Using CMS’ Amended Review Process to Close Your Claim


Though obtaining CMS approval of a Medicare Set-aside seems like one of the final pieces of the settlement puzzle, the reality is that sometimes settlement does not happen the way that we hope. If you find yourself with previously approved Medicare Set-aside that no longer reflects the claimant’s current treatment, or is impeding settlement due to its high value, CMS’ Amended Review process may be just the help your settlement needs for closure!


The Amended Review process allows for parties to request that CMS take another look at the MSA that was previously approved, as long as the following criteria are met:

  • CMS has issued a conditional approval/approved amount at least 1 but no more than 6 years prior;

  • The case has not yet settled as of the date of the request for re-review; and,

  • 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.

As you may know, this process differs from CMS’ prior policy, which did not allow parties to request a review of the MSA using post-submission documentation. The ability to obtain a revised MSA based on updated documentation is a very welcome change for those cases involving claimants who previously were receiving very expensive treatment.


Things to consider:


Time is of the essence! As noted above, the amended review process has a very specific time frame attached to it. CMS has been clear that they will not accept review requests outside of this time frame.


You’ve only got one shot! CMS allows for a one-time request only. CMS will not allow submitters to supplement the amended review request. In addition, CMS will not issue a development letter in the event that the information provided with the review request is insufficient. For example, if the prescription listing is missing from the re-review request, CMS will not request this documentation in order to issue an updated determination. This is contrary to how CMS generally handles the review of an initial WCMSA proposal. As such, it is imperative that all of supporting documentation is gathered and ready to go.


**In fact, CMS requires submission of all medical documentation related to the settling injury(s)/body part(s) since the previous submission date rather than the last two years.


Not limited to high value MSAs! While significant reductions are possible, we recommend that you consider the Amended Review process in lower value cases in addition to those high dollar MSAs. Consider using the review process where a claim has become stagnant and CMS’ prior determination is no longer a reflection of the claimant’s future treatment needs. Of course, the change must meet the threshold noted above, but that threshold should not lead you to discount requesting an amended review of a relatively low value MSA.

So, what do you look for?

  • Changes in prescription medications

  • Removal/implantation of spinal cord stimulator

  • Treatments (such as surgeries, injections, etc.) have already been completed

  • Drop-off in frequency of treatment

If you think your claim is eligible for an Amended Review, send it over! We will be happy to take a look and let you know what we think. Even if the MSA does not meet the criteria for review of the MSA at the time of our review, we can help you identify changes in treatment that may allow for an Amended Review in the future.


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