Breast Enlargement 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 Commissioner will only routinely fund breast enlargement (augmentation mammoplasty) surgery if one of the following criteria is met: Developmental failure resulting in unilateral or bilateral absence of breast tissue/asymmetry e.g. Poland Syndrome/ Tuberous Breast Deformity To correct breast asymmetry due to trauma or as a result of surgery (mastectomy or lumpectomy) that results in a significant deformity. In all other circumstances, The Commissioner will only fund breast augmentation surgery to correct breast asymmetry when ALL the following criteria are met: Sexual maturation has been reached. BMI as measured by the NHS is between 18 and 25 and has been within this range for 1 year as measured and recorded by the NHS Confirmed non-smoker and/or documented abstinence prior to procedure Asymmetry equal to, or greater, than 30% difference in volume between the breasts as measured by 3D body scan to assess breast volume* 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
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Breast Enlargement
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 Commissioner will only routinely fund breast enlargement (augmentation mammoplasty) surgery if one of the following criteria is met:
Developmental failure resulting in unilateral or bilateral absence of breast tissue/asymmetry e.g. Poland Syndrome/ Tuberous Breast Deformity
To correct breast asymmetry due to trauma or as a result of surgery (mastectomy or lumpectomy) that results in a significant deformity.
In all other circumstances, The Commissioner will only fund breast augmentation surgery to correct breast asymmetry when ALL the following criteria are met:
Sexual maturation has been reached.
BMI as measured by the NHS is between 18 and 25 and has been within this range for 1 year as measured and recorded by the NHS
Confirmed non-smoker and/or documented abstinence prior to procedure
Asymmetry equal to, or greater, than 30% difference in volume between the breasts as measured by 3D body scan to assess breast volume*
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
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