Mansfield & Ashfield View - Carpal Tunnel Surgery€¦ · Web viewRecent wrist trauma Previous...
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Carpal Tunnel Surgery Submission of this form is a declaration by the clinician that this patient meets the clinical criteria set out in the Nottinghamshire 2018 Restricted Policy for the procedure indicated. ONCE THIS FORM IS FULLY COMPLETED AND EVIDENCE OF CRITERIA BEING MET IS RECORDED IN PATIENT NOTES EMAIL THIS FORM TO: MACCG.IFRteam- [email protected] Greater Notts and Mid Notts CCGs may withhold payment to Providers for procedures that do not have prior approval declarations. Retrospective audits of Declarations are performed to ensure compliance with the Policy. This form can also be used to indicate that a procedure meets the exclusion criteria of the policy. Patient Details Name: Date of Birth: NHS No. GP Practice Clinician Details Name: Professiona l Reference Number: (GMC/NMC) Date: Organisation NUH SFHFT MSK HH GP / Other: PLEASE INDICATE THE RESTRICTED PROCEDURE CRITERIA DECLARED AS MET AND RECORDED IN PATIENT NOTES The Surgery may be commissioned if at least ONE of the following criteria applies: The symptoms are interfering with activities of daily living AND the patient has not responded to a minimum of 6 months of conservative management, including: >8 weeks of night-time use of wrist splints Appropriate analgesia Corticosteroid injections (given at least twice prior to referral) in appropriate patients A shared decision making process / tool discussing treatment options is clearly documented Objective Neurological deficit consistent with CTS i.e. constant sensory blunting or weakness of thenar abduction (wasting or weakness of abductor pollicis brevis). Rheumatoid disease Recent wrist trauma Previous wrist surgery Asymmetry equal to, or greater, than 30% difference in volume between the breasts as measured by 3D body scan to assess breast volume* The referral must detail conservative methods tried and the length of time that each of these was carried out. Nerve conduction studies (EMG) are generally NOT needed to confirm the diagnosis. Patients with wasting of the hand muscles should be urgently referred and are outside the scope of this policy. Other indications will require Individual Funding Requests (IFR) Please add any additional information below CLINICIANS MAY USE THIS FORM TO DECLARE THAT THE INDICATED PROCEDURE IS EXCLUDED FROM THE POLICY FOR THE FOLLOWING REASON: Emergency Reasonable suspicion of cancer It is part of reconstruction following treatment for cancer, traumatic injury or the correction of congenital malformation Not carrying out the procedure would have
Transcript of Mansfield & Ashfield View - Carpal Tunnel Surgery€¦ · Web viewRecent wrist trauma Previous...
Carpal Tunnel Surgery
Submission of this form is a declaration by the clinician that this patient meets the clinical criteria set
out in the Nottinghamshire 2018 Restricted Policy for the procedure
indicated.ONCE THIS FORM IS FULLY
COMPLETED AND EVIDENCE OF CRITERIA BEING MET IS RECORDED IN PATIENT NOTES EMAIL THIS FORM TO:
Greater Notts and Mid Notts CCGs may withhold payment to Providers for
procedures that do not have prior approval declarations.
Retrospective audits of Declarations are performed to ensure compliance with the
Policy.
This form can also be used to indicate that a procedure meets the exclusion criteria of the
policy.
Patient DetailsName:Date of Birth:NHS No.GP Practice
Clinician DetailsName:Professional Reference Number: (GMC/NMC)Date:
Organisation NUH SFHFT MSK HH
GP / Other:
I Confirm that the patient meets the current clinical guideline / policy for the restricted procedure as detailed in the Restricted Policy 2018
I Confirm that I have explained the prior approval process to the patient ad that the patient has given consent to share their information with the commissioner
PLEASE INDICATE THE RESTRICTED PROCEDURE CRITERIA DECLARED AS MET AND RECORDED IN PATIENT NOTES
The Surgery may be commissioned if at least ONE of the following criteria applies: The symptoms are interfering with activities of daily
living AND the patient has not responded to a minimum of 6 months of conservative management, including:
>8 weeks of night-time use of wrist splints Appropriate analgesia Corticosteroid injections (given at least twice prior
to referral) in appropriate patients A shared decision making process / tool
discussing treatment options is clearly documented
Objective Neurological deficit consistent with CTS i.e. constant sensory blunting or weakness of thenar abduction (wasting or weakness of abductor pollicis brevis).
Rheumatoid disease
Recent wrist trauma
Previous wrist surgery
Asymmetry equal to, or greater, than 30% difference in volume between the breasts as measured by 3D body scan to assess breast volume*
The referral must detail conservative methods tried and the length of time that each of these was carried out.
Nerve conduction studies (EMG) are generally NOT needed to confirm the diagnosis.
Patients with wasting of the hand muscles should be urgently referred and are outside the scope of this policy.
Other indications will require Individual Funding Requests (IFR)
Please add any additional information below
CLINICIANS MAY USE THIS FORM TO DECLARE THAT THE INDICATED PROCEDURE IS EXCLUDED FROM THE POLICY FOR THE FOLLOWING REASON:
Emergency Reasonable suspicion of cancer It is part of reconstruction following treatment for cancer,
traumatic injury or the correction of congenital malformation Not carrying out the procedure would have an adverse
effect on physical functional development of a child
