Excluded: Procedure not routinely funded

Application form: - Breast Surgery – General (including Augmentation, AsymmetryMastopexy and other breast surgery not covered by specific forms) (Policy 2)

Name of Referring Clinician
GP Name and Surgery
Patient NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? / Yes ☐No ☐
Is this a patient/guardian led application? / Yes ☐No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐ /
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐ /
Routine: Decision needed in 4 to 6 weeks. / ☐ /
This form covers general breast surgery and includes but is not limited to augmentation, asymmetry and mastopexy. Please use alternative form for breast reduction surgery.
Please note purely aesthetic or cosmetic breast surgery is not normally funded.
Breast augmentation for small breasts and augmentation or corrective surgery for asymmetry are considered low priority and therefore not generally funded unless there is congenital absence.
Where breast asymmetry is requested, evidence that the breasts are greater than 3 full cup size difference is required for consideration.
Aesthetic or cosmetic surgery is not generally considered for funding in those aged 18 years or under.
Mastopexy (breast lift) is not funded.
Email the completed form to the IFR service:or consideration.
The policy statements are available at

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

Clinical Criteria required for consideration of treatment / Please Tick
  1. Is the patient over 18 years of age?
/ YES☐NO☐
  1. What is the procedure and basis of application?
☐Augmentation due to congenital absence of breast tissue, nipple and areola
☐Breast asymmetry where there is evidence of at least 3 cup size difference
☐Significant breast asymmetry as a result of Poland syndrome
☐Mastopexy
Please provide clinical evidence:
  1. Please state the patient’s bra and cup sizes:
Bra Size / Right cup size / Left cup size
  1. Photographic evidence although not essential, will assist in assessing this case and support application.
The IFR service will accept photographic evidence from either the clinician or direct from the patient. Please attach good quality photographic evidence to the request.
  1. Please describe the patient’s symptoms which are significantly affecting their activities of daily living:

  1. Has the patient had any previous related surgery?
Please provide details including whether NHS or privately funded:
  1. *Exceptional health need:
Please provide details why this patient should be an exception to the current policy or considered to have an exceptional health need for the intervention requested. Please attach any relevant letter or reports to the application.
  1. Body Mass Index (BMI)
Please provide current BMI
BMI / kg/m2
Height / cm
Weight / kg
  1. Is the patient a non-smoker?
/ YES☐NO☐

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

Please email the completed form to for consideration.

*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:

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

and

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

However:

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

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

•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.

Management of Psychological Issues: The NICE clinical guideline on BDD(obsessive compulsive disorder; clinical guideline 31; National Institute for Health and Clinical Excellence) states that for people known to be at higher risk of BDD or people with mild disfigurements or blemishes who are seeking a cosmetic procedure, ALL healthcare professionals should routinely consider and explore the possibility of BDD.

Therefore clinicians seeing a patient who requests cosmetic surgery should perform a BDD triage as per NICE guidance (Clinical Guideline 31: Obsessive compulsive disorder and body dysmorphic disorder. Full guideline section 10.4.2.2; page 230) and those with suspected or diagnosed BDD seeking cosmetic surgery or dermatological treatment should be assessed by a mental health professional with specific expertise in the management of BDD (section 10.4.2.3).

Patients’ whose desire for surgery reflects serious psychopathological disorders (such as Body Dysmorphic Disorder (BDD), or irredeemable relationship problems would not normally be suitable for surgery but should receive appropriate alternative treatment and support.

South, Central and West Commissioning Support Unit January 2018 2BD