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Arden's Day Blog

Arden's Day is a type I diabetes care giver blog written by author Scott Benner. Scott has been a stay-at-home dad since 2000, he is the author of the award winning parenting memoir, 'Life Is Short, Laundry Is Eternal'. Arden's Day is an honest and transparent look at life with diabetes - since 2007.

type I diabetes, parent of type I child, diabetes Blog, OmniPod, DexCom, insulin pump, CGM, continuous glucose monitor, Arden, Arden's Day, Scott Benner, JDRF, diabetes, juvenile diabetes, daddy blog, blog, stay at home parent, DOC, twitter, Facebook, @ardensday, 504 plan, Life Is Short, Laundry Is Eternal, Dexcom SHARE, 生命是短暂的,洗衣是永恒的, Shēngmìng shì duǎnzàn de, xǐyī shì yǒnghéng de

Dexcom G5 CGM System is now covered under Medicare

Scott Benner

From - July 14, 2017

Important information regarding the recent Medicare announcement

Dexcom has begun to distribute Dexcom G5 CGM System supplies directly to eligible Medicare beneficiaries. We have contracted with Ascensia to provide the Contour® Next One blood glucose meter in the bundle of products covered by Medicare. Today, we are not licensed to service all 50 states, so we will also be using Medicare distributors to support us.

What does this ruling mean? Who is covered? 
The ruling means Medicare patients with type 1 and type 2 diabetes on intensive insulin therapy who meet the following criteria may now be able to obtain reimbursement:

  • The beneficiary requires a therapeutic CGM. The beneficiary has diabetes mellitus; and,
  • The beneficiary has been using a home blood glucose monitor (BGM) and performing frequent (four or more times a day) BGM testing; and,
  • The beneficiary is insulin-treated with 3 or more daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  • The beneficiary's insulin treatment regimen requires frequent adjustments by the beneficiary on the basis of therapeutic CGM testing results.
  • Within six (6) months prior to ordering the CGM, the beneficiary had an in-person visit with the treating practitioner to evaluate their diabetes control and determine that the above criteria are met; and,

Every six (6) months following the initial prescription of the CGM, the beneficiary has an in-person visit with the treating practitioner to assess adherence to their CGM regimen and diabetes treatment plan.

Note: With the initial Medicare coverage ruling, there is a requirement that patients only use the Dexcom G5 Receiver to view their glucose data and not a smart phone or other device. We realize that many patients want to use their smart phone to view their glucose data and we are continuing to work with CMS regarding this decision. For now, exclusive use of the G5 receiver is the requirement for Medicare reimbursement. Dexcom has no ability to override this decision, therefore, we must advise our customers not to use the app with the Medicare product. If a patient feels it is critical to have the ability to use the app, a non-Medicare reimbursed Dexcom system is available for purchase with a prescription. 

Get started with Dexcom today

The Medicare coverage decision for Dexcom G5 is a victory for patient access, and we hope, a first step in getting access to the entire Dexcom G5 set of capabilities. Beneficiaries should reach out to 1-800-MEDICARE with any questions about the Medicare requirements for Dexcom CGM.

Are other CGM products covered as well? 
The ruling specifically states that only CGM products labeled as a replacement of fingerstick blood glucose testing for diabetes treatment decisions by the FDA and referred to in the ruling as “therapeutic CGM” will be covered. Thus, Dexcom G5 CGM System is the only therapeutic CGM on the market set to be covered by Medicare at this time.

How do I get my Dexcom G5 CGM System? 
New patients should contact Dexcom by visiting and submitting a Dexcom G5 CGM interest form. Priority will be given to existing Dexcom CGM patients followed by new patients in the order they were originally received. As our sales representatives work through the queue, patients can expect to hear from Dexcom or an authorized Dexcom distributor about getting started. This will be a slow process but we will ramp as quickly as we can. 

Who will send me my Dexcom G5 CGM System? 
We are happy to announce that Dexcom will begin to distribute Dexcom G5 CGM System supplies directly to eligible Medicare beneficiaries within the next few weeks. We have contracted with Ascensia to provide the Contour® Next One blood glucose meter in the bundle of products covered by Medicare. Today, we are not licensed to service all 50 states, so we will also be using Medicare distributors to support us.  

How much can I expect to pay for my Dexcom G5 CGM System? 
Patients who are covered by Medicare can expect to cover 20% of the costs, although this additional amount may be covered by secondary insurance. Medicare will cover the remaining 80%.

I am using a Dexcom G4 PLATINUM CGM. How will this affect me? 
The ruling specifically states that only CGM products approved by the FDA as a replacement of fingerstick blood glucose testing for diabetes treatment decisions would be covered, so the Dexcom G4 PLATINUM will not apply. Currently, only the Dexcom G5 CGM System meets this criteria and would be eligible for Medicare coverage. Patients using Dexcom G4 PLATINUM may want to talk to their physicians or Dexcom to see if they would be eligible for Dexcom G5 CGM System.

I still have questions. Who can I contact? 
Please call Dexcom Customer Service at 888-738-3646 for additional information.

You Too Can Bolus for Chinese Take Out

Scott Benner

A successful insulin bolus is all about the balance between amount and timing.

Arden recently had Chinese takeout that consisted of sesame chicken, white rice and edamame. 

Take a look at her 24 hour Dexcom graph and see if you can guess what time Arden ate the Chinese food. The yellow block represents a restart of her Dexcom CGM.


Now lets talk about the insulin that we used for the meal. Try not to look at the next graph yet...

History tells me that Arden will need between 9 and 10 units of insulin for this food. I don't know how much she'll eat and I don't know how many carbs the food contains. Honestly, I don't care about the carb count for two reasons. 1. I know historically how much insulin this food requires, the trick is to time it correctly. 2. Even if I use the correct amount of insulin the bolus won't work if it's mis-timed.

Example of Correct Amount of Insulin not leading to desired result

Bolusing the entire amount too soon will cause a crash while eating because the carbs will get overpowered by the insulin. Correcting this low will lead to a crazy high later (unless you add insulin, which you'll likely be afraid to do because of the initial low. However, that would likely be the correct thing to do). Outcome: UNDESIRED

Bolusing the entire amount too late will cause a spike that won't come down because the carbs will overpower the insulin, rocketing the BG. This result now voids the "correct" amount of insulin. Yes you used the correct amount of insulin for the food initially but the unintended spike has not been compensated for by insulin. Mis-timing the insulin created another insulin requirement. This spike will last forever without more insulin. Outcome: UNDESIRED

Take away: The insulin, even in the correct proportion, will inevitably not be successful if it is mis-timed. 

What does timing mean in simple terms?

The fight between carbs and insulin needs to be balanced. Imagine a tug of war. If one side pulls first, the flag in the middle of the rope becomes uncentered. Now the side that pulled first has a huge advantage that the other side probably can't overcome. When we bolus we want the insulin and the carbs to pull at the same time so that the flag stays right in the middle. 

The first step to a balanced pre bolus is understanding the insulin. Man-made insulin does not work immediately and you need to figure out how long it takes to work for you. It may be five, ten, fifteen or more minutes, figure it out. None of this will work without pre bolusing. Trust that. 

Once you know how long it takes for your insulin to begin to reduce your BG, consider the food. Something sugary will hit your BG quicker while a heavier less volatile carb like bread may take longer to start pulling up your BG but then last much longer in your system. Each food type will need different timing considerations and hence a different pre bolus. 

None of this needs to be perfect because you can always readdress as you go (made easier with the Dexcom CGM and an insulin pump but not undoable with injections).

Understand the roll of basal insulin. Pumpers have a basal rate set that is trying to hold a steady BG during the day. When carbs are added and your insulin needs increase, you aren't just stuck with one weapon (bolus) you can also blanket the carb richer hours with more basal insulin. (Extra basal also does wonders bringing down a spike or stubborn high BG). So don't just use a targeted strike (bolus), carpet bomb too with an increased basal rate. Decreased basal rates are also effective in handling stubborn lows without carbs. 

Okay lets take a breath because none of this is nearly as complicated as it seems. Lets go over some basic tenets and then look at the Chinese food graph.

  • You have to pre-bolus to create a balanced fight between carbs and insulin.
  • Temporary basal rate increases and decreases are a vital tool.
  • If your BG is too high. You didn't use enough insulin, you mis-timed it or a combination of both.
  • If your BG is too low. You used too much insulin, you mis-timed it or a combination of both.
  • When your BG gets high do not spend time trying to figure out why, just get it down. Figure it out later.
  • When something goes wrong, its not a mistake to beat yourself up over. It is actionable data, a learning experience that will help you make a better decision next time. 
  • CGM users: Stop the arrow without causing another one. Bump and nudge the graph line. Small adjustments will keep you off the diabetes rollercoaster.
  • It is far easier to stop a low or falling BG then it is to effect a high and stubborn BG. 
  • Often you get what you expect so expect BGs in the 70 - 110 range and make them your goal. CGM users: Set thresholds that allow you to react before it is too late. 
  • Be bold with insulin.

It's time to look at the graph from the Chinese food. Do you remember when you thought Arden ate? Did you guess around 3 pm? Actually, the spike at 3 pm was one tiny snack with a mis-timed pre-bolus. The take-out was at 7 pm. Check it out.

Simply put. I cranked up Arden's basal about 20 minutes before the food arrived and bolused 3.00. Thats 4.00 units in, 6.00 more needed. The next 1.50 went in when the food began to create space between pre-bolus. I need to stretch the insulin impact because there are two different carbs at work in this example. The sugar on the chicken is going to act fast so the pre-bolus and temp basal needed a head start. The next issue is the white rice which brings a heavy impact that is also long-lasting so we need force and staying power. I held the balance of the insulin until the rice started to make its impact around 7:40 pm. I should have bolused the remaining 3.80 all at once but I played it a bit safe because I knew that we were about to lose the Dexcom data for two hours. Had I sent the entire 3.80 at 7:40 the BG wouldn't have made it to 140. Thats it. We tested half way through the Dexcom restart to be safe and to make sure that Arden didn't need more insulin. 

You may be inclined to say that this is too much effort but I contend that the few moments that it took to make these adjustments is a far better world to live in then spending the next five hours bolusing a high number that just won't move. It will take you a few tries to make sense of everything but one day you'll have it and all of this will feel easy. Arden eats what she wants and her A1c has been between 5.6 and 6.2 for four years. Be bold with insulin!

You many also like:
Blog post: Anatomy of a High Carb Breakfast
Podcast: Bold With Insulin

If you want to continue to find out more about how we manage type 1 diabetes please check out my podcast. The Juicebox Podcast is free and available on all podcast apps and online. Subscribe and start listening today!

I am not a doctor and this is not advice. Disclaimer is here.

Brenda Menjivar Guardado

Scott Benner

Please listen, share and call

Brenda Menjivar Guardado is a 21 year living with type 1 diabetes. She fled El Salvador and sought asylum in the U.S. but her insulin is being mismanaged by U.S. Immigration and Customs Enforcement (ICE). Fearing for her life Brenda asked to be deported. She is currently in the system, now in Laredo Texas, and no one can be sure that she is receiving proper care.

Nasal Glucagon Study in Phase 3

Scott Benner

from Medscape, Marlene Busko

SAN DIEGO — Giving one puff of a dry glucagon powder inside the nose of an adult with type 1 diabetes who was having a moderate to severe hypoglycemic episode was easy for a caregiver to do and led to recovery within 30 minutes in almost all patients in a phase 3 study.

Specifically, the treated patients recovered from hypoglycemia within a half hour in 96% of cases, and 90% of the caregivers (typically a spouse) found the product easy to use, Elizabeth R Seaquist, MD, University of Minnesota School of Medicine, Minneapolis, reported at the recent American Diabetes Association (ADA) 2017 Scientific Sessions.

It is premature to comment on when the product will be available in the US,” he cautioned, but if the NDA is approved, “we are excited to bring this product to market as quickly as possible.

"We conclude that this 3-mg dose of nasal glucagon in a needle-free, user-friendly package provides a potential alternative to currently available injectable recombinant glucagon," she said.

"It really does look like [this investigational product] could be a good alternative to [intramuscular injectable] glucagon for treating severe hypoglycemia away from a hospital setting," she reiterated to Medscape Medical News.

Read the entire report here

Medtronic deal with Aetna ties insulin pump payment to patient results

Scott Benner

This does not feel right...

My opinion.... Medtronic has way too much power in the insulin pump space. You may also want to check out Mike Hoskin's thoughts on the subject over at Diabetes Mine. 

By Bill Berkrot Reuters

Medtronic Plc said on Monday it signed an agreement with health insurer Aetna Inc under which payment for its insulin pump systems will be tied to how well diabetes patients fare after switching from multiple daily insulin injections.

The deal is the latest example of the move toward contracts for prescription drugs and medical devices that attempt to bring down soaring healthcare costs by tying reimbursements to whether the products achieve their intended results.

The deal with Aetna will measure health outcomes for patients who transition to one of three Medtronic pumps that self-adjust to keep blood sugar levels in proper range based on patients' individual needs for insulin.

"This agreement reinforces our shift towards value-based healthcare," Hooman Hakami, president of the Medtronic diabetes group, said in a statement. "We know technology alone isn't enough and ultimately improved outcomes are what matter."

Patients with type 1 diabetes and those with type 2 who have progressed to the need for insulin typically check blood sugar levels several times a day and inject insulin as needed. The pumps eliminate that chore.

Medtronic declined to discuss financial details of the Aetna agreement, but said such deals tie revenue to achievement of clinical improvement targets, as well as shared savings for delivering on or exceeding clinical outcomes and cost targets.

Suzanne Winter, vice president of the Medtronic diabetes group in the Americas, said the Aetna agreement will initially focus on whether patients on its pumps achieve their A1c targets, a commonly used measure of blood sugar levels. The American Diabetes Association recommends A1c levels below 7.

In the future it may look at other measures, such as hypoglycemia episodes, time in proper glycemic range, and patient satisfaction, Winter said.

Medtronic already has an agreement with UnitedHealth Group Inc that is moving toward including patient outcomes and other metrics, such as total cost of care, and the company is discussing similar deals with other insurers, Winter said.

Pharmaceutical companies are also beginning to embrace reimbursement options that take patient outcomes into consideration.

U.S. biotech Amgen Inc, in an effort to improve patient access to its expensive new cholesterol drug Repatha, has offered contract options that include refunding the cost of the drug if patients suffer a heart attack or stroke while on the medicine intended to prevent them.

(Reporting by Bill Berkrot; Editing by David Gregorio)