Procedure that requires prior approval
Application form: - Adhesive Capsulitis (Frozen Shoulder)
GP Name and Surgery
Patients 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. / ☐ /
Prior approval is not required for the following Red flag symptoms:
Emergency referral - same day:
-Acutely painful red warm joint– e.g. suspected infected joint.
-Trauma leading to loss of rotation and abnormal shape - unreduced shoulder dislocation.
Urgent referral (<2/52) to secondary care:
-Shoulder mass or swelling - suspected malignancy or tumour
-Sudden loss of ability to actively raise the arm (with or without trauma) - acute cuff tear.
-New symptoms of inflammation in several joints – oligo or poly-arthritis or systemic inflammatory joint disease (rheumatology referral).
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service:or consideration.
The policy statements are available at
Clinical Criteria required for consideration of treatment / Please Tick
- Please confirm the following:
AND The patient had had symptoms for more than 3 months that have been unresponsive to all of the following:
-Analgesics / nonsteroidal anti-inflammatory drugs (NSAIDSs)
-Physiotherapy for subsequent domestic exercise programme
-Corticosteroid injection with supervised physiotherapy / manual therapy
Please provide specific clinical evidence in support of the above / YES☐NO☐
- Consultant to confirm which intervention is to be undertaken
☐Manipulation under anaesthesia as the surgeon considers this to be the only option and benefits of the procedure outweigh the risks. The patient has been informed of the associated risks which include humerus fracture.
☐Arthroscopic capsular release as symptoms have been present for 6 months and unresponsive to other appropriate interventions.
- Patient’s Body Mass Index:
Height / cm
Weight / kg
- Is the patient a non-smoker?
South, Central and West Commissioning Support Unit April 2018 TVPC74 BU