Excluded: Procedure not routinely funded
Application form: Breast Reduction Surgery – Male (Gynaecomastia)
Name of GP/Clinician requesting funding
Practice Name/Trust of applicant
Contact telephone number
Contact NHS.Net email address
Patients NHS Number
Consultants name (if known)
For onward referral
Hospital/NHS Trust name (if known)
For onward referral
Please note that Aesthetic Breast Surgery is a Procedure Not Routinely Funded. There is no evidence that
aesthetic breast surgery will resolve psychological symptoms only which arise from the size and/or shape of the
breast.
Please note that unless the patient fully meets the criteria and there are exceptional health needs clearly
demonstrated in the form which are deemed acceptable by the panel, it is unlikely that funding will be
approved.
This form is to be completed by the GP/Consultant when applying for individual patients for clinical procedures which require Prior Approval or
Procedures Not Routinely Funded.
Email the completed form and papers to the IFR service at: Bucks.IFRrequests@nhs.net for consideration.
Please note that unless there are exceptional health needs clearly demonstrated in the form which are deemed acceptable by the panel it is
unlikely that funding will be approved.
Patient Consent By submitting this request you are confirming that you have fully explained to the patient the proposed treatment and they
have consented to you raising this request on their behalf.
Is the patient aware of this referral and the contents of this form and supporting documents?
YES
NO
I confirm that the patient consents to the CCG IFR Team accessing personal clinical information about them that is
held by IFR staff to enable full consideration of this funding request?
YES
NO
Please complete the following sections in full. Incomplete applications will not be considered and will be
returned.
Clinical Criteria required for consideration for treatment
Please tick and add details where
requested
1. Confirmation of patient’s date of birth
DOB:
If the patient is below 20 years of age provide clinical evidence
that they are at least 2 years post pubertal
2. In the case on men under the age of 20 has a period of 2 years
YES
NO
been allowed for natural resolution?
3. Does the patient have a Body Mass Index (BMI) of 25 or less for
at least 2 years before surgery? Please state the patient’s
a)
b)
c)
d)
BMI
Height
Weight
Does the patient have a waist to hip ratio of 0.94 or less?
4. Is the patient a non-smoker?
South, Central and West Commissioning Support Unit November 2015
YES
NO
BMI:
Height:
Weight:
YES
NO
YES
NO
PLEASE TURN OVER
5. Has the patient maintained their BMI for at least 2 years?
YES
NO
6. Does the patient have Grade 3 and 4 Gynaecomastia on the
Rohrich classification, where at least 500g of breast tissue could
be surgically removed on each affected side, and there is
associated ptosis?
YES
NO
7. Has the any aetiology noted in the patient’s history, related to this
surgical request?
If YES please give details on the investigation, and management
and outcome.
YES
NO
8. Does the patient have any documented pain in the shoulders,
neck, back and /or arm? Is the pain long-standing and of
increasing intensity.
Please provide details
YES
NO
9. Has the patient had at least 2 years of documented conservative
management?
YES
NO
YES
NO
YES
NO
Please provide all details of what treatment plan, physio advice
and /or exercise regime that the patient has received for their
back pain
10. Does the patient suffer from Lordotic posture (curvature of the
spine)?
11. Does the patient suffer from Ulnar pain from thoracic nerve
compression?
12. Exceptional health need: Please provide details
SIGNATURE OF CLINICIAN …………………………………………………………….
DATE: …………………………………………………..
Exceptional Status (what makes the individual sufficiently different from the ‘usual’ in policy terms). Central to
consideration of individual requests for funding is the concept of the case being exceptional.
In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest
that they are:
 Significantly different to the general population of patients with the condition in question
and
 likely to gain significantly more benefit from the intervention than might be expected from the average patient
with the condition.
However:
 The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception.
 If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their
circumstances are not, by definition, exceptional.
 Social value judgments (the 'worth’ of patients) are not relevant to the consideration of exceptional status but
there may rarely be exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in
respect of social or health related benefits for others.
Please email the completed form to Bucks.IFRrequests@nhs.net for consideration.
South, Central and West Commissioning Support Unit November 2015