What is the recommended process for ordering a Dexcom (continuous glucose monitoring system) for a 16-year-old female patient with type 2 diabetes mellitus?

Ordering Dexcom CGM for a 16-Year-Old Female with Type 2 Diabetes

Real-time continuous glucose monitoring (rtCGM) or intermittently scanned continuous glucose monitoring (isCGM) should be offered for diabetes management in youth with type 2 diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are capable of using devices safely (either by themselves or with a caregiver). 1

Clinical Eligibility Assessment

Before ordering, verify the patient meets clinical criteria:

• Insulin regimen status: The strongest evidence supports CGM for youth with type 2 diabetes on multiple daily injections (MDI) or insulin pump therapy 1
• Capability assessment: Confirm the patient (or caregiver) can safely operate the device, including understanding alerts, responding to glucose trends, and performing sensor changes 1
• Basal insulin users: If the patient is only on basal insulin (not MDI), CGM can still be offered based on 2024 guidelines that expanded indications to include adults on basal insulin, though youth-specific evidence is more limited 1

Device Selection: Dexcom G6 or G7

For this 16-year-old, Dexcom G6 or G7 are the preferred CGM systems because:

• Both are FDA-approved for treatment decisions without confirmatory fingerstick testing 1, 2
• Dexcom G6 demonstrates 92.3% accuracy within ±20% of reference values and maintains performance through 10 days of wear 2
• The factory-calibrated design eliminates daily fingerstick calibrations, reducing treatment burden 2
• Real-time sharing features allow parents/caregivers to remotely monitor glucose data, which is associated with improved device utilization and glycemic outcomes in adolescents 3

Ordering Process

Step 1: Obtain prescription requirements

• Written prescription specifying: Dexcom G6 or G7 CGM system, quantity of sensors (typically 3 sensors per month for 10-day wear), transmitter (1 every 3 months for G6), and receiver if smartphone is not available 1
• Document medical necessity: Type 2 diabetes diagnosis, current insulin regimen (specify MDI or pump), and clinical rationale for CGM 1

Step 2: Insurance verification and prior authorization

• Submit prior authorization with documentation of insulin therapy (MDI or pump) 1
• Include recent HbA1c values and history of glucose monitoring 1
• Emphasize that guidelines recommend CGM for youth with type 2 diabetes on intensive insulin therapy 1

Step 3: Patient and family education requirements

• Robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use 1
• Training must cover: sensor insertion technique, alert customization, interpreting glucose trends, responding to hypoglycemia/hyperglycemia alerts, and when to perform confirmatory fingersticks 1
• Ensure patient maintains capability to perform self-monitoring of blood glucose for sensor calibration (if using older systems) or verification of discordant readings 1

Step 4: Optimize utilization

• CGM devices should be used as close to daily as possible for maximal benefit 1, 4
• For intermittently scanned devices, instruct scanning at minimum once every 8 hours 1
• Set up Share/Follow features to allow parental monitoring, which is associated with improved outcomes in adolescents (94.8% of youth ages 13-18 use this feature with mean 2.4 followers) 3

Common Pitfalls to Avoid

• Inconsistent use: Emphasize that benefits correlate with ongoing consistent device use; intermittent use reduces clinical value 1, 4
• Inadequate training: Insufficient education is a major barrier to successful CGM adoption; schedule dedicated training sessions before device initiation 1
• Insurance denials: If initial authorization is denied for type 2 diabetes, appeal with guideline citations showing CGM is recommended for youth with type 2 diabetes on intensive insulin therapy 1
• Skin reactions: Assess for skin irritation or allergic reactions at follow-up visits, as these can impair adherence 1
• Gaps in sensor wear: Instruct patient to insert new sensor before removing old one to avoid data gaps 4

Follow-Up Monitoring

• Review CGM data at routine visits focusing on: time in range (70-180 mg/dL), time below range (<70 mg/dL and <54 mg/dL), time above range (>180 mg/dL), and glucose management indicator 1
• Assess device utilization patterns and troubleshoot barriers to consistent use 1
• Evaluate technical competency and reinforce proper sensor insertion technique 1