5 Steps to Getting an Insulin Pump or Continuous Glucose Monitor
If you take multiple daily doses of insulin and check your blood glucose several times a day, an insulin pump and/or continuous glucose monitor (CGM) can help you better manage your diabetes. With an insulin pump, you can adjust both long-acting basal and rapid-acting bolus doses to more precisely deliver insulin for your body’s needs.
With a CGM, you get a clear picture of glucose levels, patterns, and trends throughout the day—much clearer than you could ever get with finger-stick monitoring.
Some combination pump–CGMs take it a step further by suspending insulin delivery if your blood glucose levels are predicted to drop dangerously low.
Two combo devices can automatically adjust basal insulin delivery to both raise your blood glucose level when you’re trending low or lower your level when your glucose is too high. One of those combo devices also delivers a correction bolus to bring down high glucose.
If all of that sounds great, then your first course of action is to talk to your doctor, who can help you decide whether a pump or CGM (or both!) is right for you. If you want both devices, your health care provider can recommend the order in which you start each one, so you don’t become overwhelmed.
The process from there can seem daunting, but the following guide can get you from decision to device in five easy steps.
Step 1: Do Your Homework
Research specific devices online before seeing your doctor (the charts in this issue are a great place to start, and they’re also available online here. Certified diabetes educators and health care providers who are diabetes specialists can also provide a lot of information.
In many cases, your doctor can supply test devices for you to try before making a decision. For example, a professional version of the Dexcom G6 CGM has now been approved, so a health care provider can lend you one to test drive before you commit to buying your own.
Some device manufacturers will do a one-on-one demonstration. “What’s important for me is to let [patients] know how this device will work for them and what it can do so they can make a wise decision,” says Jenny Saling, FNP, CDE, a senior diabetes educator with Medtronic, who does in-person demos to introduce patients to the 670G insulin delivery system.
Step 2: Check Your Insurance
Once you’ve decided on a device, find out whether your insurance covers it, and how much you’ll be paying out of pocket. This varies widely by plan, and it can be confusing. Fortunately, most device manufacturers can help you navigate the process.
If this is your first diabetes device, you’ll likely have to meet certain criteria to obtain insurance coverage. Your doctor will need to complete a prior authorization, or pre-certification, form to provide “evidence of medical necessity” for some CGMs and for most or all pumps and combined systems.
Currently, most commercial insurance plans cover diabetes devices for people with type 1 diabetes and people with type 2 who take both basal and bolus insulins and who check their blood glucose levels multiple times a day. However, some insurers restrict coverage to certain device brands, so you may want to check your insurance plan for restrictions before researching devices.
Medicare has specific rules regarding pumps and CGMs. It typically covers insulin pumps only for people with type 1 diabetes. And it only covers CGMs that are approved to replace finger-stick blood glucose checks (right now, that includes Dexcom’s devices, Senseonics’ Eversense, and Abbott’s FreeStyle Libre). Medtronic, whose CGMs aren’t covered by Medicare, is actively working to change the way its devices are classified so that they’ll be covered.
How insurers categorize your device determines how you’ll receive it. The FreeStyle Libre CGM, for example, is often covered under pharmacy benefits. Insurers and Medicare cover the tubing-free Omnipod insulin pump under pharmacy benefits, too. Typically, your doctor simply writes a prescription and you take it to your pharmacy to have it filled.
While CGMs are increasingly covered by pharmacy benefits, some insurance companies (and Medicare) consider them “durable medical equipment.” All insulin pumps (except the Omnipod) and supplies fall into this category. Getting a device that’s classified as durable medical equipment is a bit more involved. Depending on your plan, you may have to receive the supplies through mail order, either directly from the manufacturer or through a distributor.
“When in doubt, check with the device company,” says endocrinologist Nicholas Argento, MD, diabetes technology director at Maryland Endocrine in Columbia, Maryland. “They’ll generally have a good idea about what different insurance companies or Medicare/Medical Assistance will cover, and how.”
Step 3: Learn How to Use It
Now that you have your device, it’s time to learn how to use it. This is typically much easier with a CGM than a pump. In fact, Argento says, with the exception of the implantable Eversense CGM and CGMs that are integrated with pumps, many patients get the instruction they need by simply watching videos on the company’s website or calling the company’s tech support line.
If you do need help getting started, ask your diabetes educator or a nurse to show you how. “It’s not the technical aspects of CGMs that are challenging but what to do with the information, the limitations, and what situations might require a finger-stick verification,” says Argento. Your health care provider can teach you to safely and effectively use your CGM data to manage your blood glucose and reach treatment goals.
Pumps, however, are a different story. “Starting a pump with somebody who has only used shots requires training,” says Mark Harmel, MPH, CDE, a certified diabetes educator at the University of Southern California Westside Center for Diabetes in Los Angeles.
Your doctor will write you a prescription for the pump and often prescribe personal settings—basal and bolus rates, insulin-to-carb ratios, correction factors, insulin sensitivity factor, and insulin action time—that you or a trainer will use to program the device. (Don’t worry: You’ll learn what those terms mean from your doctor or trainer.)
The pump will likely be mailed directly to your home. The training, however, will take place elsewhere, perhaps in your doctor’s office, but sometimes at a diabetes educator’s office or in another health care setting.
Before you begin, the trainer—usually a certified diabetes educator who works for the manufacturer, the doctor, or independently within a medical setting—will either enter your personal settings or teach you how to do it yourself. Your training will go beyond the technical. It’s important to know how to manage high blood glucose, for instance; the approach is different for pump wearers and includes checking your insertion site and making sure the pump is functioning properly.
A trainer will also teach you how to manage critical issues while wearing the pump. “I go through every possible thing to find out what patients know about what to do for low blood glucose, for example,” says Saling. “I don’t want them to be in a situation where they don’t know what to do.”
Step 4: Check in With Your Doctor
Touch base with your doctor a day or two after you begin using an insulin pump to make sure you’re safe and that the device is functioning properly. Once you have been using a pump or CGM, how do you know when, if ever, to add another device? “It might be a few weeks to a few months with a new pump, depending on whether they were doing carb counting or had a pump in the past or are more or less tech savvy,” Argento says. “Often, I recommend people start with a CGM as the first device and add a pump if the CGM demonstrates unmet needs that a pump can help with, such as an increase in the basal need in the early a.m. [known as the dawn phenomenon]. If someone is already on a pump, it is often easier for them to get used to a CGM because they are already using one device. Many people do best with both.”
Step 5: Troubleshoot
Even after you’ve been trained to use your devices, it won’t always be smooth sailing: CGMs can lose their signals, pump sites can become blocked, and any device can malfunction for a variety of other reasons. That’s why all device manufacturers have technical support lines that operate 24-7. Be sure to keep the number handy. Another great source of device support: your diabetes educator.
Manage Your Data
You have a device. You know how to use it. Now what?
Data can play an important role in diabetes management. Information from your insulin pump and continuous glucose monitor (CGM) can reveal how aspects of your life, including medication, food, exercise, and stress, affect your glucose levels. And that can help you stay within goal range.
Most insulin pump and CGM manufacturers have dedicated platforms and apps for downloading and analyzing your data. (See a list of available data-management systems in the CGM chart on p. 54 and the pump chart on p. 60.) Certain devices connect with third-party data-management systems such as Glooko and Tidepool. These platforms cater to people who use a variety of diabetes devices: pumps, CGMs, blood glucose meters, and, in the case of Glooko, a smart insulin pen and fitness trackers. Users can download and integrate all of the data together into a single report and share it with health care providers, most of whom can download it in the office. Discuss this data in detail with your care team.
“Downloading both the pump and CGM data is huge,” says Mark Harmel, MPH, CDE, a certified diabetes educator at the University of Southern California Westside Center for Diabetes in Los Angeles. “It’s life-changing for some people. They really learn about their management.”
Nicholas Argento, MD, diabetes technology director at Maryland Endocrine in Columbia, Maryland, agrees. “People need objective feedback and help with organizing a lot of data,” he says. “Companies that invite you to interact with your data and offer insights on challenges are empowering you to use the data to improve your outcomes.”