FJI & MBB CHECKLIST Continued

FJI & MBB CHECKLIST Continued:

Procedure that requires Prior Approval

Application Form: Facet Joint InjectionsMedial Branch Blocks

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
In the first instance GP’s should refer to the Bedfordshire MSK service for assessment and treatment.
Prior approval is required for this treatment prior to referral or treatment in secondary care. All patients should have access to high quality conservative management before surgery is considered.
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:
Please note that unless 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.
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 this form in full:

Part 1: Which type of injection are you requesting?

/ Facet Joint? / YES NO / Medial Branch Block? / YES NO
a)Diagnostic? / YES NO / OR Therapeutic? / YES NO
FOR ALL PATIENTS – PLEASE PROVIDE THE FOLLOWING: Please complete ALL sections in full

Details of historical pain: Please note the Panel will only consider your request for Facet Joint Injections or Medial Branch Blocks if the patient has had documented pain in the long-term, i.e. one year or over.

a)Cause of Pain
b)Type of Pain
c)Duration of Pain
d)Recent Average Pain Score(s) over the latest 3 monthswith all dates / (NB: Pain scores must be via McGill Pain Questionnaire, or VAS)
e)What non-drug treatments & measures which have been tried, (please include all conservative measures)?
f)Has this patient received any pain treatment privately? / YES NO
If YES, please indicate which treatments have been treated privately?

Please provide patients
Body Mass Index (BMI)
Weight
Height

/ Body Mass Index (BMI)
Weight
Height

Is the patient a non-smoker?

/ YES NO

Does the patient require intra-articular injections or branch blocks for the management of somatic or non-radicular pain of lumbar origin?

Please provide details
/ YES NO

Has the patient had a diagnosis confirmed via a previous a controlled diagnostic local anaesthetic block?
If ‘Yes’ please give details:

/ YES NO
Does the patient have well documented pain significantly affecting the activities of daily living?
Full details must be given: / YES NO
Has the patient tried all conservative management (bed rest, exercise, pharmacotherapy including analgesia and muscle relaxants) for at least 3 months?
Please provide details / YES NO
Has the patient been through or is part of a comprehensive pain management programme?
Please give full details: / YES NO
What drugs have been tried for this condition?
Drug / Dose / Date Started (approx) / Date Stopped (approx) / Outcome Reason for Stopping/ Continuing –(e.g. state the side effect if it did not work, or reason for continuing)
Part 2: For patients who have already received previous Facet Joint Injection & Medial Branch Blocks:
Please confirmwhether this patient has received previous injections/ blocks previously? / YES(please provide details) / NO(go to PART 3)
Date of most recent Facet Joint Injection (FJI) or Medial Branch Block / DATE:
Number of previous injections/ blocks and over what period of time
Anatomical site of previous injections/blocks
Details of the extent of the health benefit received from injections/ blocks, and duration of relief:
If funding is not approved what is the possible alternative treatment?
Why do you think this patient should be an exception to current policy or considered to have an exceptional health need for the intervention requested? (please see footnote for definition)

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:

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.

Please email the completed form to for consideration.

South, Central and West Commissioning Support Unit October 2015