Hip arthroscopy · Web viewTreatment of sepsis Loose bodies (radio-graphically proven) Excision of radiological proven labral tears in the absence of osteoarthritis or other pathology

Hip arthroscopy

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:

[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 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 use of hip arthroscopy for the management of Hip Impingement Syndrome or other indications is covered by a separate policy.

See East Midlands Commissioning Policy Arthroscopy of the Hip In summary, commissioned only for:

Treatment of sepsis

Loose bodies (radio-graphically proven)

Excision of radiological proven labral tears in the absence of osteoarthritis or other pathology for patients meeting the policy criteria.

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