YES NO normal functioning Please provide details Intractable cough with a high level of streptococcal YES NO antibody. Please give details Severe halitosis has been demonstrated to be due YES NO to tonsil crypt debris. Please provide details Is there evidence of sleep apnoea with a suspected YES NO cause of enlarged tonsils obstructing airway? Please provide details Is the frequency of episodes increasing or decreasing. YES NO Please provide details Patient’s Body Mass Index (BMI) Height Weight Is the patient a non-smoker? YES NO Exceptional health need, please provide details: SIGNATURE OF CLINICIAN DATE: ……………………………………………………………. ………………………………………………….. Exceptional Status (what makes the individual sufficiently different from the in policy terms) Central to consideration of individual ‘usual’ requests for funding is the concept of the case being exceptional. In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest that they are: Significantly different to the general population of patients with the condition in question and likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. However: The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception. If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional. Social value judgements (the 'worth’ of patients) are not relevant to the consideration of exceptional status but there may rarely be exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in respect of social or health related benefits for others. Please email the completed form to for consideration.
normal functioning Please provide details YES NO Intractable cough with a high level of streptococcal antibody. Please give details YES NO Severe halitosis has been demonstrated to be due to tonsil crypt debris. Please provide details YES NO Is there evidence of sleep apnoea with a suspected cause of enlarged tonsils obstructing airway? Please provide details YES NO Is the frequency of episodes increasing or decreasing. Please provide details YES NO Patient’s Body Mass Index (BMI) Height Weight Is the patient a non-smoker? YES NO Exceptional health need, please provide details: SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: ………………………………………………….. Exceptional Status (what makes the individual sufficiently different from the ‘usual’ in policy terms) Central to consideration of individual requests for funding is the concept of the case being exceptional. In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest that they are: Significantly different to the general population of patients with the condition in question and likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. However: The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception. If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional. Social value judgements (the 'worth’ of patients) are not relevant to the consideration of exceptional status but there may rarely be exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in respect of social or health related benefits for others. Please email the completed form to for consideration.
Tonsillectomy-Form-BD-v.1-22.10.2015.docx