Benign skin lesion excision (also see Congenital pigmented

lesions (treatment of))

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@nhs.net

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:

Organisation NUH SFHFT MSK HH

GP / Other:

I Confirm that the patient meets the current clinical guideline / policy for the restricted procedure as detailed in the Restricted Policy 2018

I 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 commissioner

PLEASE INDICATE THE RESTRICTED PROCEDURE CRITERIA DECLARED AS MET AND RECORDED IN PATIENT NOTES

Surgical removal, or cryotherapy of benign skin lesions are ONLY commissioned if there is at least one of:

Significant functional disability resulting in severe restriction of Activities of Daily Living (ADL) or a risk to a critical life sustaining function.

Recurrent infection (at least 2 courses of antibiotics)

Recurrent bleeding/trauma (at least 3 documented episodes)

There is a risk on future malignancy (especially with respect to lesions in children)

Benign skin lesions are only commissioned for removal in a secondary care setting where the site, nature of the lesion (e.g. suspicion of malignancy) or age of patient (especially children) requires specialist skills

Biopsy of benign lesions is commissioned where the nature of the lesion is uncertain (especially in children –in secondary care)In case of diagnostic uncertainty in adults consider tele-dermatology pathway.In case of rapid growth or other features suspicious of dysplasia/ malignancy use 2ww pathway.

All other benign skin lesions meeting the criteria should be removed in primary care.

Specific criteria apply to lipomas

Please add any additional information below

CLINICIANS MAY USE THIS FORM TO DECLARE THAT THE INDICATED PROCEDURE IS EXCLUDED FROM THE POLICY FOR THE FOLLOWING REASON:

Emergency Reasonable suspicion of cancer It is part of reconstruction following treatment for cancer,

traumatic injury or the correction of congenital malformation Not carrying out the procedure would have an adverse

effect on physical functional development of a child