Prior Approval Form - Adenoidectomy

PRIOR APPROVAL FORM - ADENOIDECTOMY

How to complete:

-Add GP/Consultant details

-Add Patient details

-Tick to answer yes or no to criteria listed under the procedure being requested

-Provide supporting information to evidence assessment in the free text area or attach supporting information such as clinic letter

-Email form to RMS

PART A – MUST BE COMPLETED FOR ALL REQUESTS

Patient Information
Name:
Address: / DoB:
NHS No:
Home Tel No:
Mobile Tel No:
GP/Consultant Information
Name:
Address: / Tel No:
NHS net email address:
Requesting clinician – please confirm the following:
Patient Consent: The Patient hereby gives consent for disclosure of information relevant to their case from professionals involved and to the CCG. / Yes / No
I have informed the patient that this intervention will only be funded where the criteria are met. / Yes / No
I confirm that I have reviewed the patient against the commissioning criteria and that the information provided within this application is accurate. / Yes / No
I confirm that the patient is willing to undertake this invention if the funding request is approved. / Yes / No

PART B – ELIGIBILITY MUST BE COMPLETED FOR ALL REQUESTS

Policy Statement
Surgery for Adenoidectomy will only be funded in conjunction with Tonsillectomy OR Grommet Insertion.
An adenoidectomy as a standalone procedure has been categorised as Not Routinely Funded and will only be funded if an Individual Funding Request (IFR) application proves exceptional clinical need.
Treatments which are undertaken without approval will not be funded. A referral should only take place where the referral criteria below are fulfilled.
The following cohorts of patients are no longer suitable to be referred for treatments designated as requiring funding approval:

• Patients with a BMI of 35 or greater
• Patients who smoke who have not COMPLETED a smoking cessation course prior to referral

1. If the patient refuses to complete a smoking cessation course or has been unable to stop smoking, authorisation for the procedure can only be given by the GP as an exception to this policy having taken into account of all the circumstances and risks.

If the patient is a smoker, have they COMPLETED a smoking cessation course prior to referral? / Yes / No

1. If the patient has a BMI of 35 or greater, authorisation for the procedure can only be given by the GP as an exception to this policy having taken into account of all the circumstances and risks.

Is the patient’s BMI less than 35 / Yes / No

1. If the patient does not fit the above requirements for treatment due to exceptional circumstances, if yes, please state why:

Eligibility Criteria with Tonsillectomy
Recurrent bacterial tonsillitis, defined by:

• 7 in the past year

OR

• 5 in each 2 preceding years

OR

• 3 in each of the 3 preceding years

/ Yes / No
Peritonsillar abscess / Yes / No
Guttate psoriasis which is exacerbated by recurrent tonsillitis / Yes / No
Enlarged tonsils causing obstruction of the airway, which may be the cause of obstructive sleep apnoea / Yes / No
Eligibility Criteria with Grommet Insertion
Indicate which ear is to proposed to treat / Right / Left / Bilateral
The patient has had persistent bilateral otitis media with effusion / Yes / No
The patient has a hearing loss of at least 25 dBL [WH1]or more / Yes / No
OR The child has 3 episodes in a 12 months period of documented bilateral otitis media with effusion, with any degree of hearing loss / Yes / No
AND there is documented evidence of significant developmental, social or educational delay / Yes / No
OR The child has suffered more than 6 documented episodes of acute otitis media in 12 months. / Yes / No
OR The patient has severe retraction of the tympanic membrane, if the clinician feels this may be reversible and reversing it may help avoid erosion of the ossicular chain or the development of cholesteatoma / Yes / No

Please provide evidence below to support the information provided. Without evidence your application may be rejected. If you prefer you can attach supporting information, such as a clinic letter, rather than completing the box below.

Supporting information:

[WH1]TBC 25 or 30 dBL