CMS Eliminates the One Year Waiting Period for Amended Reviews of WCMSAs

In a recent Alert issued on January 21, 2025, the Centers for Medicare and Medicaid Services (CMS) announced an important change to the Workers’ Compensation Medicare Set-Aside (WCMSA) Amended Review process. The Amended Review process allows parties a one-time request to submit new medical documentation to modify a previously approved WCMSA for cases meeting the Amended Review criteria. Currently, Amended Review requests cannot be submitted until one year after a WCMSA has been approved. Effective April 7, 2025, CMS will allow parties to seek an Amended Review of a previously approved WCMSA at any time after it is approved by CMS.

In order to qualify for an Amended Review of a previously approved WCMSA, the case must not already have been settled and the amount of the new WCMSA must change by 10% or $10,0000, whichever is greater. An Amended Review is not allowed if the only basis for the request is the approval of a new generic version of a medication that was included in the original WCMSA submission. It is important to note that the parties only get one bite at the apple, and thus the timing of the use of the Amended Review process should be carefully considered.

Some examples of where the Amended Review process could be helpful include, when an injured worker has undergone a surgery, had an implantable device removed or an expensive medication discontinued that were included in the previously approved WCMSA . If you have a previously approved WCMSA that no longer reflects the likely future medical exposure of the claim, I encourage you to contact us to see if an Amended Review makes sense.

By: Gregory Lisowski, JD MSCC
(866) 306-9423
glisowski@msaservicesllc,com