Excluded: Procedure Not Routinely Funded
FACET JOINT INJECTIONS & MEDIAL BRANCH BLOCK CHECKLIST
The South Central Priorities Committee policies were adopted by the Aylesbury Vale Clinical Commissioning Group and Chiltern
Clinical Commissioning Group on the 1st April 2013. The Priorities Committee considered the evidence for the clinical and cost
effectiveness of facet joint injections and medial branch blocks for the diagnosis and treatment of chronic low back and neck pain.
The Committee concluded that the evidence for cost effectiveness is inadequate and therefore recommends that NHS funding for
facet joint injections and medial branch blocks for diagnostic and treatment is a Procedure Not Routinely Funded / Low Priority.
The Policies for can be found at:
http://www.fundingrequests.cscsu.nhs.uk/buckinghamshire/cosmetic-other-surgeries-devices-screening-diagnostics-and-other-therapiespolicy-statements/.
Please complete the following questions and return to: Individual Funding Request (IFR) Service via email:
Bucks.IFRrequests@nhs.net
Information about the clinician who is supporting the use of facet injections
Referrer Name:
Referrer Address &
Clinic:
PATIENTS DETAILS
NHS No:
Hospital/ Ref No:
Which type of injection are you requesting?
Diagnostic:
YES
NO
Therapeutic:
YES
NO
FOR ALL PATIENTS – PLEASE PROVIDE THE FOLLOWING: Please complete ALL sections in full
PART 1: Details of historical pain: Please note the Panel will only consider your request for Facet Joint Injections if the
patient has had documented pain in the long-term, i.e. one year or over.
Cause of Pain
Type of Pain
Duration of Pain
Recent Average Pain Score(s) over the
latest month and dates
What non-drug treatments & measures which have been tried, (please include all conservative measures)?
Has this patient received any pain treatment privately?
YES
NO
If YES, please indicate which treatments have been treated privately?
South, Central and West Commissioning Support Unit - April 2015 – v3.3
PLEASE TURN OVER
FACET JOINT INJECTIONS CHECKLIST Continued:
What drugs have been tried for this condition?
Drug
Dose
Date
Started
(approx)
Date
Stopped
(approx)
Outcome & Reason for Stopping/ Continuing – (e.g. state
the side effect if it did not work, or reason for continuing)
PART 2: For patients who have already received previous Facet Joint Injections:
Please confirm whether this patient has received Facet Joint Injections previously?
Date of most recent Facet Joint Injection (FJI)
YES (please
NO (go to
provide details)
PART 3)
DATE:
Number of previous FJI injections and over what period of
time
Anatomical site of previous FJI injections
Details of the extent of the health benefit received from FJI injections, and duration of relief:
Please provide details of the Exceptional Health Need of this patient: http://www.fundingrequests.cscsu.nhs.uk/wpcontent/uploads/2013/10/Exceptional-health-need-statement-for-IFRs-27.1.15.pdf
PART 3: Exceptional health need of this patient?
PART 4: If funding is not approved what is the possible alternative treatment?
Clinician’s Signature:
South, Central and West Commissioning Support Unit – April 2015 – v3.3
Date:
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