Anatomy of a WCMSA: Section-by-Section Walkthrough

A complete Workers' Compensation Medicare Set-Aside Arrangement report is a structured analytical document, not a free-form narrative. Every shop's deliverable looks slightly different in formatting, but the substantive sections are dictated by the WCMSA Reference Guide and by what the Workers' Compensation Review Contractor (WCRC) examines when CMS review applies. Understanding the anatomy matters whether or not the case will be submitted: post-July 17, 2025, $0 cases no longer go to CMS at all (see our companion guide on the end of $0 WCMSA proposals), and many funded cases below the review thresholds are not voluntarily submitted either. The report is increasingly a settlement-file artifact whose audience is the parties, the carrier's MSP compliance program, the professional administrator, and a possible future MSP recovery action — not necessarily the WCRC.

This is a structural reference. It walks the report section by section, explains what belongs in each section and why, surfaces the defects that historically triggered CMS counter-proposals, and shows what a future-medical line item looks like in the allocation. It is written for the people who read these reports for a living: defense counsel evaluating an allocation, claims operations leads QA-ing a vendor deliverable, professional administrators receiving the file at settlement, and MSA preparers training new analysts.

The Standard Report Structure

A complete WCMSA report typically contains, in order:

Cover page and case identification
Executive summary with allocation total
Claimant demographics and rated age
Injury history and date of injury
Medical records review summary
Treatment summary by body part / diagnosis
Future medical projections (CPT-coded)
Future prescription projections (NDC-coded)
One-time projected procedures
Allocation total and structure
Administration recommendation
Source data and methodology disclosures
Appendices (rated age letter, supporting medical records index, fee schedule references)

Section numbering varies across shops. The substantive content does not.

1. Cover Page and Case Identification

The cover page identifies the case and the parties. Typical fields: claimant name, date of birth, Medicare beneficiary identifier (MBI) where available, claim number, date of injury, jurisdiction, the carrier or self-insured employer, defense counsel of record, claimant's counsel of record, the preparing shop, the report date, and the version number.

Why it matters. The cover page is the document's primary identifier in the carrier's MSP compliance system and in any future Section 111 reporting. The MBI ties the case to the Common Working File, the claim number ties the report to the carrier's claim system, and the date-of-injury and jurisdiction control the applicable fee schedule. A cover page missing any of these fields creates downstream reporting friction.

Common defects: missing MBI on a known beneficiary, jurisdiction mismatched with the fee schedule used in pricing (a common error when claims have venued in a state different from where treatment occurred), or claimant DOB inconsistent with the rated age letter.

2. Executive Summary with Allocation Total

A one-page summary stating the allocation total, the period in years, the lump-sum versus structured recommendation, and the CMS submission posture (submit-for-review, do-not-submit, or $0). Many shops include a small reconciliation table showing how the total breaks down across future medical, future prescriptions, and one-time projected procedures.

Why it matters. The executive summary is what a busy claims supervisor reads first and may be all that some downstream audiences read at all. It also feeds directly into the carrier's Section 111 reporting workflow: the MSA Amount, MSA Period, and lump-sum-or-structured indicator that go into the Claim Input File come from this summary block. A summary that does not match the underlying allocation arithmetic is a problem the moment it propagates to the reporting file.

Common defects: rounding inconsistencies between the summary and the line-item totals, period stated in the summary that does not match the rated-age-derived horizon, or lump-sum recommendation in the summary contradicted by an annuity-friendly structure in the body.

3. Claimant Demographics and Rated Age

The claimant's chronological age at settlement, the rated age (if used), the rated age underwriter or underwriters, the date of the rated age letter, and a brief explanation of the methodology by which the rated age was derived. The CDC Life Tables are the agency's reference; the current applicable table per CMS guidance is "Table 1: Life Table for the total population: United States, 2023" (effective September 20, 2025; referenced in Section 10.3 of WCMSA Reference Guide v4.5, April 13, 2026). The prior 2022 Life Table was operative June 14, 2025 through September 19, 2025 under v4.4.

Why it matters. The rated age is the single largest non-medical driver of the allocation total. A 50-year-old with a rated age of 65 carries roughly fifteen fewer years of future-care projection than a chronological 50-year-old, and the dollar impact of that fifteen-year compression on a typical allocation is in the hundreds of thousands of dollars. The rated age section must show its work — which underwriter issued the rating, which mortality table they referenced, what the supporting medical record summary contained — so a reviewer can evaluate whether the rated age is defensible. (See our guide on rated-age methodology for the full underwriting walkthrough.)

Common defects: rated age cited without an attached letter, rated age that uses a mortality table older than the table currently published in the Reference Guide, multiple rated ages obtained without an explanation of why the chosen one was used, or chronological-age life expectancy used where a rated age would have been appropriate to obtain.

4. Injury History and Date of Injury

A factual recitation: how the injury occurred, the body parts involved, the initial diagnosis, the accepted-versus-denied posture of the claim, and any subsequent body-part additions or complications. Cumulative-trauma claims and claims with multiple dates of injury require careful articulation here.

Why it matters. The injury history defines the scope of work-related care that the MSA must cover. Every line item in the future-medical and future-prescription sections must trace back to a body part or diagnosis acknowledged here. Body parts not acknowledged in the injury history but appearing in the allocation create internal inconsistency that a reviewer will challenge.

Common defects: a body part included in the allocation but never identified in the injury history, an undocumented mid-claim body-part expansion that the carrier did not actually accept, or a cumulative-trauma claim with an unclear date of injury that produces an ambiguous fee-schedule applicability.

5. Medical Records Review Summary

A summary of the medical records reviewed: providers seen, dates of service, primary diagnoses encountered, procedures performed, and significant findings. Many shops present this as a chronology, others as a provider-by-provider summary. The section identifies which records were reviewed and which (if any) the preparer was unable to obtain.

Why it matters. The medical records section is the evidentiary base for the future-care projection. Every projected item in the allocation should trace to records described here. Section 9.4.3 of the Reference Guide is explicit: the WCRC's allocation determination "relies on the claimant's past use and future recommended treatment as supported by the medical records." Where evidence-based guidelines and the treating provider conflict, the treating provider's plan is given preference. Records summarized weakly or selectively undermine the projection that depends on them.

Common defects: significant gaps in the record set not flagged (a primary treating physician's records absent without explanation), the records summary inconsistent with the treatment summary that follows it (a procedure described in one section and not the other), or a records summary so abbreviated that the reviewer cannot trace projected items to their evidentiary basis.

6. Treatment Summary by Body Part

For each accepted body part or diagnosis: the course of treatment over the life of the claim, the current treatment regimen, the treating provider's most recent assessment of future care needs, and any documented release-from-care or maximum-medical-improvement status. This section moves from descriptive (what happened) to predictive (what is expected to continue).

Why it matters. This is the analytical bridge between the medical record and the allocation. The strength of the future projection depends on whether this section honestly reflects what the treating provider actually anticipates. A treatment summary that asserts ongoing care without a treating-provider statement supporting it is weak; a summary that pulls from a recent visit note describing the planned course is strong.

Common defects: future care asserted from outdated records (a regimen described from a five-year-old visit note when more recent records show a different status), treatment summary that aggregates across body parts in a way that obscures which care is for which condition, or summary that describes the claimant's actual past usage but does not project forward in a way the allocation can rely on.

7. Future Medical Projections (CPT-Coded)

The line-item allocation for future medical care: physician visits, diagnostics, durable medical equipment, physical therapy, injections, and other recurring or expected items. Each line item is structured around four elements: the CPT code (or HCPCS code), the unit cost (per the applicable fee schedule), the frequency (per year), and the duration (number of years, typically the rated-age-derived period). The total for the line item is unit cost × frequency × years.

A typical future-medical line item looks like this:

CPT Code	Description	Unit Cost	Frequency / Year	Years	Total
99213	Established patient office visit, level 3	$87.43	4	22	$7,693.84
72148	MRI lumbar spine without contrast	$416.20	0.5	22	$4,578.20
97110	Therapeutic exercises (PT, per 15 min)	$32.85	24	8	$6,307.20
64483	Lumbar transforaminal epidural injection	$621.50	2	22	$27,346.00
E0114	Crutches, underarm, wood, adjustable	$34.20	0.1	22	$75.24

(Codes and pricing are illustrative. Actual per-unit costs come from the applicable state workers' compensation fee schedule or, where unavailable, the Medicare Physician Fee Schedule for the locality, per the Reference Guide.)

Why it matters. The line-item table is the allocation's analytical core. Each line is independently defensible: the CPT code describes a Medicare-covered service, the unit cost cites the applicable fee schedule, the frequency reflects either documented usage or treating-provider recommendation, and the duration reflects the rated-age-derived horizon (or a shorter horizon for items with limited useful life, like durable medical equipment with a defined replacement cycle).

Common defects: pricing pulled from the wrong fee schedule (a national Medicare rate where a state WC fee schedule applies, or vice versa), frequencies set at guideline minimums when the records show higher actual utilization or higher treating-provider-recommended utilization, durable medical equipment included as a recurring line when it is appropriately a one-time or replacement-cycle item, and items included that have no documented basis in the medical records (the most common WCRC counter-trigger historically).

8. Future Prescription Projections (NDC-Coded)

The drug-by-drug prescription allocation: each medication identified by NDC, the dose, the frequency, the unit cost, and the duration. CMS pricing methodology for prescriptions, per Section 9.4.6.1 of the Reference Guide, is Average Wholesale Price (AWP), defaulting to the lowest non-repackaged generic AWP unless a brand-name is being filled or the claimant or claimant's attorney insists on brand-name in writing. The Red Book (Micromedex / IBM, now Merative) is the canonical AWP source the WCRC and most shops use.

A typical prescription line item:

NDC	Drug	Strength	Daily Dose	Days/Year	Years	AWP/Unit	Total
00378-1234-01	Pregabalin (generic Lyrica)	75 mg	2 caps/day	365	22	$0.92	$14,765.20
00093-5678-01	Cyclobenzaprine (generic Flexeril)	10 mg	2 tabs/day PRN	180	22	$0.18	$1,425.60

(Pricing is illustrative and based on publicly cited Red Book examples; actual AWPs change continuously.)

Why it matters. Drugs are typically a meaningful share of the allocation, sometimes the largest share on chronic-pain cases. Generic-versus-brand selection has a 5-to-15× cost impact on many drugs (the often-cited Lyrica versus generic pregabalin example shows roughly a 90% cost reduction for the generic). Section 9.4.6.1 sets the default to generic; brand-name use must be supported by documented clinical necessity or a written claimant-attorney insistence.

Common defects: brand-name pricing used without documentation of necessity, dose escalation not reflected in the projection (claimant's records show a stable dose at 75 mg but the projection assumes the higher tier), drugs projected for the full rated-age horizon when the records support a shorter expected use, or drugs included that are not Medicare-covered for the indication (a Medicare Part D coverage check is part of the analytical work).

9. One-Time Projected Procedures

Procedures that are not recurring: a planned spinal fusion, a knee replacement, an intrathecal pump replacement at a documented interval, a spinal cord stimulator revision, or other significant interventions identified in the records. Each is allocated as a distinct line with the procedure code, the unit cost (often higher than fee-schedule rates because of facility, anesthesia, and implant components), and the timing.

Section 9.4.5 of the Reference Guide provides specific calculation guidance for replaceable implants. Per the methodology described in versions through v4.5, an implanted device's replacement frequency is calculated by subtracting one year from the injured worker's life expectancy for the initial placement, then dividing the remaining whole-number years by the device's useful life (commonly 7 years for non-rechargeable spinal cord stimulators or intrathecal pumps; 9 years for rechargeable devices), rounding down. For example, a 24-year life expectancy yields one initial placement plus three replacements (24 − 1 = 23; 23 / 7 = 3.28; round down to three replacements).

Why it matters. One-time procedures are high-dollar items with timing-specific allocation logic. Errors here are large in absolute dollars and visible to a reviewer. The replacement-frequency calculation is a frequent counter-trigger when applied incorrectly.

Common defects: replacement frequency miscounted (off by one because the initial placement was double-counted as a replacement, or because the rounding direction was reversed), procedure included on the basis of a guideline rather than a treating-provider recommendation, or unit cost that does not include facility and anesthesia components for an implant procedure.

10. Allocation Total and Structure

The aggregated total of future medical, future prescriptions, and one-time procedures, expressed as the recommended allocation amount and recommended structure (lump sum versus annuity, with initial deposit and anniversary deposit if structured).

Why it matters. The allocation total is the operative output of the report — the dollar number that funds the MSA. The lump-sum-versus-annuity decision affects the Section 111 reporting fields (Field 39 of the post-April 2025 Claim Input File requires a lump-sum-or-structured indicator), the funding mechanics of the settlement, and the long-term economics of the MSA. The Reference Guide does not require structured funding, but a structured annuity is generally less expensive at settlement (because of the time value of money) and produces a predictable funding stream that some carriers and administrators prefer.

If structured, the report should show the arithmetic explicitly: Initial Deposit + (Anniversary Deposit × (Period − 1)) = Total Allocation. The Section 111 reporting layer requires this arithmetic to reconcile, and a report that does not show its work places that burden on the carrier's compliance team.

Common defects: lump-sum total in the body but a structured recommendation in the executive summary, structured arithmetic that does not reconcile to the total (off-by-one period errors are typical), or a structure that does not align with the rated-age period in the demographics section.

11. Administration Recommendation

The recommended administrator: professional or self. If professional, often the report identifies a specific administrator (Ametros, IMPAXX, Rising Medical Solutions, or another) or notes that the choice is left to the parties. The recommendation should reflect the case profile — claimant capability, MSA size, complexity of future care — rather than a default house preference.

Why it matters. CMS's Section 17 language strongly recommends professional administration, but the choice belongs to the claimant. The administration recommendation drives the Section 111 reporting Field 43 (Professional Administrator EIN) — see our companion guide on the April 2025 Section 111 expansion for the operational mechanics. A report that recommends professional administration but does not identify the administrator's EIN or facilitate the EIN handoff to the RRE creates a foreseeable Section 111 reporting gap. Our decision framework on professional vs. self-administration walks the variables that should drive this recommendation.

Common defects: a default professional-administration recommendation on every case regardless of profile, a self-administration recommendation on a case where the claimant capability or MSA size points the other direction, or a recommendation made without identifying the administrator EIN that the RRE will need for Field 43.

12. Source Data and Methodology Disclosures

A list of the records reviewed (typically by provider and date range), the fee schedule used, the AWP source for prescriptions, the rated age underwriter's letter (often appended), and any methodological choices that depart from default (a brand-name drug pricing, a guideline-based projection in the absence of treating-provider input, a non-standard replacement frequency, etc.).

Why it matters. The methodology disclosures are the report's auditability layer. A reviewer (the WCRC, a future MSP recovery contractor, the carrier's compliance auditor) needs to be able to retrace the analytical path from the records to the allocation. The disclosures section is where the report says, in its own words, what it did and why.

Common defects: methodology disclosures that are boilerplate rather than specific to the case, undocumented departures from default (a brand-name drug pricing without explanation), or fee-schedule references that do not specify the version or effective date used.

13. Appendices

Typically: the rated-age letter, an index of medical records reviewed (often with bates ranges), fee schedule citations, and any documentary appendices specific to the case (denial notice, settlement language excerpt, treating provider statement).

Why it matters. Appendices are where the report's evidentiary backing lives. A defensible MSA can be reconstructed from its appendices alone if the body of the report were lost. A report whose appendices are incomplete is materially weaker even if the body looks polished.

Common defects: rated-age letter referenced in the body but missing from the appendix, records index that does not match the records summary in the body, or appendices that are placeholders rather than complete documents.

What CMS Reviewers Look For (When Review Applies)

Post-July 17, 2025, CMS does not review $0 cases. Funded cases above the review thresholds ($25,000 for current beneficiaries, $250,000 for those with reasonable expectation of Medicare entitlement within 30 months) may be voluntarily submitted; many are not. When a case is submitted, the WCRC's review is grounded in the Reference Guide and in the analytical patterns it has developed since CMS began review.

In practice, the WCRC examines:

Whether the projected items are documented in the medical record. Section 9.4.3 is the operative guidance: the determination relies on past use and treating-provider-recommended future care. Items that appear in the allocation without records support are routinely countered.

Whether the pricing is correctly drawn from the applicable fee schedule. Pricing errors are mechanical and high-frequency in counter-proposals. The right fee schedule for the locality and the right Medicare fee schedule fallback where a state WC schedule does not apply must be visible.

Whether the rated age methodology is sound. A rated age that is inconsistent with the records on file, that uses an outdated mortality table, or that is not supported by an underwriter letter is challenged.

Whether the prescription methodology follows Section 9.4.6.1. Brand-name pricing without documented necessity is the most common counter on the prescription side. The agency's default expectation is generic.

Whether replacement-procedure calculations follow Section 9.4.5. The off-by-one error patterns are familiar to the WCRC.

Whether the allocation reconciles internally. Summary totals matching line-item totals, structured arithmetic reconciling, and demographics consistent with the rated age period.

A report that handles each of these correctly tends to clear review without counter. A report that misses on multiple items receives a counter-proposal that may take weeks to resolve and may end with the carrier funding a higher allocation than the original report contemplated.

Common Defects That Trigger Counter-Proposals

Pulling the failure modes together, the recurring defects historically observed in WCRC counter-proposals are:

Items in the allocation without records support
Frequencies set at guideline minimums where treating-provider documentation supports higher
Pricing from the wrong fee schedule for the locality
Brand-name prescription pricing without documented necessity
Replacement-procedure frequency miscalculated (Section 9.4.5 off-by-one)
Rated age inconsistent with the records or not supported by an underwriter letter
Internal reconciliation errors between summary, body, and structured arithmetic
Missing or incomplete appendices supporting the report's claims
Body-part inclusion in the allocation that the injury history does not establish
Missing treating-provider statement or release-from-care note where one is needed

A preparing shop with disciplined QA catches each of these before delivery. A shop without that discipline produces reports that look complete but generate counter-proposals when reviewed.

Practical Implications

For defense counsel reviewing a vendor deliverable. Work through the report in section order before signing off. The most common red flags are: a body part in the allocation that the injury history does not establish, frequencies set at obviously low utilization for the documented condition, brand-name drugs priced without necessity documentation, and a structured arithmetic that does not reconcile. Catching these before the file is finalized avoids a counter-proposal cycle (where review applies) or a downstream documentation gap (where review does not apply).

For claims operations leads doing vendor QA. Build a checklist that walks each section against the Reference Guide and confirms the appendices match the body. The goal is not to redo the analyst's work; it is to surface the structural defects that have a high recurrence rate.

For professional administrators receiving the file at settlement. The administration recommendation, the structured-or-lump-sum decision, and the line-item allocation are the operative inputs to the administration plan. A report whose administration recommendation does not match the case profile, or whose line-item allocation is incoherent with the projected administration plan, should be flagged back to the preparing shop before funding.

For preparing shops. The structural anatomy is not optional. A delivery-driven shop that abbreviates the medical records summary, the methodology disclosures, or the appendices in service of speed is producing a report that is fragile under review and weak as a settlement-file artifact for a case that will not be reviewed.

Sources

WCMSA Reference Guide v4.5 (April 13, 2026 PDF) — CMS — Section 9.4.3 (review considerations), Section 9.4.5 (replacement procedures), Section 9.4.6.1 (prescription pricing methodology), Section 10.3 (rated-age and life expectancy), Section 17 (administration)
WCMSA Reference Guide v4.4 (July 2025 PDF) — CMS — historical reference; CDC Life Tables update implemented in this version
Workers' Compensation Medicare Set-Aside Arrangements — CMS
What's New — Workers' Compensation Medicare Set-Aside Arrangements (CMS)
Updated WCMSA Reference Guide and Implementation of Two New Policies by CMS — Medivest — practitioner commentary on Section 9.4.3 and 9.4.5 updates
Dealing with Drugs in the Medicare Set-Aside — Nyhan, Bambrick, Kinzie & Lowry — practitioner reference on Section 9.4.6.1 and AWP pricing examples
Drug Pricing from Micromedex Red Book — Merative — canonical AWP source description

A redacted sample WCMSA showing the section structure described above, including the allocation tables and the methodology disclosures, is available at zicron.claims/msa/sample. For settlements that need a 48-hour MSA built to the structural standard described here, see zicron.claims/msa.

Anatomy of a WCMSA: A Section-by-Section Walkthrough of What's in the Report