Procedure That Requires Prior Approval

Procedure that requires Prior Approval

Application Form: Cholecystectomy

Name of GP/ Consultant requesting funding
Practice Name/ Trust of applicant
Contact telephone number
Contact NHS.Net email address
Patients NHS Number
Consultants name (if known)
For onward referral
Hospital/ NHS Trust name (if known)
For onward referral
This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical procedures which require Prior Approval or Procedures Not Routinely Funded.
Email the completed document and papers to the IFR service at:
Patient Consent: By submitting this request you are confirming that you have fully explained to the patient the proposed treatment and they have consented to you raising this request on their behalf.
Is the patient aware of this referral and the contents of this form and supporting documents? / YES / NO
I confirm that the patient consents to the CCG IFR Team accessing personal clinical information about them that is held by IFR staff to enable full consideration of this funding request? / YES / NO

Please complete the following sections in full. Incomplete applications will not be considered and will be returned.

1.  Clinical Criteria required for consideration for treatment / Please tick and add details and dates where requested
1.  Does the patient have a diagnosis including symptomatic calculus of cholecystitis/ cholangitis/ biliary colic/ impacted gallstone or gallstone pancreatitis?
If ‘Yes’ full details are needed: / YES NO
2.  Does the patient have silent asymptomatic gallstones?
If ‘Yes’ please confirm one of the following:
a) Where there is clear evidence of patients being at risk of Gallbladder Carcinoma.
b) With family history of carcinoma gallbladder
c)  With a single gallstone of > 3cm in size
d)  With a Porcelain gall bladder
e)  With gallbladder polyps >10mm in size
Please give full details: / YES NO
a, b, c or d?
3.  With Sickle cell disease and other chronic haemolytic diseases
Please give full details: / YES NO
4.  Immunocompromised patient and transplant recipient patient
Please give full details: / YES NO
5.  Is the patient undergoing abdominal surgery for other indications(e.g. cirrhosis of the liver or other Gastro-intestinal indications)
Please give full details: / YES NO
6.  Does the patient have an increased risk of developing complication (with non-functioning gall bladder, gallstones > 2cm size, choledocholithiasis and obstructive jaundice)
Please give full details: / YES NO
7.  Does the patient have complex diabetes (uncontrolled glycaemia, diabetics with co-morbidities such as heart failure, renal failure or circulatory problems)
Please give full details: / YES NO
8.  Does the patient have symptoms significantly affecting the activities of daily living?
Please give details: / YES NO
9.  Please provide patient current
a) Patient’s Body Mass Index (BMI)
b) Height
c) Weight / BMI
Height
Weigth
10. Is the patient a non-smoker? / YES NO
11. Exceptional health need of this patient, please provide full details:

SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: …………………………………………………..

Exceptional Status (what makes the individual sufficiently different from the ‘usual’ in policy terms) Central to consideration of individual requests for funding is the concept of the case being exceptional.

In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest that they are:

Ø  Significantly different to the general population of patients with the condition in question

and

Ø  likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition.

However:

Ø  The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception.

Ø  If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional.

Ø  Social value judgements (the 'worth’ of patients) are not relevant to the consideration of exceptional status but there may rarely be exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in respect of social or health related benefits for others.

Please email the completed form to for consideration.

South, Central and West Commissioning Support Unit - October 2015