Important CMS WCMSA Change


On August 1, 2012, the Director of Financial Services Group, Department of Health & Human Services, Centers for Medicare & Medicaid Services, issued a memo regarding the impact of the removal of coverage of Transcutaneous Electrical Nerve Stimulation (TENS) Units for Chronic Low Back Pain (CLBP) on Workers’ Compensation Medicare Set-Aide Allocation (WCMSA) proposals.

This memorandum alerts applicable CMS Regional Offices and provides guidance to submitters of WCMSA proposal amounts to a recent CMS coverage change that affects pricing determinations for TENS units included within submitted Workers’ Compensation Medicare Set-Aside (WCMSA) proposals.

On June 8, 2012, CMS released a Decision Memo that addressed conditions for coverage of a TENS unit for chronic low back pain. (Click here to review this Decision Memo entirety.) The Decision Memo’s definition of CLBP and guidance for coverage of TENS Units states:

  •  CLBP is defined as “an episode of low back pain that has persisted for three months or longer; and is not a manifestation of a clearly defined and generally recognizable primary disease entity.”
  • A TENS Unit is not reasonable and necessary for the treatment of CLBP, in accordance with the provisions of section 1862(a)(1)(A) of the Social Security Act.

The recent change in coverage of TENS units for CLBP will have the following impacts upon the WCMSA proposal review process:

  •  Effective June 8, 2012, for those WC cases settled prior to June 8, 2012, and where the settlement included pricing for TENS for CLBP, CMS will consider funds spent for TENS for CLBP by beneficiaries and claimants as being an appropriate expenditure of funds as part of the WCMSA.
  •  For those WC cases that were not settled prior to June 8, 2012, and where the WCMSA proposal includes funding for TENS for CLBP as part of the WCMSA, CMS will re-review the cases and remove pricing for TENS for CLBP. (Regional Offices shall obtain requests for a case re-review from submitters along with a signed statement indicating a settlement had not occurred prior to June 8, 2012.)

Once CMS performs a re-review of the WCMSA to remove pricing for TENS for CLBP, beneficiaries and claimants may not use funds from their WCMSA to pay for non-covered TENS for CLBP. Doing so constitutes an inappropriate expenditure of WCMSA funds.

Direct questions or concerns to Elizabeth V. Poole at (410) 786-6683.

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