Procedure that requires Prior Approval
Application Form: Cholecystectomy
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
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
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.
1. Clinical Criteria required for consideration for
treatment
1. Does the patient have a diagnosis including
symptomatic calculus of cholecystitis/ cholangitis/
biliary colic/ impacted gallstone or gallstone
pancreatitis?
Please tick and add details and dates where requested
YES
NO
YES
NO
If ‘Yes’ full details are needed:
2. Does the patient have silent asymptomatic
gallstones?
If ‘Yes’ please confirm one of the following:
a) Where there is clear evidence of patients being
at risk of Gallbladder Carcinoma.
b) With family history of carcinoma gallbladder
c) With a single gallstone of > 3cm in size
d) With a Porcelain gall bladder
e) With gallbladder polyps >10mm in size
a, b, c or d?
Please give full details:
South, Central and West Commissioning Support Unit - October 2015
PLEASE TURN OVER
3. With Sickle cell disease and other chronic
haemolytic diseases
Please give full details:
YES
NO
4. Immunocompromised patient and transplant
recipient patient
Please give full details:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
5. Is the patient undergoing abdominal surgery for
other indications(e.g. cirrhosis of the liver or other
Gastro-intestinal indications)
Please give full details:
6. Does the patient have an increased risk of
developing complication (with non-functioning gall
bladder, gallstones > 2cm size, choledocholithiasis
and obstructive jaundice)
Please give full details:
7. Does the patient have complex diabetes
(uncontrolled glycaemia, diabetics with comorbidities such as heart failure, renal failure or
circulatory problems)
Please give full details:
8. Does the patient have symptoms significantly
affecting the activities of daily living?
Please give details:
9. Please provide patient current
a) Patient’s Body Mass Index (BMI)
b) Height
c) Weight
BMI
Height
Weigth
10. Is the patient a non-smoker?
YES
NO
11. Exceptional health need of this patient, please provide full 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.
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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