Life Care Plans prepared by Non-Treating Physicians

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(Ref: 4/22/03 Memo Q15)

When the parties to a Workers’ Compensation (WC) settlement present CMS  with “life care plans” or similar evaluations prepared by non-treating physicians to support and justify their proposed Workers’ Compensation Medicare Set-aside Arrangements (WCMSA), Medicare will consider accepting such evaluations if the physician does all of the following:

  1. Examines the claimant;
  2. Reviews the claimant's medical records;
  3. Contacts any of the claimant's treating physicians (if applicable);
  4. Is available to answer CMS’ questions;
  5. Prepares a report that summarizes the above; and
  6. Offers a written medical opinion as to all of the reasonably anticipated future medical needs of the claimant related to the claimant's work injury or illness/disease.

Please note that such a life care plan or evaluation is not automatically conclusive. The CMS may not credit the report if there is information that calls  the evaluation or plan into question for some reason, such as contrary evidence, internal conflicts, or if the plan is not credible on its face.

Source: The Centers for Medicare and Medicaid Services

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