Snowcrystal
New Member
I'm just getting my head around the process of NHS funding for bariatric surgery. I thought I would post a copy of my PCT Exceptional Treatment Prior Approval Form for others to see and compare with their own...Mine is Lewisham...
Hope it helps others...Snowxx
Prior Approval Form - Bariatric Surgery
Please note that funding for surgery cannot be approved by the prior approval process unless the patient has a BMI of 40 kg/m2 or more, or has a BMI between 35 kg/m2 and 40 kg/m2 and other significant disease that could be improved if they lost weight (for example, type 2 diabetes or high blood pressure).
Evidence of the steps in the care pathway that the patient has undergone prior to a request for bariatric surgery are sought in this form. NICE guidance on this care pathway can be accessed at http://www.nice.org.uk/nicemedia/pdf/word/CG43NICEGuideline.doc .
Bariatric surgery is recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.
Patient Details
1. Surname ______________________ 2. Forename(s) _________________________
3 Address _____________________________________________________________
______________________________________ Post Code _______________________
4. Date of Birth ____/____/_______ 5. Patient’s BMI _________________kg/m2
6. In your view, is the patient generally fit for anaesthesia and surgery ?
Yes [ ] No [ ]
7. Is the patient committed to the need for long-term follow-up?
Yes [ ] No [ ]
8. For patients whose BMI is under 50 kg/m2, please give details of all appropriate non-surgical measures that have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months. Please include details of any referrals.
Physical Activity Date advice given _____/_____/_______
Details _____________________________________________________________
_____________________________________________________________________
Dietary Change Date advice given _____/_____/_______.
Details ______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Drug Interventions
Details of drug prescribed including name of drug(s) prescribed, date first prescribed, duration of treatment and reasons for stopping the drug (where this is relevant)
________________________________________________________________________
________________________________________________________________________
8. For patients whose BMI is between 35 and 40 kg/m2, does the patient have other significant disease that could be improved if they lost weight?
Yes [ ] No [ ]
Please give details of any such disease
_______________________________________________________________________
_______________________________________________________________________
Details of person completing this form
This form must be completed by the patient’s GP or by a hospital consultant.
Signature _________________________________ Date _____/_____/________
Name ______________________________________________GP/Consultant*
(* delete as applicable)
Address ___________________________________________________________
______________________________________________ Post Code _____/_____/_____
Telephone Number __________________________
E-mail Address ___________________________________________________________
Please complete and return the form by post to ETA Acute Commissioning Manager ETA,
Hope it helps others...Snowxx
Prior Approval Form - Bariatric Surgery
Please note that funding for surgery cannot be approved by the prior approval process unless the patient has a BMI of 40 kg/m2 or more, or has a BMI between 35 kg/m2 and 40 kg/m2 and other significant disease that could be improved if they lost weight (for example, type 2 diabetes or high blood pressure).
Evidence of the steps in the care pathway that the patient has undergone prior to a request for bariatric surgery are sought in this form. NICE guidance on this care pathway can be accessed at http://www.nice.org.uk/nicemedia/pdf/word/CG43NICEGuideline.doc .
Bariatric surgery is recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.
Patient Details
1. Surname ______________________ 2. Forename(s) _________________________
3 Address _____________________________________________________________
______________________________________ Post Code _______________________
4. Date of Birth ____/____/_______ 5. Patient’s BMI _________________kg/m2
6. In your view, is the patient generally fit for anaesthesia and surgery ?
Yes [ ] No [ ]
7. Is the patient committed to the need for long-term follow-up?
Yes [ ] No [ ]
8. For patients whose BMI is under 50 kg/m2, please give details of all appropriate non-surgical measures that have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months. Please include details of any referrals.
Physical Activity Date advice given _____/_____/_______
Details _____________________________________________________________
_____________________________________________________________________
Dietary Change Date advice given _____/_____/_______.
Details ______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Drug Interventions
Details of drug prescribed including name of drug(s) prescribed, date first prescribed, duration of treatment and reasons for stopping the drug (where this is relevant)
________________________________________________________________________
________________________________________________________________________
8. For patients whose BMI is between 35 and 40 kg/m2, does the patient have other significant disease that could be improved if they lost weight?
Yes [ ] No [ ]
Please give details of any such disease
_______________________________________________________________________
_______________________________________________________________________
Details of person completing this form
This form must be completed by the patient’s GP or by a hospital consultant.
Signature _________________________________ Date _____/_____/________
Name ______________________________________________GP/Consultant*
(* delete as applicable)
Address ___________________________________________________________
______________________________________________ Post Code _____/_____/_____
Telephone Number __________________________
E-mail Address ___________________________________________________________
Please complete and return the form by post to ETA Acute Commissioning Manager ETA,
