PRIOR APPROVAL

Flash Glucose Monitoring System – Application for the continuation of funding for use in adults, young people and children 4 years of age and older with diabetes mellitus as defined in NHS England criteria, March 2019.

Patient NHS No.

Trust	GP name
Patient hospital number	Consultant making request	GP code/ Practice code
Patient initials and date of birth	Consultant contact details	GP post code
Only fully completed forms will be accepted for consideration.

If the patient does not meet routine commissioning criteria, please consider if there are any individual exceptional clinical circumstances.

Please see http://www.miltonkeynesccg.nhs.uk/referrals-and-priorities-policies/

.

I confirm that the person is under the care of the Diabetes Specialist Team	Yes
2. Please confirm which indication(s) apply to this person (please tick box or type X and provide details requested)
2.1 Type 1 diabetes OR other form of diabetes on haemodialysis and on insulin treatment with intense monitoring > 8 times a day

2.2 Diabetes associated with cystic fibrosis on insulin treatment

2.3 Type 1 diabetes and pregnant please state due date………………………………………………………………………………………………….

2.4 Type 1 diabetes with disability that requires carers to support management

2.5 Type 1 diabetes with occupational circumstances please state occupation…………………………………………………………………………

2.6 Type 1 diabetes with psychosocial circumstances please state details………………………………………………………………………………

2.7 Type 1 diabetes with recurrent severe hypoglycaemia

2.8 Type 1 diabetes with impaired awareness of hypoglycaemia
Baseline HbA1c

Target HbA1c

Current HbA1c

Please confirm that there has been an improvement in symptoms

Yes No

If Yes, Please provide details on clinical improvement in symptoms e.g. reduction in hypoglycaemic episodes, reduction in DKA, improvement in psychosocial wellbeing

…………………………………………………….……………………………….…………

…………………………………………………….……………………………….…………
Average number of blood glucose tests performed per day at baseline	Average number of blood glucose test strips performed per day over the last 3 months	Evidence confirmed by	BG meter data download Diagnostic CGM	Please state the patient’s next anticipated review date:

………………………………

3. I confirm that the patient contract completed at initiation has been discussed (signed by the patient/ carer and member of the specialist team) and that the patient is aware that if they do not use the technology appropriately it will be discontinued, and that funding policy will be subject to review and may be stopped in the future (please tick box or type X)	Yes

4. I confirm that the patient /parents/carers has been assessed as being able to competently continue using the device, interpret readings and they are willing continue to take appropriate action as documented in the patient contract e.g. appointment attendance, scanning at least eight times a day, data sharing, participation in national audit and use of a formulary cost effective strip (please tick box or type X)	Yes

5. I confirm that the specialist diabetes team will send timely communication to the GP, to continue the supply of the sensors, following the review of flash glucose monitoring system in clinic (please tick box or type X)	Yes

6. Continuation of funding

Funding will be provided for continuation of treatment where there is clear evidence of an initial and ongoing adequate response to treatment. This information should be submitted via a follow-up form which will require Prior Approval
7. Please provide any other relevant information

8. I confirm that the patient (or in the case of a minor or vulnerable adult where the parent/guardian or legal carer) has given consent for the patient identifiable data on this form to be shared with the CCG Medicines Management / Optimisation or Contracts Team. This data may then be used 1. In the interests of the care of the patient 2. For clinical audit purposes 3. To validate against subsequent invoices.	Yes No

Form completed by
Date:

I confirm that the patient continues to meet the criteria for the technology: Consultant/Specialist Diabetes Nurse/Dietician signature*
Date

*Electronic signatures are acceptable

NHSE Criteria, March 2019, for Flash Glucose Monitoring Funding:-

1. People with Type 1 diabetes

OR with any form of diabetes on haemodialysis and on insulin treatment

who, in either of the above, are clinically indicated as requiring intensive monitoring >8 times daily, as demonstrated on a meter download/review over the past 3 months

OR with diabetes associated with cystic fibrosis on insulin treatment

2. Pregnant women with Type 1 Diabetes - 12 months in total inclusive of post-delivery period. 3. People with Type 1 diabetes unable to routinely self-monitor blood glucose due to disability who require carers to support glucose monitoring and insulin management.

4. People with Type 1 diabetes for whom the specialist diabetes MDT determines have occupational (e.g. working in insufficiently hygienic conditions to safely facilitate finger-prick testing) or psychosocial circumstances that warrant a 6-month trial of Libre with appropriate adjunct support.

5. Previous self-funders of Flash Glucose Monitors with Type 1 diabetes where those with clinical responsibility for their diabetes care are satisfied that their clinical history suggests that they would have satisfied one or more of these criteria prior to them commencing use of Flash Glucose Monitoring had these criteria been in place prior to April 2019 AND has shown improvement in HbA1c since self-funding.

6. For those with Type 1 diabetes and recurrent severe hypoglycaemia or impaired awareness of hypoglycaemia, NICE suggests that Continuous Glucose Monitoring with an alarm is the standard. Other evidence-based alternatives with NICE guidance or NICE TA support are pump therapy, psychological support, structured education, islet transplantation and whole pancreas transplantation. However, if the person with diabetes and their clinician consider that a Flash Glucose Monitoring system would be more appropriate for the individual’s specific situation, then this can be considered.

Other requirements:

1. Education on Flash Glucose Monitoring has been provided (online or in person)

2. Agree to scan glucose levels no less than 8 times per day and use the sensor >70% of the time.

3. Agree to regular reviews with the local clinical team.

4. Previous attendance, or due consideration given to future attendance, at a Type 1 diabetes structured education programme (DAFNE or equivalent if available locally)

Note: Continuing prescription for long-term use of Flash Glucose Monitoring-post initial 6 months- would be contingent upon evidence of agreeing with the above conditions and that on-going use of the Flash Glucose Monitoring is demonstrably improving an individual’s diabetes self-management- for example improvement of HbA1c or Time In Range; improvement in symptoms such as DKA or hypoglycaemia; or improvement in psycho-social wellbeing.

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This form should be returned to mkccgpharmacy@nhs.net

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