Epidural injections (for low back pain) - Mid Notts Pathways



1148487-70226000-671830-671728002476500906780PLEASE INDICATE THE RESTRICTED PROCEDURE CRITERIA DECLARED AS MET AND RECORDED IN PATIENT NOTESNot commissioned for patients who have non-specific / axial low back pain.Not commissioned for patients with failed back pain surgery syndrome The CCGs commission epidural injections when ONE of the following criteria have been met:The patient has undergone discectomy – a single injection will be commissioned.Patient has acute (up to 12 weeks duration) and severe sciatica and is being treated as part of an integrated MSK pain management pathway Please add any additional information below00PLEASE INDICATE THE RESTRICTED PROCEDURE CRITERIA DECLARED AS MET AND RECORDED IN PATIENT NOTESNot commissioned for patients who have non-specific / axial low back pain.Not commissioned for patients with failed back pain surgery syndrome The CCGs commission epidural injections when ONE of the following criteria have been met:The patient has undergone discectomy – a single injection will be commissioned.Patient has acute (up to 12 weeks duration) and severe sciatica and is being treated as part of an integrated MSK pain management pathway Please add any additional information below-723900-731520Epidural injections (for low back pain) Submission of this form is a declaration by the clinician that this patient meets the clinical criteria set out in the Nottinghamshire 2018 Restricted Policy for the procedure indicated.ONCE THIS FORM IS FULLY COMPLETED AND EVIDENCE OF CRITERIA BEING MET IS RECORDED IN PATIENT NOTES EMAIL THIS FORM TO:MACCG.IFRteam-nottscountyccgs@Greater Notts and Mid Notts CCGs may withhold payment to Providers for procedures that do not have prior approval declarations.Retrospective audits of Declarations are performed to ensure compliance with the Policy.This form can also be used to indicate that a procedure meets the exclusion criteria of the policy.Patient DetailsName:Date of Birth:NHS No.GP Practice Clinician DetailsName:Professional Reference Number: (GMC/NMC)Date:OrganisationNUHSFHFTMSKHHGP / Other:I Confirm that the patient meets the current clinical guideline / policy for the restricted procedure as detailed in the Restricted Policy 2018I Confirm that I have explained the prior approval process to the patient ad that the patient has given consent to share their information with the commissioner00Epidural injections (for low back pain) Submission of this form is a declaration by the clinician that this patient meets the clinical criteria set out in the Nottinghamshire 2018 Restricted Policy for the procedure indicated.ONCE THIS FORM IS FULLY COMPLETED AND EVIDENCE OF CRITERIA BEING MET IS RECORDED IN PATIENT NOTES EMAIL THIS FORM TO:MACCG.IFRteam-nottscountyccgs@Greater Notts and Mid Notts CCGs may withhold payment to Providers for procedures that do not have prior approval declarations.Retrospective audits of Declarations are performed to ensure compliance with the Policy.This form can also be used to indicate that a procedure meets the exclusion criteria of the policy.Patient DetailsName:Date of Birth:NHS No.GP Practice Clinician DetailsName:Professional Reference Number: (GMC/NMC)Date:OrganisationNUHSFHFTMSKHHGP / Other:I Confirm that the patient meets the current clinical guideline / policy for the restricted procedure as detailed in the Restricted Policy 2018I Confirm that I have explained the prior approval process to the patient ad that the patient has given consent to share their information with the commissioner207264090144600020758158442960002476500-731520CLINICIANS MAY USE THIS FORM TO DECLARE THAT THE INDICATED PROCEDURE IS EXCLUDED FROM THE POLICY FOR THE FOLLOWING REASON:EmergencyReasonable suspicion of cancerIt is part of reconstruction following treatment for cancer, traumatic injury or the correction of congenital malformationNot carrying out the procedure would have an adverse effect on physical functional development of a child00CLINICIANS MAY USE THIS FORM TO DECLARE THAT THE INDICATED PROCEDURE IS EXCLUDED FROM THE POLICY FOR THE FOLLOWING REASON:EmergencyReasonable suspicion of cancerIt is part of reconstruction following treatment for cancer, traumatic injury or the correction of congenital malformationNot carrying out the procedure would have an adverse effect on physical functional development of a child ................
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