Excluded: Procedure not routinely funded
Application form: Breast Surgery – General (Augmentation, Asymmetry, Mastopexy)
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. An exception may be made if the patient meets the criteria below and the exceptionality is clearly
demonstrated on the second page. Cosmetic breast surgery will not be funded for patients under the age of 18.
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. Does the patient have a Body Mass Index (BMI) of 27 (Female) /
YES
NO
25 (Male) or less for at least 2 years before surgery?
Please state the patient’s
BMI:
a) BMI
Height:
b) Height
c) Weight
Weight:
d) Does the patient have a waist to hip ratio of 0.85 (Female) or
YES
NO
2. Is the patient a non-smoker?
YES
NO
3. Has the patient maintained their BMI for at least 2 years?
YES
NO
less?
South, Central and West Commissioning Support Unit November 2015
PLEASE TURN OVER
4. Please provide photographs to support this patient’s case.
Cases will not be considered without photographs.
YES
5. Please state the patient’s cup sizes and for Male patient’s please
state volume.
Right
6. Is there evidence of amastia (Absence of breast tissue, nipple
and areola)?
YES
NO
7. Does the patient have a congenital condition causing the absence
of breast tissue?
Please provide details.
YES
NO
8. Is there compelling evidence of psychological distress, social
distress, or adverse physical health effects on this patient?
(Please see footnote). List of medication required plus any
additional reports.
If YES please provide an explanation
YES
NO
9. Is there a reason to believe that corrective surgery will lead to an
improvement in health status for the patient? (Please see
footnote).
If YES please provide an explanation.
YES
NO
NO
Left
10. Please give all details of all treatments already received for the same condition?
11. 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 judgements (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