Update to Medicare Set Aside

On January 4, 2019 the Centers for Medicare & Medicaid Services (CMS) issued the newest version (2.9) of the Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) Reference Guide.

There are a few notable updates that have the potential to increase the cost of a Medicare Set Aside (MSA) if not monitored closely.

Spinal Cord Stimulators:

Per existing policy, CMS defaults to a non-rechargeable spinal cord stimulator (SCS) when it is not specified in the MSA. The update has added language regarding the time to replace a SCS, stating that a non-rechargeable SCS should be replaced every seven years. A rechargeable SCS is replaced every nine years.

This is a significant change that has the possibility of greatly increasing the cost of maintaining an SCS over an applicant’s lifetime. Per Tower MSA Partners, a majority of implanted SCS are rechargeable. This makes specificity in the MSA all the more important.


CMS has added a section about Lyrica to the Pharmacy Guidelines and Conditions.

Lyrica’s inclusion is significant because there is no generic form for this drug, which increases costs. Pfizer’s patent expires on June 30, 2019, at which point it remains to be seen how long it will take for a generic form to surface and whether the cost will be comparable to Lyrica.


It has become increasingly important to use specificity in the types of medical equipment and prescriptions included in an MSA. This is a good reminder to ask for clarification from treating doctors and to scrutinize requests for authorization (I.E. whether the type of spinal cord stimulator is specified). There is a potential to save many thousands of dollars by paying close attention to Requests for Authorization and submitting these requests to Utilization Review.

Amanda Rocha
San Luis Obispo Office