ManagedCareCGM

This site is intended for managed care professionals in the U.S.

This site is intended for managed care professionals in the U.S.

Professionals in Canada should visit CanadaCGM.com

Continuous Glucose Monitoring

Education for Managed Care, Pharmacy, and Payer Professionals

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Broadening Access to Continuous Glucose Monitoring for Patients With Type 2 Diabetes

Source: The Journal of the American Medical Association

“…the studies by Karter et al. and Martens et al. provide additional evidence that patients with type 2 diabetes benefit from the use of CGM in terms of improved HbA1c level, time spent in the target blood glucose range, and reduced hypoglycemic episodes…”

“…institutional changes that promote its use in primary care will go a long way to improving diabetes control and reducing complications, particularly among the populations most in need. The time has come to broaden access to CGM for patients with type 2 diabetes.”


What’s Wrong with This Picture? A Critical Review of Current Centers for Medicare & Medicaid Services Coverage Criteria for Continuous Glucose Monitoring

Source: Diabetes Technology & Therapeutics

Key Takeaway: Current CMS eligibility criteria for CGM coverage is limited and inconsistent relative to current scientific evidence. To expand access to all individuals who would benefit from CGM, it is recommended that CMS modify its eligibility requirements to include all Medicare beneficiaries who meet any one of the first four criteria below, and who also meet the fifth criterion: 

 

Criterion

Supporting Evidence

1.

Diagnosed with T1D.

CGM use confers:
Significant reductions in
• HbA1c
• severe hypoglycemia events
• %TBR
• diabetes-related hospitalizations

Significant improvements in
• %TIR
• treatment satisfaction with less diabetes distress

2.

Diagnosed with T2D and treated with any insulin regimen.

CGM use confers:
Significant reductions in
• HbA1c
• %TBR
• diabetes-related hospitalizations
Significant increases in %TIR

3.

Diagnosed with T2D and documented problematic hypoglycemia regardless of diabetes therapy. This would include a history of at least one of the following conditions: Level 2 (moderate) hypoglycemia, characterized by glucose levels ≤54 mg/dL; Level 3 (severe) hypoglycemia, characterized by physical/mental dysfunction requiring third-party assistance; or nocturnal hypoglycemia

CGM use confers:
Significant reductions in
• diabetes-related hospitalizations, including severe hypoglycemia events
• hypoglycemia fear and

Increased patient confidence in avoiding/treating hypoglycemia, thereby supporting treatment adherence

4.

Advanced CKD at risk for hypoglycemia.

CGM use facilitates:
• More frequent treatment changes and improved glycemic control without increased risk of hypoglycemia
• Effective monitoring and managing of glycemic levels in nondiabetes patients with ESRD undergoing dialysis

5.

In-person or telemedicine consultation with the prescribing health care provider before CGM initiation and every 6 months thereafter while continuing CGM therapy. (Coverage for telemedicine consults should be available for all patients regardless of geographic location.)

Use of telemedicine consults:
Significantly reduces
• the incidence of severe hypoglycemia events
• diabetes-related distress

Significantly improves medication adherence
• Effectively addresses the obstacles caused by the COVID-19 pandemic
• Are more effective for patients who are residents of cities and using the websites as their
intervention method

Use of downloaded CGM data into standardized reports:
• Supports patient education
• Enhances patient engagement in their self-management


Benefits of Real-Time Continuous Glucose Monitoring in Pregnancy

Source: Diabetes Technology and Therapeutics

Key Takeaway: The CONCEPTT (CGM in pregnant women with type 1 diabetes) trial provided high-quality, randomized-controlled trial data demonstrating that the use of real-time CGM was associated with lower HbA1c at 34 weeks, suggesting improved maternal glucose levels during the late second and early third trimesters.7 Importantly, this was accompanied by 7% higher time in range (TIR) and 5% lower time above range (TAR) without increasing maternal hypoglycemia. Beyond impacting surrogate markers of maternal glycemia, using CGM led to clinically significant reductions in large for gestational-age infants, neonatal hypoglycemia, and neonatal intensive care unit (NICU) admissions.7 A systematic review combining data from CONCEPTT with that of the type 1 diabetes arm of the GlucoMOMS trial also showed evidence for a reduction in preeclampsia.7–9 


Clinical Implications of Real-time and Intermittently Scanned Continuous Glucose Monitoring

Source: Diabetes Care

Key Takeaways: CGM has emerged as a new standard of care for individuals with insulin-treated diabetes. Two types of CGM systems are now available: real-time CGM (rtCGM) and intermittently scanned (isCGM). rtCGM systems automatically transmit a continuous stream of glucose data to the user, provide alerts and active alarms, and transmit glucose data in real time to a smart phone and/or other display device. The current isCGM system provides the same type of data but requires the user to purposely scan the sensor to obtain information, and it does not have alerts and alarms. Both CGM technologies have significant advantages over self-monitoring of blood glucose; however, differences in the features and capabilities of the two approaches must be considered when guiding patient selection of the system that meets their individual needs.


Continuous Glucose Monitoring: An Emerging Standard of Care

Source: American Journal of Managed Care

Key Takeaway: The use of CGM is proven to reduce A1C, reduce time spent in hypo- and hyperglycemia and improve time in range (TIR) for Type 1 and Type 2 patients using intensive insulin, defined as multiple daily injections of insulin or getting insulin through an insulin pump.  This has resulted in guidelines and recommendations from professional societies such as the ADA recommending CGM as a standard of care for Type 1 and Type 2 patients using intensive insulin.  CGM is an important monitoring tool that is best accessed by providers and patients in the pharmacy channel.


Continuous Glucose Monitoring with Dexcom G6

Source: First Report Managed Care

Key Takeaway: Diabetes is a complex chronic disease that for some Type 1 and Type 2 patients requires the use of intensive insulin defined as 3 or more injections/day or insulin through a pump.  The adverse consequences of using insulin are severe and can result in a coma, seizure or even death which leads many patients and caregivers deciding to use less insulin as prescribed preventing achievement of glycemic goals.  Real-time CGM with alerts/alarms, remote monitoring and reporting can help patients use their insulin safely and effectively to achieve lower A1Cs, spend less time in hypo- and hyperglycemia and spend more time in range (TIR).  The benefits of CGM are seen when it is used to make diabetes treatment decisions such as insulin dosing, diet and lifestyle in a timely manner.  Accessing CGM devices via a pharmacy benefit allows patients to start CGM faster, stay safe while using insulin and engage pharmacists, providing additional support and interventions that have been shown to improve diabetes outcomes.


Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range

Source: Diabetes Care

Key Takeaway: Successful utilization of CGM technology in routine clinical practice remains relatively low due to a lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward.  In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue and established targets for time in range (TIR), time below range (TBR) and time above range (TAR).  These are metrics that only CGM can measure and overcome the limitations of metrics such as A1C which are reflective of a 3 month average of glycosylated hemoglobin and does not account for day to day glycemic variability or factors such as anemia which can skew A1C low.

CGM-based Targets for Different Diabetes Populations