopathy - May 2017

Prior approval is not required where the patient meets the criteria in full.

If the criteria are not fully met, prior to referral and treatment, please check with our referral triage service that the patient is eligible by fully completing the following:
General Funding Form
or provide detailed clinic letters which clearly indicate how the policy criteria are met.
Please email the completed form/letters to the referral service at Bucks.IFRrequests@nhs.net for consideration.

Consultants must ensure that funding is in place prior to treatment.

 

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