CMS-10407 CMS-10407_Coverage_Example_Narratives

Maternity Care
A healthy, 28-year-old woman decides to start a family and begins taking prenatal vitamins in
February. Her doctor confirms she is pregnant at the end of March, and recommends an
ultrasound, which shows the pregnancy is normal. She receives routine, prenatal care, as
recommended by national guidelines. She attends a cycle of childbirth and breastfeeding classes.
Finally, in late November, she gives birth to a child; the delivery is normal and uncomplicated.
Mother and child are released on the second hospital day.

DISCLAIMER: This narrative and the accompanying benefit scenario illustrate care for a
hypothetical patient receiving maternity care. The care, and cost of care, will vary for each
patient. No portion of this narrative or the accompanying benefit scenario should be construed
as recommendations for care, or cost of care, by the United States Government.

Management of Type II Diabetes
A 52-year-old man has type II diabetes. His diabetes is well-controlled with metformin (1000
mg) twice daily and Lantus® insulin (20 units), administered once daily. He is also on rampril to
maintain appropriate blood pressure and kidney function, and aspirin to prevent cardiovascular
disease. He visits his endocrinologist or primary care physician four times a year, his podiatrist
twice a year, and his ophthalmologist once a year. Twice yearly, he receives tests for blood
glucose, hemoglobin A1C, urinalysis, and glomerular filtration rate. Once yearly, he receives
tests for microalbuminuria, a lipid panel, and a comprehensive metabolic panel. He purchases
medication and supplies as needed.

DISCLAIMER: This narrative and the accompanying benefit scenario illustrate care for a
hypothetical patient receiving treatment for type II diabetes. The care, and cost of care, will vary
for each patient. No portion of this narrative or the accompanying benefit scenario should be
construed as recommendations for care, or cost of care, by the United States Government.

Treatment of Breast Cancer
A 42-year-old female patient (5’5”, 160lbs or 73 kg), previously in good health, has a screening mammogram,
which shows a suspicious abnormality in the upper outer quadrant. No lump can be palpated. The patient’s
primary care physician refers her to a surgeon.
At the initial consultation, the surgeon performs a full medical history and physical and discusses findings from
the screening mammogram. The surgeon subsequently refers the patient for a diagnostic mammogram, a breast
MRI, and a core needle biopsy of the lesion. At the second visit, the surgeon reviews with the patient the results
of the biopsy, which shows an infiltrating ductal carcinoma, and discusses treatment options. The patient is
scheduled for a partial mastectomy and sentinel node biopsy, with the appropriate preoperative testing.
The sentinel lymph node biopsy comes back positive, and the surgeon decides accordingly to perform an
axillary lymphadenectomy. The surgery is done in a same-day surgery suite, and the patient is able to leave a
few hours after the surgery is completed. Pathology review of the surgical specimens shows a 2 cm primary
tumor and 2 positive lymph nodes. Examination of the tumor tissue shows negative estrogen and progesterone
receptors, and no amplification of Her-2/neu. Accordingly, the patient has Stage IIA (T1, N1, M0) triplenegative breast cancer.
After the operation, the patient is referred to an oncologist. The oncologist provides a thorough discussion of the
treatment options at the initial visit, and subsequently places the patient on a regimen of
doxorubicin/cyclophosphamide for 4 cycles, followed by taxol for 4 cycles. Chemotherapy is delivered
according to a dose-dense regimen every two weeks with Neulasta® (pegfilgrastim) administered between
infusions to boost the patient’s blood cell count. Because doxorubicin has been shown to cause certain heart
problems, the patient has a multigated acquisition (MUGA) scan of her heart. The following are details of her
chemotherapy:


Doxorubicin/cyclophosphamide: This regimen involves chemotherapy every other week, with an
injection of pegfilgrastim (white blood cell stimulating factor) self-administered 2 days after every
chemotherapy. There are 4 rounds of chemotherapy (for a total of 8 weeks) with a CBC and metabolic
panel check.



Taxol: Therapy consists of 4 dose-dense rounds of taxol administration with pegfilgrastim treatment 2
days post-chemotherapy. CBC and a metabolic panel are checked on the day of administration.

During the course of her chemotherapy, the patient begins to experience depression and anxiety that affect her
ability to function. At an office visit, she describes her symptoms to her oncologist, who refers her to a mental
health professional. She begins weekly, individual mental health counseling sessions and is given a prescription
for fluoxetine.
Three weeks after completing chemotherapy, she starts a course of radiation therapy. This consists of 5
treatments a week for 6.5 weeks. After 25 treatments of whole breast radiation, a 7-treatment boost is
administered to the tumor bed.
DISCLAIMER: This narrative and the accompanying benefit scenario illustrate care for a hypothetical patient
receiving treatment for breast cancer. The care, and cost of care, will vary for each patient. No portion of this
narrative or the accompanying benefit scenario should be construed as recommendations for care, or cost of
care, by the United States Government.