Procedure that requires prior approvalApplication form: - Tongue Tie(Policy 57)

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. / ☐ /
Prior approval is required for infants with feeding problem who do not fully meet the funding criteria and older children and adults with speech problems.
For older children and adults with speech problems where division of the frenulum may be considered appropriate, prior approval is always required.
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.
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration.
The policy statements are available 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.

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
For Infants with feeding problems
  1. Confirmation of the date of birth of the patient

  1. Details of the breast feeding difficulties.

  1. Is this procedure to be done in an outpatient setting?
If not what are the contra indications?
/ YES ☐NO ☐
  1. Is this procedure to be done as a day-case or in-patient surgery?
Please provide details. / YES ☐NO ☐
  1. Has the patient been assessed by a health visitor or midwife with specialist expertise in breast feeding?
Please provide details. / YES ☐NO ☐
  1. 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 older children or adults with speech problems
  1. Is the patient older than 5 years old?
/ YES ☐NO ☐
  1. Please provide details of how speech is impaired and the severity of the condition
.
  1. Are the speech sounds affected consistent with tongue tie?
Please give details. / YES ☐NO ☐
  1. Has a Speech and Language Therapist assessed the patient and confirmed that:
  • It is highly likely that the speech problem is due to the tongue tie
  • The patient is unlikely to grow out of the speech problem
  • Conservative management (e.g. speech therapy is unlikely to be successful.
Please provide clinical evidence. / YES ☐NO ☐
  1. Have other causes of speech abnormalities been ruled out?
Please provide details. / YES ☐NO ☐
  1. Please provide the patient’s:
BMI / kg/m2
Height / cm
Weight / kg
  1. Is the patient a non-smoker?
/ YES ☐NO ☐
  1. Exceptional Health Need; please give details:

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.

South, Central and West Commissioning Support Unit October 2015 57BD