Independent Medical Review update 2020

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

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 14,100             92,566
Total Number of Unique Applications 13,961 13,636 13,951 11,450 10,236 11,697             74,931
Total Number of Eligible Applications 12,792 12,654 12,952 10,627 9,607 11,290             69,926

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) 1,979
No Signature 469
No UR Attached 1,226
Untimely 700
Other 631
Total 5,005

**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 (June 2020)

“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 295 80% 20%
Evaluation & Management
151 82% 18%
Therapies
144 78% 22%
DIAGNOSTIC TESTING 3,246 91% 9%
EMG/NCV/NCS
380 92% 8%
Imaging, Radiology
1,311 91% 9%
Lab & Pathology
1,199 91% 9%
Other Diagnostic Tests
356 91% 9%
* DMEPOS 1,730 93% 7%
Durable Medical Equipment
649 94% 6%
Electrical Stimulation
407 92% 8%
Prosthetics / Orthotics
265 91% 9%
Supplies
409 93% 7%
EVALUATION & MANAGEMENT 766 84% 16%
Dental Services
20 35% 65%
Evaluation & Management
122 84% 16%
Medical Specialties
624 85% 15%
HOME HEALTH/TRANSPORTATION 103 90% 10%
Home Health
87 90% 10%
Transportation
16 94% 6%
INJECTIONS 1,587 94% 6%
Peripheral
630 90% 10%
Spine
840 95% 5%
Other Injection
117 97% 3%
PHARMACEUTICALS 7,125 92% 8%
Antidepressants
237 83% 17%
Anti-Epilepsy Drugs
663 87% 13%
Benzodiazepines
161 98% 2%
Muscle Relaxants
1,111 97% 3%
NSAIDs
554 87% 13%
Opioids
2,054 92% 8%
Proton Pump Inhibitors
206 86% 14%
Sedative/Hypnotics
360 94% 6%
Topical Analgesics
1,041 94% 6%
Other Pharmaceuticals
738 89% 11%
PROGRAMS 142 80% 20%
REHABILIATION 3,083 90% 10%
Acupuncture
528 87% 13%
Chiropractic
371 88% 12%
Physical Therapy / Occupational Therapy
1,718 91% 9%
Other Therapies
466 89% 11%
SURGERY 1,034 91% 9%
Adjunct Surgical Services
274 94% 6%
Arthroscopic Surgery
265 96% 4%
Non-arthroscopic Surgery
362 91% 9%
Surgical Consult
133 93% 7%

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

July 2020