Revisiting CMS’s Amended Review Process to Reduce WCMSAs

By Mark Popolizio, J.D., Kristen Carlson, J.D.

June 24, 2026 / 6 min read

In 2017, the Centers for Medicare and Medicaid (CMS) introduced its Amended Review process. Notably, this meant that for the first time CMS allowed parties to submit a new WCMSA proposal to reduce a prior CMS WCMSA approval based on changes in the claimant’s medical treatment (or other considerations) post-approval. Prior to Amended Review, CMS would not consider such requests, which, in some instances, resulted in parties being left with (or forced to accept) a CMS approved WCMSA amount that did not accurately reflect future treatment based on subsequent changes in circumstances.

workers in a meeting

Over the past few years (as we previously reported), CMS has made certain key (and positive) changes to its Amended Review process. For example, in 2023, CMS eliminated its prior six-year time-period to file an Amended Review submission.^[1]Last year, effective April 7, 2025, CMS eliminated its one year waiting period to file an Amended Review request and now allows an Amended Review filing at any time after it approves a WCMSA.^[2] Both of these changes have expanded opportunities for workers’ compensation insurers to use the Amended Review process.

In the big picture, Amended Review can play an important role in reducing WCMSA allocations and getting claims settled. If you are not using Amended Review, or not using it to its full potential, it may be a good time to revisit this process as part of your WCMSA cost-mitigation protocols going forward.

Toward this goal, the below provides a general refresher of Amended Review and how Verisk’s “Second Look” service can help insurers use this process to reduce WCMSAs as follows:

What is CMS’s Amended Review process?

CMS’s Amended Review allows parties a one-time request to submit new medical documentation to adjust a prior WCMSA approval for cases meeting its Amended Review criteria.^[3]Through Amended Review, CMS allows a new WCMSA proposal to be submitted for its consideration. This process is typically used to seek a reduction in a prior CMS approved WCMSA.

To aid our discussion, the following generic case example may help better conceptualize Amended Review from a practical standpoint:

Parties submit a WCMSA to CMS for “x” amount.
However, CMS issues a counter-higher approval for “y” amount.
The parties are unable to settle and the claim remains open.
Post CMS approval, the claimant’s medical condition improves, or there is a change in the claimant’s treatment regimen, or there are other potential changes which would arguably justify a lower WCMSA amount than the amount CMS had previously approved.
In this situation, Amended Review may provide the parties an opportunity to submit a new (and lower) WCMSA proposal.

From the above example, the questions become: (a) what are CMS’s Amended Review requirements? (b) What should insurers look for in evaluating potential cases for Amended Review? and (c) How can Verisk help insurers with the Amended Review process? These questions are addressed as follows:

CMS’s Amended Review requirements

CMS’s current Amended Review criterion is as follows:

Can only be used one-time per claim;
CMS has issued a WCMSA approval;
The case has not yet settled as of the date of the Amended Review request; and
Projected care has changed by at least 10% or $10,000 (whichever is greater) compared to CMS’s previously approved amount.^[4]

If the above conditions are met, CMS will allow an Amended Review request to be filed for its review and consideration.^[5] If CMS approves the Amended Review request, the new approved amount takes effect on the date of settlement.^[6]

Which cases may qualify for Amended Review?

Determining which cases may be ideal for Amended Review is an important part of this process. In this regard, typical, and non-exhaustive examples, include situations where surgeries or procedures for implanted devices have occurred after the original WCMSA approval, the claimant’s treatment has stabilized or reduced, changes or reductions in medication have resulted in less monthly spend, there has been a reduction in claims costs or reserves, or there has been change in the claimant’s personal health resulting in a lower life expectancy (and rated age). Of note, CMS precludes the use of Amended Review in certain circumstances. For example, approval of new generic medication cannot be used as the basis for an Amended Review request.^[7]Likewise, a WCMSA submitter change alone is not sufficient grounds for an Amended Review request.^[8]

Verisk’s “Second Look” – Amended Review Savings Case Examples

Verisk’s MSA Second Look service can help you leverage CMS’s Amended Review process.

Our consultative approach to MSA Second Look helps you maximize the one chance you have at obtaining an Amended Review approval from CMS—and gain savings for eligible claims. Our robust process tracks changes in CMS pricing and medications. We also carefully compare the prior MSA approval against the current changes in the claimant’s treatment. This allows us to deliver significant reductions and identify further cost mitigation opportunities before submitting for the Amended Review.

Overall, our MSA Second Look has helped our customers achieve extraordinary WCMSA savings since CMS implemented its Amended Review process back in 2017. For example, in 2026 thus far alone, our MSA Second Look service delivered over $7 million in client savings, with total client savings exceeding $67 million over the life of CMS’s Amended Review program.

Second Look Savings Examples

Expanding on the above, the following examples highlight how Amended Review can be used and how our Second Look service has helped customers reduce WCMSAs through Amended Review:

Case #1: Second Look Savings = $965,550

Original WCMSA approved by CMS: $1,042,675.
Primary cost drivers were particularly high-cost brand name medications
Case determined eligible for Amended Review.
New medical records revealed overall reduction in Rx, and provider documented discontinuation of one of the prescribed medications, along with a change to the generic form of another medication.
Verisk’s Second Look resulted in an approved Amended Review WCMSA total of $77,125.00 (Savings: $965,550).

Case #2: Second Look Savings = $713,715

Original WCMSA approved by CMS: $775,997.
Primary cost driver was the Rx, particularly high-cost brand name medications
Case determined eligible for Amended Review.
New medical records revealed overall reduction in Rx, with the brand name medications no longer being prescribed.
In addition, the updated records demonstrated additional treatment modalities were no longer needed, and the life expectancy was adjusted down.
Verisk’s Second Look resulted in an approved Amended Review WCMSA total of $62,282.00 (Savings: $713,715).

Case #3: Second Look Savings = $641,105

Original WCMSA approved by CMS: $679,957.
Primary cost driver was the spinal cord stimulator (SCS) replacements, intrathecal pain pump and costly long-acting opioid.
Case determined eligible for Amended Review.
Updated records demonstrated the SCS was no longer of benefit and was due to be removed, the intrathecal pain pump was no longer recommended, and the opioid was discontinued
Verisk’s Second Look resulted in an approved Amended Review WCMSA total of $38,851.00 (Savings: $641,105).

Going forward

As noted above, CMS’s recent updates have expanded the availability of the Amended Review process to a wider set of potential claims. Accordingly, this process offers workers’ compensation insurers with an increased opportunity to reduce prior approved WCMSA amounts for qualifying cases and get claims settled. In this regard, workers’ compensation insurers and other stakeholders should consider reviewing their claims inventory to see if they have any claims that would qualify for Amended Review, either on a case-by-case basis or perhaps as part of a larger targeted settlement project. Keep in mind, as highlighted above, Verisk’s Second Look service can help you navigate the Amended Review process to reduce WCMSAs to optimize claim settlement.

In the interim, please do not hesitate to contact the authors if you have any questions, or would like to learn more about Verisk’s Second Look service.

[1] CMS made this change as part of its Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide (Version 3.9, May 15, 2023) update. Prior to this change, Amended Reviews were only allowed between 12 and 72 months after CMS approval. Version 3.9 removed the 72‑month cap. Id.

[2] CMS announced this change as part of an Alert released in January 2025. In this Alert, CMS stated, in pertinent part, as follows: “Amended Reviews: Currently, amended review requests cannot be submitted until 1 year after a WCMSA case has been approved. Effective April 7, 2025, amended review requests will be allowed at any time after a WCMSA case is approved.” Id.

[3] WCMSA Reference Guide (Version 4.5, April 13, 2026), Chapter 16.3.

[4] WCMSA Reference Guide (Version 4.5, April 13, 2026), Chapter 16.3.

[5] CMS states as follows: “Where [this criteria is met], CMS will permit a one-time request for re-review in the form of a submission of a new cover letter, all medical documentation related to the settling injury(s)/body part(s) since the previous submission date, the most recent six months of pharmacy records, a consent to release information, and a summary of expected future care.” WCMSA Reference Guide (Version 4.5, April 13, 2026), Chapter 16.3. Further, as part of this process, CMS notes that “[i]n order to justify that the projected care would result in a 10% or $10,000 change (whichever is greater), the submitter must return CMS’ Recommendation Sheet that was included in CMS’ conditional approval letter and identify the following: [a] Line items that were included in the approved amount, but are for care that has already been provided to the beneficiary. Please identify where references to records indicating that the care has already been provided can be found in the updated proposal. [b] Line items for care that is no longer required. Please identify where references to replacement treatment can be found in the updated proposal. [c] If additional care is required that was not otherwise included in CMS’ conditional approved amount, please add line items.” Id. In addition, CMS states that “[i]n the event that treatment has changed due to a state-specific requirement, a life-care plan showing replacement treatment for denied treatments will be required if medical records do not indicate a change. Requests for changes to treatment plans will not be accepted without supporting medical documentation.” Id.

[6] WCMSA Reference Guide (Version 4.5, April 13, 2026), Chapter 16.3. On this point, CMS states: "Where a re-review request is reviewed and approved by CMS, the new approved amount will take effect on the date of settlement, regardless of whether the amount increased or decreased." Id.

[7] WCMSA Reference Guide (Version 4.5, April 13, 2026), Chapter 16.3. On this point, CMS states: “The approval of a new generic version of a medication by the Food and Drug Administration does not constitute a reason to request an amended review for supposed changes in projected pricing. CMS will deny the request for re-review if submitters fail to provide the above-referenced justifications with the request for re-review. Submitters will not be permitted to supplement the request for re-review, nor will they be developed.” Id.

[8] WCMSA Reference Guide (Version 4.5, April 13, 2026), Chapter 16.3. On this point, CMS states: “A change of submitter alone is not sufficient grounds to require an amended review. For the requirements to change a submitter, see Section 19.4.” Id.