Author: Carolyn McKaige
All the talk these days of CMS eliminating waiting periods for Amended Review of an MSA has cast a shadow on its predecessor – the Re-Review process. If you get a result from CMS and don’t want to bite the one-time Amended Review apple just yet, Re-Review is alive and well and yielding results. This option is available upon receipt of a Centers for Medicare and Medicaid Services (CMS) counterproposal on a submitted Medicare Set-Aside (MSA). While the industry has seen mixed results when filing Requests for Re-Review, Allan Koba has obtained a recent success in this ever-murky area.
Case Facts
A Medicare beneficiary sustained work related lumbar and cervical spine injuries on December 30, 2010. Based on the medical records, a proposed MSA was submitted in the amount of $159,791 including future medical treatment consisting of physician visits, diagnostic testing, prescription medications, physical therapy, laboratory work, cervical fusion with post-operative physical therapy, acupuncture, and injections. Lumbar surgery was not included as in September 2023, the treating orthopedic discussed surgical treatment but indicated he would hold off on surgical intervention and continue conservative treatment. No specific procedure was noted. Further, in July 2024, the treating physical medicine and rehabilitation physician stated lumbar surgery was not medically necessary. Therefore, provisions for lumbar surgery were not included in the future care plan.
Successful Results
CMS issued a counterproposal, approving an MSA in the amount of $269,020. The areas of discrepancy were that CMS included a lumbar fusion with post-operative physical therapy as well as annual urine drug screens. It was subsequently uncovered that Claimant had undergone a lumbar fusion after the proposed MSA was prepared, but prior to CMS submission of the MSA. Allan Koba attorneys issued a Request for Re-Review to CMS, arguing missing documentation existed at the time of submission of the MSA to CMS. The medical records were provided evidencing Claimant had already undergone the lumbar fusion. It was further argued that the inclusion of urine drug screens was not appropriate as none had been conducted or recommended within the last two years. CMS agreed with the Request for Re-Review and issued an updated decision letter approving the MSA for the original submitted about of $159,791.
How We Can Help
If you have a CMS approved MSA you believe may be ripe for consideration for a Request for Re-Review, please reach out to Allan Koba Compliance Solutions. Our legal and medical expertise will guide your case-specific needs and walk you through each step of the process. Stay tuned for more updates and feel free to reach out with any Medicare-related questions at info@allankoba.com.
