On November 6, 2013, CMS issued an updated WCMSA Reference Guide to provide additional information on the CMS WCMSA approval process. The updated Reference Guide includes several new sections, which are outlined below.
• 9.4.1.1—Most Frequent Reasons for Development Requests. This section discusses the five most frequent reasons for development requests.
• 9.4.2—WCRC Team Background and Resources Used. This section describes the qualifications of the WCRC reviewers and references the resources that the WCRC uses in the review process. The WCRC (Workers’ Compensation Review Contractor) is the CMS contractor that reviews WCMSA submissions.
• 9.4.3—WCRC Review Considerations. This section addresses general factors that the WCRC reviewers look at in reviewing WCMSAs.
• 9.4.4—Medical Review. This section discusses issues related to the basic process that WCRC reviewers follow in reviewing medical treatment pricing for WCMSAs:
• 9.4.5—Medical Review Guidelines. This section discusses WCRC pricing guidelines related to the following: diagnostics; spinal cord stimulators and intrathecal pumps; surgeries/procedures; lab tests; TENS units; state-specific statutes; CMS medical records guidelines; and treatment recommended outside a provider’s area of expertise.
• 9.4.6—Pharmacy. This section addresses WCRC review and pricing guidelines for prescription medications, along with the following topics: CMS’ recognized pharmacy compendia; medically accepted indications and off-label use; compounded drug products; benzodiazepines and barbiturates; PRN or as-needed drugs; physician-dispensed drugs; Part B drugs and drug prices; intrathecal pain pumps; dual-designation drugs; drug weaning; drug tapering; and drug contraindications, drug warnings and precautions, and drug Interactions.
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