PRIOR APPROVAL FORM

EPIDURAL INJECTIONS FOR LUMBAR BACK PAIN

How to complete:

-Add GP/Consultant details

-Add Patient details

-Tick to answer yes or no to criteria listed under the procedure being requested

-Provide supporting information to evidence assessment in the free text area or attach supporting information such as clinic letter

-Email form to f sending from an nhs.net address or if you are using a glos.nhs.uk email send to

-Response will be sent from Gloucestershire CCG to preferred contact for reply within a maximum of 10 working days.

Please note that unless the patient fully meets the criteria, funding will not be approved unless there are exceptional reasons.

PART A – MUST BE COMPLETED FOR ALL REQUESTS

GP/CONSULTANT DETAILS
NAME:
ADDRESS:
PREFERRED CONTACT FOR REPLY (Email):
PATIENT’S DETAILS
NAME:
NHS No: / Date of Birth
Patient Consent: The Patient hereby gives consent for disclosure of information relevant to their case from professionals involved and to the CCG. / Yes / No
I have informed the patient that this intervention will only be funded where the criteria are met. / Yes / No

PART B – MUST BE COMPLETED FOR ALL REQUESTS

Access Criteria

Radicular pain consistent with the level of spinal involvement demonstrated through appropriate imaging
OR
evidence of nerve-root irritation with a positive nerve-root tension sign [straight leg raise-positive between 30 and 70 degree or positive femoral tension sign] / Yes
Yes / No
No
AND symptoms persist despite some non-operative management for at least 6 weeks / Yes / No
Occasionally, epidural injections may be the only effective management for a cohort of patients. These patients may be considered for prior approval for further epidural injections if they demonstrate sustained benefit (pain reduced by 50% on appropriate pain measure)from the procedure objectively evidenced provided the following criteria are also met: / Yes / No
Patient hasparticipated in a comprehensive back pain programme including psychology & physiotherapy – please give details / Yes / No
AND have had a surgical review and participate in self-directed physiotherapy
OR Patient cannot tolerate medications and pain is significantly impacting on quality of life and activities of daily living / Yes
Yes / No
No

Please provide evidence below to support the information provided. Without evidence your application will be rejected. If you prefer you can attach supporting information, such as a clinic letter, rather than completing the box below.

Supporting information: