|RE: Patient's Name and Address:
Patient's Date of Birth: 1957-10-28
To Whom It May Concern:
This letter serves as a Prescription and Letter of Medical Necessity for the above referenced patient for an insulin pump and related diabetic supplies.
The following prerequisites have been met:
- Patient has demonstrated ability to self monitor blood glucose levels (>4X/day).
- Patient is motivated to achieve and maintain improved glycemic control.
- Patient/significant other is physically and intellectually able to operate the pump.
- Patient demonstrates compliance with dietary and insulin regimen consisting of 3 injections per day and a total of 57 units per day.
Patient exhibits one or more of the following:
- Glycosylated hemoglobin level of 7.8 %.
- History of severe glycemic excursions
- Wide fluctuations in blood glucose levels
- Dawn phenomenon
Day to day variations in work schedule, mealtimes, and/or activity level, which confound the degree of regimentation required to self-manage glycemia with multiple daily injections. I certify that this information is correct. The insulin pump has been proven to lower HbA1c resulting in improved diabetes control , lower the risk of hypoglycemia , , reduce hospitalizations due to treatment of extremes in blood glucose , improve quality of life , prevent or delay diabetes complications and increase life expectancy .
-  Insulin pump therapy: A new way to achieve strict metabolic control, and lower the risk of severe hypoglycemia. Boland et. Al, Diabetes, 1998;47 (Suppl 1): #1320
-  Reduction in Severe Hypoglycemia with Long-term Continuous Subcutaneous Insulin Infusion in type 1 diabetes. Bode et al. Diabetes Care 1996;19:324-327.
-  CSII for the Treatment of Diabetic Patients with Hypoglycemia Unawareness. Hirsch et al. Diabetes Nutrition & Metabolism 1991;4:41-43.
-  Lifetime benefits and costs of intensive therapy as practiced in the DCCT. The DCCT research group JAMA 1996;276:1409-1415.
-  Effect of Patient selected Intensive Insulin Therapy on Quality of Life. Chantelau et al. Patient education and counseling 1997; 30:167-173.
-  The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control & Complications Trial (DCCT) N Engl J Med. 1993;329:977-986.