APPLICATION FOR PRIOR APPROVAL FOR FUNDING
Referral For Assessment For Spinal Surgical Opinion:
Lumbar Spine-related non-acute back or leg pain
that has not responded to conservative management
STRICTLY PRIVATE AND CONFIDENTIAL
PART A: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS
PATIENT INFORMATION
Does this case need to be
reviewed urgently due to
clinical need?
If yes, please explain
(An urgent request is one which requires urgent consideration and a decision
YES because the patient faces a substantial risk of significant harm or death if a
NO
decision is not made before the next scheduled monthly meeting of the IFR
Panel. What is the window of opportunity and the timescale required for
optimum treatment?)
Name
Male
Female
Address
Post Code
Date of Birth
NHS Number
Referrer’s Details (GP/Consultant/Clinician):
Name
Address
Post Code
Telephone
Email
GP Details (if not referrer):
Name
Practice
By submitting this form you confirm that the information provided is, to the best of your knowledge, true and
complete and you confirm (unless otherwise stated in the box below) that you have:






Discussed all alternatives to this intervention with the patient.
Had a conversation with the patient about the most significant benefits and risks of this intervention.
Advised the patient that NHS Decision Making Aids are available online should the patient wish to access
them at http://sdm.rightcare.nhs.uk/pda/
Informed the patient that this intervention is only funded where criteria are met or exceptionality
demonstrated.
Checked that the patient is happy to receive postal correspondence concerning their application.
Discussed with the patient whether any additional communication requirements (e.g. different language,
format or limited capacity) are needed (please specify requirements in the box below).
Additional Information:
I understand that it is a legal requirement for fully informed consent to be obtained from the patient (or a legitimate
representative of the patient) prior to disclosure of their personal details for the purpose of a panel/IFR team to
decide whether this application will be accepted and treatment funded. By submitting this form I confirm that the
patient/representative has been informed of the details that will be shared for the aforementioned purpose and
consent has been given.
Signed Referrer:
………………………………….….…………………
Date:……………………………………..
PART B: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS
If your patient does not meet the following criteria then please ALSO fill out Part C of this form outlining
the patient’s exceptionality. If the criteria are met you only need complete Parts A and B.
NOTE: THIS POLICY DOES NOT COVER:

Acute back pain conditions due to fracture, dislocation, complications of tumour or infection
AND/OR

Nerve root or spinal compression responsible for progressive neurological deficit.
AND/OR

Spinal deformity
Criteria for Referral for Spinal Surgical Opinion on lumbar spine
related non-acute back or leg pain

Patients with evidence of nerve root involvement
1. Has the patient experienced radicular pain persisting for a minimum of 8 weeks with
evidence of nerve root involvement from patient history and examination i.e. the
pain typically spreads distally in a dermatomal distribution?
YES  NO 
AND
2. Does full, multidisciplinary clinical assessment suggest that benefits of surgical
intervention outweigh risks and are highly likely to exceed those of further
conservative management?
YES  NO 
Note: Patients with leg pain that does not feature clinical signs of nerve root
involvement i.e. no dermatomal pattern, should be managed conservatively
without referral. If central canal stenosis is suspected, please refer to section
3 below regarding diagnostic uncertainty

Patients with non-specific low back pain
Surgical opinion is not normally commissioned for patients with non-specific low back pain
i.e. without evidence of nerve root involvement or red flags.
Patients will be considered exceptions to this policy where the following NICE guidance
applies:
YES  NO 
1. Has the patient completed an optimal package of care, including a combined
physical and psychological treatment*?
YES  NO 
2. Does the patient still have severe non-specific low back pain for which they would
consider surgery?
YES  NO 
3. Would the patient being referred consider surgery having discussed the risks of
spinal fusion*?
*see policy for definition

Diagnostic uncertainty in patients with severe persistent pain
Pain that persists despite treatment should be managed in accordance with CKS guidance
on how to manage chronic back pain that persists despite treatment:
‘Recheck for red flags for serious conditions, for indicators of risk of long-term pain and
disability, and for signs and symptoms of other conditions that can cause back pain.’
A surgical opinion on diagnosis may be requested if the following criteria are met:
1. Is there severe persistent pain?
YES  NO 
AND
2. Is there diagnostic uncertainty on recheck?
YES  NO 
Please provide evidence below to support the information you have provided.
Without evidence this application will be rejected.
Supporting Information – Please provide photographs as supporting evidence.
Supporting
Information
Please document the
evidence you are
enclosing along with
any other information
that you feel is relevant
PLEASE SEND THIS FORM TO THE CCG IF THE ABOVE CRITERIA ARE FULLY MET
AND EVIDENCED. IF NOT, PLEASE GO ON TO COMPLETE PART C.
PART C: INDIVIDUAL FUNDING REQUEST
ONLY COMPLETE IF PATIENT DOES NOT MEET THE CRITERIA IN PART B
Exceptionality
Please note that not meeting the criteria is not in itself exceptional. The sections
below must be completed, clearly outlining a comprehensive and thorough case
for the exceptionality of your patient, to enable the IFR Panel to reach a funding
decision.
Explain why the
patient is significantly
different to the general
population of patients
with the condition in
question
Explain why the
patient is likely to
benefit more from the
intervention than
might normally be
expected for patients
with that condition
Brief and relevant health history, including patient’s current health status and any other co-morbidities,
health issues and current medication.
Clinical History
relevant to the case
What treatments has
the patient tried? Is
this patient unable to
tolerate the usual
care? What services
has the patient been
referred to?
The patient is welcome to provide a statement and photographs to support this application if they wish.
The completed form should be sent in confidence with any other supporting documents to:
North Somerset CCG:
Bristol CCG:
South Gloucestershire CCG:
Prior Approval Applications
Individual Funding Request Team
Individual Funding Request Team
Musculoskeletal Interface
South Plaza,
Suite 15, Corum 2
Service Clevedon Hospital, Old
Marlborough Street,
Corum Business Park,
Street, Clevedon, BS21 6BS
Bristol,
Warmley,
mskinterface@nhs.net
BS1 3NX
Bristol, BS30 8FJ
Individual Funding Applications
ifrbristol@nhs.net
ifrsglos@nhs.net
Individual Funding Request Team
Castlewood, Tickenham Road,
North Somerset, BS21 9BH
ifrnsomerset@nhs.net
In order to comply with information governance standards, emails containing identifiable patient data should only
be sent securely, i.e. from an nhs.net account
Bristol
CATEGORY
Prior Approval
VERSION
1516.1
North Somerset
CATEGORY
Prior Approval
VERSION
1516.1
South Gloucestershire
CATEGORY
Prior Approval
VERSION
1516.1