Independent Medical Review update 2019
Case Decisions Issued
"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