An Open Letter to Policy Makers Regarding Reimbursements for Continuous Glucose Monitors
January 2020
To whom it may concern:
Several people living with diabetes have encountered problems with the interpretation and implementation of Diabetes Canada’s Clinical Practice Guidelines (CPG) by policy makers in the private and public sector. Policy makers have a critical role to appropriately guide effective and cost-effective treatment that is founded on valid scientific review. Application of guidelines by those knowledgeable about the evidence and the patient population is essential for good patient care. Inappropriate interpretation may result in people with diabetes being deprived of evidence-based interventions that can prevent morbidity and mortality.
Recently, we became aware that reimbursement policies for continuous glucose monitors (CGM) are being considered and implemented that deny access to people living with diabetes because of misapplication of our CPG. Specifically, this statement from our guidelines is being misinterpreted:
Diabetes Canada “recommends that diabetes be treated with regular insulin injections and, in addition to a healthy diet with regular exercise, managed by proper insulin adjustments and testing a minimum of four times per day.”
We are concerned that this Diabetes Canada’s CPG recommendation is applied in a manner that denies appropriate care and we are clarifying our position on CGM and recommendations related to glucose monitoring.
A CGM is a wearable device that automatically measures glucose levels every few minutes, day and night, using a sensor inserted under the skin. The readings are relayed in real time to a compatible device (e.g. smart phone), which can be read by the patient or caregiver, even remotely. CGMs can be used as a stand-alone device or in conjunction with an insulin pump as part of an integrated system.
Diabetes Canada recommends that people with type 1 diabetes who have not achieved their glycemic target should have access to a CGM to improve glycemic control. CGM gives people with type 1 diabetes a more complete picture of their blood sugar control, as opposed to a moment-in-time snapshot that comes from intermittent finger-prick testing, and can lead to better short- and long-term treatment decisions and health outcomes.
It can help identify when glucose is trending up or down and will alert for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) to allow the user to take immediate action to treat. CGM has been shown to reduce A1C (a measure of average blood sugar over a three-month period) and increase the percentage of time spent at target glycemic range. Better outcomes associated with CGM use are greatest with long-term use.
The CPG also recommend that people with diabetes who experience recurrent or severe hypoglycemia, or impaired awareness of hypoglycemia, are considered for CGM in order to reduce or eliminate the risk of severe hypoglycemia and to attempt to regain hypoglycemia awareness. Furthermore, women with type 1 diabetes in pregnancy should be offered use of CGM to improve glycemic control and reduce neonatal complications.
A restriction that requires plan members -- who were prescribed CGM for valid clinical reasons, -- to return to finger-prick testing in order to be considered for coverage of CGM is not consistent with Diabetes Canada recommendations. Requiring plan members to modify their prescribed treatment may negatively impact their diabetes management and health and put them at greater risk for both short- and long-term complications.
Coverage that considers CGM to be medically necessary only when standard care “continues to result in hypoglycemia” is not consistent with Diabetes Canada recommendations. As noted, CGM has been shown to reduce hypoglycemia episodes, reduce A1C and increase the percentage of time spent at target glycemic range, help prevent hyperglycemia and diabetic ketoacidosis, and improve glucose management during pregnancy and neonatal outcomes.
We encourage policy makers to ensure their health policies align with Diabetes Canada’s evidence-based guidelines and towards the best possible health outcomes. If you have any questions, we would welcome a meeting to discuss in greater detail.
Sincerely,
Seema Nagpal, PhD
Download a copy of this letter.