Biological mesh - Mid Notts Pathways€¦ · Web viewBreast reconstruction Mastectomy...
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Biological mesh 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 Use of biological mesh is only commissioned for the following indications- please indicate which applies: Hernia Primary ventral and inguinal hernia repair in non-infected fields Recurrent hernias, reinforced hernia repair Hernia prophylaxis Hernia repair in the contaminated or potentially contaminated fields (most widely used) Complex abdominal wall hernia repair Breast reconstruction Mastectomy Reconstructive surgery Pelvic organ prolapse: Pelvic organ prolapse (POP) Laparoscopic ventral mesh rectopexy (rectal prolapse) 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 Biological mesh - Mid Notts Pathways€¦ · Web viewBreast reconstruction Mastectomy...
Biological mesh
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
Use of biological mesh is only commissioned for the following indications- please indicate which applies:
HerniaPrimary ventral and inguinal hernia repair in non-infected fieldsRecurrent hernias, reinforced hernia repairHernia prophylaxisHernia repair in the contaminated or potentially contaminated fields (most widely used)Complex abdominal wall hernia repair
Breast reconstructionMastectomyReconstructive surgery
Pelvic organ prolapse:Pelvic organ prolapse (POP)Laparoscopic ventral mesh rectopexy (rectal prolapse)
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
