Independent Medical Review update 2019

Case Decisions Issued

This graph contains the total number of IMR Case Decisions issued to the nearest thousand for each of the last twelve months. Also listed are the monthly averages for the length of time to complete determinations.

(CLICK IMAGE ABOVE TO VIEW LARGE GRAPH)

"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 Application Filings

2019 IMR Filings Jan Feb March April May June July Aug Sept Oct Nov Dec Total
Total Number of IMR Applications Received 18,728 18,093 19,262 20,052 19,886 17,695 19,812 18,306 17,504 19,067 - - 185,544
Total Number of Unique Applications 14,791 14,556 15,481 16,062 15,788 14,176 15,507 14,679 13,856 15,611 - - 150,326
Total Number of Eligible Applications 13,747 13,639 14,948 15,095 14,815 13,279 14,510 13,696 13,338 14,917 - - 141,108

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 Year-to-Date
Conditionally Non-Certified (CNC) 2,508
No Signature 748
No UR Attached 2,485
Untimely 2,328
Other 1,149
Total 9,218

**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
BEHAVIORAL AND MENTAL HEALTH SERVICES 3,011 77% 23%
Evaluation & Management
1,443 77% 23%
Therapies
1,568 76% 24%
DIAGNOSTIC TESTING 46,333 91% 9%
EMG/NCV/NCS
4,942 84% 16%
Imaging, Radiology
17,989 88% 12%
Lab & Pathology
18,021 92% 8%
Other Diagnostic Tests
5,381 94% 6%
* DMEPOS 25,140 92% 8%
Durable Medical Equipment
10,064 93% 7%
Electrical Stimulation
5,753 91% 9%
Prosthetics / Orthotics
3,824 90% 10%
Supplies
5,499 92% 8%
EVALUATION & MANAGEMENT 11,414 83% 17%
Dental Services
661 81% 19%
Evaluation & Management
1,486 88% 12%
Medical Specialties
9,267 91% 9%
HOME HEALTH/TRANSPORTATION 1,895 92% 8%
Home Health
1,464 92% 8%
Transportation
431 91% 9%
INJECTIONS 20,243 89% 11%
Peripheral
7,566 87% 13%
Spine
11,496 90% 10%
Other Injection
1,181 90% 10%
PHARMACEUTICALS 100,805 90% 10%
Antidepressants
4,006 73% 27%
Anti-Epilepsy Drugs
7,911 81% 19%
Benzodiazepines
2,310 97% 3%
Laxatives 
1,305 84% 16%
Muscle Relaxants
14,480 96% 4%
NSAIDs
7,781 83% 17%
Opioids
32,271 89% 11%
Proton Pump Inhibitors
2,785 88% 12%
Sedative/Hypnotics
5,476 92% 8%
Topical Analgesics
12,860 94% 6%
Other Pharmaceuticals
9,620 89% 11%
PROGRAMS 2,548 83% 17%
REHABILIATION 46,204 91% 9%
Acupuncture
8,260 90% 10%
Chiropractic
5,281 90% 10%
Physical Therapy / Occupational Therapy
25,461 91% 9%
Other Therapies
7,202 89% 11%
SURGERY 15,032 91% 9%
Adjunct Surgical Services
3,947 93% 7%
Arthroscopic Surgery
3,634 90% 10%
Non-arthroscopic Surgery
5,259 89% 11%
Surgical Consult
2,192 92% 8%

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

November 2019