Excluded: Procedure not routinely funded
Application form: - Breast Reduction Surgery – Female
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. / ☐ /
Please note that Aesthetic Breast Surgery is a Procedure Not Routinely Funded. There is no evidence that aesthetic breast surgery will resolve psychological symptoms only which arise from the size and/or shape of the breast.
Please note that unless the patient fully meets the criteria and there are exceptional health needs clearly demonstrated in the form which are deemed acceptable by the panel, it is unlikely that funding will be approved.
Note: Action should be taken before making an application and evidence provided to demonstrate that symptoms are not relieved by wearing a brassiere fitted by a trained bra fitter and that if procedure is indicated for back pain there should be documented evidence of 2 years conservative management.
This form is to be completed by the GP when applying for funding for individual patients for clinical procedures which require Prior Approval or Procedures Not Routinely Funded.
Email the completed form and papers to the IFR service at: 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- Does the patient have a Body Mass Index (BMI) of 26 or less for at least 2 years?
b)Height
c)Weight.
d) Does the patient have a waist to hip ratio of 0.85 or less? / YES☐NO☐
BMI:
Height:
Weight:
YES☐NO☐
- Is the patient a non-smoker?
- Has the patient maintained their BMI for at least 9 months?
- Does the patient have a bra cup size of greater than GG?
- Has the patient been for a professional bra fitting?
- Does the patient have documented pain in the shoulders, neck, back and /or arms? The pain should be long-standing and of increasing intensity.
- Does the patient have significant back pain which has not responded to at least 2 years of documented conservative management?
- Does the patient have shoulder grooving from bra straps?
- Does the patient have ulceration of the skin of the shoulder?
- Does the patient have Intertrigo between the breasts and the chest wall?
- Does the patient suffer from Lordotic posture (curvature of the spine)?
- Does the patient suffer from Ulnar pain from thoracic nerve compression?
- Exceptional health1,2 need:
SIGNATURE OF CLINICIAN …………………………………………………………….DATE: …………………………………………………..
1 Management of Psychological Issues: The NICE clinical guidance on Body Dysmorphic Disorder (BDD) (Obsessive Compulsive Disorder, Clinical Guidance 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 31: Obsessive Compulsive Disorder and Body Dysmorphic Disorder. Full guidance 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 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.
2 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.
South, Central and West Commissioning Support Unit May 2018 TVPC16 BE