Version 2.9 of the Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide released

On January 4, 2019, The Centers for Medicare and Medicaid Services (CMS) released an updated Workers Compensation Medicare Set-Aside (WCMSA) Reference Guide, Version 2.9.

One of the major updates in Version 2.9 is additional language regarding justification for inclusion of Lyrica® in WCMSAs, stating as follows:

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.

As we have indicated in previous blogs, this confirms that the Workers’ Compensation Review Contractor (WCRC) will continue to include Lyrica for radicular pain stemming from supporting structure of the spinal cord.

Section 9.4.5 of Version 2.9 includes an update on spinal cord stimulators (SCS). The previous version stated, “Routine revisions will not include the lead implantation.” The new release states:

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.

Depending on the specific file, this will cause an additional cost to the SCS fee if there is a historical pattern for the need to relocate leads. The WCMSA Reference guide now clarifies SCS pricing by stating:

“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.”

Other updates in Version 2.9 include:

  • Additional CPT codes added to Table 9-3: Spinal Cord Stimulator Surgery CPT Codes.
  • The 2015 CDC Life Table added in Section 10.3.
  • Development Letters and Alert Templates display “Workers’ Compensation Review Contractor (WCRC)” with the WCRC customer service number 833-295-3773, instead of auto populating with individual Regional Office reviewer names and direct phone numbers.

As always, Optum will continue to keep you updated and informed of any changes that occur in relation to WCMSAs, the WCRC and Medicare Secondary Payer (MSP) compliance.