Independent Medical Review (IMR) Update 2022

Case Decisions

Month Total Issued Average Age from
Assigned Date
(in days)
Average Age from
Complete Medical
Records (in days)
January 11,009 31 12
February 9,555 27 11
March 10,259 26 10
April 10,654 27 10
May 11,123 27 10
June      
July      
August      
September      
October      
November      
December      
Total 52,600 - -

"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 12,641 13,005 15,674 14,888 14,234               70,442
Total Number of Unique Applications 10,388 10,641 12,899 12,166 11,751               57,845
Total Number of Eligible Applications 9,498 9,782 11,941 11,217 11,258               53,696

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) 1,643
No Signature 372
No UR Attached 877
Untimely 916
Other 341
Total 4,149

**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 24 100% 0%
BEHAVIORAL AND MENTAL HEALTH SERVICES 1,616 81% 19%
Evaluation & Management
496 87% 13%
Therapies
1,120 79% 21%
DIAGNOSTIC TESTING 19,352 91% 9%
EMG/NCV/NCS
1,629 93% 7%
Imaging, Radiology
7,514 92% 8%
Lab & Pathology
8,511 91% 9%
Other Diagnostic Tests
1,698 88% 12%
* DMEPOS 10,140 92% 8%
Durable Medical Equipment
3,088 95% 5%
Electrical Stimulation
1,724 92% 8%
Prosthetics / Orthotics
1,763 89% 11%
Supplies
3,565 91% 9%
EVALUATION & MANAGEMENT 4,039 86% 14%
Dental Services
184 89% 11%
Evaluation & Management
567 80% 20%
Medical Specialties
3,288 86% 14%
HOME HEALTH 507 92% 8%
INJECTIONS 8,675 96% 4%
Peripheral
3,679 93% 7%
Spine
4,967 98% 2%
Other Injection
29 86% 14%
PHARMACEUTICALS 29,142 92% 8%
Antidepressants 753 73% 27%
Anti-Epilepsy Drugs 2,578 92% 8%
Anti-Infectives 469 97% 3%
Benzodiazepines 456 96% 4%
Laxative 415 91% 9%
Muscle Relaxants 4,781 99% 1%
NSAIDs 2,913 84% 16%
Opioids 7,940 93% 7%
Proton Pump Inhibitors 872 86% 14%
Sedative / Hypnotics 860 93% 7%
Topical Analgesics 4,573 97% 3%
Other Pharmaceuticals 2,532 88% 12%
PROGRAMS 1,176 84% 16%
REHABILIATION 19,172 93% 7%
Acupuncture
3.617 93% 7%
Chiropractic
2,267 88% 12%
Physical Therapy / Occupational Therapy
10,810 94% 6%
Other Therapies
2,478 95% 5%
SURGERY 6,981 91% 9%
Adjunct Surgical Services
2,801 94% 6%
Arthroscopic Surgery
1,411 85% 15%
Non-arthroscopic Surgery
2,008 89% 11%
Surgical Consult
761 92% 8%
TRANSPORTATION 135 96% 4%

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

June 2022