Insulin-treated diabetes (first and second class)

Your step-by-step plan

1. 1

   Step 1: Collect at least 6 months of CGM data

   Item 3: monthly data, the reports to send, the targets, and the device and any pump.6 months of data

   Monthly CGM data for the preceding 6 months, up to 12 months when available, from a CGM that meets the FAA's requirements.

   Stability

   • At least 6 months of stable, adequate control, shown by the CGM data
   • A new diagnosis, or any concern about control, may call for a longer period

   Reports for each month

   DexcomMedtronicAny other device

   Dexcom: for each month of data

   • Overview Report
   • Ambulatory Glucose Profile (AGP) Report
   • Alert Settings
   • Weekly Overlays/Graphs (for each week of the month)

   Medtronic: for each month of data

   • Assessment & Progress Report
   • Weekly Overlays/Graphs (for each week of the month)

   Any other device: for each month of data

   • estimated A1c (and/or glucose management indicator [GMI])
   • average glucose
   • coefficient of variation
   • standard deviation
   • time in range
   • sensor usage
   • weekly overlays/graphs

   Original digital reports, in colour when possible.

   Each report must show

   • Time in range, 70–180
   • Average glucose
   • Standard deviation
   • Coefficient of variation, if the software gives it
   • Alarm settings, high and low on
   • Device make and model
   • Weekly glucose graphs
   • Not: No daily or hourly pump statistics

   Targets

   Sensor wear

   90% or more

   Time in range, 70–180 mg/dL

   70% or more

   Overall readings, 70–250 mg/dL

   90% or more

   Readings under 70 mg/dL

   Less than 4%

   Readings under 54 mg/dL

   Less than 1%

   Readings over 250 mg/dL

   Less than 5%

   Coefficient of variation

   36% or less (under 33% preferred)

   Glucose management indicator

   Less than 7%

   Auto Mode

   More than 90%

   Meeting the targets is not enough on its own: the weekly graphs must also show consistent control, with few readings under 70 or over 250 mg/dL.

   Your CGM

   • FDA-approved, appropriate for your age
   • Real-time, no manual scanning
   • Predictive arrows that warn before highs and lows
   • Adjustable high and low alert levels
   • Accuracy (MARD) of 10% or less
   • Calibrated as often as required
   • Your own, unblinded, never shared
   • Alarms and repeat alarms on

   If you use an insulin pumpA pump is not required.

   • Can suspend insulin for a predicted low or a pressure change
   • Insulin FDA-approved for pump use
   • Pump FDA-approved with your CGM, separately and together
   • Not: No self-built systems

   Show the FAA's words: Collect at least 6 months of CGM data

   ITEM # 3 Monthly CGM data with a device that meets FAA requirements for the preceding 6 months (up to 12 months when available).

   CGM data should demonstrate consistent, effective ongoing use; time-in-range (70– 180 mg/dL); and for excursions below 54, below 70, and above 180, and above 250 mg/dL.

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   The individual must demonstrate stability and adequate control, verified by CGM data, for a minimum of 6 months. If a new diagnosis of Insulin-treated Diabetes Mellitus (ITDM) or any concern regarding adequacy of control exist, this may require a longer stability period.

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   Consideration will be given to those individuals who have been clinically stable on their current treatment regimen for a period of 6-months or more.

   FAA source: Guide for Aviation Medical Examiners – Diabetes Mellitus Type I or Type II, Insulin Treated (CGM option, all classes). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   When providing CGM Data reports, for each month of data, include the following reports based on your device. Submit the original digital reports IN COLOR (when possible):

   DEXCOM

   Overview Report

   Ambulatory Glucose Profile (AGP) Report

   Alert Settings

   Weekly Overlays/Graphs (for each week of the month)

   MEDTRONIC

   Assessment & Progress Report

   Weekly Overlays/Graphs (for each week of the month)

   OTHER DEVICES

   …The data report should include estimated A1c (and/or glucose management indicator [GMI]), average glucose, coefficient of variation, standard deviation, time in range, sensor usage, and weekly overlays/graphs.

   A. CONTINUOUS GLUCOSE MONITOR (CGM) DATA on a device that meets the FAA’s minimum CGM device feature requirements.

   1. Readings from (at a minimum) the preceding 6 months for initial certification and thereafter 3 months.

   2. Analyze to identify percentage of time in the following ranges:

   a) Less than 54 mg/dL

   b) Less than 70mg/dL

   c) Between 70 and 180 mg/dL

   d) Above 180 mg/dL

   e) Above 250 mg/dL

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   DO Submit the required weekly or monthly graphs.

   …DO NOT submit daily or hourly statistics from insulin pumps.

   …6. Printout reports must include monthly summary showing: Time-In-Range (TIR) Values for 70-180 mg/dL; Average Glucose Levels; Standard Deviation (SD); and (when provided by the reporting software) Coefficient of Variability [CoV] values. Reports must include weekly glucose value data graphics. All data must be legible.

   …a) Time-In-Range (TIR) Values for 70-180 mg/dL;

   b) Average Glucose Levels;

   c) Standard Deviation (SD); and (when provided by the reporting software)

   d) Coefficient of Variability [CoV] values;

   e) Alarm Settings, indicating both high and low alarms are active;

   …f) Device manufacturer and current model; and

   g) Reports must include weekly glucose value data graphics. All data must be legible. Failure to provide these values could result in a delay in processing the application.

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   Parameter Target Range for Certification Consideration

   Auto Mode Greater than 90%

   Coefficient of Variance Less than or equal to 36% (< 33% preferred)

   Glucose Management Indicator (GMI) Less than 7%

   Glucose readings - less than 54 mg/dl less than 1%

   Glucose readings - less than 70 mg/dl less than 4%

   Glucose readings - greater than 250 mg/dl less than 5%

   Overall glucose readings - 70-250 mg/dl 90% or greater

   Sensor wear 90% of the time or greater

   Time in Range (TIR) of 70*-180 mg/dl 70% or greater

   *Note: TIR 70 per ADA guidance.

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   While it is important that the CGM data meets the FAA CGM goals noted below, it is also essential that the weekly graphs/overlays demonstrate consistent glycemic control with minimal excursions below 70 mg/dL and/or above 250 mg/dL.

   If the CGM data meets the CGM goals but glycemic control is inconsistent on the weekly graphs/overlays, this will be considered unacceptable and may jeopardize medical certification eligibility.

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   B. CGM DEVICE FEATURES: The FAA does not endorse any particular manufacturer, however, the CGM device must have the following features:

   1. Must be FDA-approved and appropriate for age;

   2. Must be a real-time CGM (automatically transmits glucose data to the user) without the need to manually scan the sensor (e.g., intermittently scanned CGM);

   3. Have “predictive arrow trends” that provide warnings of potentially dangerous glucose levels (high or low) before they occur;

   4. Able to customize low and high glucose levels;

   5. Have a high-accuracy rating with an overall Mean Absolute Relative Difference (MARD) of 10% or less.

   …6. Printout reports must include monthly summary showing: Time-In-Range (TIR) Values for 70-180 mg/dL; Average Glucose Levels; Standard Deviation (SD); and (when provided by the reporting software) Coefficient of Variability [CoV] values. Reports must include weekly glucose value data graphics. All data must be legible.

   …7. Calibrated to at least the minimum frequency required by the manufacturer or endocrinologist;

   …8. Must be the individual’s own, unblinded CGM that cannot be shared with anyone else.

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   The individual cannot use anyone else’s CGM (e.g., blinded CGM device, which is professional use only).

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   NOTE: CGM Alarm Settings and Repeat Alarm Settings should be turned ON.

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   SETTINGS: Alarm Settings and Repeat Alarm Settings should be turned ON

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   C. INSULIN PUMP REQUIREMENTS:

   1. If using an insulin pump, it must have the ability to suspend insulin for a predictive low glucose or predicted pressure changes;

   2. Insulin used in the pumps must be FDA approved for that use; and

   3. Insulin pumps must also be FDA approved as compatible with the CGM device. (Not all CGM devices are compatible with all insulin pumps.)

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   15. Do I have to get an insulin pump?

   No. However, if you choose to get an insulin pump, both the pump and CGM need to be FDA approved, both separately and in combination. Self-built systems are NOT acceptable for flying.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   CGM devices that currently meet the required features (as of 08/30/2023) include:

   Dexcom G7

   Dexcom G6

   Dexcom G5

   Dexcom G4 PLATINUM

   Freestyle Libre 3

   Medtronic MiniMed 670G system CGM with insulin pump

   Medtronic MiniMed 630G system CGM with insulin pump

   Medtronic MiniMed 780G system CGM with insulin pump

   Medtronic Guardian Connect CGM system

   Senseonics’ Eversense CGM (90-day monitor)

   Senseonics’ Eversense E3 CGM (180-day monitor)

   This list may not be all-inclusive. Refer to the CGM Device Features in Item B.

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   6. Why is the blood sugar range so narrow?

   The recommended blood glucose range is not intended to be “narrow,” but reflects generally accepted treatment guidelines and the needs of safety. Safety concerns arise when blood sugar falls outside of the 70mg/dl - 250 mg/dL range.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   13. I know I have to submit CGM data to the FAA. How do I get this information?

   Most devices have the ability to print out customized data reports to your computer. Check your device’s user guide for instructions as well as computer and software requirements as these may differ between manufacturers. (Note: Some devices will not allow the export of data onto your phone or tablet.)

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

2. 2

   Step 2: Get the 4 required reports

   Items 1, 2, 4 and 5, each performed within the past 90 days.Four things to bringOne question inside

   Are you 40 or older?

   Are you 40 or older?

   The cardiac requirements differ at age 40.

   40 or olderUnder 40

   • Endocrinology reportItem 1

     Within 90 days before the exam

     An in-person comprehensive evaluation by your treating board-certified endocrinologist, within the past 90 days.

     What to send

     • The actual, current, detailed clinical progress note
     • It may be labelled a progress note, consultation note, or history and physical
     • Not: Not from a mid-level practitioner
     • Not: Not a patient encounter summary or a letter

     The note must cover

     • Diabetes history: onset, past treatment, hospitalizations
     • Complications and other conditions
     • Lifestyle: eating, weight, sleep, activity, tobacco, alcohol, substances, driving incidents
     • Medications: compliance, side effects, alternative medicine
     • Glucose monitoring results and pump settings
     • Screens for depression, anxiety, disordered eating and cognition
     • Diabetes education and barriers to self-management
     • Lows and highs in the past 12 months
     • Physical exam: BMI, blood pressure, thyroid, skin and a full foot exam
     • Assessment, 12-month prognosis and treatment changes
     • The date of the next follow-up, every 3 months for the FAA

     Sustained lows, for example: under 70 for over 30 minutes, or under 54 for over 15. Sustained highs, for example: over 250 for over 60 minutes, or over 300 for over 30.

   • Laboratory panelItem 2

     Within 90 days before the exam

     The comprehensive laboratory panel, performed within the past 90 days.

     The panel

     • A1C from the last 90 days, plus every value from the 12 months before
     • Complete blood count
     • Lipids: total, LDL and HDL cholesterol, triglycerides
     • Liver function tests
     • Microalbumin or urine albumin-to-creatinine ratio
     • Kidney function: creatinine, BUN, eGFR
     • Thyroid-stimulating hormone (TSH)
     • Vitamin B12, when clinically indicated
     • Potassium, when clinically indicated or on an ACE inhibitor, ARB or diuretic

   • Eye evaluationItem 4

     Within 90 days before the exam

     An eye evaluation from a board-certified ophthalmologist, performed within the past 90 days. Without retinopathy, an optometrist may be acceptable.

     It must include

     • Visual acuity, with and without correction, each eye and both: near, intermediate and distance
     • Cataracts, if any
     • Colour vision, with the test and method used
     • Eye pressure (IOP), with the test and method, and any treatment
     • Visual fields, with the test and method; confrontation fields are acceptable
     • A dilated fundus exam: no retinopathy, or its degree and any treatment
     • Diagnosis, prognosis and recommendations

   • Cardiac evaluationItem 5

     Within 90 days before the exam

     A comprehensive, in-person cardiac risk evaluation from a board-certified cardiologist, with lab work and an ECG, performed within the past 90 days.

     The evaluation

     • By the cardiologist, not a mid-level practitioner
     • A baseline ECG, whatever your age
     • The actual, detailed clinical progress note
     • Not: Not an after-visit summary or a letter
     • If anything is abnormal: a report on the diagnosis, symptoms, risk factors, treatment, other tests, and the yearly risk of a disabling cardiac event

     Stress testFrom age 40

     • Maximal treadmill test (Bruce)
     • 100% of predicted maximum heart rate, unless symptoms, medications or a medical reason prevent it
     • Complete Stage 3, at least 9 minutes
     • The worksheet, the interpretive report and all the actual ECG tracings: at rest, every stage, peak and recovery

     Under 85% of maximum heart rate and under 9 minutes (6 from age 70) may lead to denial. Computer-generated sample tracings are not accepted in place of the actual ones.

     The FAA asks that beta blockers, diltiazem, verapamil and digitalis be held 24–48 hours before the test, unless contraindicated and only with your treating physician's consent. If they are not, the cardiologist explains why.

     With a bundle branch block, LVH or diffuse ST/T wave changes at rest, the FAA requires a stress echo or nuclear stress test.

     The AME may not issue if the test shows

     • Exercise test: under 85% of predicted maximum heart rate; under 9 minutes (under 6 from age 70); or ST depression of 1 mm or more, unless further evidence, such as a nuclear study or stress echo, reviewed and reported by a qualified cardiologist, shows no reversible ischemia or wall motion abnormalities
     • Nuclear stress test: reversible ischemia, a negative change from the prior study of the same type, an ejection fraction of 40% or less, or a fall of 10% or more from a prior study
     • Stress echo: exercise-induced wall motion abnormalities, a negative change from the prior study of the same type, an ejection fraction of 40% or less, or a fall of 10% or more from a prior study

   Show the FAA's words: Get the 4 required reports

   Submit the following performed within the past 90 days:

   ITEM # 1 Initial Comprehensive clinical consultation from your treating board-certified endocrinologist (M.D. or D.O.), not a mid-level practitioner. This may be a labeled progress note, consultation note, or history and physical.

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM #1: INITIAL COMPREHENSIVE REPORT

   …INITIAL COMPREHENSIVE in-person evaluation performed within the past 90 days from the treating board-certified endocrinologist. The individual must submit a copy of the actual comprehensive current, detailed Clinical Progress Note. (We will NOT accept the patient encounter summary or a letter from the endocrinologist.) It must detail and comment on ALL of the following *1:

   A. DIABETES HISTORY:

   1. Characteristics at onset (age, symptoms, etc.):

   a) Review previous treatment and response

   b) Frequency/cause/severity of past hospitalizations

   c) Complications and common comorbidities:

   Any end organ damage (macrovascular or microvascular);

   Presence of hemoglobinopathies or anemias;

   High blood pressure or abnormal lipids and treatment; and

   Visits to a specialist (what type and why)

   d) Lifestyle and behavior patterns:

   Eating patterns and weight history;

   Sleep behavior and physical activity;

   Familiarity with carbohydrate counting, if applicable;

   Tobacco, alcohol, and substance use; and

   Any motor vehicle accidents or incidents pertinent to their history of diabetes

   2. Medication and Reporting:

   a) Medication compliance;

   b) Medication intolerance or side effects;

   c) Complementary or alternative medicine use;

   d) Glucose monitoring (meter/CGM) results and data use; and

   e) Review insulin pump settings

   3. Screening for Psychosocial conditions:

   a) Screen for depression, anxiety, disordered eating (ex: Patient Health Questionnaire 9 or 2 [PHQ-9 or PHQ-2] or similar);

   b) Cognitive impairment assessment (and formal testing, if clinically indicated); and

   c) Diabetes self-management education and support:

   History of dietician/diabetes educator visits; and

   Screen for barriers to diabetes self-management

   4. Glucose control:

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   It must detail and comment on ALL of the following *1:

   A. DIABETES HISTORY:

   …4. Glucose control:

   a) HYPOglycemia:

   Any symptomatic episodes in the past 12 months requiring treatment or assistance by another individual, with comment on timing, awareness, frequency, causes, and treatment.

   Sustained episodes, e.g., CGM/FSBG values below 70 mg/dL for over 30 minutes or below 54 mg/dL for over 15 minutes, with comment on symptoms and treatment.

   b) HYPERglycemia:

   Any symptomatic episodes in the past 12 months with comment on timing, awareness, frequency, causes, and treatment.

   Sustained episodes (e.g., CGM/FSBG values above 250 mg/dL for over 60 minutes or above 300 mg/dL for over 30 minutes) with comment on symptoms and treatment.

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   It must detail and comment on ALL of the following *1:

   …B. PHYSICAL EXAM (Must narrate what is examined and any findings):

   1. Height, Weight, Body Mass Index (BMI);

   2. Pulse and blood pressure including orthostatic blood pressure, when indicated;

   3. Thyroid palpation and skin exam (acanthosis nigricans, insulin injection or insertion sites, lipodystrophy); and

   4. Comprehensive foot exam:

   a) Visual inspection; screen for PAD (check pedal pulses; refer for ABI if diminished); and

   b) Determination of temperature, vibration or pinprick sensation, and 10-g monofilament exam

   C. ASSESSMENT AND PLAN:

   1. Current status of diabetes including an assessment of compliance, glucose control, and stability as well as their ability to monitor and respond accordingly to HYPO and HYPER glycemic events and administer insulin doses;

   2. Prognosis for progression over the next 12 months; and

   3. Recommendations for treatment changes

   D. DATE OF NEXT CLINICAL FOLLOW-UP (Required every 3 months for FAA.)

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM # 2 Lab - Initial/Annual comprehensive panel. (See Certification Aid for required list.)

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM #2: LAB

   LAB - Initial/Annual comprehensive panel performed within the past 90 days:

   A. A1C Within last 90 days AND all prior values from the preceding 12 months

   B. CBC Complete Blood Count

   C. Lipids Total, LDL [low density lipoprotein], HDL [high density lipoprotein], cholesterol, and triglycerides

   D. LFT’s Liver function tests

   E. Microalbumin or spot urinary albumin-to-creatinine ratio

   F. Renal function Serum creatinine, BUN (blood urea nitrogen), eGFR (estimated glomerular filtration

   G. TSH Thyroid-stimulating hormone

   H. Vitamin B12 When clinically indicated

   I. Potassium Serum level when clinically indicated or when taking ACE-I (angiotensin converting enzyme inhibitors), ARBs (angiotensin II receptor blockers), or diuretics

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM # 4 Eye evaluation from a board-certified ophthalmologist (M.D. or D.O.). If no retinopathy, an exam by an optometrist (O.D.) may be acceptable; AND

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM #4: EYE EVALUATION (updated 09/30/2026)

   EYE EVALUATION (diabetic eye exam) performed within the past 90 days from a board-certified ophthalmologist (M.D. or D.O.). If you do not have retinopathy, an optometrist (O.D.) may be acceptable. Evaluation must include:

   A. VISUAL ACUITY (with and without correction) each eye separately and together for:

   1. Near;

   2. Intermediate; and

   3. Distance vision

   B. EVALUATION FOR OTHER RETINAL OR CLINICALLY SIGNIFICANT EYE DISEASE:

   1. Cataracts, any evidence;

   2. Color vision deficiency: test used; method used;

   3. Intra Ocular Pressure (IOP) reading (and treatment if required): test used, method used; and

   4. Visual field defects: type of test, method used (confrontation fields are acceptable).

   C. DILATED FUNDUS EXAM with documentation of absence of retinopathy or degree of retinopathy, if present, and any treatment indicated or recommended.

   D. DIAGNOSIS, PROGNOSIS, AND RECOMMENDATIONS FOR TREATMENT OR FOLLOW-UP.

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM # 5 Cardiac Risk Evaluation from a board-certified cardiologist (M.D. or D.O.), not a mid-level practitioner.

   Evaluation must include lab and ECG;

   Age 40 and above must also include an initial exercise stress test (EST)

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM #5: CARDIAC RISK EVALUATION (Updated 08/30/2023)

   …A. INITIAL CARDIAC RISK EVALUATION:

   1. Evaluation from a board-certified cardiologist assessing cardiac risk factors;

   2. Baseline ECG (regardless of age);

   …3. The evaluation must be COMPREHENSIVE, in-person, and performed within the past 90 days from the treating board-certified cardiologist. The individual must submit a copy of the actual comprehensive current detailed Clinical Progress Note. (We will NOT accept the patient encounter summary [after visit summary] or a letter.)

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   ITEM #5: CARDIAC RISK EVALUATION (Updated 08/30/2023)

   CARDIAC RISK EVALUATION performed within the past 90 days from a board-certified cardiologist (M.D. or D.O.), not a mid-level practitioner. The document submitted MUST be from the actual in-person office evaluation and resultant current, detailed Clinical Progress Note:

   …B. STRESS TEST (Maximal exercise treadmill stress testing (Bruce):

   1. Beginning at age 40,

   2. every 5 years thereafter, and

   3. at any age when clinically indicated:

   See Graded Exercise Stress Test Protocol.

   C. IF THERE ARE ANY ABNORMALITIES on the ECG, stress test, or identification of any cardiac conditions, the cardiologist must provide a report that details:

   1. Any confirmed or suspected diagnosis

   2. Clinical status including any symptoms

   3. Control of cardiac risk factors (HTN, smoking, hyperlipidemia, exercise, weight)

   4. Treatment or monitoring required or recommended and any side effects

   5. Were other investigations conducted or recommended (attach reports)

   6. Risk of any acutely disabling cardiovascular event (annualized percentage risk)

   FAA source: ITDM – Certification Aid (CGM). FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   GXT requirements:

   100% of predicted maximal heart rate (PMHR), unless medically contraindicated or prevented either by symptoms or medications;

   Complete Stage 3 (equivalent to at least 9 minutes);

   Studies of less than 85% of maximum predicted heart rate and less than 9 minutes of exercise (6 minutes for age 70 or greater) may serve a basis for denial; and

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   Beta blockers and calcium channel blockers (specifically diltiazem and verapamil) or digitalis preparations should be discontinued for 24-48 hours prior to testing (if not contraindicated and only with the consent of the treating physician) in order to obtain maximum heart rate.

   If the GXT is done on beta blockers, calcium blockers, or digitalis medications, the applicant must provide explanation from the treating cardiologist as to why the medication(s) cannot be held.

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   The worksheet with blood pressure/pulse recordings at various stages, interpretive report, and actual ECG tracings* must be submitted.

   Tracings must include a rhythm strip;

   A full 12-lead ECG recorded at rest - supine and standing. (Anything less than a full 12-lead will not be accepted); and

   One or more times during each stage of exercise, at the end of each stage, at peak exercise, and every minute during recovery for at least 5 minutes or until the tracings return to baseline level.

   *Computer generated, sample-cycle ECG tracings are unacceptable in lieu of the standard tracings. If submitted alone, this may result in deferment until this requirement is met.

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   If a plain GXT is required and is uninterpretable for any reason, a radionuclide GXT will then be required before further consideration

   In patients with bundle branch blocks (BBB), LVH, or diffuse ST/T wave changes at rest, a stress echo or nuclear stress test will be required.

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

   IF ANY OF THE FOLLOWING ARE NOTED, THE AME MAY NOT ISSUE.

   Exercise stress test (EST)

   PMHR less than 85% ; (predicted maximal heart rate)

   Time less than 9 minutes--under age 70;

   Time less than 6 minutes --age 70 or greater

   1 mm ST depression or greater at any time during stress testing - UNLESS the applicant has additional medical evidence such as a nuclear imaging study or a stress echocardiogram showing the absence of reversible ischemia or wall motion abnormalities reviewed and reported by a qualified cardiologist.

   Nuclear stress test

   Evidence of reversible ischemia OR

   Negative change from the prior study of the same type OR

   Ejection Fraction (EF) reported as 40% or less OR

   EF decrease by 10% or more from a prior study

   Stress echo

   Exercised induced wall motion abnormalities (WMA) OR

   Negative change from the prior study of the same type OR

   EF 40% or less OR

   EF decreased by 10% or more from a prior study

   FAA source: Guide for Aviation Medical Examiners – Graded Exercise Stress Test Requirements. FAA date 29 May 2024; checked by Crosscheck 14 October 2026.

3. 3

   Step 3: Take everything to your AME

   How your items reach the FAA, and how long a certificate for a CGM user lasts.

   Your AME defers: the information is submitted to the FAA, and an initial Special Issuance requires an FAA decision.

   If you already hold a Special Issuance for another condition

   Your existing Special Issuance will be invalid because of the additional diagnosis, and you will need a new authorization letter.

   How it reaches the FAA

   • A complete package within 14 days; incomplete ones are not reviewed
   • Each document uploaded separately: each visit's note, labs by collection date, CGM data by month
   • CGM data as the original colour digital report, in PDF, is strongly recommended
   • Upload by your AME is fastest; mailing colour printouts is the alternative
   • Not: Not mailed as well, once your AME has uploaded them

   Good to know

   • As of 30 September 2026, the baseline certification for CGM users is 6 months; a 12-month certificate is considered case by case, only for exceptionally well-controlled pilots with all required documentation

   Show the FAA's words: Take everything to your AME

   Treated with ANY type of insulin

   …DEFER Submit the information to the FAA.

   Initial Special Issuance – Requires FAA Decision

   FAA source: Diabetes Mellitus Disposition Table. FAA date 27 September 2023; checked by Crosscheck 14 October 2026.

   F. HOW TO SUBMIT DOCUMENTS FOR INITIAL OR RECERTIFICATION/RENEWAL

   …Coordinate with your AME to make sure that A COMPLETE package is sent to the FAA WITHIN 14 DAYS. Partial or incomplete packages will NOT be reviewed and will cause a DELAY in certification. Your AME may submit the documents to the FAA using the AMCS document upload feature.

   UPLOAD EACH DOCUMENT SEPARATELY:

   Endocrinologist current, detailed Clinical Progress Notes (each visit separately).

   Cardiologist current, detailed Clinical Progress Note (each visit separately).

   Ophthalmologist current, detailed Clinical Progress Note (each visit separately).

   Lab Results (separated by date of collection).

   CGM Data (separated by month). We strongly recommend uploading the original color digital report in PDF format.

   Other pertinent documentation deemed necessary by you or your AME.

   The fastest and most efficient way to submit reports to the FAA is through your AME as a direct upload.

   …As an alternative to your AME uploading digital reports, you may mail the diabetes information in paper format (color printouts preferred) using one of the following addresses:

   …If your documents have been uploaded by your AME using the AMCS document upload feature, DO NOT also mail the documents. Duplication of documents will delay the review of your medical certification file.

   FAA source: ITDM (CGM) – Submitting Documents for Initial and Renewal. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   8. I am currently on a Special Issuance (SI) for another condition. How will ITDM affect that?

   Your existing SI will be invalid due to the additional diagnosis. You will need a new authorization letter.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   Additional information may be required on a case-by-case basis.

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   As of 09/30/2026, the baseline certification for CGM users is 6 months. Extending to a 12-month certificate will be considered on a case-by-case basis only for exceptionally well-controlled individuals with all required documentation.

   FAA source: ITDM – Renewal Certificate Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

4. 4

   Step 4: During review

   Continue to submit your endocrinologist report and monthly CGM printouts every 3 months.Two things to bring

   • Endocrinologist report

     Every 3 months

     While the FAA reviews your exam, send your endocrinologist report every 3 months.

     Without current information, the FAA has to request it, which delays the review.

   • Monthly CGM printouts

     Every 3 months

     While the FAA reviews your exam, send your monthly CGM printouts every 3 months.

     Without current information, the FAA has to request it, which delays the review.

   Show the FAA's words: During review

   While your exam is under review: Continue to submit your endocrinologist report and monthly CGM printouts EVERY 3 MONTHS. This will ensure the FAA has the most current information. If current information is not submitted, the FAA will then have to request it, which will delay the certification review.

   FAA source: ITDM – Initial Certificate Consideration Requirements. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

5. 5

   Step 5: In flight, and when something goes wrong

   Backup supplies, your CGM and any pump, changing devices, and the days you fly.

   What the FAA's FAQ says about flying with a CGM and insulin: what to carry, and what to do when something goes wrong.

   Have with you in flight

   • A glucometer and test strips
   • A backup sensor for the CGM
   • A backup insulin pen, if you use an insulin pump

   If the CGM stops working

   • Go to your backup plan for the rest of the flight
   • Check your blood sugar by finger stick every 30 minutes

   If you cannot correct your blood sugar, treat it as any in-flight emergency and land as soon as practicable.

   If a device breaks or supplies run out on a trip

   • Replace it as soon as possible
   • If you cannot, finish the scheduled trip on your backup system (finger sticks and injections), staying compliant with your Special Issuance
   • Not: No new trip until the system your Special Issuance authorizes is working again, and no added legs

   If neither the primary nor the backup system works, stop flying. The FAQ calls this an absolute flight safety requirement.

   If you have symptoms or are impaired on a trip

   • Stop flying, as your Special Issuance and 14 CFR 61.53 require
   • Contact your treating endocrinologist about any change to your insulin treatment
   • Contact your AME with the details; your AME should contact the FAA

   Insulin pumps

   • A pump can fail and deliver too little or too much insulin: have a backup way to take insulin
   • With a sudden cabin depressurization, consider turning off or disconnecting the pump
   • If needed, clear bubbles in the tubing from changes in cabin pressure

   Suspending insulin for a low reading is a good safety feature, and a pump whose reservoir is not in direct line for delivery is preferred.

   Changing devices

   • 7 daysMoving to a pump for the first time, from injections
   • No ground timeChanging a pump or CGM you already use
   • No ground timeOpen loop to closed loop

   Crosscheck's reading of two FAA documents, which word it differently.

   The FAA's FAQ: no ground time if you already use a pump or CGM and change devices, or go from an open loop to a closed loop; a 7-day ground trial if you have never used a pump and start one.

   The FAA's medication chart: 7 days when moving between injections and a pump, either way, or for new insulin or CGM devices.

   The days you fly

   • The goal is to avoid low blood sugar (hypoglycemia) while flying; ask your endocrinologist whether to adjust anything on flying days

   Your devices on the aircraft

   • Most current medical devices should be approved as personal electronic devices; check with the operator of the aircraft you fly (AC 20-164A)

   Show the FAA's words: In flight, and when something goes wrong

   You should have all the following available during flight:

   Glucometer (glucose meter) and test strips.

   Backup sensor for the CGM device.

   Backup insulin pen available if using an insulin pump.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   If the CGM stops working, go to a back-up plan for the remainder of the flight and measure your finger stick blood sugar every 30 minutes. If you are unable to correct your blood sugar, treat this as any in flight emergency and land as soon as practicable.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   19. What do I do if my device breaks while traveling or I run out of supplies?

   Replace the machine as soon as possible.

   If you cannot do this, finish the scheduled trip with your back-up system (finger sticks and injections) and remain compliant with the SI.

   Once the trip concludes, do not start a new trip until the system authorized in the SI is back in place and functional.

   While you may complete at trip once on the road, you are NOT authorized to add additional legs to the trip.

   If neither the primary nor the backup system is functional, you must terminate flight activity. This is an absolute flight safety requirement.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   9. What do I do if I develop symptoms or become incapacitated/impaired due to my blood glucose levels while I am on a trip?

   You must disqualify yourself from flight activities as required by both the SI and 14 CFR 61.53;

   Contact your treating endocrinologist to determine if there is a need to change your insulin treatment; and

   Contact your AME with details surrounding the event.

   Your AME should contact the FAA to discuss your case.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   18. I do not use an insulin pump. Do I need to make any changes from my normal routine on the days that I fly?

   The goal is to avoid hypoglycemia while flying. Talk with your board-certified endocrinologist about whether or not adjustments should be made on days when you are flying.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   16. Are there any concerns with the insulin pumps?

   Yes, the pump could potentially fail or malfunction delivering too little or too much insulin.

   In the event of failure or malfunction, a backup insulin delivery must be available.

   In the event of sudden cabin depressurization, consider turning off or disconnecting the pump.

   If necessary, clear any bubbles in tubing seen with changes in cabin pressure.

   17. Are there any features that make some insulin pumps better for flying?

   The ability to suspend insulin delivery for a low reading is a good safety feature. In addition, a pump in which the insulin reservoir is not in direct line for delivery is preferred.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   20. Is there a required ground time if I change pumps or CGM devices?

   If you are already using a pump or CGM device and you change devices, no there is no ground time.

   If you have NEVER used a pump previously, and you start using a pump for the first time, there is a seven (7) day ground trial period.

   There is no required ground time if changing from an “open loop” to a “closed loop” system.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.

   Medication Adjustment

   When changing the dose, formulation (e.g., immediate vs. extended release), or switching to a different drug/device within the same class.

   Adjusting Medication Observation Time

   …Within Group A1, if adding new type of insulin to regimen

   …7 days

   …*Note: no time is needed for minor dose change within the same drug class (short to short, long to long)

   …If transitioning between insulin injection to/from pump; or new insulin/CGM devices

   7 days

   FAA source: Acceptable Combinations of Diabetes Medications. FAA date 30 September 2026; checked by Crosscheck 14 October 2026.

   12. How do I know if my CGM and/or insulin pump is legal for flight as an “authorized personal electronic device?”

   Most current medical devices should be approved; however, the pilot needs to verify this with the aircraft operator for the aircraft that they fly. It is not feasible for the FAA to maintain a list of approved devices due to the rapidly changing technology and to the large number of airframe and avionics combinations seen in the Part 91, 91k, 121, and 135 fleets.

   See AC 20-164A for guidance.

   FAA source: ITDM – Frequently Asked Questions. FAA date 30 August 2023; checked by Crosscheck 14 October 2026.