We are more than 20 years out from the debut of WCMSAs and over time the voluntary review process guidelines have moved from a series of CMS memos to the modern day Reference Guide format. The process evolved away from Regional Offices reviewing and approving allocations to use of a review contractor. This version of the Reference Guide contains changes to reflect the limited involvement by Regional Offices now.
Last fall, CMS released version 3.8 to clarify bases around “re-review,” which we blogged about here. Today they clarified a bit more about what happens when an errors exist in the submission. Beyond that, we are pleased to share that CMS tweaked their “Amended Review” process to make it more accessible for parties with a “stale” CMS approval. CMS will still only allow parties a one-time shot to revisit a previous CMS-approved Determination and at least one year has to have passed since the date of the Determination and its other review criteria are met. However, CMS removed its six year cap. In brief, the other criteria are: the case has not settled as of the date of the request for Amended Review; the projected care has changed such that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount; and the approval of a new generic version of a medication by the Food and Drug Administration does not constitute a reason to request Amended Review by itself.
Intrathecal Pumps, Spinal Cord Stimulators, and Peripheral Nerve Stimulator Replacement Frequency
CMS clarified its Section 9.4.5 Medical Review Guidelines to assist allocators with pricing and replacement frequency calculations for intrathecal pumps, spinal cord stimulators, and added a section on peripheral nerve stimulator replacements.
Annie M. Davidson is the Vice President of Client Success for ECS. In her role, Annie works collaboratively with clients, industry partners, and leaders at all levels to identify and execute on short-term and long-term goals and consistently exceed expectations. Prior to joining ECS, Annie practiced as an insurance defense attorney in her native Minnesota where she litigated workers’ compensation and liability insurance cases, particularly those involving MSP issues. She is admitted to practice law in the State of Minnesota and the United States District Court for Minnesota, and is a graduate of William Mitchell College of Law. Annie can be reached at email@example.com or at 651-262-9618.