CMS Issues a Revised WCMSA Reference Guide and Section 111 User Guide

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The Centers for Medicare and Medicaid Services issued a revised WCMSA Reference Guide (Reference Guide), Version 2.9, which can be found here: WCMSA Reference Guide.  In addition to changes to development and alert templates; references to removal of certain memorandum from cms.gov; and reference to the updated CDC Life Table, the Reference Guide also includes updates to Spinal Cord Stimulators (SCS), and the inclusion of Lyrica, Trazodone and other off-label drugs in an MSA.

Section 1.1 of the Reference Guide state as follows:

  • To eliminate issues around Development Letter and Alert templates auto-populating with individual Regional Office (RO) reviewer names and direct phone numbers, these will now display the generic “Workers’ Compensation Review Contractor    (WCRC)” and the WCRC customer service number “(833) 295-3773” (Appendix 5).
  • Per CMS’ request, certain references to memoranda on cms.gov have been removed.
  • The CDC Life Table has been updated for 2015 (Section 10.3).
  • Updates have been provided for spinal cord stimulators and Lyrica (Sections 9.4.5 and 9.4.6.2).

With respect to SCS, Section 9.4.5 now includes the following language:

Routine replacement of the neurostimulator pulse generator includes the lead implantation up to the number of leads related to the associated code. Revision surgeries should only be used where a historical pattern of a need to relocate leads exists…

Surgery pricing may include physician, facility, and anesthesia fees. SCS pricing is based on identification of: 1.) Rechargeable vs. Non-rechargeable and 2.) Single vs. Multiple Arrays (leads). If unknown, CMS will default to non-rechargeable single array.

This pricing methodology outlined by CMS is consistent with recent CMS approval trends.

In addition, traditionally excluded from MSAs based upon off-label usage arguments, CMS has recently included Lyrica in certain allocations.  The new Reference Guide specifically addresses off-label usage arguments with respect to Lyrica as follows:

Example 1: Lyrica (Pregabalin) is cited in MicroMedEx for an off-label medication use related to neuropathic pain from spinal cord injury, and a number of scientific studies indicate that Pregabalin shows statistically significant positive results for the treatment of radicular pain (a type of neuropathic pain). Spinal cord neuropathy includes injuries directly to the spinal cord or its supporting structures causing nerve impingement that results in neuropathic pain. Lyrica is considered acceptable for pricing as a treatment for WCMSAs that include diagnoses related to radiculopathy because radiculopathy is a type of neuropathy related to peripheral nerve impingement caused by injury to the supporting structures of the spinal cord.

The language above utilized by CMS for the inclusion of Lyrica in the MSA may be an indication of things to come not only with respect to more and more allocations including this medication, but inclusion of additional off-label medications that were previously excluded from the MSA. A second example in the Reference Guide describes circumstances in which Trazodone will be included in MSAs.

In addition to the new WCMSA Reference Guide, CMS has also issued a new Section 111 NGHP User Guide (Guide).  The updated Guide includes the confirmation that the review threshold for reporting in 2019 will remain $750 for liability insurance settlements, judgments awards or other payments and $750 for no-fault and workers’ compensation claims where there is no ongoing responsibility for medicals (ORM) that was previously posted by CMS.  The Guide can be found here – Full Guide for further review and reference.

NuQuest will continue to keep you apprised of further Medicare compliance developments as they become available.

 

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