DISEASE PROTOCOLS

DISEASE PROTOCOLS

DISEASE PROTOCOLS

(Updated 09/30/2026) The following lists the Guide for Aviation Medical Examiners Disease Protocols, and course of action that should be taken by the AME as defined by aeromedical decision considerations. (Also see condition specific CACI Certification Worksheets, which can be found in the Dispositions Section.)

STATUS SUMMARY

Protocol for Antidepressants

(Updated 04/24/2024) Antidepressants Protocol Expansion - Effective April 24, 2024:

Additional medications have been added as allowed for special issuance consideration, representing an additional class of antidepressant medications beyond SSRIs. This change, along with the addition of Wellbutrin (a Dopamine/Norepinephrine-Reuptake Inhibitor) on 05/31/2023, has resulted in the FAA’s SSRI Protocol being renamed the Antidepressant Protocol.

PLEASE NOTE: All references to SSRIs, SSRI Protocol, or SSRI program in existing checklists, worksheets, charts, or protocol pages in the AME Guide are considered encompassed in the Antidepressant Protocol and include all conditionally approved medications.

• Specifications for Neuropsychological Evaluations for
• Attention-Deficit/Hyperactivity Disorder (ADHD)

(Updated 10/30/2024) Attention-Deficit/Hyperactivity Disorder (ADHD), formerly called Attention Deficit Disorder (ADD), and medications used for treatment may result in cognitive deficits that pose a risk to aviation safety.

For individuals who have a history of ADHD or use of ADHD medications*, there are two possible evaluation paths: Fast Track and Standard Track. For information on the different tracks, any required testing, and specific documentation needed, see the following pages. The information is also linked below.

*Note: The requirements also apply if diagnosed with or took medication to treat Attention Deficit Disorder (ADD)

Disposition Table - Attention-Deficit/Hyperactivity Disorder (ADHD) and/or use of ADHD Medications (Found in ITEM 47. Psychiatric, Psychiatric Conditions) ADHD Pathway Chart

• ADHD Document Checklist
• ADHD Personal Statement Guidelines
• FAST TRACK

Fast Track - Information for the Psychologist or Neuropsychologist Fast Track - FAA ADHD Summary Fast Track – FAA ADHD General Information for Pilots and ATCS Fast Track – FAA ADHD Report Requirements

STANDARD TRACK

Standard Track – FAA ADHD General Information for Pilots and ATCS Standard Track – FAA ADHD Report Requirements

• RESOURCES
• FAA Aviation Psychologist and Neuropsychologist List
• Reference information for Neuropsychologists and Psychologists

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• FAA ADHD DOCUMENT CHECKLIST

(Updated 09/25/2024) Pilot/ATCS: Please provide the following to the doctoral level (PhD or PsyD) psychologist or neuropsychologist so they can review the materials and complete their evaluation and report. This applies to both FAST TRACK and STANDARD TRACK. Standard Track evaluation must be completed by a FAA HIMS Neuropsychologist.

The evaluation and report must be performed within 90 days of the AME exam:

To request that a copy of your agency records be sent directly to the psychologist or neuropsychologist, submit Form FAA 8065-2 - REQUEST FOR AIRMAN MEDICAL RECORDS.

Note: The above requirements also apply if diagnosed with or took medication to treat Attention Deficit Disorder (ADD)

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• ADHD - FAA PERSONAL STATEMENT GUIDELINES

(Updated 08/30/2023) This applies to both FAST TRACK and STANDARD TRACK. An applicant’s personal/self-statement must be typed, signed, and dated. It should include your name and either a PI# or Date of Birth for identification. Be sure to describe in detail each response (with more than just “yes” or “no” answer).

Write a statement which describes your diagnosis and stimulant medication history to include the following information:

If so, under what circumstance and for how long were they effective?

List all professionals involved (e.g., teacher, school counselor, therapist, psychologist, primary care physician, psychiatrist, or education specialist, if applicable).

Include all that apply:

Are they still used?

Attention-Deficit/Hyperactivity Disorder (ADHD) FAST TRACK INFORMATION

See the following pages for:

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• FAST TRACK - FAA ADHD SUMMARY
• (Updated 10/30/2024)
• Name _______________________________ Birthdate ________________
• Applicant ID#__________________________ PI# _____________________

PILOT/ATCS: Please take this summary to a doctoral level (PhD or PsyD) psychologist or neuropsychologist with training and experience in the evaluation of ADHD, preferably someone with additional subspecialty training in aviation-specific topics. The psychologist or neuropsychologist should enter the requested information in the space provided below.

When completed, submit the following to your AME for review and upload into DIWS:

☐ This completed summary;* ☐ The actual clinical report (not patient portal notes) from the doctoral level (PhD or PsyD) psychologist or neuropsychologist; AND ☐ All supporting documentation addressing each item (listed on the ADHD DOCUMENT CHECKLIST).

IF YOU ARE THE PSYCHOLOGIST OR NEUROPSYCHOLOGIST COMPLETING THIS SUMMARY:

FOUR years? ……………………………………………………………................................

not included in this category.) ………………………………………………………………...

I attest:

I am a psychologist or neuropsychologist with training and experience in conducting ADHD evaluations. Yes No I have reviewed all the required items on the ADHD Document Checklist. Yes No I have additional subspecialty training in aviation-specific topics (aviation medicine [preferred, not required]). Yes No I have conducted a face-to-face clinical interview in person or by on-screen video (not audio only). Yes No

Evaluator Name : _________________________ Credentials: PhD, PsyD, other ______

_______________________________________ _______________

Evaluator Signature Date of Evaluation

*NOTE: This Attention-Deficit/Hyperactivity Disorder (ADHD) Summary is NOT required, however, it will help to streamline and significantly DECREASE FAA review time.

AME Actions:

• NO YES*
• NO YES*
• NO YES*
• NO YES*

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• FAST TRACK - FAA ADHD EVALUATION
• INFORMATION FOR THE PSYCHOLOGIST OR NEUROPSYCHOLOGIST

(Updated 08/30/2023) FOR PILOTS OR ATCS: Provide this information sheet (prior to your appointment) to the psychologist or neuropsychologist who will be evaluating your history of ADHD and/or use of ADHD medication. The psychologist or neuropsychologist must be a doctoral level (PhD or PsyD) licensed psychologist or neuropsychologist with training and experience in the evaluation of ADHD.

Note: These requirements also apply if you were diagnosed with or took medication to treat Attention Deficit Disorder (ADD)

FOR THE PSYCHOLOGIST OR NEUROPSYCHOLOGIST:

The individual you are evaluating is a pilot or air traffic control specialist (ATCS) with a reported history of ADHD and/or use of ADHD medications*. Your findings will assist in determining this individual’s eligibility for an FAA medical certificate or clearance. Acceptance of this case for evaluation assumes you have the necessary training and experience to conduct an ADHD evaluation.

PLEASE NOTE:

This may present as:

o Compromised focused attention/concentration and/or executive skills; o Problems with verbal and nonverbal working memory; and o Issues with planning, mental flexibility, and resistance to distractions.

o ADHD Document Checklist (To be provided by the individual prior to appointment.) o Fast Track – FAA ADHD Evaluation Report Requirements o Fast Track – FAA ADHD Summary

Attention-Deficit/Hyperactivity Disorder (ADHD)

• FAST TRACK - FAA ADHD EVALUATION
• GENERAL INFORMATION FOR PILOTS AND ATCS

(Updated 10/30/2024) If you are a PILOT or ATCS with a history of ADHD or taking ADHD Medications*:

(If you are an FAA ATCS, you should report this information immediately to your RFS office).

NOTE: If you have taken medication in the past 4 years, had symptoms in the past 4 years or have a history of any other psychiatric conditions – STOP. Go to the Standard Track Evaluation – FAA ADHD Evaluation General Information.

☐ Complete a personal statement. It must be typed, signed, and dated.

The statement should describe your diagnosis and stimulant medication history.

It must include all information on FAA ADHD Personal Statement Guidelines sheet. ☐ Collect and verify you have all the documents on the ADHD Document Checklist for review.

☐ Find and make an appointment with a doctoral level (PhD or PsyD) licensed psychologist or neuropsychologist with training and experience in the evaluation of ADHD.

☐ Provide all materials in the ADHD Document checklist to the psychologist or neuropsychologist prior to your scheduled appointment. Given the extent of documents required to review, check with the evaluating psychologist or neuropsychologist to determine how much lead time they may need to review them prior to your appointment.

☐ Confirm the psychologist or neuropsychologist has a blank copy of the Fast Track – FAA ADHD Summary. The psychologist or neuropsychologist should complete both the ADHD Summary AND provide a detailed report, as outlined in the Fast Track – FAA ADHD Evaluation Report Requirements, for use by your AME.

The psychologist or neuropsychologist will meet with you for an interview. The personal/self-statement you wrote, along with the records you provided, will also be reviewed and discussed. With your permission, people who know you (e.g., parents, teachers, flight instructor, etc.) may be contacted for additional information.

The psychologist or neuropsychologist should complete the Fast Track – FAA ADHD Summary AND provide a written detailed report which covers all items in the Fast Track – FAA ADHD Evaluation Report Requirements.

Based on the interviews and record review, the psychologist or neuropsychologist may be able to determine if there is sufficient information to make a recommendation to the AME regarding whether medical certification can be issued.

☐ Complete a new 8500-8 exam (online using MedXPress); ☐ See your AME for the exam portion;

☐ Bring all the following to your AME visit:

☐ Completed FAA ADHD Summary;

☐ Actual clinical summary report from the psychologist or neuropsychologist; and ☐ Any records reviewed by the psychologist or neuropsychologist. ☐ Bring information on any other condition that may require a Special Issuance/AASI/CACI (pilots) or Special Consideration (ATCS). ☐ Keep a copy of any reports or testing generated for your files.

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• FAST TRACK - FAA ADHD EVALUATION REPORT REQUIREMENTS

(Updated 09/27/2023) The evaluation and report must be performed within 90 days of the AME exam and must include the following (at a minimum):

Do not simply list if ADHD is present or not. List all diagnoses present or past; specify in remission or residual, as appropriate.

iii. If there is no DSM diagnosis, are there any concerns regarding neurocognitive impairment or deficiencies? If so, describe their nature and severity;

When you have completed your assessment, the individual will need the following to submit to the FAA:

☐ A copy of your full report (not the patient after visit summary); ☐ A completed FAA Attention-Deficit/Hyperactivity Disorder (ADHD) Summary; and ☐ Copies of all records you reviewed to make your assessment.

Attention-Deficit/Hyperactivity Disorder (ADHD) STANDARD TRACK

See the following pages for:

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• STANDARD TRACK - FAA ADHD EVALUATION
• GENERAL INFORMATION FOR PILOTS AND ATCS

(Updated 08/28/2024) Attention-Deficit/Hyperactivity Disorder (ADHD) is a condition that may be aeromedically disqualifying. The evaluation and testing must be performed in-person by a HIMS Neuropsychologist. The responsibility of the HIMS Neuropsychologist is to identify any neurocognitive deficit/impairment that has aeromedical significance.

A. An initial battery of ADHD tests will be required along with potential supplemental tests if:

(Note: If ADHD testing is conducted, the individual must have discontinued ADHD medication at least 90 days prior to testing);

Evaluation; and/or

B. What are the FAA’s testing specifications? Testing specifications required by the FAA are listed on an FAA secure site used by professionals with training regarding the specifications. Authorized professionals should use the secure portal. For access, the HIMS Neuropsychologist should email a request to 9-amc-aam-NPTesting@faa.gov.

C. What are the urinalysis requirements? If ADHD testing is required, the applicant will need to complete a urinalysis for amphetamines and methylphenidate within 24 hours after completing testing. Arrange for a urinalysis order to be sent to a laboratory and be sure it is conducted within 24 hours after testing. Actual laboratory results are required (not clinical summary of results). Testing data cannot be used without the supporting urinalysis and may result in deferral and/or request for re-evaluation.

D. Who can order a urinalysis? This varies by state law and regulations. Pilots or ATCS should verify if the evaluating HIMS Neuropsychologist has the ability to order the urinalysis. If not, coordinate with your AME or your primary care physician to order the laboratory test. You may also contact a drug testing laboratory near the evaluating HIMS Neuropsychologist’s office to inquire what type of order is required to conduct the drug testing for occupational/licensing purposes. Specify that the test must test for both amphetamines and methylphenidate, which are two different test panels. Prior to the appointment for urinalysis the following checklist is suggested:

☐ Identify a drug testing laboratory;

☐ Review FAA requirements to conduct two separate tests for amphetamines AND methylphenidate; ☐ Check hours of operation;

☐ Check if walk-ins are taken for drug testing or if an appointment is required; and ☐ Ask if they require lab orders for occupational/licensing drug testing to meet the FAA requirement (physician, psychologist, or none)

E. The HIMS Neuropsychologist must:

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• STANDARD TRACK - FAA ADHD EVALUATION REPORT REQUIREMENTS

(Updated 09/27/2023) This evaluation and testing must be performed IN-PERSON by a HIMS Neuropsychologist within 90 days of the AME exam and must include the following (at a minimum):

Do not simply list if ADHD is present or not. List all diagnoses present or past; specify in remission or residual, as appropriate.

iii. If there is no DSM diagnosis, are there any concerns regarding neurocognitive impairment or deficiencies? If so, describe the nature and severity;

The individual is exhibiting functioning that is completely within normal limits and lacking any suspicion of neurocognitive deficit. The final report should also document abnormalities found in the INITIAL BATTERY and what additional testing dismissed the abnormalities as a diagnostic concern.

If the individual’s results raise concerns or show neuropsychological impairment, then include the following in the report:

WHEN YOU HAVE COMPLETED YOUR ASSESSMENT: Submit to the AME of record (for direct upload into AMCS) or as specified in the FAA letter:

☐ Copy of your full report (not the patient portal notes) containing a MINIMUM of all the above elements;

☐ Copies of all records you reviewed to make your assessment. (Exclude copies of any Fast Track document if already submitted to FAA and any records previously received by you from the FAA.);

☐ Copies of all computer score reports; and ☐ An appended score summary sheet that includes raw scores, percentile scores, and/or standard scores for all tests administered.

When available, pilot norms must be used. If pilot norms are not available for a particular test or inappropriate for a specific applicant, then the normative data/comparison group relied upon for interpretation (e.g., general population, age/education-corrected) must be specified.

• Attention-Deficit/Hyperactivity Disorder (ADHD)
• REFERENCE INFORMATION FOR THE PSYCHOLOGIST OR NEUROPSYCHOLOGIST

(Updated 08/30/2023) The responsibility of the psychologist or neuropsychologist is to identify any neurocognitive deficit/impairment that has aeromedical significance. Attention-Deficit/Hyperactivity Disorder (ADHD), formerly called Attention Deficit Disorder (ADD), is a condition that may be aeromedically disqualifying. For reference information and comments on specific tests, authorized professionals should use the portal at FAA Neuropsychology Testing Specifications. For access to the portal, psychologists and neuropsychologists should email a request to 9- amc-aam-NPTesting@faa.gov.

Protocol for Binocular Multifocal and Accommodating Devices

(Updated 04/29/2026)

See Lens Implant Status Summary

VISION STANDARDS:

Contact lenses (bifocal or multifocal) requires

Protocol for Bundle Branch Block (BBB)

(Updated 05/29/2024) A. PREVIOUSLY DOCUMENTED AND EVALUATED: No further evaluation required unless there is a change in condition.

B. RIGHT (RBBB): If a complete RBBB is identified at:

AME ACTIONS:

Protocol for Cardiac Testing

Coronary Artery Calcification (CAC) Scoring; Calcium Score;

Coronary Computed Tomography Angiography (CCTA)

(Updated 01/28/2026)

Protocol for Cardiac Valve Replacement

(Updated 05/29/2024) For applicants with tissue or mechanical valve replacement(s):

INITIAL CONSIDERATION:

FOLLOW-UP CERTIFICATION:

After initial certification, all classes are usually followed at 12-month intervals with the following requirements:

Note:

SUBMITTING INFORMATION TO THE FAA:

Protocol for Cardiovascular Evaluation (CVE)

(Updated 05/29/2024) An FAA CVE is comprised of Cardiology Evaluation + Lab Testing

Cardiology Evaluation should be submitted in the form of a current, detailed Clinical Progress Note and include:

It must specifically include:

Labs must be current (performed no more than 90 days before the AME exam) and include:

Note: CVE does not include stress testing. See the corresponding disposition table or FAA letter to identity which type of stress test (if any) is required.

Protocol for Conductive Keratoplasty

Conductive Keratoplasty (CK) is a refractive surgery procedure. It is acceptable for aeromedical certification, with Special Issuance, after review by the FAA.

The following criteria are necessary for initial certification:

• Coronary Heart Disease (CHD)/ Coronary Artery Disease (CAD)
• RECERTIFICATION Status Summary

(Updated 03/25/2026) Name ______________________________ Birthdate _______________________________

Applicant ID# ___________________________ PI# ____________________________________

Instructions: If you do not have a current special issuance for CHD/CAD, STOP. Go to the Coronary Heart Disease disposition table.

If you have a valid special issuance authorization or special consideration:

Reference: 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

Results of testing performed no more than 90 days before the AME exam.

Blood Pressure __________ / ___________ LDL-C _________ A1c __________

☐ Current medication list attached OR list all current therapy (medication and dose):

_____________________________________________________________________________ _____________________________________________________________________________

reference?..............................................................................................................

guidelines?..........................................................................................................................

required intervention; or use of nitrates for any reason) in the past year………….

*For any “NO* items or significant interval change(s), attach a current, detailed Clinical Progress Note which addresses these items.

Cardiologist name Cardiologist Signature Date of evaluation

AME Actions:

☐ INITIAL certification CAD/CHD: AME must defer. See the CORONARY HEART DISEASE disposition table. ☐ RECERTIFICATION: If the individual has an AASI for Coronary Heart Disease, all items above all in the “YES” column, and there have been NO significant interval history changes or concerns, follow AASI instructions.

IF ANY ANSWER FALLS IN NO* COLUMN ABOVE OR THERE HAS BEEN SIGNIFICANT INTERVAL HISTORY CHANGE OR ANY CONCERNS, THE AME MUST DEFER.

NOTE: As of 05/29/24 for routine cases, follow-up stress test is not required. If after FAA review it is determined that a stress test is required, this status summary and a current, detailed Clinical Progress Note must be submitted.

Protocol for Coronary Heart Disease – 1st and 2nd Class and ATCS

(Updated 03/25/2026)

Use this guidance for:

Recovery period:

After the required recovery period, obtain the following and submit to the FAA. Post-event testing should NOT be obtained until AFTER the recovery period. The AME is required to DEFER.

It must specifically include:

It is the responsibility of each pilot/ATCS to provide the medical information required to determine his/her eligibility for airman medical certification.

To aid in the review process, it is critical that the individual’s full name and date of birth appear on all correspondence and reports. The AME may upload the reports electronically; however, the CD containing images must be mailed.

Alternatively, the AME may mail all items together in one package—do not send items in separate shipments. Mail the CD or ONE complete package to one of the following:

For employee ATCS, submit all information to your Regional Flight Surgeon’s office.

NOTE: No consideration will be given for special issuance/special consideration until ALL the required data has been received.

If an employee ATCS or contract tower ATCS also desires an airman medical certificate, then all the requirements for an airman medical certificate apply.

If FAS Cardiology Consultant or FAS Cardiac Panel is required, allow additional time for the package contents to be verified for completeness prior to cardiologist review.

Protocol for Coronary Heart Disease – 3rd Class

(Updated 05/29/2024)

Use this guidance for:

Submit the following to the FAA for medical certificate consideration. The AME is required to DEFER:

Recovery period. There is NO mandatory recovery period per Public Law 114-190 5/2017, but the applicant should be released by the treating physician before obtaining the following evaluations.

It must specifically include:

Note: Do not submit imaging on CD unless requested by the FAA.

It is the responsibility of each applicant to provide the medical information required to determine his/her eligibility for airman medical certification.

To aid in the review process, it is critical that the applicant’s full name and date of birth appear all correspondence and reports. Bring all information to your AME to upload into your FAA record.

Note: If Images (CDs) are required, all items should be mailed to one of the following:

No consideration will be given for special issuance until ALL the required data has been received.

• Civil Aerospace Medical Institute (CAMI)
• Aerospace Medical Certification Division
• Limited Certificate Petition

(Updated 04/24/2024) Name: _________________________________PI#: ___________________

Address: ________________________________Date of Birth: ___________

In the event you are found not fully qualified for the class of medical certificate sought, would you accept a lower class and/or a certificate with one of the following limitations? ☐ Yes ☐ No

If yes, indicate what limitation would be acceptable:

☐ Second class privileges limited to Aerial Application (crop dusting, etc.) ☐ Second class privileges limited to Flight Engineer duties. ☐ Valid for balloon operations only.

☐ Two-Pilot Crew

Limited second-class/Full third-class privileges.

Not valid for carrying passengers or cargo for compensation, except if serving as pilot of fully qualified 2-pilot crew.

☐ Not valid for pilot in command except if serving as pilot of fully qualified 2-pilot crew.

Signature: _______________________________Date: __________________

NOTE: Pilots operating under 14 CFR Part 121 operations are not eligible to accept a lower class with the above limitations. This page is provided in the AME guide for your convenience. It is NOT required unless listed as an evaluation data item in a disposition table of the AME Guide or requested by the FAA.

Specifications for Neuropsychological Evaluations for Treatment with SSRI Medications

(Updated 01/29/2020) Depressive disorders and medications used to treat depression are medically disqualifying for pilots and FAA Air Traffic Control Specialists. However, the Federal Air Surgeon has established a policy for Authorizations for Special Issuance (SI) of medical certificates for pilots and Special Consideration (SC) clearance for FAA ATCS treated with selective serotonin reuptake inhibitor (SSRI) medications who meet specific criteria.

Why is a neuropsychological evaluation required? Depression and other conditions treated with selective serotonin reuptake inhibitor (SSRI) medications, as well as the SSRIs themselves, may produce cognitive deficits that would make an airman unsafe to perform pilot duties. This guideline outlines the requirements for a neuropsychological evaluation.

Who may perform a neuropsychological evaluation? Neuropsychological evaluations must be conducted by a licensed clinical psychologist who is either board certified or “board eligible” in clinical neuropsychology. “Board eligible” means that the clinical neuropsychologist has the education, training, and clinical practice experience that would qualify him or her to sit for board certification with the American Board of Clinical Neuropsychology, the American Board of Professional Neuropsychology, and/or the American Board of Pediatric Neuropsychology.

Will I need to provide any of my medical records? You should make records available to the neuropsychologist prior to the evaluation, to include:

What must the neuropsychological evaluation report include? At a minimum:

What is required for testing?

To promote test security, itemized lists of tests comprising psychological/neuropsychological test batteries have been moved to a secure site. Authorized professionals should use the portal at FAA Neuropsychology Testing Specifications. For access, email a request to 9- amc-aam-NPTesting@faa.gov.

What must be submitted? The neuropsychologist’s report as specified in the portal, plus:

When available, pilot norms must be used. If pilot norms are not available for a particular test, then the normative comparison group (e.g., general population, age/education-corrected) must be specified. Also, when available, percentile scores must be included.

Recommendations should be strictly limited to the psychologist’s area of expertise. For questions about testing or requirements, email 9-amc-aam-NPTesting@faa.gov .

What else does the neuropsychologist need to know?

Useful references for the neuropsychologist:

Philadelphia: Lippencott Williams & Wilkins.

Protocol for Diabetes Mellitus - Diet Controlled

A medical history or clinical diagnosis of diabetes mellitus may be considered previously established when the diagnosis has been or clearly could be made because of supporting laboratory findings and/or clinical signs and symptoms. When an applicant with a history of diabetes is examined for the first time, the AME should explain the procedures involved and assist in obtaining prior records and current special testing.

Applicants with a diagnosis of diabetes mellitus controlled by diet alone are considered eligible for all classes of medical certificates under the medical standards, provided they have no evidence of associated disqualifying cardiovascular, neurological, renal, or ophthalmological disease. Specialized examinations need not be performed unless indicated by history or clinical findings. The AME must document these determinations on FAA Form 8500-8.

Protocol for Diabetes Mellitus

Treated with Any Medication Other Than Insulin

All Classes

(Updated 01/28/2026) If taking any form of insulin do NOT use this protocol. Go to www.faa.gov/go/itdm.

Applicants with a diagnosis of diabetes mellitus controlled by medication must submit the following information for consideration of an Authorization for Special Issuance Medical Certificate (Authorization) for any class. See Acceptable Combinations of Diabetes Medications for allowable medications, combinations, and required recovery periods after starting or changing medication(s).

INITIAL AUTHORIZATION:

o A detailed summary of the history of the condition;

o Treatments and outcomes;

o Current medications, dosage, and side effects (if any);

o Physical exam findings;

o Results of any testing performed;

o Diagnosis;

o Assessment;

o Plan (prognosis); and o Follow-up.

SUBSEQUENT EXAMS:

GENERAL CONSIDERATIONS:

The individual should not perform pilot or safety-related duties until required recovery periods have elapsed and the treating physician has consulted with the AME who issued the certificate, AMCD, or RFS and has determined that the condition is:

o Under control;

o Stable; and o Presents no risk to aviation safety.

DIABETES or HYPERGLYCEMIA ON MEDICATIONS STATUS REPORT

(Updated 01/28/2026) Name ________________________________ Birthdate ______________________

Applicant ID# __________________________ PI#___________________________

If you take any type of insulin. STOP. Do not use this page. Go to www.faa.gov/go/insulin to find the correct documents.

Please have the provider who treats your diabetes enter the information in the space below.

Return the completed status report to your AME for upload into your FAA file.

(A1C lab value must be taken more than 30 days after medication change and within 90 days of re/certification)

_______________________________________________________________________

_____________________________________________________________________________ If YES is circled on any of the questions below, please attach narrative, tests, etc.

• Cardiac……………………………………………. Yes No
• Neurological………………………………………. Yes No
• Ophthalmological……………………….……… Yes No
• Peripheral neuropathy…………………………… Yes No
• Renal disease…………………………………….. Yes No

__________________________________ ________________

Treating Provider Signature Date

Note: Acceptable Combinations of Diabetes Medications and copies of this status report for future follow-ups can be found at www.faa.gov/go/diabetic.

Protocol for Diabetes Mellitus Type I or Type II

Insulin Treated - CGM Option

(Updated 09/30/2026) 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. The FAA has an established policy that permits the special issuance medical certification to some insulin treated applicants. Individuals certificated under this policy will be required to provide medical documentation regarding their history of treatment, accidents, and current medical status. If certificated, they will be required to adhere to monitoring requirements. There are no restrictions regarding flight outside of the United States air space.

CONTINUOUS GLUCOSE MONITORING (CGM PROTOCOL) - ALL CLASSES:

For consideration for first- or second-class airman certification, the airman must submit Continuous Glucose Monitoring (CGM) data and ALL the certification requirements as outlined below:

For details of what specific information must be included for each requirement/report, see the links below (or the following pages in this document) for:

• A. PILOT INFORMATION - INITIAL CERTIFICATION
• B. INITIAL CERTIFICATE CONSIDERATION REQUIREMENTS
• C. CERTIFICATION AID
• D. INFORMATION SUBMISSION REQUIREMENTS
• E. RENEWAL CERTIFICATE REQUIREMENTS
• F. SUBMITTING DOCUMENTS FOR INITIAL AND RENEWAL
• G. CGM DATA REPORT EXAMPLES
• H. FREQUENTLY ASKED QUESTIONS (FAQs)
• NON-CGM PROTOCOL - THIRD CLASS OPTION:

Third class airmen may elect to use either the CGM protocol or the non-CGM protocol. See the links below (or the following pages in this document) for details of what specific information must be included for each requirement/report for third-class certification.

• A. INITIAL CERTIFICATION
• B. MONITORING AND ACTIONS REQUIRED DURING FLIGHT OPERATIONS
• C. RE-CERTIFICATION
• D. DIABETES ON INSULIN RE-CERTIFICATION STATUS REPORT
• DIABETES MELLITUS TYPE I OR TYPE II INSULIN TREATED CGM OPTION

A. PILOT INFORMATION - INITIAL CERTIFICATION

(Updated 09/30/2026)

If you are a PILOT:

Find an Aviation Medical Examiner (AME) to work with you through the FAA process:

☐ Establish care and obtain an evaluation with a board-certified endocrinologist. (See Item #1 – ITDM Initial Certificate Consideration Requirements) ☐ Select, in conjunction with your board-certified endocrinologist, an appropriate Continuous Glucose Monitor (CGM) device that meets all FAA monitoring criteria. (See “Item # 3 - Continuous Glucose Monitor Data” of the ITDM Initial Certificate Consideration Requirements).

☐ Collect a minimum of 6 months of CGM data.

☐ Separate the data by month (e.g., Jan. 1-31, Feb. 1-28, March 1-31, etc.). ☐ Review the CGM Data - Report Examples. Verify you provide the correct report views based on the type of CGM device used.

☐ Verify your CGM report identifies the percentage of time spent with glucose:

☐ Less than 54 mg/dL;

☐ Less than 70 mg/dL;

☐ Between 70 and 180 mg/dL;

☐ Above 180 mg/dL; and ☐ Above 250 mg/dL ☐ Obtain initial lab battery and submit copies of A1C from at least past 12 months. ☐ Obtain an eye evaluation from a board-certified ophthalmologist (M.D. or D.O.). If you do not have retinopathy, an optometrist (OD) may be acceptable. ☐ Obtain a cardiac evaluation from a board-certified cardiologist. Must be a physician, (M.D. or D.O), not a mid-level practitioner.

☐ Obtain an ECG.

☐ Undergo a Stress Test Bruce Protocol (if age 40 or older).

☐ Take to your AME all of the above items and any other information on any other condition(s) that may require a Special Issuance ☐ See your AME and complete a new 8500-8 exam ☐ The AME is not authorized to issue an initial medical certificate and must transmit the application and physical examination as DEFERRED ☐ The AME may assist with uploading the documents (See uploading guidance.)

IMPORTANT NOTE:

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 requested it, which will delay the certification review.

DIABETES MELLITUS TYPE I OR TYPE II INSULIN TREATED - CGM OPTION

B. INITIAL CERTIFICATE CONSIDERATION REQUIREMENTS

(Updated 09/30/2026) For consideration for first- or second-class medical certification, the applicant must submit Continuous Glucose Monitoring (CGM) data. Requirements are below. For information on the specific information needed for each requirement/report (items #1-5), see the CGM – Certification Aid.

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 concerns regarding adequacy of control may require a longer stability period.

Additional information may be required on a case-by-case basis. For information on how to send documents to the FAA, see How to Submit Documents for Initial or Recertification/Renewal. 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 labeled progress note, consultation note, or history and physical.

Note: for initial evaluations, the former “Diabetes on Insulin Re-Certification Status Report” (now called “Diabetes on Insulin Re-Certification Status Report NON CGM – Third Class Option”) will NOT be accepted. The Initial Comprehensive report contains significant additional information.

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

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. (See chart on next page.)

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)

INITIAL CERTIFICATE CONSIDERATION REQUIREMENTS (Page 2 of 2) (Updated 09/30/2026)

(Continued)

ITEM # 3 OTHER DEVICES ☐ The data report should include estimated A1c (and/or GMI - glucose management indicator), average glucose, coefficient of variation, standard deviation, time in range, sensor usage, and weekly overlays/graphs. ☐ A list of acceptable CGM devices can be found the CGM Option – Certification Aid.

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

CGM GOALS: See table below for parameters and target range.

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 70mg/dl and/or above 250mg/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.

*Note: TIR 70 per ADA guidance.

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 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) IMPORTANT NOTE:

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.

• DIABETES MELLITUS TYPE I OR TYPE II - INSULIN TREATED CGM OPTION
• C. CERTIFICATION AID

(Updated 09/30/2026) The following are the specifics of the ITEM numbers listed in the Initial and Renewal requirements:

ITEM #1: INITIAL COMPREHENSIVE REPORT (Updated 03/30/2022)

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:

3. Screening for Psychosocial conditions:

4. Glucose control:

CERTIFICATION AID (Page 2 of 5)

(Updated 09/30/2026)

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

C. ASSESSMENT AND PLAN:

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

*1 Modified from American Diabetes Association (ADA) Standards of Medical Care 2020

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 ITEM #3: CONTINUOUS GLUCOSE MONITOR (CGM) DATA (Updated 08/30/2023)

When submitting CGM data:

☐ DO Submit the required weekly or monthly graphs. (See examples on the following pages)

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

☐ 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):

CERTIFICATION AID (Page 3 of 5)

(Updated 09/30/2026)

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.

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

CERTIFICATION AID (Page 4 of 5)

(Updated 09/30/2026) d) Coefficient of Variability [CoV] values;

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

Failure to provide these values could result in a delay in processing of the application. 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.

C. INSULIN PUMP REQUIREMENTS:

ITEM #4: EYE EVALUATION

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:

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

CERTIFICATION AID (Page 5 of 5)

(Updated 08/30/2023) 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.

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:

A. INITIAL CARDIAC RISK EVALUATION:

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

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:

• DIABETES MELLITUS TYPE I OR TYPE II - INSULIN TREATED CGM OPTION
• D. INFORMATION SUBMISSION REQUIREMENTS

(Updated 09/30/2026) NAME___________________________ PI# or MID# ____________________________ ****This document is for AME or aviator use. DO NOT SBUMIT TO THE FAA. ****

• DIABETES MELLITUS TYPE I OR TYPE II - INSULIN TREATED CGM OPTION
• E. CGM RENEWAL CERTIFICATE REQUIREMENTS

(Updated 09/30/2026) Once the individual has obtained an Authorization for Special Issuance, they should submit the requirements specified in their Authorization Letter. The item numbers below correspond to the numbers on Initial Certificate Consideration Requirements sheet.

Note: The AME may NOT re-issue a medical certificate UNLESS the Authorization Letter specifically indicates the AME may re-issue a time-limited certificate.

In general, the renewal information required is as follows:

EVERY 6 MONTHS

ITEM #1 Every 3 months, a comprehensive endocrinology clinical examination. ☐ Every 6-month visit must be in-person and performed by your endocrinologist. ☐ The 3-month interval visits may be in person or virtually at the discretion of the endocrinologist. These interval visits may be from your endocrinologist or a mid-level practitioner [physician assistant (PA) or nurse practitioner (NP)] associated with your endocrinologist:

☐ It should include all parts of the clinical examination: a summary of the history of the condition; current medications (dosages and side effects, if any); clinical exam findings; comprehensive foot exam (e.g., visual inspection, sensation, 10-g monofilament exam, etc.); results of any testing performed; diagnosis; assessment; plan (prognosis); and follow-up.

☐ After the examination, obtain the current, detailed Clinical Progress Note from your provider.

NOTE: A letter from your endocrinologist is NOT sufficient and cannot substitute for a current detailed Clinical Progress Note. ☐ If additional visits occur, submit those actual clinic record(s) to the FAA also. ITEM #3 Monthly CGM data reports for the previous 6 months:

☐ Collect data for each month. Separate the data by month (e.g., Jan. 1-31, Feb. 1-28, March 1-31, etc.);

☐ Continue ongoing use with a CGM device that meets FAA requirements.

EVERY 12 MONTHS

☐ All items listed in the “EVERY 6 MONTHS” section above, PLUS:

☐ ITEM #2 - Lab - Annual comprehensive panel;

☐ ITEM #4 - Eye evaluation from a board-certified ophthalmologist (M.D./ D.O.) preferred; an optometrist (OD) may be acceptable if there is no history of retinopathy.

☐ ITEM #5 - Cardiac Risk Evaluation for age 40 and above from a board-certified cardiologist, including lab;

☐ ECG, stress test, or other cardiac testing, if clinically indicated;

(Note: stress test required every five (5) years, sooner if concerns or clinically indicated.

ADDITIONAL INFORMATION MAY BE REQUIRED ON A CASE-BY-CASE BASIS.

CGM RENEWAL CERTIFICATE REQUIREMENTS (Page 2 of 2)

(Updated 09/30/2026)

EVERY 24 MONTHS:

ITEM #5 Cardiac Risk Evaluation for UNDER Age 40 o From either your board-certified-endocrinologist OR a board-certified cardiologist, including lab;

o ECG, stress test or other cardiac testing, if clinically indicated;

(Note: stress test required every five [5] years, sooner if concerns or clinically indicated.)

Submit all above items to your AME for upload into your FAA file. See How to Submit Documents for Initial or Recertification/Renewal.

As of 09/30/2026, 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.

DIABETES MELLITUS TYPE I OR TYPE II - INSULIN TREATED CGM OPTION

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

(Updated 08/30/2023) 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. See instructions on How to Upload Documents.

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:

• Regular mail (US postal service)
• Federal Aviation Administration
• Civil Aerospace Medical Institute, Building 13
• Aerospace Medical Certification Division, AAM-313
• PO Box 25082
• Oklahoma City, OK 73125-9914
• OR

Special mail (FedEx, UPS, etc.)

• Federal Aviation Administration
• Medical Appeals Section, AAM-313
• Aerospace Medical Certification Division
• 6700 S. MacArthur Boulevard, Building 13, Room 308
• Oklahoma City, OK 73169

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.

DIABETES MELLITUS TYPE I OR TYPE II INSULIN TREATED - CGM OPTION

G. CGM DATA REPORT EXAMPLES

(Updated 08/30/2023) The following pages show CGM Data report examples for various devices. Please submit any CGM graphs IN COLOR.

CGM DATA REPORT EXAMPLES (Page 2 of 7)

CGM DATA REPORT EXAMPLES (Page 3 of 7)

Note: Submit graphs in color.

CGM DATA REPORT EXAMPLES (Page 4 of 7)

CGM DATA REPORT EXAMPLES (Page 5 of 7)

Note: Submit graphs in color.

CGM DATA REPORT EXAMPLES (Page 6 of 7)

CGM DATA REPORT EXAMPLES (Page 7 of 7)

• DIABETES MELLITUS TYPE I OR TYPE II INSULIN TREATED - CGM OPTION PROTOCOL
• H. FREQUENTLY ASKED QUESTIONS (FAQs) (Page 1 of 4)
• (Updated 08/30/2023)
• POLICY FAQs

Advances in diabetes management utilizing CGM technology provides pilots and the FAA better information about blood glucose levels and advanced warning of potentially dangerous glucose levels before they occur. CGM technology also allows the FAA to evaluate consistency of blood glucose control both in flight and on the ground.

Various flight safety considerations for this serious health condition could not be safely mitigated for commercial operations until recently. Advances in technology and diabetes management now provide the FAA better parameters to consider Class I and II medical certification for some insulin-dependent airmen.

At the time of initial publication, only Canada and the United Kingdom allow the use of insulin in their pilots with an equivalent Class I or II medical. Unlike the FAA, those aviation authorities can impose specific operational limitations on the medical certificate (e.g., “valid only for two pilot operations” or requiring the other pilot to be both aware of the diabetic condition and able to provide emergency treatment.)

The FAA policy follows current medical standards of care for diabetes to ensure pilots are safe to fly in the complex aviation environment and reduce the risks of end-organ damage. If the latter is present, the potential risk of cognitive impairment is increased, which could be magnified in a hypoxic or high-stress environment, affecting safety.

While your physicians understand how to keep your blood sugar stable while on the ground, they may not be familiar with the additional challenges of the demanding aviation environment and may not consider them when determining clinical limitations. FAA guidance addresses these aviation-specific concerns.

Yes. Hypoglycemia can lead to cognitive impairment, loss of consciousness, and seizure. Hyperglycemia can potentially cause sudden incapacitation, but it can also cause damage to eyes, heart, kidneys, and nervous system.

• FREQUENTLY ASKED QUESTIONS (FAQs) (Page 2 of 4)
• (Updated 08/30/2023)
• BLOOD SUGAR FAQs

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.

CGM technology allows the FAA to ensure ongoing safety through consistent blood glucose control both in flight and on the ground regardless of the pilot’s flight schedule.

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

o Your AME should contact the FAA to discuss your case.

CONTINUOUS GLUCOSE MONITOR (CGM) AND INSULIN PUMP FAQs

The FAA lists the required functions of CGMs in the Guide for Aviation Medical Examiners (AME Guide). While we do not endorse specific brands, we have added a list of devices we know meet these requirements. See “Item # 4 - Continuous Glucose Monitor Data” of the ITDM Initial Certificate Consideration Requirements.

The CGM is more accurate, measuring within 10% of the actual blood sugar. It is also independent of the pilot’s action. Turbulence can make it impossible for pilots to perform finger sticks, even with an autopilot and/or second pilot. The CGMs can enable notifications and alerts for specific blood glucose values and show predictive trends, both of which are required. The CGM can also communicate with an insulin pump.

FREQUENTLY ASKED QUESTIONS (FAQs) (Page 3 of 4)

(Updated 08/30/2023) 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.

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.)

You should have all the following available during flight:

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.

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.

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

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.

FREQUENTLY ASKED QUESTIONS (FAQs) (Page 4 of 4)

(Updated 08/30/2023) 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.

Protocol for Insulin Treated Diabetes Mellitus NON-CGM Protocol - Third Class Option

See following pages for:

• A. INITIAL CERTIFICATION
• B. MONITORING AND ACTIONS REQUIRED DURING FLIGHT OPERATIONS
• C. RECERTIFICATION

D. DIABETES ON INSULIN RE-CERTIFICATION STATUS REPORT NON-CGM – THIRD CLASS OPTION

Protocol for Insulin-Treated Diabetes Mellitus

Non-CGM - Third-Class Option

(Updated 07/27/2022) Consideration will be given only to those individuals who have been clinically stable on their current treatment regimen for a period of 6 months or more. The FAA has an established policy that permits the special issuance medical certification to some insulin treated applicants. Individuals certificated under this policy will be required to provide medical documentation regarding their history of treatment, accidents, and current medical status. If certificated, they will be required to adhere to monitoring requirements. There are no restrictions regarding flight outside of the United States air space.

The following is a summary of the evaluation protocol and an outline of the conditions that the FAA will apply for third class applicants not using a CGM device.

A. INITIAL CERTIFICATION

NOTE: Student pilots may wish to ensure they are eligible for medical certification prior to beginning or resuming flight instruction or training. In order to serve as a pilot in command, you must have a valid medical certificate for the type of operation performed.

B. MONITORING AND ACTIONS REQUIRED DURING FLIGHT OPERATIONS

To ensure safe flight, the insulin using diabetic airman must carry during flight a recording glucometer; adequate supplies to obtain blood samples; and an amount of rapidly absorbable glucose, in 10 gm portions, appropriate to the planned duration of the flight. The following actions shall be taken in connection with flight operations:

(Note: Insulin pumps are acceptable)

C. RECERTIFICATION 1. For documentation of diabetes management, the applicant will be required to carry and use a whole blood glucose measuring device with memory and must report to the FAA immediately any hypoglycemic incidents, any involvement in accidents that result in serious injury (whether or not related to hypoglycemia); and any evidence of loss of control of diabetes, change in treatment regimen, or significant diabetic complications. With any of these occurrences, the individual must cease flying until cleared by the FAA.

D. RE-CERTIFICATION STATUS REPORT NON-CGM – THIRD CLASS OPTION

See following pages.

DIABETES ON INSULIN Re-Certification STATUS REPORT

NON-CGM – THIRD CLASS OPTION

(Updated 06/29/2022) Name __________________________________ Birthdate ________________________

Applicant ID# _____________________________ PI# ____________________________

Class applied _________________________ Circle one: INITIAL / Re-Certification

Please have the provider who treats your diabetes enter the information in the space below. Return the completed status report to your AME or to the FAA at:

☐ 1. Provider printed name________________________________ phone ________________

☐ 2. Date of last clinical encounter for Diabetes ______________________________________

☐ 3. Date of most recent DIABETES MEDICATION CHANGE ___________________________ And describe what was changed:

☐ 4. Quarterly hemoglobin A1c (A1c’s must be done > 30 days after meds change and < 90 days of recertification.)

• Quarterly
• A1Cs
• Value Date

#1 #2 #3 #4 ☐ 5. Review the blood glucose self-monitoring log book, recording device download, or continuous glucose monitoring (CGM) data, if used. Comment on stability, variance (highs and lows), and any other concerns you have. If control is good and there are no concerns, state that also. _______ _________

________

________

DIABETES ON INSULIN Re-Certification STATUS REPORT

NON-CGM – THIRD CLASS OPTION

(Updated 11/07/2019) Name __________________________________ Birthdate ________________________

Applicant ID# _____________________________ PI# ____________________________

In lieu of #6 and #7, the physician’s office may attach a current medication list. The list should note for what condition the medications are used.

☐ 6. List Insulin treatment schedule:

☐ 7. List ALL other current medications* (for any condition) and why they are used/diagnosis treated. Dosage is not required.

IF YES on any of the questions below, please attach narrative, tests, etc.

☐ 8. Any side effects from medications..........................................................................Yes No

☐ 9. ANY episode of hypoglycemia in the past year

REQUIRING ASSISTANCE from another person...................................................Yes No

☐ 10. Any evidence of progressive diabetes induced end organ disease:

Cardiac........................................................................................................Yes No

Neurological.................................................................................................Yes No

Ophthalmological ........................................................................................Yes No

Neuropathy .................................................................................................Yes No

Renal disease .............................................................................................Yes No

☐ 11. Any clinical concerns or other comments? ..........................................................Yes No

____________________________ ___________________

Treating Provider Signature Date

For more information, see:

Protocol for Maximal Graded Exercise

Stress Test Requirements

(Updated 05/29/2024)

o 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.

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

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

o 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 o 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.

o Tracings must include a rhythm strip;

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

Protocol for History of Human

Immunodeficiency Virus (HIV) Related Conditions

Persons on antiretroviral medication will be considered only if the medication is approved by the U.S. Food and Drug Administration and is used in accordance with an acceptable drug therapy protocol. Acceptable protocols are cited in Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents developed by the Department of Health and Human Services Panel on Clinical Practices for Treatment of HIV Infection.

For persons taking HIV medication for long-term prevention or Pre-Exposure Prophylaxis (PrEP), see Item 48. General Systemic - Human Immunodeficiency Virus (HIV).

Application for special issuance must include reports of examination by a physician knowledgeable in the treatment of HIV-infected persons and a medical history emphasizing symptoms and treatment referable to the immune and neurologic system. In addition, these reports must include a "viral load" determination by polymerase chain reaction (PCR), CD4+ lymphocyte count, a complete blood count, and the results of liver function tests. An assessment of cognitive function (preferably by CogScreen or other test battery acceptable to the Federal Air Surgeon) must be submitted. Additional cognitive function tests may be required as indicated by results of the cognitive tests. At the time of initial application, viral load must not exceed 1,000 copies per milliliter of plasma, and cognitive testing must show no significant deficit(s) that would preclude the safe performance of airman duties.

Application for special issuance must include reports of examination by a physician knowledgeable in the treatment of HIV-infected persons and a medical history emphasizing symptoms and treatment referable to the immune and neurologic system. For initial consideration, see the following Human Immunodeficiency Virus (HIV) Specification Sheet for the required clinical reports and documentation (including cognitive testing).

If granted Authorization for Special Issuance, follow-up requirements will be specified in the Authorization letter. However, the usual requirements will be:

HUMAN IMMUNODEFICIENCY VIRUS (HIV) SPECIFICATION

(Updated 08/28/2024) Persons who are infected with the HIV and who do not have a diagnosis of Acquired Immunodeficiency Syndrome (AIDS) may be considered for any class medical certificate, if otherwise qualified. Persons on an antiretroviral medication will be considered only if the medication is approved by the U.S. Food and Drug Administration and is used in accordance with an acceptable drug therapy protocol. Current studies should be submitted no later than 30-days from test date. In order to be considered for a medical certificate the following data must be provided:

To promote test security, itemized lists of tests comprising psychological/neuropsychological test batteries have been moved to this secure site.

Authorized professionals should use the secure portal. For access, email a request to 9-amc-aam-NPTesting@faa.gov.

All of the above should be submitted together in one mailing to:

Using US Postal Service: or Using special mail (UPS, FedEx, etc.)

Federal Aviation Administration Federal Aviation Administration Aeromedical Certification Branch-AAM-300 Aeromedical Certification Branch-AAM-300 Mike Monroney Aeronautical Center Mike Monroney Aeronautical Center PO Box 25082 6700 S. MacArthur Blvd, Room B-59

Oklahoma City, OK 73125 Oklahoma City, OK 73169

*For applicants with a history of cytomegalovirus (CMV) retinitis, a current ophthalmological evaluation with visual fields must be provided with the initial application and at 6 month-intervals thereafter.

UNDER 2 YEAR SURVEILLANCE HIV SPECIFICATION

(Updated 06/30/2021) Please provide our office with a current status report from a treating physician knowledgeable and experienced in the treatment of HIV-infected persons. This report should include the information outlined below, along with any separate additional testing.

The results should be sent to the Aerospace Medical Certification Division (AMCD) After review, if the airman is determined qualified, AMCD/Regional Flight Surgeon (RFS) will send a letter to the airman authorizing the Aviation Medical Examiner (AME) to issue a new time-limited medical certificate, as applicable.

Both the initial and subsequent medical determinations may only be made by the RFS or AMCD.

The current status report should include:

AFTER 2 YEARS SURVEILLANCE HIV SPECIFICATION

(Updated 06/30/2021) Please provide our office with a current status report from a treating physician knowledgeable and experienced in the treatment of HIV-infected persons. This report should include the information outlined below, along with any separate additional testing.

The results should be sent to the Aerospace Medical Certification Division (AMCD) After review, if the airman is determined qualified, AMCD/Regional Flight Surgeon (RFS) will send a letter to the airman authorizing the Aviation Medical Examiner (AME) to issue a new time-limited medical certificate, as applicable.

Both the initial and subsequent medical determinations may only be made by the RFS or AMCD.

The current status report should include:

Protocol for Initial Evaluation of Implanted Pacemaker

(Updated 05/29/2024) A 2-month recovery period is required after pacemaker implantation to allow for recovery and stabilization. After the 2-month recovery period, submit the following:

Note: Evaluation of Pacemaker Dependency is no longer required for any class as of 08/25/2021.

It is the responsibility of each applicant to provide the medical information required to determine his/her eligibility for airman medical certification.

To aid in the review process, it is critical that the airman’s full name and date of birth appear all correspondence and reports. Send all information in one mailing to:

No consideration will be given for special issuance until ALL the required data has been received.

*Note: The Pacemaker Status Summary is not required, however, it will help to significantly DECREASE FAA review time.

PACEMAKER STATUS SUMMARY

(Updated 12/03/2025)

Name _______________________________ Birthdate ________________ Applicant ID#__________________________ PI# _____________________ Please take this summary sheet to your cardiologist and have them enter the requested information in the space provided. Submit either this summary* or all supporting documentation addressing each item to your AME for upload into your file as Cardiac – Pacemaker Info.

replaced, circle No………………………………………………………

Cardiologist signature Date

Notes: As of 05/29/2024 - Routine medical certificate will be annually until there is less than 12 months until the Elective Replacement Interval (ERI). At that point, the aeromedical certification will terminate the month before the ERI.

As of 08/25/2021 - Evaluation of Pacemaker Dependency is no longer required for any class. This Pacemaker Status Summary is NOT required; however, it will help to streamline and significantly DECREASE FAA review time.

• / /
• Manufacturer Model / /
• Yes No
• Years Months volts
• RV LV ohms
• ohms
• RV LV
• RV LV
• Yes No
• Yes No

Protocol for Medication Controlled

Metabolic Syndrome

(Glucose Intolerance, Impaired Glucose tolerance, Impaired Fasting Glucose,

Insulin Resistance, and Pre-Diabetes)

(Updated 07/26/2023) An applicant with a diagnosis of diabetes mellitus treated with a medication not including insulin may be considered by the FAA for an Authorization of a Special Issuance of a Medical Certificate (Authorization). For medications currently allowed and required observation times, see chart of Acceptable Combinations of Diabetes Medications.

The initial Authorization decision is made by the AMCD and may not be made by the AME. An AME may re-issue a subsequent airman medical certificate under the provisions of the Authorization.

The initial Authorization determination will be made on the basis of a report from the treating physician. There must be sufficient information to rule out diabetes mellitus. For favorable consideration, the report must contain a statement regarding the medication used, dosage, the absence or presence of side effects and clinically significant hypoglycemic episodes, and an indication of satisfactory control of the metabolic syndrome. The results of an A1C hemoglobin determination within the past 30 days must be included. Note must also be made of the presence of cardiovascular, neurological, renal, and/or ophthalmological disease. The presence of one or more of these associated diseases will not be, per se, disqualifying but the disease(s) must be carefully evaluated to determine any added risk to aviation safety.

Re-issuance of a medical certificate under the provisions of an Authorization will also be made on the basis of reports from the treating physician. The contents of the report must contain the same information required for initial issuance and specifically reference the presence or absence of satisfactory control, any change in the dosage or type of medication, and the presence or absence of complications or side effects from the medication. In the event of an adverse change in the applicant's status (development of diabetes mellitus, poor control or complications or side effects from the medication), or the appearance of an associated systemic disease, an AME must defer the case with all documentation to the AMCD for consideration.

If, upon further review of the deferred case, AMCD decides that re-issuance is appropriate, the AME may again be given the authority to re-issue the medical certificate under the provisions of the Authorization based on data provided by the treating physician, including such information as may be required to assess the status of associated medical condition(s).

At a minimum, follow-up evaluation by the treating physician of the applicant's metabolic syndrome status is required annually for all classes of medical certificates.

An applicant with metabolic syndrome should be counseled by his or her AME regarding the significance of the disease and its possible complications, including the possibility of developing diabetes mellitus.

The applicant should be informed of the potential for hypoglycemic reactions and cautioned to remain under close medical surveillance by his or her treating physician.

The applicant should also be advised that should their medication be changed or the dosage modified, the applicant should not perform airman duties until the applicant and treating physician has concluded that the condition is:

Protocol for Musculoskeletal Evaluation

The AME should defer issuance.

An applicant with a history of musculoskeletal conditions must submit the following if consideration for medical certification is desired:

NOTE: If the applicant is otherwise qualified, the FAA may issue a limited certificate. This certificate will permit the applicant to proceed with flight training until ready for a medical flight test. At that time, and at the applicant's request, the FAA (usually the AMCD) will authorize the student pilot to take a medical flight test in conjunction with the regular flight test. The medical flight test and regular private pilot flight test are conducted by an FAA inspector. This affords the student an opportunity to demonstrate the ability to control the aircraft despite the handicap. The FAA inspector prepares a written report and indicates whether there is a safety problem. A medical certificate and statement of demonstrated ability (SODA) may be provided to the airman from AMCD/RFS office if the MFT is successful and the airman is otherwise qualified.

When prostheses are used or additional control devices are installed in an aircraft to assist the amputee, those found qualified by special certification procedures will have their certificates limited to require that the device(s) (and, if necessary, even the specific aircraft) must always be used when exercising the privileges of the airman certificate.

Specifications for Neuropsychological Evaluations for Potential Neurocognitive Impairment

(Updated 06/26/2024) Why is a neuropsychological evaluation required? Head trauma, stroke, encephalitis, multiple sclerosis, other suspected acquired or developmental conditions, and medications used for treatment, may produce cognitive deficits that would make an airman unsafe to perform pilot duties. This guideline outlines the requirements for a neuropsychological evaluation.

Who may perform a neuropsychological evaluation? Neuropsychological evaluations should be conducted by a qualified neuropsychologist with additional training in aviation-specific topics. The following link contains a list of neuropsychologists who meet all FAA quality criteria: FAA Neuropsychologist List.

Will I need to provide any of my medical records? You should make records available to the neuropsychologist prior to the evaluation, to include:

What must the neuropsychological evaluation report include? At a minimum:

What is required in the “core test battery?”

To promote test security, itemized lists of tests comprising psychological/neuropsychological test batteries have been moved to a secure site. Authorized professionals should use the portal at FAA Neuropsychology Testing Specifications. For access, email a request to 9-amc-aam-NPTesting@faa.gov.

What must be submitted? The neuropsychologist’s report as specified in the portal, plus:

When available, pilot norms must be used. If pilot norms are not available for a particular test, then the normative comparison group (e.g., general population, age/education-corrected) must be specified. Also, when available, percentile scores must be included.

Recommendations should be strictly limited to the psychologist’s area of expertise. For questions about testing or requirements, email 9-amc-aam-NPTesting@faa.gov.

What else does the neuropsychologist need to know?

Ethical Principles of Psychologists and Code of Conduct (2002) as well as applicable federal law.

FAA Specifications for Neurologic Evaluation

(Updated 03/27/2024) INFORMATION FOR THE AIRMAN: To ensure the neurological evaluation meets FAA requirements, we strongly recommend that you share all pages of this specification sheet with your neurologist. Your Aviation Medical Examiner (AME) or personal physician may help you locate a board-certified neurologist. The FAA requires a neurological evaluation to determine your ability to hold a medical certificate. The evaluation must meet the following criteria to be considered:

☐ Current (must be performed within the last 90 days);

☐ Performed by a board-certified physician (M.D., D.O., or physician degree equivalent (e.g., MBBS), who also holds a current board certification by the American Board of Psychiatry and Neurology or equivalent accrediting authority. (if you are uncertain, consult your AME); and ☐ Evaluation must meet the Comprehensive Neurological Evaluation criteria listed in Item A below.

The following will cause a delay in the processing of your medical application:

- Evaluations which do not meet the above criteria;

- Neurologist evaluation which does not address all the requested information in Item A; - Missing or incomplete information requested in Items B - D.

IMPORTANT:

Regular First Class Mail OR Special Delivery/Overnight Mail

Federal Aviation Administration Federal Aviation Administration Aerospace Medical Certification Division Aerospace Medical Certification Division CAMI Building 13, Room 308 AAM-300 6500 S. Macarthur Boulevard P.O. Box 25082 CAMI Building 13, Room 308 AAM-300

Oklahoma City, OK 73125 Oklahoma City, OK 73169

INFORMATION FOR THE NEUROLOGIST: Your patient is an airman who must meet regulatory requirements in order to be issued a medical certificate. Your comprehensive report should provide a complete neurological picture for the FAA to review in making a determination for issuance. The information you provide will be reviewed by a physician with expertise in aerospace medicine, therefore, it is not our expectation that you address the aerospace implications in this evaluation, but to provide the clinical facts, historical and exam findings, and specialist opinion pertaining to this airman’s neurologic concerns and/or conditions.

A. COMPREHENSIVE NEUROLOGICAL EVALUATION

The neurological evaluation and examination must be done in accordance with the 1997 documentation guidelines published by the Centers for Medicare and Medicaid Services and must be detailed enough for a clear understanding of the nature and extent of the neurological disorder and any limitations. The report submitted to the FAA must include, at a minimum, the following:

7. Social and family history:

*Notes:

PRIOR TESTING, TREATMENT, OR OTHER RECORDS:

In addition to the Comprehensive Neurological Evaluation, the airman should provide the following (Items B-D below). See the following page for specifications of document submission.

B. PRIOR TREATMENT RECORDS

Prior treatment records from the current or previous treating physician(s) are an important aspect of the evaluation. When submitting the following treatment records to the FAA, include all of the following in the format* noted:

C. IMAGES/TESTING*

This may include CT, MRI, Ultrasound, X-Rays, CT Angiogram, MR Angiogram, EEG, or other testing ordered by the neurologist or other physician. Test records submitted must include:

D. HOSPITAL, EMERGENCY ROOM (ER), AND TREATMENT RECORDS

For each hospitalization or ER visit for a neurological condition or concern, you must submit:

The airman’s name and FAA reference identification (MID, PI, and/or APP ID#) should be on all correspondence and reports.

Protocol for Obstructive Sleep Apnea

(Updated 05/27/2026) Decision Considerations Disease Protocols - Obstructive Sleep Apnea (OSA) 1. OSA Treated Status Report

2. OSA Treated with PAP and Use of Two Machines

Guidance

For AMEs Who Elect to Perform OSA Assessment 11. AASM Guidelines 12. AME Statement (signature document)

AME Assisted Special Issuance

Supplemental and Educational Information

• OSA TREATED STATUS REPORT
• (Updated 05/27/2026)
• Name _______________________________ Birthdate ________________
• Applicant ID #_______________________ PI# _____________________

AIRMAN (Pilot/ATCS). Complete #1 & #2. Sign, date, and take to your physician or healthcare provider who treats your OSA. After completion, bring to your AME for upload into your FAA file.

#1. Initial review (First time reported to the FAA) Date of sleep study _____________ Recertification (I have an SI/SC) #2. I have been using for OSA as prescribed: CPAP PAP Dental Device

I am tolerating therapy well and have no symptoms of OSA (e.g., daytime sleepiness, lack of mental attention or concentration, or cognitive impairment).

Signature ________________________________________ Date __________________________

******************************************************************************************************************************* If you are the physician or provider treating this individual:

Review all clinical data, complete, sign, and date this report, or submit a current, detailed Clinical Progress Note that addresses ALL items below. For FAA purposes, initial untreated AHI of 15 or higher requires treatment with a PAP device.

Initial untreated Apnea Hypopnea Index (AHI) _________________

*If any concerns with the quality or duration of sleep, or “NO*” answers you MUST DEFER or contact AAM. Upload any Clinical Progress Notes or PAP Data.

Physician or treating provider signature _______________________ Date _____________________________

Printed name or office name __________________________________ Office phone number ________________

AME Instructions. Upload this document as “OSA TREATED STATUS REPORT”.

If uploading the sleep study, use “OSA - Sleep Study”.

OSA Treated with PAP and Use of Two Machines (or more)

(Updated 09/29/2021) Airmen with obstructive sleep apnea (OSA) treated with PAP (CPAP, BiPAP, or APAP) may use one machine at home and a separate, portable machine while traveling. Continuation of the Special Issuance is based on the CUMULATIVE time used.

To submit download data from two (or more) machines:

A. If all machines are used during a normal month (a continuous 30-day period):

B. If a single machine is used for more than a month (a continuous 30-day period) and then additional machines are used:

Successful continuation of Special Issuance will rely on combined usage time and the percentage of time used.

Target goals:

OSA Protocol (General Information on OSA) and Decisions Consideration Table

Sleep apnea has significant safety implications due to cognitive impairment secondary to the lack of restorative sleep and is disqualifying for airman medical certification. The condition is part of a group of sleep disorders with varied etiologies. Specifically, sleep apneas are characterized by abnormal respiration during sleep. The etiology may be obstructive, central or complex in nature. However, no matter the cause, the manifestations of this disordered breathing present safety risks that include, but are not limited to, excessive daytime sleepiness (daytime hypersomnolence), cardiac dysrhythmia, sudden cardiac death, personality disturbances, refractory hypertension and, as mentioned above, cognitive impairment.

Certification may be considered once effective treatment is shown.

This protocol is designed to evaluate airmen who may be presently at risk for Obstructive Sleep Apnea (OSA) and to outline the certification requirements for airmen diagnosed with OSA. While this protocol focuses on OSA, the AME must also be mindful of other sleep-related disorders such as insomnia, parasomnias, sleep-related movement disorders (e.g., restless leg syndrome and periodic leg movement), central sleep apnea and other hypersomnias, circadian rhythm sleep disorders, etc., that may also interfere with restorative sleep. All sleep disorders are also potentially medically disqualifying if left untreated. If one of these other sleep-related disorders is initially identified during the examination, the AME must contact their RFS or AMCD for guidance.

Risk Information

The American Academy of Sleep Medicine has established the risk criteria (utilizing Tables 2 and 3) for OSA. When applying Table 2 and 3, the AME is expected to employ their clinical judgment.

Educational information for airmen can be found in the FAA Pilot Safety Brochure on Obstructive Sleep Apnea. Supplemental information for AMEs can be found in OSA Reference Materials, which can be found at end of the Protocols section.

Persons with physical findings such as a retrograde mandible, large tongue or tonsils, neuromuscular disorders, or connective tissue anomalies are at risk of OSA requiring treatment despite a normal or low BMI. OSA is also associated with conditions such as refractory hypertension requiring more than two medications for control, diabetes mellitus, and atrial fibrillation. Over 90% of individuals with a BMI of 40 or greater have OSA requiring treatment. Up to 30% of individuals with OSA have a BMI less than 30.

OSA QUICK-START for AMEs

The AME while performing the triage function must conclude one of six possible determinations. The AME is not required to perform the assessment or to comment on the presence or absence of OSA. For more information, view this instructional video on the screening process.

Step 1 - Determine into which group (1-6) the airman falls.

Applicant Previously Assessed:

Group 1: Has OSA diagnosis and is on Special Issuance. Reports to follow.

Group 2: Has OSA diagnosis OR has had previous OSA assessment. NOT on Special Issuance. Reports to follow.

Applicant Not at Risk:

Group 3: Determined to NOT be at risk for OSA at this examination.

Applicant at Risk/Severity to be assessed:

Group 4: Discuss OSA risk with airman and provide educational materials.

Group 5: At risk for OSA. AASM sleep apnea assessment required.

Applicant Risk/Severity Extremely High:

Group 6: Deferred. Immediate safety risk. AASM sleep apnea assessment required.

Reports to follow.

Step 2 – Document findings in Block 60.

Step 3 – Check appropriate triage box in the AME Action Tab.

Step 4 – Issue, if otherwise qualified.

In assessing airmen for groups 4 and 5, the AME is expected to use their own clinical judgment, using AASM information, when making the triage decision.

Some AMEs have voiced the desire to perform the OSA assessment. While we do not recommend it, the AME may perform the OSA assessment provided that it is in accordance with the clinical practice guidelines established by the American Academy of Sleep Medicine.*

*If a sleep study is conducted, it must be interpreted by a sleep medicine specialist.

AME actions

AME Actions - On every exam, the AME must triage the applicant into one of 6 groups:

o Follow AASI/SI for OSA o Notate in Block 60; and o Issue, if otherwise qualified

o If the airman is under treatment, provide the requirements of the AASI and advise the airman they must get the Authorization of Special Issuance; o Give the applicant Specification Sheet A and advise that a letter will be sent from the Federal Air Surgeon requesting more information. The letter will state that the applicant has 90 days to provide the information to the FAA/AME; o Notate in Box 60;

o Issue, if otherwise qualified

o Calculate BMI; and o Consider AASM risk criteria Table 2 & 3 o If the AME determines the applicant is not currently at risk for OSA (Group/Box 3 of OSA flow chart), select Group 3 on the AME Action Tab:

o Give the applicant Specification Sheet B and advise that a letter will be sent from the Federal Air Surgeon requesting more information. The letter will state that the applicant has 90 days to provide the information to the FAA/AME o Notate in Block 60; and o Issue, if otherwise qualified

o Notate in Block 60. THE AME MUST DEFER

Obstructive Sleep Apnea Specification Sheet A:

Information Request

(Updated 05/27/2026) Your application for airman medical certification indicates that you have been treated or previously assessed for Obstructive Sleep Apnea (OSA).

You must provide the following information to the Aerospace Medical Certification Division (AMCD) or your Regional Flight Surgeon within 90 days:

• A completed and signed OSA TREATED STATUS REPORT
• OR

o A signed FAA Compliance with Treatment sheet or equivalent;

o The results and interpretive report of your most recent sleep study; and o A current Detailed Clinical Progress Note from your treating physician indicating that OSA treatment is still effective.

For CPAP/ BIPAP/ APAP:

A copy of the cumulative annual PAP device report. Target goal should show use for at least 75% of sleep periods and an average minimum of 6 hours use per sleep period.

For Dental Devices or for Positional Devices:

Once Dental Devices with recording / monitoring capability are available, reports must be submitted.

Please submit the aforementioned information to your AME for upload into your FAA file using your reference number (PI, MID, or APP ID).

• OBSTRUCTIVE SLEEP APNEA SPECIFICATION SHEET B:
• ASSESSMENT REQUEST

(Updated 05/27/2026) Due to your risk for Obstructive Sleep Apnea (OSA), and in order to review your eligibility for medical certification, you must provide the following information to the Aerospace Medical Certification Division (AMCD) or your Regional Flight Surgeon’s Office within 90 days for review:

If your sleep study is positive for a sleep-related disorder, you may not exercise the privileges of your medical certificate until you provide:

• A completed and signed OSA TREATED STATUS REPORT
• OR

If you are not diagnosed with a sleep-related disorder or the study was negative for a sleep-related disorder, you may continue to exercise the privileges of your medical certificate, but the evaluation report along with the results of any study, if conducted, must be sent to the FAA. All information provided will be reviewed and is subject to further FAA action.

Please submit the aforementioned information to your AME for upload into your FAA file using your reference number (PI, MID, or APP ID).

For AMEs Who Elect to Perform the OSA Assessment

Evaluating the risk of Obstructive Sleep Apnea (OSA) requires clinical judgment based on an integrated assessment of history, symptoms, AND physical/clinical findings. If an AME elects to perform the assessment for OSA, he/she must follow the American Academy of Sleep Medicine guidelines.

After completing the assessment, if the diagnosis of OSA is not made, the AME must sign and submit the AME Assessment Statement - OSA. If the AME confirms the presence of OSA, then full clinical note with test results, if performed, must be submitted.

History of findings that suggest increased risk of OSA include:

Symptoms that suggest an increased risk of OSA include:

Physical/clinical findings that suggest increased risk of OSA include:

AME ASSESSMENT STATEMENT – OSA (Updated 06/29/2022) AMEs who elect to perform an OSA assessment and find that the applicant does not meet the American Academy of Sleep Medicine (AASM) diagnostic criteria for OSA, must submit this statement to the FAA.

Airman/ Patient Name __________________ DOB: ____________

Reference Number (PI, MID, or App ID): ______________________

_____ (initial) I have performed an OSA assessment in accordance with AASM guidelines and have determined that there is no evidence of OSA requiring treatment at this time. (If a sleep study was performed it must be attached).

PHYSICIAN NAME ____________________________________________________

Office Telephone Number: ______________________________________________

• PHYSICIAN
• SIGNATURE________________________________________DATE____________

Mail this statement to:

Using Regular Mail (US Postal Service) or Using Special Mail (FedEx, UPS, etc.)

Federal Aviation Administration Federal Aviation Administration Aerospace Medical Certification Division AAM-300 Aerospace Medical Certification Division AAM-300 Civil Aerospace Medical Institute Civil Aerospace Medical Institute, Bldg. 13 PO Box 25082 6700 S. MacArthur Blvd., Room 308

Oklahoma City, OK 73125-9867 Oklahoma City, OK 73169

• FAA COMPLIANCE WITH TREATMENT
• OBSTRUCTIVE SLEEP APNEA (OSA)

(Updated 10/25/2023) I ____________________________ (print name) certify that (check one):

___ I have been using __________________ (CPAP/ Dental / or Positional Device) for OSA as prescribed. I am tolerating the therapy well and have no symptoms of OSA (e.g., daytime sleepiness or lack of mental attention or concentration).

___ I have been surgically treated for OSA and I have no symptoms of OSA (e.g., daytime sleepiness or lack of mental attention or concentration).

I understand and acknowledge that I will receive the new requirements for continuation of my special issuance or special consideration (ATCS) of Obstructive Sleep Apnea and I will comply with the requirements at my next FAA medical certificate renewal or reapplication.

• Applicant Name: _________________________________________
• Date of Birth: ____________________________________________
• Reference Number: (PI, MID, or APP ID): _________________________

Applicant Signature _______________________________________ Date _______

OSA – FREQUENTLY ASKED QUESTIONS (FAQS)

(Updated: 02/24/2021)

GENERAL:

The instructional video for AMEs is available here.

See OSA reference materials.

No. This process is for obstructive sleep apnea only. If it is clear that the airman suffers from a different sleep disorder, DEFER and submit any supporting documentation for FAA decision.

TRIAGE:

The AME should triage the airman based on the FAA OSA Flow Chart, supporting clinical guidelines, and good clinical judgment to determine the appropriate category for the airman.

No. If there has been NO CHANGE in his/her risk factors, follow Group/Box 2 of the flow chart and submit a copy of the previous assessment. However, if there has been a change in risk factors (e.g., elevated BMI, new atrial fibrillation, refractory hypertension, etc.), triage using the flow chart to determine if the airman needs a repeat assessment.

Yes. It is only required for Group/Box 4 to document that education was given. However, it may be useful to document the rationale for triage decisions, especially for Group/Box 2, 5, and 6.

SLEEP EVALUATION AND SLEEP STUDY:

No. Please reference the AASM guidelines. A sleep evaluation is needed when the triage process indicates that the airman is at high risk for OSA. The sleep evaluation is used to determine if a sleep study is warranted.

No. This statement page is only used by an AME who PERFORMS the sleep evaluation (in accordance with AASM guidelines) and finds that the airman does not have evidence of OSA. This is NOT to be used for the routine triage function.

They are:

*Please note, Type III and Type IV are NOT acceptable for FAA purposes.

Yes. The FAA requires that the test be either a Type I laboratory polysomnography or a Type II (7 channel) unattended home sleep test (HST) that provides comparable data and standards to laboratory diagnostic testing. It does not have to be a chain of custody study.

In communities where a Level II HST is unavailable, the FAA will accept a level III HST. If the HST is positive for OSA, no further testing is necessary and treatment in accordance with the AASI must be followed. However, if the HST is equivocal, a higher-level test such as an in-lab sleep study will be needed unless a sleep medicine specialist determines no further study is necessary and documents the rationale.

The AME may only interpret the sleep study if he/she is a sleep medicine specialist.

CERTIFICATE, EXTENSION, AND DENIAL PROCESS:

No. Issue a regular (not time limited) certificate, if the airman is otherwise qualified. The AME MAY NOT issue a time-limited certificate without an authorization from the FAA.

No. Once the airman is compliant with and doing well on treatment, he has met the requirements for 14 CFR 61.53. The airman may return to flight status with the current certificate issued by the AME, PROVIDED that ALL the required information regarding OSA evaluation and treatment has been submitted to the FAA for review.

The FAA will keep track of the 90 days.

Yes. The AME may issue this year based on the previous SI/AASI if those requirements were met.

No. An airman currently on an SI/AASI for OSA will receive a new SI/AASI letter this year. At that point, he/she will have to comply with the new documentation requirements.

The airman may request a one-time, 30-day extension by phone by calling AMCD at (405) 954- 4821 and selecting Option 1 when prompted. They may also mail a request to AMCD (see Specification Sheet B for address) or by contacting their RFS office.

TREATMENT AND FOLLOW UP:

The airman may submit the completed compliance statement and required documents to the FAA for review as soon as they are tolerating the therapy without difficulty and have no symptoms of OSA.

In most cases an AHI of 16 or more will require CPAP.

Yes. Once a diagnosis of OSA is established, a Special Issuance is required. When the airman submits the required supporting documents to the FAA, he/she will be evaluated for a Special Issuance.

Yes. Issue a regular certificate (Group/Box 2), if the airman is otherwise qualified, and submit the required information for FAA decision.

Follow Group/Box 2 and submit the required information for FAA decision.

The AME should follow the triage flow chart. If the airman is determined to be Group/Box 5 or 6, he/she will need a sleep evaluation. If a sleep study is warranted, it will need to be an approved test type (see FAQ #9). Submit the required information for FAA decision.

Follow Group/Box 2 and submit the required information for FAA decision.

Berlin Questionnaire©

Height (m) Weight (kg) Age______ Male / Female _____ Please choose the correct response to each question.

Category 1 Category 2

Scoring Berlin Questionnaire

The questionnaire consists of 3 categories related to the risk of having sleep apnea. Patients can be classified into High Risk or Low Risk based on their responses to the individual items and their overall scores in the symptom categories.

Categories and Scoring:

Category 1: Items 1, 2, 3, 4, and 5;

Item 1: if ‘Yes’, assign 1 point

Item 2: if ‘c’ or ‘d’ is the response, assign 1 point Item 3: if ‘a’ or ‘b’ is the response, assign 1 point Item 4: if ‘a’ is the response, assign 1 point Item 5: if ‘a’ or ‘b’ is the response, assign 2 points Add points. Category 1 is positive if the total score is 2 or more points.

Category 2: items 6, 7, 8 (item 9 should be noted separately).

Item 6: if ‘a’ or ‘b’ is the response, assign 1 point Item 7: if ‘a’ or ‘b’ is the response, assign 1 point Item 8: if ‘a’ is the response, assign 1 point Add points. Category 2 is positive if the total score is 2 or more points.

Category 3 is positive if the answer to item 10 is ‘Yes’ or if the BMI of the patient is greater than 30kg/m2.

(BMI is defined as weight (kg) divided by height (m) squared, i.e.., kg/m2).

High Risk: if there are 2 or more categories where the score is positive. Low Risk: if there is only 1 or no categories where the score is positive.

Epworth Sleepiness Scale

The original version of the ESS was first published in 1991. However, it soon became clear that some people did not answer all the questions, for whatever reason. They may not have had much experience in some of the situations described in ESS items, and they may not have been able to provide an accurate assessment of their dozing behavior in those situations. However, if one question is not answered, the whole questionnaire is invalid. It is not possible to interpolate answers, and hence itemscores, for individual items. This meant that up to about 5 % of ESS scores were invalid in some series. In 1997, an extra sentence of instructions was added to the ESS, as follows:

‘‘It is important that you answer each question as best you can’.

With this exhortation, nearly everyone was able to give an estimate of their dozing behavior in all ESS situations. As a result, the frequency of invalid ESS scores because of missed item- responses was reduced to much less than 1%.

The 1997 version of the ESS is now the standard one for use in English or any other language. It is available in pdf here.

STOP BANG Questionnaire

Height inches/cm:

Age:

• Male/Female
• BMI:

Weight lb/kg:

Collar size of shirt: S, M, L, XL, or inches/cm neck circumference:

Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

Yes No

Do you often feel tired, fatigued, or sleepy during daytime? Yes No

Yes No

Do you have or are you being treated for high blood pressure? Yes

No

Yes No

Yes No

Yes No

Yes No

* Neck circumference is measured by staff

High risk of OSA: Answering yes to three or more items

Low risk of OSA: Answering yes to less than three items

Adapted from:

• STOP Questionnaire
• A Tool to Screen Patients for Obstructive Sleep Apnea

Frances Chung, F.R.C.P.C.,* Balaji Yegneswaran, M.B.B.S.,† Pu Liao, M.D.,‡ Sharon A. Chung, Ph.D.,§ Santhira Vairavanathan, M.B.B.S.,_ Sazzadul Islam, M.Sc.,_ Ali Khajehdehi, M.D.,† Colin M. Shapiro, F.R.C.P.C.# Anesthesiology 2008; 108:812–21 Copyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Specifications for Psychiatric Evaluations

(Updated 12/12/2024) Why is a psychiatric evaluation required? Mental disorders, as well as the medications used for treatment, may produce symptoms or behavior that would make an airman unsafe to perform pilot duties. This guideline outlines the requirements for these evaluations.

Will I need to provide any of my medical records? You should make records available to the psychiatrist prior to their evaluations, to include:

THE PSYCHIATRIC EVALUATION

Who may perform a psychiatric evaluation? Psychiatric evaluations must be conducted by a qualified psychiatrist who is board-certified by the American Board of Psychiatry and Neurology or the American Board of Osteopathic Neurology and Psychiatry.

What must the psychiatric evaluation report include? At a minimum:

What must be submitted by the psychiatrist? The psychiatrist’s comprehensive and detailed report, as noted above, plus copies of supporting documentation. Recommendations should be strictly limited to the psychiatrist’s area of expertise. Psychiatrists with questions are encouraged to email 9-AVS-Psychiatry-Branch@faa.gov.

Specifications for Psychiatric and Psychological Evaluations

(Updated 12/12/2024) Why are both a psychiatric and a psychological evaluation required? Mental disorders, as well as the medications used for treatment, may produce symptoms or behavior that would make an airman unsafe to perform pilot duties. Due to the differences in training and areas of expertise, separate evaluations and reports are required from both a qualified psychiatrist and a qualified clinical psychologist for determining an airman’s medical qualifications. This guideline outlines the requirements for these evaluations.

Will I need to provide any of my medical records? You should make records available to both the psychiatrist and clinical psychologist prior to their evaluations, to include:

THE PSYCHIATRIC EVALUATION

Who may perform a psychiatric evaluation? Psychiatric evaluations must be conducted by a qualified psychiatrist who is board-certified by the American Board of Psychiatry and Neurology or the American Board of Osteopathic Neurology and Psychiatry.

What must the psychiatric evaluation report include? At a minimum:

What must be submitted by the psychiatrist? The psychiatrist’s comprehensive and detailed report, as noted above, plus copies of supporting documentation. Recommendations should be strictly limited to the psychiatrist’s area of expertise. Psychiatrists with questions are encouraged to email 9-AVS-Psychiatry-Branch@faa.gov.

THE PSYCHOLOGICAL EVALUATION

Who may perform a psychological evaluation? Clinical psychological evaluations must be conducted by a clinical psychologist who possesses a doctoral degree (Ph.D., Psy.D., or Ed.D.), has been licensed by the state to practice independently, and has expertise in psychological assessment. We strongly advise using a psychologist with experience in aerospace psychology. Using a psychologist without this background may limit the usefulness of the report.

What must the psychological evaluation include? At a minimum:

What is required in the “core test battery?”

To promote test security, itemized lists of tests comprising psychological/neuropsychological test batteries have been moved to a secure site. Authorized professionals should use the portal at FAA Neuropsychology Testing Specifications. For access, email a request to 9-amc-aam-NPTesting@faa.gov.

What must be submitted?

The neuropsychologist’s report as specified in the portal, plus:

Recommendations should be strictly limited to the psychologist’s area of expertise. For questions about testing or requirements, email 9-amc-aam-NPTesting@faa.gov.

What else does the psychologist need to know?

Ethical Principles of Psychologists and Code of Conduct (2002) as well as applicable federal law.

Additional Helpful Information:

Aeromedical Psychology (2013). C.H. Kennedy & G.G. Kay (Editors). Ashgate.

ADDENDUM – IF NEUROPSYCHOLOGICAL TESTING IS INDICATED

Who may perform a neuropsychological evaluation? Neuropsychological evaluations should be conducted by a qualified neuropsychologist with additional training in aviation-specific topics. The following link contains a list of neuropsychologists who meet all FAA quality criteria: FAA Neuropsychologist List.

Requirements for the evaluation. Requirements for providing records to the neuropsychologist, conducting the evaluation, and submitting reports are the same as noted above for the clinical psychologist.

What is required in the “core test battery?”

To promote test security, itemized lists of tests comprising psychological/neuropsychological test batteries have been moved to a secure site. Authorized professionals should use the portal at FAA Neuropsychology Testing Specifications. For access, email a request to 9-amc-aam-NPTesting@faa.gov.

What must be submitted?

The neuropsychologist’s report as specified in the portal, plus:

When available, pilot norms must be used. If pilot norms are not available for a particular test, then the normative comparison group (e.g., general population, age/education-corrected) must be specified. Also, when available, percentile scores must be included.

Recommendations should be strictly limited to the psychologist’s area of expertise. For questions about testing or requirements, email 9-amc-aam-NPTesting@faa.gov.

Protocol for Renal Transplant

An applicant with a history of renal transplant must submit the following if consideration for medical certification is desired:

Six-Minute Walk Test (6MWT) - FAA Result Sheet

(Updated 03/25/2026) NAME___________________________________________ DOB__________________________________

APPLICANT ID#___________________________________ PI#___________________________________

Please have the provider who treats your cardiac or pulmonary condition complete this sheet. The test must be done in accordance with the American Thoracic Society (ATS) Guidelines for the Six-Minute Walk Test. In most cases, a minimum of 400 m is required for medical certification/clearance.

Submit this sheet and any other supporting documentation to your AME for upload into your file.

TEST RESULTS (For YES or NO questions, please circle answer.)

• Baseline End of
• 1 minute
• End of
• 2 minutes
• End of
• 3 minutes
• End of
• 4 minutes
• End of
• 5 minutes
• End of
• 6 minutes
• HEART RATE
• SpO2 (%)
• DYSPNEA
• Scale of 0 to 5 (none to severe)
• FATIGUE
• Scale of 0 to 5 (none to severe)

_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________

Treating provider’s signature ________________________________ Date of evaluation ________________

Treating provider’s printed name: ____________________________ Phone number: ________________

Protocol for Substances of Dependence/abuse (Drugs - Alcohol)

Protocol for Thromboembolic Disease

(Updated 03/27/2024) An applicant with a history of thromboembolic disease must submit the following if consideration for medical certification is desired:

Warfarin (Jantoven): For applicants who are just beginning warfarin (Jantoven) treatment the following is required:

NOAC/DOACs: For applicants who are just beginning treatment the following is required: