FAQs: Diabetes and DOT Physicals

FAQs for the Final rule published 9/19/18

When does the new rule take effect?

November 19, 2018

The new rule specifies a “TC”. What is this?

The “TC” or “Treating Clinician is “the healthcare professional who manages, and prescribes insulin for, the treatment of the individual’s diabetes as authorized by the healthcare professional’s State licensing authority.

The new rule specifies “ITDM”. What is this?

ITDM stands for “insulin-treated diabetes mellitus.

What is form MCSA-5870?

This is the form where the “TC” will attest that the individual maintains a stable insulin regimen and proper control of his or her diabetes.

You can find form MCSA-5870 here.

How long does the driver have to get a physical after the TC completes form MCSA-5870?

A DOT Physical must be conducted no later than 45 days after the TC completes form MCSA-5870.

How long can an insulin-dependent diabetic be certified?

Maximum certification is 12 months.

What if an insulin-dependent diabetic has a severe hypoglycemic episode?

If an insulin-dependent diabetic has a severe hypoglycemic episode they are prohibited from driving and must report to their TC (Treating Clinician) as soon as reasonably practicable. The prohibition is in effect until the individual again has a stable regimen and the treatment is under control. The TC must then complete a new MCSA-5870 form. The FMCSA does not explicitly state that a new physical will be required, but existing regulations require a new physical to be conducted “whose ability to perform his/her normal duties has been impaired by a physical or mental injury or disease” (49CFR391.45). There is no minimum waiting period after a severe hypoglycemic episode until a driver may resume activities if approved by their TC. The reason is that many severe hypoglycemic episodes are often the result of short-term causes and so no mandatory waiting time fits all circumstances.

What issues can cause a driver with insulin-dependent diabetes from being qualified?

Individuals with severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy are permanently disqualified.

What if a driver already has a diabetes waiver and is “grandfathered” under 49CFR391.64?

The “grandfather” regulation in 49CFR391.64 will be eliminated by this rule, effective November 19, 2019.  All drivers will then be required to follow this rule and the modified regulations.

Can ITDM (Insulin-Treated Diabetes Mellitus) drivers transport passengers or Hazardous materials?

The rule concludes that any individual who maintains a stable insulin regimen and proper control of their ITDM can operate any category of CMV (Commercial Motor Vehicle) safely.

Do I still need to visit my endocrinologist?

The FMCSA realized that there is a doctor shortage, and endocrinologists are not available in all parts of the country. This is why they created the term “TC” or Treating Clinician. Whether it is an endocrinologist, or family doctor, or nurse practitioner, whoever is licensed in your state and provides your treatment will be the person responsible for filling out the evaluation form MCSA-5870.

What does the driver have to provide the TC for the evaluation?

The rule requires that the driver provide at least 3 months of self-monitored blood glucose readings to the TC in order to qualify for the maximum 12 month physical. The frequency of the monitoring is determined by the TC. The rule does state that the readings must be made by a glucometer that can download and print the readings for the use of the TC.

What if an ITDM (Insulin-Treated Diabetes Mellitus) driver does not have 3-months of self-monitored blood glucose readings?

The CME (Certified Medical Examiner) has the discretion to grant the individual up to but not more than a 3-month MEC to allow time for the individual to collect the necessary records.

How often does a driver have to self-monitor their blood glucose?

The rule does not establish a frequency of self-monitoring. The TC and the driver will work together to ensure that sufficient monitoring is available for an informed decision.

What will the TC have to certify?

The TC will have to certify that the driver’s insulin regimen is effective and stable. They will have to state that there has been no severe hypoglycemic episode resulting in a loss of consciousness or seizure, or requiring the assistance of another person, or resulting in impaired cognitive function.

Will ITDM (Insulin-Treated Diabetes Mellitus) drivers be required to carry “readily-absorbable glucose” in case of a moderate or severe hypoglycemic episode (low blood sugar affecting consciousness)?

The rule does not require ITDM drivers to carry “readily-absorbable glucose”. Any medicine or treatment required will be determined by the TC.

Who decides if a driver is qualified, the TC (Treating Clinician) or the CME (Certified Medical Examiner)?

The qualification decision is the responsibility of the CME. Their job is to examine the driver and make a qualification decision. Any medical condition disclosed by the driver should be accompanied by a release. This is true with mood disorders, sleep apnea, and now ITDM (Insulin-Treated Diabetes Mellitus). The FMCSA considers this a two-step process for each medical condition that affects the physical.

How long does the TC have to treat a driver before filling out the evaluation form MCSA-5870?

The FMCSA does not require the TC treat the driver for any specific period. It is up to the independent medical judgment of the TC if they have sufficient information to complete the form.

Will eye exams be required?

The only required eye exam will be the standard vision test performed by the CME during the DOT Physical exam. Any additional testing, such as eye exams, A1Cc testing, neuropathy exams, will be the responsibility of the TC before completing the evaluation form MCSA-5870.

Are A1C tests required?

The evaluation form MCSA-5870 does ask if HbA1C has been measured intermittently over the last 12 months, with the most recent measure within the preceding 3 months. The most recent result should be attached to the form. However, not having an A1C result does not automatically disqualify a driver.

Is the A1C limit still 10%?

In 2015, the FMCSA MRB (Medical Review Board) recommended that anyone with uncontrolled diabetes should be disqualified from operating a CMV (Commercial Motor Vehicle). “Uncontrolled” was determined to be 10% or higher. However, this one size fits all number has been determined to be unfair for a number of reasons (racial bias, test accuracy, individual glycation rate). Additionally, while a “high” A1C is a clear indicator of a health risk, it does not show any hypoglycemic episodes (consciousness affected when blood sugar gets too low). For these reasons, it is now discouraged to qualify or disqualify a driver based on A1C alone. It is up to the independent medical judgment of the TC (Treating Clinician) to determine if a driver maintains a stable insulin regimen and proper control of his or her diabetes.

Will the driver’s diabetes information fall under HIPAA?

Yes. The rule states that a driver would have to provide his or her consent for a TC or certified ME to share medical information with other entities, including the motor carrier.

What is the CMS opinion on this rule?

CMS has been a “second set of eyes” for the benefit of our clients and Certified Medical Examiners for over 20 years. We have reviewed hundreds of thousands of physicals, and have seen every specific situation imaginable. We were on the TIDA (Trucking Industry Defense Association) discussion board last year to examine what happens when a DOT Physical is not completed correctly and a major traffic accident happens.

Overall, this rule is fair and needed in our current driver shortage. Today’s medicines allow people to live very normal lives with a good insulin treatment program.

The rule does place a large amount of responsibility on the TC (Treating Clinician), a person whose motivation is to have their patient continue care with them. If a TC feels a driver may not quite be qualified, they will realize that the patient can go to another provider down the street and may be encouraged to not act in the interest of public safety.

Also, the requirement for a driver to report severe glycemic episodes and voluntarily place themselves out of service is rubbish. 90+% of drivers will not self-report conditions that negatively affect their income and way of life.

The absolute worst thing that can happen to a driver (and the poor souls around her or him) is a loss of consciousness while moving 50,000 pounds at 50 mph. This is why sleep apnea is a big deal, and why medicines that affect consciousness or pain are a big deal. This is why insulin-dependent diabetics have been automatically disqualified for the past 70 years. A driver who is on a stable regimen and tolerates medicine well is relatively safe. Time will tell if this new rule is too lenient or not, and the measurement will be in human lives.