Independent Medical Review (IMR) Update 2024, Q3

Case Decisions

Month Total Issued Average Age from
Assigned Date
(in days)
Average Age from
Complete Medical
Records (in days)
January 11,589 27 7
February 10,926 24 6
March 11,450 24 6
April 12,142 24 6
May 11,368 25 6
June 9,840 28 6
July 12,464 28 6
August 12,756 30 6
September 13,330 30 8
October      
November      
December      
Total 105,865 - -

"Average Age from Assigned Date" represents the average number of calendar days required to process an IMR from the date the Notice of Assignment and Request for Information (NOARFI) was mailed to the date the Final Determination Letter (FDL) was mailed.

"Average Age from Complete Medical Records" represents the average number of calendar days required to process an IMR from the date MAXIMUS received all necessary records to the date the FDL was mailed.

IMR Applications

Jan Feb Mar
Apr May Jun Jul 
Aug Sep Oct Nov Dec Total
Total Number of IMR Applications Received 15,032 15,354 16,063 16,776 17,305

15,964

17,941

17,277 16,444       148,156
Total Number of Unique Applications 12,477 12,750 13,325 13,759 14,296 13,097 14,709 14,091 13,594       122,098
Total Number of Eligible Applications 11,228 11,646 12,146 12,399 12,859 11,793 13,216 12,587 12,407       110,281

Total IMR Applications are the gross number received by the IMRO in the given calendar month. Once duplicate filings have been identified and removed, those Unique Applications are screened for eligibility.

IMR Ineligible Applications

Eligible Applications are those accepted by the IMRO for review. Reasons for applications being found ineligible include: 

  • It lacks the signature of the injured worker (or representative);
  • It is not on time, that is, not submitted within 30 days of receipt of the UR decision;
  • The utilization review report is not attached to the application; or
  • The utilization review is invalid because it contains a conditionally noncertified (CNC)** decision.
Reason Total Count
Conditionally Non-Certified (CNC) 6,339
No Signature 834
No Signature & No UR 61
No UR Attached 2,011
Untimely 1,706
Other 866
Total 11,817

**Conditionally noncertified (CNC) decision: A UR decision that has been denied because the treating physician has not provided the medical information requested by the claims administrator that is required to make a medical necessity determination on the treatment recommendation.

Treatment Requests and Outcomes

“Treatment request” refers to the medical treatment that was denied in UR and challenged through the IMR process. IMR cases have at least one treatment, or may have more than one. Treatment requests are classified into broad categories and subcategories; specific detail is found in the Final Determination Letter.

  • Uphold – the IMRO decided that the disputed service was not medically necessary and appropriate.
  • Overturn – the IMRO decided that the disputed service is medically necessary and appropriate.

Category/Subcategory Number of
Decisions
UR
Upheld
UR
Overturned
ACCOMMODATION 153 88% 12%
BEHAVIORAL AND MENTAL HEALTH SERVICES 3,335 79% 21%
Evaluation & Management
740 78% 22%
Therapies
2,595 80% 20%
DIAGNOSTIC TESTING 21,898 82% 18%
EMG/NCV/NCS
2,732 84% 16%
Imaging, Radiology
13,284 84% 16%
Lab & Pathology
4,507 78% 22%
Other Diagnostic Tests
1,375 75% 25%
* DMEPOS 17,857 89% 11%
Durable Medical Equipment
5,854 92% 8%
Electrical Stimulation
4,520 92% 8%
Prosthetics / Orthotics
3,584 85% 15%
Supplies
3,899 85% 15%
EVALUATION & MANAGEMENT 8,459 77% 23%
Dental Services
643 65% 35%
Evaluation & Management
1,234 77% 23%
Medical Specialties
6,582 78% 22%
HOME HEALTH 1,122 87% 13%
INJECTIONS 16,901 91% 9%
Spine
9 89% 11%
Peripheral
8,950 90% 10%
Other Injection
7,942 92% 8%
PHARMACEUTICALS 59,945 89% 11%
Antidepressants 1,666 71% 29%
Anti-Epilepsy Drugs 5,322 89% 11%
Anti-Infectives 1,037 94% 6%
Benzodiazepines 733 93% 7%
Laxative 1,034 80% 20%
Muscle Relaxants 9,846 97% 3%
NSAIDs 6,459 77% 23%
Opioids 14,649 91% 9%
Sedative / Hypnotics 1,415 92% 8%
Topical Analgesics 10,276 92% 8%
Other Pharmaceuticals 7,508 81% 19%
PROGRAMS 2,798 78% 22%
REHABILIATION 40,090 90% 10%
Acupuncture
7,702 93% 7%
Chiropractic
4,434 90% 10%
Other Therapies
5,968 90% 10%
Physical Therapy / Occupational Therapy
21,986 89% 11%
SURGERY 13,026 84% 16%
Adjunct Surgical Services
4,912 88% 12%
Arthroscopic Surgery
2,466 79% 21%
Non-arthroscopic Surgery
4,423 83% 17%
Surgical Consult
1,225 85% 15%
TRANSPORTATION 534 94% 6%

*DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

October 2024