Updated WCMSA Reference Guide Issued; Addresses Recent Alarming Trends

CMS, Medicare Set-Asides, MSP News on January 7, 2019
Posted by Jean S. Goldstein, JD

An updated Workers’ Compensation Medicare Set-Aside Reference guide was issued today.   The revised guide, version 2.9 can be found here.

The updates in this guide are as follows:

  • To eliminate issues around Development Letter and Alert templates auto populating with individual Regional Office (RO) reviewer names and direct phone numbers, these will now display the generic “Workers’ Compensation Review Contractor (WCRC)” and the WCRC customer service number “(833) 295-3773”
  • Per CMS’ request, certain references to memoranda on cms.gov have been removed.
  • The CDC Life Table has been updated for 2015 (Section 10.3). (See our prior blog post here.)
  • Updates have been provided for spinal cord stimulators and Lyrica (Sections 9.4.5 and 9.4.6.2).

Of important note is the update to the portion of the guide that address spinal cord stimulators, as it includes the following revisions and clarification:

Routine replacement of the neurostimulator pulse generator includes the lead implantation up to the number of leads related to the associated code. Revision surgeries should only be used where a historical pattern of a need to relocate leads exists.

Pricing for Spinal Cord Stimulator (SCS) Surgery

Surgery pricing may include physician, facility, and anesthesia fees. SCS pricing is based on identification of: 1.) Rechargeable vs. Non-rechargeable and 2.) Single vs. Multiple Arrays (leads). If unknown, CMS will default to non-rechargeable single array.

Additionally, the updated guide also addresses a very problematic area, as related to the inclusion of off-label prescription medications, and specifically the medication, Lyrica.  In the updated guide, Lyrica is used as an example of a medication that is used for many off-label indications.  The guide indicates that,

Lyrica (Pregabalin) is cited in MicroMedEx for an off-label medication use related to neuropathic pain from spinal cord injury, and a number of scientific studies indicate that Pregabalin shows statistically significant positive results for the treatment of radicular pain (a type of neuropathic pain). Spinal cord neuropathy includes injuries directly to the spinal cord or its supporting structures causing nerve impingement that results in neuropathic pain. Lyrica is considered acceptable for pricing as a treatment for WCMSAs that include diagnoses related to radiculopathy because radiculopathy is a type of neuropathy related to peripheral nerve impingement caused by injury to the supporting structures of the spinal cord.

Up until very recently, Lyrica was excluded as an off-label medication when used for radiculopathy without injury to the spinal cord. However, as we discussed, we have certainly seen the inclusion of Lyrica in many cases submitted for CMS’ review and approval.

As always, we will continue to monitor all CMS issued correspondence, and keep you updated of changes that may impact your claims.