CMS Amended Review

by Nancy Heidrich

January 22, 2021

The Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide Version 2.6 published on July 10, 2017 introduced the CMS Amended Review as another re-review option. The Amended Review allows the parties a one-time request for re-review in the form of a new submission. To be accepted for the amended review, CMS requires all medical documentation since the previous submission date, the most recent six months of pharmacy records, a Consent to Release, and a summary of expected future care. In addition, the following criteria must be met:

  • The CMS determination amount was issued at least 12 months but no more than 72 months prior.
  • The case has not settled.
  • The change in care results in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

CMS will not accept an amended review request if the change is due to the substitution of a newly FDA approved generic version of a medication.

The amended review request is a one-time opportunity with no second chances. CMS does not issue development letters for amended review requests and will not accept another re-review request once an amended review has been requested. That means all requirements must be met at the time of the request. This includes all medical records dated after the date of the prior submission. This is the date CMS received the submission and can be found in paragraph one of the determination letter. If these medical records reference treatment by another provider for the settling injury or body part and those records are not provided, CMS will reject the re-review request. Additionally, if there are payments documented on the payout for treatment provided, but records are not submitted, CMS will reject the re-review request.

CMS requires the most recent six months of pharmacy records. CMS has not expanded on this requirement; therefore, it is suggested that the pharmacy guidelines for a regular submission be followed. The preference is to provide the WC prescription claim records or ledger and, if not available, the prescription claim records from the pharmacy benefit manager (PBM). If neither of these are available, CMS suggests individual pharmacy claim records. If none of these are available, the medical records must provide the details of the current drug regimen.

A signed Consent to Release is required and must include the language that CMS implemented on April 1, 2020. This language indicates that the beneficiary reviewed the submission package and understands the WCMSA intent, submission process and associated administration.

The summary of future medical care or cost projection must be based on all medical documentation since the previous submission date, not the last two years of current treatment. Each line item on the CMS approval letter’s future treatment and prescription drugs allocation must be addressed. To remove a line item for any service that has already been provided or is no longer required, CMS requires the reference in the records be identified to support the removal. This is not based on the last two years of treatment records, the records provided since the last submission must support the removal. If additional services are required, these items must be included on the cost projection. CMS requires the reference in the records be identified to support the additional service. If a line item is changed such as a different frequency or a different life expectancy, the reference in the records that support the change must be identified.

Once all criteria for the amended review request are met, the submission can be made electronically via the Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) or by mail. Keep in mind this is a one-time request and CMS will not accept another re-review request, therefore it is important that all criteria are met prior to submitting the request.