Summary of Benefits and Coverage

Foot Fracture

(DT - OMB control number: 1545-0047/Expiration Date:
12/31/2019)(DOL - OMB control number: 1210-0147/
Expiration date: 5/31/2022)(HHS - OMB control number:
0938-1146/Expiration date: 10/31/2022)

In June, a healthy 25 year old female forcibly twists her left foot. She is in severe pain and cannot get up
or walk on her own. She is taken by ambulance to the emergency department at a nearby hospital. A
hospital physician examines her, consistent with clinical guidelines, and finds that she has bone
tenderness and cannot ambulate his foot. She reports that she has never had ankle sprains or fractures
before. The physician orders an x-ray and diagnoses her with a clinically significant fracture of her fifth
metatarsal. The bone is adequately aligned. She is released from the emergency department the same day
with a prescription for pain medication, crutches and a splint which she wears for the next week. She
follows up with an orthopedic specialist twice. On the first visit, the patient is still in pain while bearing
minimal weight on the ankle. The specialist removes the splint, orders an x-ray and places a weightbearing cast on the ankle. On the second visit, five weeks later, the specialist takes another x-ray, removes
the cast, and orders physical therapy sessions to restore mobility and regain strength.

DISCLAIMER: This narrative and the accompanying benefit scenario illustrate care for a hypothetical
patient receiving treatment for an ankle fracture. 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.

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 (Expires 10/31/2022). The time required to
complete this information collection is estimated to average [0.08] hours 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.