Procedure that requires Prior Approval
Application Form: Non Specific Back Pain (Including Spinal Discectomy, Spinal Fusion,
Trigger Point & Sclerosant Injections)
There is a separate proforma for Facet Joint injections, Medial Branch Blocks and Epidural Injections
Name of GP/ Consultant 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
In the first instance GP’s should refer to the Bedfordshire MSK service for assessment and treatment.
Prior approval is required for this treatment prior to referral or treatment in secondary care. All patients should have
access to high quality conservative management before surgery is considered.
This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical
procedures which require Prior Approval or Procedures Not Routinely Funded.
Email the completed document and papers to the IFR service at: Beds.IFRrequests@nhs.net
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 this form in full
1. Part 1: Which type of treatment are you
requesting? (E.g. Spinal Fusion, Spinal
Discectomy, Trigger Point Injection etc.)
a) Diagnostic?
YES
b) Therapeutic?
NO
YES
NO
FOR ALL PATIENTS – PLEASE PROVIDE THE FOLLOWING: Please complete ALL sections in full
2. Details of historical pain: Please note the Panel will only consider your request if the patient has had
documented pain in the long-term, i.e. one year or over.
Does the patient have a confirmed diagnosis/cause for this pain?
Please give full details:
a) Type of Pain
b) Duration of Pain
South, Central and West Commissioning Support Unit
October 2015
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(NB: Pain scores must be via McGill Pain Questionnaire, or VAS)
c) Recent Average Pain Score(s) over the
latest 3 months with all dates:
d) Which non-drug treatments & measures have been tried, (please include all conservative measures)?
3. Please confirm the locations of Pain that the patient has? E.g. Thigh, foot, central etc.
Does the patient have pain significantly affecting activities of daily living?
YES
NO
Full details must be given:
Has the patient been through a comprehensive pain management
programme?
YES
NO
YES
NO
Please give full details:
e) Has this patient received any pain treatment privately?
f)
If YES, please indicate which treatments have been treated privately?
What drugs have been tried for this condition?
Drug
Dose
Date
Started
(approx)
South, Central and West Commissioning Support Unit
Date
Stopped
(approx)
Outcome & Reason for Stopping/ Continuing – (e.g. state
the side effect if it did not work, or reason for continuing)
October 2015 2
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Part 2: For patients who have already received previous treatment or surgery for this
Please confirm whether this patient has received treatment previously?
YES (please
NO (go to
provide details)
PART 3)
Please provide specific details of all interventions/treatments
Type and Number of previous interventions/treatments?
Also, please indicate over what period of time?
Anatomical site of previous interventions/treatments
:
Details of the extent of the health benefit received from previous interventions/treatments, and detail the duration of
relief this provided:
Has the patient been involved in active rehabilitation programmes
YES
NO
If yes, please provide details
Please provide the patients
Body Mass Index (BMI)
Height
Weight
Body Mass Index (BMI)
Height
Weight
Is the patient a non-smoker?
YES
NO
Why do you think this patient should be an exception to current policy or considered to have an exceptional health
need for the intervention requested? (please see footnote for definition)
If funding is not approved what is the possible alternative treatment?
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.
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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 Beds.IFRrequests@nhs.net for consideration.
South, Central and West Commissioning Support Unit
October 2015