Letters to the Editor

January 2002

Jan 1, 2002

When Will Medicare Cover the Cost of Insulin Pumps for Type 2s?

I am a loyal Diabetes Health subscriber. I have a personal and professional interest in a Business Brief entitled "Medicare Chips In, More Diabetes Patients May Now Be Able to Get Insurance Coverage for Pumps" (August 2001, p. 20). I was very excited to see this information since the company I represent processes insulin pumps for potential pump candidates inclusive of Medicare patients.

All documentation from Medicare currently states that Medicare covers only type 1 patients per their guidelines. You cited information in the article that people with type 2 diabetes and a C-peptide level of 1.0 ng/ml or less may also be able to get coverage for their insulin pump.

The new guidelines you mentioned in your article are not yet released in any documents by Medicare, from what we have been told by region representatives and our local ombudsman. We have been told that if we provide an insulin pump to a new type 2 patient with a C-peptide level between 0.6 ng/ml and 1.0 ng/ml, the pump will be denied and the patient would be ultimately responsible for the charges.

Physicians and patients alike are reading articles about this in many journals and insisting that Medicare will pay when, in fact, it is not paying for type 2 patients or patients with elevated C-peptide.

I am aware of a clinical study that was performed under the auspices of the Health Care Finance Administration (HCFA), entitled "Medicare Coverage Policy - Decisions - C-Peptide Levels as a Criterion for Use of the Insulin Pump (#CAG-00092A)." It is an excellent study; however, it does not replace the Medicare guidelines.

You have a wonderful magazine, and I use it many times for in-servicing our staff. You always have the latest and greatest information. Thank you for the updates from someone who has had diabetes for 38 years!

Janet O'Neil
Manager of Customer Service
Weston, Florida

Editor's note: Thank you for your letter. According to our knowledge, Medicare may change its guidelines at some point—"may" being the operative word. The guidelines have not yet changed to cover new Medicare recipients with type 2 diabetes who meet the other criteria, according to Disetronic Medical Systems. We realize that this type of announcement could cause confusion about whether or not the change in coverage is in effect. Medicare has not given out further information about when the change might take place.

More Coverage of Lantus

In all fairness to people with type 1 diabetes who do or do not use pumps, Lantus deserves far more coverage than Diabetes Health is giving it.

I have seen my HbA1c levels drop dramatically, from 9% to 7.2%, in my first three months of using Lantus. I take one injection per day at bedtime. I no longer have to mess around with basal settings and attachments that come with using a pump. I have encountered increasing numbers of ex-pump users who have switched to Lantus, and increasing numbers of diabetes specialist doctors who are prescribing it.

I can't understand why such a miraculous product, which can help so many, is not covered more often.

Robert Dehlendorf
Bozeman, Montana

Question About How to Use Lantus

Recently you had an article about the new Lantus insulin ("A One-Shot-a-Day Insulin Is Here," July 2001, p. 41). I took the article to my doctor, and he gave me a prescription for Lantus. But I'm having trouble figuring out how to fit it into my program.

I take UL (Ultralente) insulin morning and evening for a base, take Regular insulin with each meal, and take NPH insulin at bedtime to offset the sunrise effect. Should I take Lantus in place of the UL and, if so, how much compared to the UL?

I tried to call the 800 number of Aventis, the manufacturer of Lantus, and was just told to see my doctor.

William Nichols
New Wilmington, Pennsylvania

Editor's note: We asked endocrinologist Steven Edelman, a member of our advisory board, to reply.

If you take Regular with each meal, I would recommend that you first switch to lispro (Humalog) or aspart (Novolog). Then replace the UL and NPH with Lantus equal to the total UL dose. Then follow your morning blood-glucose levels carefully and add in the NPH at night if you still need to control the dawn phenomenon.

Steven V. Edelman, MD
Veterans Hospital
San Diego, California

Cindy Onufer, RN, MA, CDE, our consulting medical editor, adds:

It is important to know that the clear, colorless, 24-hour-acting basal insulin glargine (Lantus) is recommended for once-daily injection (usually at bedtime) and cannot be mixed with any other type of insulin. If you need to take a small dose of NPH at night to treat dawn phenomenon, the NPH must be in a separate syringe (or an insulin pen). In addition, the key to success with using the rapid-acting insulin (lispro or aspart) is to gain skills at carbohydrate counting and use your carbohydrate-to-insulin ratio to adjust doses at each meal or large snack.

Question About the Glycemic Index

I am confused by your article on the Glycemic Index (GI) ("The Glycemic Index In-Depth," October 2001, p. 46). It says that the American Diabetes Association (ADA) has changed its stance on sugar because "a carbohydrate is a carbohydrate is a carbohydrate." In other words, foods with a high GI are considered equal, regardless of what kind of foods they are.

Supposedly, different types of food with the same GI enter the bloodstream in about the same amount of time. How much difference does it really make if you eat refined sugar, a potato or an apple? How many minutes are we talking about? I know if I use glucose to treat low blood glucose, it will take effect faster than a marshmallow, but the time difference is only about 10 minutes. To treat a low that is huge, how much difference does it really make which types of food you eat in terms of normal dietary intake?

Polly Thosath Carlson
Spokane, Washington

Editor's note: We asked Marion J. Franz, MS, RD, CDE, to respond.

When professionals talk about "a carbohydrate is a carbohydrate is a carbohydrate," they are referring to the recommendation from the American Diabetes Association that the total amount of carbohydrate in the food and meal—and not the source or the type of the food—is the first priority when planning food and meals.

However, it is also true that different carbohydrates do have different glycemic responses. When researchers compare 50 grams of glucose to different foods that also contain 50 grams of carbohydrate, they note some differences in the glucose peak of the different foods. The Glycemic Index refers mainly to the peak response and not to how quickly glucose from foods enters the bloodstream. Indeed, the rate at which the glucose from different foods enters the bloodstream is very similar. The response to glucose (or bread) is assumed to be 100 percent, and different carbohydrates, based on their glucose response, are given their percentage response compared to glucose (or bread). This is called their GI. There is a great deal of individual variation in the response to different sources of carbohydrate, which makes it very difficult to make recommendations that apply to everyone with diabetes. So the bottom line is that people with diabetes should begin by considering the total amount of carbohydrate in foods and meals, and then, by using pre- and post-meal glucose responses, they can determine whether some foods, even if the carbohydrate is equal, produce a greater glucose response. If you discover this, it may mean that next time you need to eat less of that particular food or take additional pre-meal rapid-acting insulin or medication.

Marion J. Franz, MS, RD, CDE
Nutrition Concepts by Franz, Inc.
Minneapolis, Minnesota

A Low-Carbohydrate Diet Controls My Diabetes

In February 2000, I was diagnosed with type 2 diabetes. I immediately went on a low-carbohydrate diet, eating no more than 30 grams per day of carbs. My cholesterol dropped from 270 to 165. My bad (LDL) cholesterol dropped to 90, and my triglycerides went down to 125. I have never felt better. I find it hard to understand why anyone with type 2 diabetes would eat bread or pasta. Yet, they continue to do so.

My blood-glucose levels are under control (84.120 mg/dl), and my HbA1c is 4.9%. All this was achieved without taking any medications. Just strict adherence to a low-carb diet.

Herbert M. Kay
Point Charlotte, Florida

Thank You for Your Article About People With Diabetes in Jail

I was recently diagnosed with type 2 diabetes while I was incarcerated. I am still in jail. While I was visiting a hospital at the University of California-San Diego, I was blessed to have run across a copy of Diabetes Health. It has given me great insight and has provided me with more information about diabetes than the medical staff at the jail has. I would think that the medical staff at my jail would at least give me some sort of orientation, dietary advice or guidelines to follow. Regarding your article on police ("Officers of the Law Ignore Special Needs of People With Diabetes," October 2001, p. 37), I need this information as a form of support for some of my grievances about issues such as food, nutrition, exercise and neuropathy. The information in the article will help me and other people with diabetes in jail controlled by authorities who are insensitive to this life-threatening ailment. It will also help people like me who are newly diagnosed and somewhat ignorant about the issues—the treatment and politics—surrounding incarceration and diabetes.

Thank you for helping me and other people with diabetes in jail who are trying to live normal lives.

Roderick Mabry
San Diego, California

Officers of the Law Are Trained About Diabetes Awareness

I am a bilingual CDE who appreciates your magazine! Not only has Diabetes Health educated, stimulated and entertained me, but it has made me think about the patients I serve.

Your recent article about people with diabetes who were mistreated by the police prompted me to write to you about my personal experience with the Denver, Colorado, sheriff's training department. Since 1997, I have been giving one-hour orientations on diabetes and hypoglycemia awareness three to four times per year. There are anywhere between eight and 30 attendees in each class. These employees of the sheriff's department are interested in learning how to deal with people with diabetes who need their help. It has been a rewarding experience for all of us. The truth is that law enforcement is present when people need help.

I want to let you and your readers know that officers of the law in Colorado are trained to be knowledgeable about the symptoms of hypoglycemia. This condition is not only a threat to inmates but is a possible threat to police officers as well.

Silvia Almanza, RN, CDE
Aurora, Colorado

A Clarification About CDE Certification

The Board of Directors of the National Certification Board for Diabetes Educators (NCBDE) would like to clarify information about the certification program. This letter is written in response to a letter by Alice Buck, RN, and a response to her letter by Carole Mensing, RN, CDE, that ran in the February 2001 issue of Diabetes Health (p. 11).

In the letter, Alice Buck talked about the American Association of Diabetes Educators (AADE) and its stringent requirements for getting a Certified Diabetes Educator (CDE) certification.

Independent and separate from other organizations, including the AADE and the American Diabetes Association (ADA), the NCBDE is the board responsible for the development and administration of the certification program for diabetes educators. The Certification Examination for Diabetes Educators is considered to be a mastery-level examination, not entry-to-practice. This is reflected in the professional education and professional practice eligibility guidelines. The professional practice experience requirements—effective since 1998—include a minimum of two years' experience in diabetes self-management education, a minimum of 1,000 hours of diabetes self-management education experience within the past five years, and a requirement that the applicant be currently practicing as a diabetes educator at the time of application for the certification examination.

The CDE credential demonstrates to patients, employers and the public that the certified healthcare professional has met education and experience requirements and possesses distinct and specialized knowledge. Recognition of the value of the CDE credential by employers who require it for employment and by states that require it to get reimbursement for diabetes education services is a distinction the NCBDE is proud to have achieved. It is important to understand, however, that the employer or the agency, not the NCBDE, chooses whether or not the CDE credential is required.

Anyone with questions or concerns about the certification may contact the NCBDE on the Web at www.ncbde.com; by phone at (847) 228-9795; by fax at (847) 228-8469; or by mail at E. Algonquin Road, Suite #4, Arlington Heights, Illinois 60005.

Joyce E. Bohren, MEd
Executive Director, NCBDE
Arlingon Heights, Illinois

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