Form CMS-10407 Diabetes Narrative

Summary of Benefits and Coverage and Uniform Glossary (CMS-10407)

CMS-10407 - Diabetes Narrative-

SBC Disclosure

OMB: 0938-1146

Document [pdf]
Download: pdf | pdf
Management of Type 2 Diabetes
A 52-year-old man has type 2 diabetes. His diabetes is well controlled with metformin (500 mg) twice
daily and long-acting insulin (Insulin glargine 100 ml/unit injectable solution, 20 units), administered
once daily. He does not have any other complications associated with his diabetes. He is also on
Lisinopril (20 mg) to maintain appropriate blood pressure and kidney function, and aspirin as a
cardiovascular preventive service. He visits his primary care physician four times a year, his podiatrist
once a year, and his ophthalmologist once a year. Twice yearly he receives tests for his hemoglobin A1C.
Once a year he receives blood tests for microalbuminuria, a lipid panel, and a comprehensive metabolic
panel. He purchases medication and supplies as needed, including testing supplies so he can test his
insulin levels. In addition, he receives diabetes self-management education and medical nutrition therapy
education.
He receives an annual influenza vaccine, but has never received a pneumococcal vaccine, so he will
receive one this year and another after he turns 65 years of age. His glucagon kit has expired so he will
purchase a new kit this year.

DISCLAIMER: This narrative and the accompanying benefit scenario illustrate care for a hypothetical
patient receiving treatment for type 2 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.

OMB control number: 0938-1146
Expiration date: XX/XX/XXXX
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection
is estimated to average [0.08 hour] per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


File Typeapplication/pdf
File TitleDiabetes-Narrative
SubjectSBC Narrative
AuthorAcumen, LLC
File Modified2019-08-22
File Created2019-04-15

© 2025 OMB.report | Privacy Policy