Hysterectomy for Heavy Menstrual Bleeding Non Cancer

Hysterectomy for Heavy Menstrual Bleeding Non Cancer

Hysterectomy for heavy menstrual bleeding – non cancer

Policy statement: / Hysterectomy for heavy menstrual bleeding – Non Cancer
OPCS codes: Q071, Q072, Q073, Q074
Q075, Q076, Q078, Q079, Q081, Q082
Q083, Q088, Q089 / Eligibility Criteria – Prior Approval Needed

THIS FORM MUST BE COMPLETED IN FULL AND SUBMITTED WITH THE APPROPRIATE CLINICAL INFORMATION

Patient details / Referring GP details
Surname: / GP:
Forename(s): / GP Contact:
Address:
Postcode: / Practice Address:
Postcode:
Date of Birth: / GP Practice Code:
NHS No:
Clinical criteria for referral for the procedure as detailed in the policy
Hysterectomy for non-cancerous heavy menstrual bleeding will only be funded by Mid Nottinghamshire CCGs within NICE guidance and when;
Please refer to the Service Restriction Policy additional information / Tick all appropriate boxes
There has been an unsuccessful trial and appropriate clinical assessment, with a levonorgestrel-releasing intrauterine system LNG-IUS, e.g. Mirena®, unless contraindicated, for at least 12 months which has not successfully relieved symptoms or has produced unacceptable side effects.
And
The following are not clinically appropriate:
  1. Endometrial ablation if normal uterus or if LNG-IUS contraindicated or if ablation is contraindicated e. g. previous multiple caesarean section
  2. Uterine Artery Embolisation (for fibroids under 3cm)
  3. Myomectomy (for fibroids over 3cms)

Please include relevant patient history to support criteria above i.e. reason for consultation, dates etc…
Patient Information leaflet
NHS Choices Patient Information Leaflet Heavy Periods Treatment
I confirm that I have explained the prior approvals process to the patient / Yes / No
I confirm that the patient meets the current clinical guideline/policy for referral outlined in the as detailed in the Service Restriction Policy April 2017 / Yes / No
Name ofReferrer…………………………………………………………..Date.……………
(To be completed by Assessor)
THIS REQUEST HAS BEEN ACCEPTED FOR AN ONWARD REFERRAL
THIS REQUEST HAS BEEN DECLINED
(Delete as appropriate)
Rational….
Name ofAssessor………………………………………………………….. Date.……………
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