RR 1
Anywhere, ON
A1B 2C33

Patient's Date of Birth: 1957-10-28
HN#: 123456789

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 [1], lower the risk of hypoglycemia [2], [3], reduce hospitalizations due to treatment of extremes in blood glucose [4], improve quality of life [5], prevent or delay diabetes complications and increase life expectancy [6].

__________________________________________________________________________

References

• [1] 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
  
• [2] Reduction in Severe Hypoglycemia with Long-term Continuous Subcutaneous Insulin Infusion in type 1 diabetes. Bode et al. Diabetes Care 1996;19:324-327.
  
• [3] CSII for the Treatment of Diabetic Patients with Hypoglycemia Unawareness. Hirsch et al. Diabetes Nutrition & Metabolism 1991;4:41-43.
  
• [4] Lifetime benefits and costs of intensive therapy as practiced in the DCCT. The DCCT research group JAMA 1996;276:1409-1415.
  
• [5] Effect of Patient selected Intensive Insulin Therapy on Quality of Life. Chantelau et al. Patient education and counseling 1997; 30:167-173.
  
• [6] 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.