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Case Re-Review Request

On this page, you can submit a re-review request for the case number displayed at the top of the page. You will need to provide the reason for the request, as well as additional information depending on the type of re-review you are requesting.

Note: All fields are required.

FieldDescription
Request Type

Choose one of the following:

  • Medical
  • RX (Pharmacy)
  • Both (Medical & Pharmacy)
Reason for Request

If Option 2 is selected, you will be required to submit supporting documentation.

  • Option 1
    You believe CMS's determination contains obvious mistakes (e.g., a mathematical error or failure to recognize Medical records already submitted showing a surgery, priced by CMS, that has already occurred).
  • Option 2
    You believe you have additional evidence, not previously considered by CMS, which was dated prior to the submission date of the original proposal which warrants a change in CMS' determination; or you believe a submission error exists in the documentation previously submitted that leads to a change in pricing of no less than $2,500.00.
  • Amended Review
    You believe projected care has changed so much that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS' previously approved amount.

Note: The option for an Amended Review only appears if the case is eligible.

New Proposed MSA AmountThe total dollar amount of the new proposed Medicare Set-Aside (MSA) you are requesting. Enter both the dollar and cents amounts in the two fields.

Amended Reviews Only:

Enter the new proposed Medicare Set-Aside (MSA) Amount in the fields provided.

Note: You may only request an Amended review one time per case. If your request for an Amended Review is denied (even if the case is not eligible), you may not request another re-review. To be eligible for an Amended Review, the case:

  • Has been reviewed and approved
  • Cannot have a previous request for an Amended Review
  • Must result in a 10% or $10,000 change (whichever is greater) in CMS' previously approved amount. For example:

New Proposed MSA = $88,000
$88,000 minus $80,000 = $8,000 difference
The difference is at least 10% so this amount is eligible.

New Proposed MSA = $95,000
$95,000 minus 80,000 = $15,000 difference
The difference is at least $10,000 so this amount is eligible.

New Proposed MSA = $65,000
$80,000 minus $65,000 = $15,000 difference
The difference is at least $10,000 so this amount is eligible.

Note: The New Proposed MSA Amount can be greater than or less than the Approved MSA Amount, as long as the difference is at least 10% or $10,000 (whichever is greater).

Click Continue to proceed to the Case Re-Review Request Details page, where you will add supporting information for your request.

Click Cancel to cancel your re-review request and display the Cancel Re-Review Request Confirmation page.

Click Print this page to print a copy of this page for your records.

April 2025

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