Epidural 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@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 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

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