1. Category: Prior Approval and Not commissioned

Prior approval from the Integrated Care Board (ICB) will be required before any prior approval treatments proceed in secondary care unless an alternative contract arrangement has been agreed with the ICB that does not necessitate the requirement of prior approval before treatment

Unless an alternative contract arrangement has been agreed with the ICB that does not necessitate the requirement of prior approval before treatment, prior approval must be sought from the ICB, prior approval forms are available from the ICB via cwicb.ardenifr@nhs.net

This policy applies to all service providers in secondary care and community services where procedures to improve aesthetic appearance are performed

Policy restriction does not apply to situations where patients require a cosmetic or reconstructive procedure to restore normal or near normal function or appearance as a direct consequence of trauma, burns, destructive surgery, NHS funded treatment, cancer treatment or a recognised congenital malformation

These cases are eligible for NHS funding as part of the treatment plan under routine commissioning arrangements and would be subject to a planned course of treatment within an agreed timescale, which may be long term in some cases

However, further revision for cosmetic improvement will not be funded

This policy applies to any and all procedures or treatments which are primarily aimed at improving aesthetic appearance (excluding the situations outlined above)

The term “cosmetic procedures” is used in this document to denote these procedures and treatments

It is important to note that this includes not only some of the procedures that may be undertaken in the specialty of plastic and reconstructive surgery, but also in other specialties (including dermatology, ENT surgery, ophthalmology, maxillofacial surgery and general surgery)

Common cosmetic procedures and treatments are listed in the table below, but this is not an exhaustive list of conditions and procedures

If there is any doubt about whether a treatment would be considered as cosmetic, advice should be sought from the ICB via cwicb.ardenifr@nhs.net

General practitioners must note the provisions of this policy before making a referral to secondary care or Community services (where applicable) for a cosmetic procedure

Patients who do not meet the eligibility criteria set out in this policy should not be referred.

However, on occasions general practitioners may not be best placed to decide whether or not the policy criteria apply in a particular case and thus may refer to secondary care or Community services (where applicable) for an opinion only

In cases of doubt, prior approval should be obtained from the ICB before referral

Although the policy does not apply to treatments that can be prescribed in primary care, or minor surgical procedures that can be carried out entirely within a general practice, GPs may wish to base their decision to treat on the principles and criteria contained within this policy

Patients who do not meet the eligibility criteria set out in this policy will not be offered NHS funding

Where the treating NHS clinician (General Practitioner or Consultant) believes that the individual clinical circumstance of their patient makes them an exception to the policy, and merits funding on an exceptional ground, the NHS treating clinician will need to make an application in accordance with the ICB’s Individual Funding Request (IFR) policy

As such, IFR applications will need to demonstrate that there are unlikely to be other ‘similar patients’ in the population for which the ICB is responsible. (ie. demonstrate that the patient’s clinical presentation is significantly different to the general population of other patients with the same presenting medical condition at the same stage of progression (“the cohort patients”), and/or is likely to gain significantly more benefit from the intervention than might be expected for the average patient with the same clinical condition at the same stage of progression)

It should be noted that the vast majority of applications for individual case funding for cosmetic procedures suggest that there are various psychological disorders and psychosocial factors associated with the physical problem (e.g. depression, anxiety, feelings of revulsion regarding the physical problem, social withdrawal, problems with sexual relationships and perceptions of teasing/bullying/ostracising by others because of the physical problem)

The co-existence of these factors cannot, therefore, in itself be considered as ‘exceptional’ in these cases

To confirm; the ICB will not support cosmetic surgery to elevate psychological symptoms and the co-existence of these factors are not considered as ‘exceptional’ in these cases. When there is particular concern over psychological well-being, patients should be referred to the appropriate service for appropriate psychological assessment, treatment and/or support

Obtaining a psychiatric opinion that the patient’s cosmetic problem is contributing to their psychological state does not necessarily indicate that the patient is exceptional and will not guarantee that an IFR will be agreed. Therefore, psychiatric referral should not be made solely to support an IFR

Where there are significant concerns regarding a child’s psychological well-being, a referral should be made to the appropriate service for psychological assessment, intervention, and/or support

In cases where children are reported to be experiencing bullying, teasing, or social exclusion due to variations in appearance—whether this occurs in school, online, within the community, or in other social settings—there is an expectation that these concerns are addressed robustly and in collaboration with relevant agencies, including educational providers, safeguarding teams, and mental health services

2. Background

Treatments designed to improve aesthetic appearance are often carried out to change a person’s physical appearance for aesthetic rather than medical reasons in order to achieve what they perceive to be a more desirable look

Compared to healthcare interventions that improve health and that save lives, the Coventry and Warwickshire Integrated Care Board (“the ICB”) consider funding of treatments designed to improve aesthetic appearance to be of low priority in allocating limited NHS resources

However, the ICB recognises that, in certain cases, a cosmetic procedure may be justified to alleviate or improve a physical deformity that most people would recognise as being severely abnormal, or to meet a clinical need other than improvement of aesthetic appearance

This policy sets out principles and examples of eligibility criteria for funding treatment in such cases

The following procedures found within this policy are based on NHS England’s Evidence-Based Interventions (EBI) programme (https://ebi.aomrc.org.uk/interventions/);

• Breast reduction (reduction mammoplasty), including:

o Female breast reduction and Gynaecomastia Surgery

o Correction of breast asymmetry

o Breast reduction for gynaecomastia

• Revision of breast augmentation
• Removal of benign skin lesions
• Chalazia Removal

Rationale

This is a planned policy revision, which aims to make the limits and eligibility criteria for NHS-funded cosmetic procedures fair, clear and explicit to the public, patients and providers

Principles

The ICB Framework for Commissioning underpins development of this policy. All decisions will be taken in the context of the overall financial position of the ICB

3. Indication

The premise of the policy is that the ICB does not routinely fund cosmetic procedures unless the eligibility criteria in section 4 are met

The responsibility for presenting the information relevant to eligibility criteria rests with the NHS clinician. The ICB, as commissioner, is ultimately responsible for assessing whether or not the eligibility criteria are in keeping with the content and the principles of the policy

4. Eligibility Criteria

Aesthetic procedures for patients who are deemed to be within the normal morphological range will be considered purely cosmetic and therefore NOT funded on the NHS

However, funding may be appropriate to alleviate or improve a physical deformity that most people would recognise as being severely abnormal

Referrals for the revision of treatments originally performed outside the NHS will NOT normally be supported and patients should be referred back to the practitioner who carried out the original procedure

However, in cases where there are significant complications following an aesthetic procedure (for example, infection), or circumstances that require the transfer of a patient to the NHS for appropriate management, the patient will be entitled to routine NHS treatment to treat that complication; but this may not be equivalent to revision of the original procedure. (An example is that complications due to removal of breast implants may be treated by removal of the implants, but the implants will not be replaced)

Patients previously treated within the NHS should be considered for revision surgery based on clinical need and priority

Surgical outcomes (e.g. wound healing, complications etc) can be adversely affected by smoking. To ensure the best outcomes, patients must have stopped smoking at least 4 weeks prior to referral for any treatments under this policy

Applications for prior approval under this policy must record smoking status. Smoking status must be validated at pre-operative appointment using an appropriate test. Support to stop smoking is available to patients through a range of NHS stop smoking services

Please see the table below for conditions covered by the Aesthetic Commissioning Policy

Attached are links to relevant GP Gateway pages

Treatment	Status	GP Gateway reference
Female breast reduction (reduction mammoplasty)	Prior approval	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Correction of female breast asymmetry	Prior approval	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Male breast reduction (gynecomastia surgery)	Not commissioned	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Female breast enlargement (augmentation mammoplasty)	Not commissioned	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Revision of female breast augmentation	Prior approval	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Breast surgery following cancer treatment relating to an unaffected breast	Commissioned in accordance with guidelines	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Breast Lift (Mastopexy)	Not commissioned	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Inverted Nipple Correction	Not commissioned	GP Gateway Breast Enlargement Reduction Revision & Gynaecomastia
Face lifts and brow lifts (rhytidectomy)	Not commissioned	GP Gateway Face Lifts, Brow Lifts & Facial Atrophy
Treatment for facial atrophy	Not commissioned	GP Gateway Face Lifts, Brow Lifts & Facial Atrophy
Surgery on the upper eyelid (upper lid blepharoplasty)	Prior approval	GP Gateway  Surgery on the upper and lower eyelid (blepharoplasty) & browlifts
Surgery on the lower eyelid (lower lid blepharoplasty)	Prior approval	GP Gateway  Surgery on the upper and lower eyelid (blepharoplasty) & browlifts
Surgery to reshape the nose (rhinoplasty)	Not commissioned	GP Gateway Rhinoplasty
Correction of prominent ears (pinnaplasty / otoplasty), including ear pinning	Not commissioned	GP Gateway Correction of prominent ears (pinnaplasty / otoplasty), including ear pinning
Correction of male pattern baldness	Not commissioned	GP Gateway Correction of Male Pattern Baldness, Correction of Hair Loss (Alopecia), Hair Transplantation
Hair transplantation	Not commissioned	GP Gateway Correction of Male Pattern Baldness, Correction of Hair Loss (Alopecia), Hair Transplantation
Correction of hair loss (alopecia)	Not commissioned	GP Gateway Correction of Male Pattern Baldness, Correction of Hair Loss (Alopecia), Hair Transplantation
Abdominoplasty and other similar procedures for removal of excess skin from arms, legs and all other parts of the body	Prior approval	GP Gateway Abdominoplasty
Diastasis of the Rectus Abdominis	Not commissioned	GP Gateway Hernia repair (adults)
Body/face contouring and tissue transfer	Not commissioned	GP Gateway Abdominoplasty and other similar procedures for removal of excess skin from arms, legs and all other parts of the body
Removal of benign skin lesions	Prior approval	GP Gateway Benign skin lesions
Surgical treatment (including laser treatment) for telangiectasia, hirsutism, keloid scarring and acne scarring, including skin resurfacing techniques for acne and other scarring conditions	Not commissioned	GP Gateway Acne vulgaris
Laser treatment of skin conditions	Prior approval	GP Gateway Laser treatments
Tattoo removal/Surgical correction of body piercings and correction of respective problems	Not commissioned	GP Gateway Tattoo Removal
Surgical treatment of pigeon chest/chest wall deformity	Not commissioned	GP Gateway Chest Wall Deformity (Pectus carinatum / Pectus excavatum)
Non acute split earlobe repair/refashioning	Not commissioned	GP Gateway Non Acute Split Earlobe Repair/refashioning
Liposuction	Not commissioned	GP Gateway Abdominoplasty
Labiaplasty	Not commissioned	GP Gateway Labiaplasty
Vaginoplasty	Not commissioned	GP Gateway Vaginoplasty & Hymenorrhaphy
Hymenorrhaphy	Not commissioned	GP Gateway Vaginoplasty & Hymenorrhaphy
Rhinophyma (bulbous, red nose)	Not commissioned	GP Gateway Rhinophyma
Benign Meibomian Cysts (Chalazion) on the Eyelid(s)	Prior approval	GP Gateway Chalazion
Genital warts	Refer to GUM	GP Gateway Coventry & Warwickshire Sexual Health Hub
Any other treatments that are aimed at improving aesthetic appearance	Not commissioned