Independent Medical Review (IMR) Update 2020

Case Decisions

Month Total Issued Average Age from
Assigned Date
(in days)
Average Age from
Complete Medical
Records (in days)
January 12,495 26 8
February 10,653 27 8
March 13,721 25 8
April 13,800 25 12
May 9,629 24 9
June 10,104 24 9
July 10,640 24 9
August 10,390 25 9
September 11,038 26 10
October 11,214 27 10
November 10,912 27 10
December 12,150 28 11
Total 136,746 - -

"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

2020 IMR Filings Jan Feb March April May June July Aug Sept Oct Nov Dec Total
Total Number of IMR Applications Received 17,365 16,866 17,694 14,026 12,516 14,176 14,955 15,053 15,175 15,745 15,216 15,309 184,095
Total Number of Unique Applications 13,961 13,636 13,951 11,450 10,235 11,561 12,195 12,167 12,166 12,743 12,166 12,519 148,750
Total Number of Eligible Applications 12,792 12,654 12,951 10,622 9,596 10,980 11,657 11,601 11,416 11,968 11,452 12,047 139,739

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) 3.970
No Signature 822
No UR Attached 2,149
Untimely 740
Other 1,330
Total 9,011

**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 3,465 82% 18%
Evaluation & Management
1,611 83% 17%
Therapies
1,854 80% 20%
DIAGNOSTIC TESTING 48,642 89% 11%
EMG/NCV/NCS
4,603 90% 10%
Imaging, Radiology
18,317 91% 9%
Lab & Pathology
20,165 91% 9%
Other Diagnostic Tests
5,557 93% 7%
* DMEPOS 26,429 93% 7%
Durable Medical Equipment
10,934 94% 6%
Electrical Stimulation
5,262 92% 8%
Prosthetics / Orthotics
3,726 91% 9%
Supplies
6,327 92% 8%
EVALUATION & MANAGEMENT 11.074 85% 15%
Dental Services
426 75% 25%
Evaluation & Management
1,614 81% 19%
Medical Specialties
9,034 86% 14%
HOME HEALTH/TRANSPORTATION 1,768 91% 9%
Home Health
1,397 91% 9%
Transportation
371 93% 7%
INJECTIONS 21,385 91% 9%
Peripheral
8297 90% 10%
Spine
11,329 93% 7%
Other Injection
1,759 90% 10%
PHARMACEUTICALS 91,954 91% 9%
Antidepressants 3,077 78% 22%
Anti-Epilepsy Drugs 8,430 86% 14%
Anti-Infectives 1,225 94% 6%
Benzodiazepines 1,754 97% 3%
Laxative 1,213 84% 16%
Muscle Relaxants 14,259 97% 3%
NSAIDs 7,641 86% 14%
Opioids 27,400 91% 9%
Proton Pump Inhibitors 2,738 88% 12%
Sedative / Hypnotics 4,770 94% 6%
Topical Analgesics 12,392 93% 7%
Other Pharmaceuticals 7,055 89% 11%
PROGRAMS 2,226 83% 17%
REHABILIATION 46,221 90% 10%
Acupuncture
8,268 88% 12%
Chiropractic
5,024 88% 12%
Physical Therapy / Occupational Therapy
25,897 91% 9%
Other Therapies
7,032 91% 9%
SURGERY 16,612 91% 9%
Adjunct Surgical Services
4,653 94% 6%
Arthroscopic Surgery
3,990 88% 12%
Non-arthroscopic Surgery
5,759 90% 10%
Surgical Consult
2,209 90% 10%

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

January 2021