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CGM Candidate Selection Characteristics  

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Candidate selection characteristics include a variety of considerations from physical to general readiness.

From the Personal Continuous Glucose Monitoring Implementation Playbook from ADCES and AphA. Contributors include: Patricia L. Scalzo, MSN, NP, RN, CDCES, Kelly A. Brock, PharmD, RPh and Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, FADCES. This effort was supported by Dexcom & Abbott.

Who should be prescribed a CGM?

Any of the following may be an indication for Personal CGM: Type 1 or Type 2 Diabetes.
  • Taking multiple daily injections of insulin
  • Using an insulin pump
  • Frequent hypoglycemia
  • Hypoglycemia unawareness
  • High degree of glycemic variability
  • Not achieving glucose targets  

The American Diabetes Association makes the following recommendation in its 2020 Standards of Medical Care in Diabetes16: “Use of technology should be individualized based on a patient’s needs, desires, skill level, and availability of devices.” By offering a personal CGM program, providers can assess a patient’s needs, desires, and skill level and help them identify a CGM device that will work for them. The American Diabetes Association goes on to say that “Nonprofit websites can offer advice for providers and patients to determine the suitability of various options.”  

An example of a valuable not-for-profit website that can help both providers and people with diabetes make decisions as to the initial choice of device is DiabetesWise from Stanford University, funded by The Leona M. and Harry B. Helmsley Charitable Trust 

Payor Considerations

The four criteria set down by CMS17, all of which must be met for coverage, include that the patient must:

  1. Have a diagnosis of diabetes, either type 1 or type 2
  2. Use a home blood glucose monitor (BGM) and conduct four or more daily BGM tests
  3. Be treated with insulin with multiple daily injections or a constant subcutaneous infusion (CSI) pump
  4. Require frequent adjustments of the insulin treatment regimen, based on therapeutic CGM test results 

To meet the criteria, the system must be classified as a therapeutic CGM. That means users can make treatment decisions using the device. Most commercial payers have coverage for CGM. Eligibility may vary and providers can assist patients in identifying the criteria and help them navigate approval processes. 

Cost Implications of CGM Use in Type 2 Diabetes 

In the American Journal of Managed Care’s Evidence Based Diabetes Management, 201918, Kompala and Neinstein discuss that one study looked at long-term cost-effectiveness for CGM use in people with type 2 diabetes based on HbA1c reduction, projecting decreased rates of diabetes-associated complications.“ Although we anticipate that HbA1c reduction through lifestyle changes by CGM users could prevent the addition of costly new medications or dose intensification of existing treatments, more study is needed to test this. This matters: Studies looking at HbA1c compared with healthcare costs have found significant impacts. In one case, a 1% decrease in A1C was associated with $685 to $950 per year lower total healthcare costs, and in another, a 1% increase in HbA1c was associated with a 7% increase in healthcare costs over the next 3 years.”

Patient Readiness for Use of Continuous Glucose Monitoring

Is your patient with diabetes ready to utilize continuous glucose monitoring technology?  Welsh notes, in his June 2018 Diabetes Technology & Therapeutics19 article, “Role of Continuous Glucose Monitoring in Insulin-Requiring Patients with Diabetes,” that it is important to set realistic expectations of CGM use to help avoid frustrations and disappointment. “CGM use should not be imposed on those who are unwilling to use it consistently or incapable of using it beneficially.” Comprehensive training on the device is important, both initially and ongoing, and will lead to the long-term success of the individual with the CGM20. One strategy to assist the person with diabetes who is feeling uncertain if personal CGM is right for them would be to offer a short-term trial with professional CGM.21 

References: 1 Chehregosha, H, Khamseh, ME, Malek, M, et al. A View Beyond HbA1c: Role of Continuous Glucose Monitoring. Diabetes Therapy. 2019;10, 853–863 2 Sagar R, Abbas A, Ajjan R. Glucose monitoring in diabetes: from clinical studies to real-world practice. Practical Diabetes. 2019;36. 57-62. 10.1002/pdi.2215. 3 Ajjan R, Slattery D, Wright E. Continuous Glucose Monitoring: A Brief Review for Primary Care Practitioners. Advances in Therapy. 2019;36:579-596 4 Aleppo G, Laffel LM, Ahmann AJ, et al. A Practical Approach to Using Trend Arrows on the Dexcom G5 CGM System for the Management of Adults With Diabetes, Journal of the Endocrine Society, Volume 1, Issue 12, 1 December 2017, Pages 1445–1460, https://doi.org/10.1210/js.2017-00388 5 Kudva YC, Ahmann AJ, Bergenstal RM, et al. Approach to Using Trend Arrows in the FreeStyle Libre Flash Glucose Monitoring Systems in Adults, Journal of the Endocrine Society, Volume 2, Issue 12, December 2018, Pages 1320–1337, https://doi. org/10.1210/js.2018-00294 6 Šoupal J, Petruželková L, Grunberger G, et al. Glycemic Outcomes in Adults With T1D Are Impacted More by Continuous Glucose Monitoring Than by Insulin Delivery Method: 3 Years of Follow-Up From the COMISAIR Study. Diabetes Care. 2020 Jan;43(1):37-43. doi: 10.2337/dc19-0888. Epub 2019 Sep 17. 7 Mulinacci G, Alonso T, Snell-Bergeon JK, Shah VN. Glycemic Outcomes with Early Initiation of Continuous Glucose Monitoring System in Recently Diagnosed Patients with Type 1 Diabetes. Diabetes Technology & Therapeutics. 2018;21. 10.1089/ dia.2018.0257. 8 Peters, AL. The Evidence Base for Continuous Glucose Monitoring. Role of Continuous Glucose Monitoring in Diabetes Treatment. American Diabetes Association. 2018 Aug: 3-7. doi: 10.2337/db20181-3 9 American Association of Diabetes Educators Practice Paper. The Diabetes Educator Role in Continuous Glucose Monitoring. 2018. Updated Dec2019; https://www.danatech.org/media/ntgjf2di/diabetescareeducationspecialistrolecgm_aug20.pdf 10 American Diabetes Association. Standards of Medical Care in Diabetes – 2020. Diabetes Care 2020;43(Suppl 1):S77-S88 11 Peters AL, Ahmann AJ, Battelino T, et al.: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101:3922–3937 12 Garber AJ, Handelsman Y, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2020 executive summary. Endocrine Practice 2020, 26 (1): 107-139 13 Danne T, Nimri R, Battelino T, et al. International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care. 2017;40:1631–40 14 Aleppo G, Webb K. Continuous Glucose Monitoring Integration in Clinical Practice: A Stepped Guide to Data Review and Interpretation. Journal of Diabetes Science & Technology. 2018; https://doi.org/10.1177%2F1932296818813581 15 Petrie JR, Peters AL, Bergenstal RM, et al. Improving the clinical value and utility of CGM systems: Issues and Recommendations: A joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care. Oct 2017, dci170043; DOI: 10.2337/dci17-0043 16 American Diabetes Association. Standards of Medical Care in Diabetes – 2020. Diabetes Care 2020;43(Suppl 1):S77-S88 17 U.S. Centers for Medicare & Medicaid Services. Medicares Coverage of Diabetes Supplies, Services & Prevention Programs. Publication # 11022. Revised 12/01/2019 18 Kompala T, Neinstein A. A New Era: Increasing Continuous Glucose Monitoring Use in Type 2 Diabetes. American Journal Managed Care. 2019 Mar;25(4 Spec No.):SP123-SP126. 19 Welsh JB. Role of Continuous Glucose Monitoring in Insulin-Requiring Patients with Diabetes. Diabetes Technology & Therapeutics. Jun 2018.S2-42-S2-49.http://doi.org/10.1089/dia.2018.0100 20 Heinemann, L, Klonoff, D. C. An Opportunity to Increase the Benefit of CGM Usage: The Need to Train the Patients Adequately. Journal of Diabetes Science and Technology. 2019 https://doi.org/10.1177/1932296819895083 21 Longo, R, Sperling, S. Personal Versus Professional Continuous Glucose Monitoring: When to Use Which on Whom. Diabetes Spectrum. 2019;32. 183-193. 10.2337/ds18-0093 PART SIX: References Personal Continuous Glucose Monitoring Implementation Playbook 61 22 Tanenbaum ML, Adams RN, Lanning MS, et al. Using Cluster Analysis to Understand Clinician Readiness to Promote Continuous Glucose Monitoring Adoption. Journal of Diabetes Science & Technology. 2018;12(6):1108–1115 23 American Diabetes Association. Overcoming Therapeutic Inertia: Accelerating Diabetes Care for Life. American Diabetes Association Summit. Summary of Proceedings. 2019 24 Kazemian P, Shebl FM, McCann N, Walensky RP, Wexler DJ. Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016. JAMA Intern Med. 2019;179(10):1376–1385. doi:10.1001/jamainternmed.2019.2396 25 Rodbard D. Continuous Glucose Monitoring: A Review of Successes, Challenges, and Opportunities. Diabetes Technol Ther. 2016 Feb 1; 18(Suppl 2): S2-3–S2-13. doi: 10.1089/dia.2015.0417 26 Smith MB, Albanese-O’Neill A, Macieira TGR, Yao Y, et al. Human Factors Associated with Continuous Glucose Monitor Use in Patients with Diabetes: A Systematic Review. Diabetes Technology & Therapeutics. Oct 2019.589-601.http://doi.org/10.1089/ dia.2019.0136 27 Johnson ML, Martens TW, Criego AB, Carlson AL, et al. Utilizing the Ambulatory Glucose Profile to Standardize and Implement Continuous Glucose Monitoring in Clinical Practice. Diabetes Technology & Therapeutics. Jun 2019.S2-17-S2-25.http://doi. org/10.1089/dia.2019.0034 28 Danne T, Nimri R, Battelino T, et al. International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care. 2017;40:1631–40 29 Battelino T, Danne T, Bergenstal RM, et al. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations from the International Consensus on Time in Range. Diabetes Care 2019;42:1593-1603. doi10.2337/dci19-0028. 30 Bergenstal, RM. Continuous Glucose Monitoring Data as an Adjunct to A1C. Role of Continuous Glucose Monitoring in Diabetes Treatment. American Diabetes Association. 2018 Aug: 19-20. doi: 10.2337/db20181-3 31 Kruger DF, Edelman SV, Hinnen DA, Parkin CG. Reference Guide for Integrating Continuous Glucose Monitoring into Clinical Practice. The Diabetes Educator. 2019 Feb;45(1_suppl):3S-20S 32 Isaacs D, Cox C, Schwab K, et al. Technology Integration - The Role of the Diabetes Care and Education Specialist in Practice. The Diabetes Educator. 2020 Aug. 323-334. doi: 10.1177/0145721720935123 33 Greenwood DA, Howell F, Scher L, et al. A Framework for Optimizing Technology-Enabled Diabetes and Cardiometabolic Care and Education - The Role of the Diabetes Care and Education Specialist. The Diabetes Educator. 2020 Aug. 315-322. doi:10.1177/0145721720935125 34 Carlson AL, Mullen DM, Bergenstal RM. Clinical Use of Continuous Glucose Monitoring in Adults with Type 2 Diabetes. Diabetes Technology & Therapeutics. 2017;19:S4–11 35 Adolfsson P, Parkin CG, Thomas A, Krinelke LG. Selecting the Appropriate Continuous Glucose Monitoring System – a Practical Approach. European Endocrinology. 2018;14:24–29. 10.17925/EE.2018.14.1.24 36 Barnard-Kelly, KD, Polonsky, WH. Development of a Novel Tool to Support Engagement With Continuous Glucose Monitoring Systems and Optimize Outcomes. Journal of Diabetes Science and Technology, 2020;14(1), 151–154. https://doi. org/10.1177/1932296819848686

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This site and its services do not constitute the practice of medical advice, diagnosis or treatment. Always talk to your diabetes care and education specialist or healthcare provider for diagnosis and treatment, including your specific medical needs. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. To find a diabetes care and education specialist near you, visit diabeteseducator.org.

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