CMS Issues Updated Guidance for Amended Review Requests in WCMSA Cases

On January 21, 2025, CMS announced an important update to the WCMSA guidelines, introducing new flexibility for amended review requests. Effective April 7, 2025, CMS will allow parties to submit amended review requests at any time after a Workers’ Compensation Medicare Set-Aside has been approved. This is a significant shift from the current policy, which requires a one-year waiting period before an amended review request can be submitted.

Under the current WCMSA guidelines, the parties must wait at least one year from the date of approval of a Medicare Set-Aside to request an amended review. This guideline could pose a challenge when significant changes in treatment plans or associated costs arise shortly after approval of the set-aside amount. Recognizing these challenges, CMS updated its guidelines to allow immediate submissions of amended review requests.

While the timing for amended review requests has been updated, the following criteria for obtaining an amended review remain the same:

• Threshold: The parties must demonstrate that projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

• Documentation: The parties must submit a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release form, and a summary of expected future care. The parties must also return a copy of CMS’ Recommendation Sheet from the original approval letter identifying treatment already provided, treatment no longer required, and/or any additional treatment needs.

• Settlement: The case has not settled as of the date of the request for an amended review.

Importantly, CMS permits only a one-time request for an amended review, and any additional requests may be denied.

The update to the guideline is a positive development, as the parties may address and respond to changes in medical treatment promptly, improving the accuracy of Medicare Set-Asides. Additionally, by removing the one-year waiting period, the updated guideline reduces unnecessary delays and could help expedite the settlement process.  Beneficiaries may be better protected as timely updates to the Medicare Set-Asides help ensure that their medical needs are adequately funded while safeguarding Medicare’s interests.

The new Reference Guide, issued on January 17, 2025, is available here.  Please note that the current version does not yet reflect CMS’s recent amended review announcement. If you have any questions regarding the upcoming changes, please let us know. Our team is always happy to address any questions or concerns that you may have.