IMR update 2019

Case Decisions Issued

Case decisions

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"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

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.

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.Ineligible Applications

**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 2,424 77% 23%
Evaluation & Management
1,127 78% 22%
Therapies
1,247 76% 24%
DIAGNOSTIC TESTING 37,412 90% 10%
EMG/NCV/NCS
3,961 83% 17%
Imaging, Radiology
14,423 88% 12%
Lab & Pathology
14,622 92% 8%
Other Diagnostic Tests
4,406 94% 6%
* DMEPOS 20,585 92% 8%
Durable Medical Equipment
8,175 93% 7%
Electrical Stimulation
4,768 90% 10%
Prosthetics / Orthotics
3,162 90% 10%
Supplies
4,480 91% 9%
EVALUATION & MANAGEMENT 9,319 83% 17%
Dental Services
529 85% 15%
Evaluation & Management
1,212 81% 19%
Medical Specialties
7,578 83% 17%
HOME HEALTH/TRANSPORTATION 1,539 92% 8%
Home Health
1,182 92% 8%
Transportation
357 92% 8%
INJECTIONS 16,407 89% 11%
Peripheral
6,066 88% 12%
Spine
9,331 90% 10%
Other Injection
1,010 90% 10%
PHARMACEUTICALS 83,014 90% 10%
Antidepressants
3,360 73% 27%
Anti-Epilepsy Drugs
6,407 81% 19%
Benzodiazepines
1,910 97% 3%
Laxatives 
1,068 84% 16%
Muscle Relaxants
11,971 96% 4%
NSAIDs
6,439 83% 17%
Opioids
26,625 91% 9%
Proton Pump Inhibitors
2,330 88% 12%
Sedative/Hypnotics
4,536 92% 8%
Topical Analgesics
10,532 94% 6%
Other Pharmaceuticals
7,836 89% 11%
PROGRAMS 2,107 84% 16%
REHABILIATION 37,290 91% 9%
Acupuncture
6,599 91% 9%
Chiropractic
4,283 91% 9%
Physical Therapy / Occupational Therapy
20,597 92% 8%
Other Therapies
5,811 89% 11%
SURGERY 12,260 91% 9%
Adjunct Surgical Services
3,253 93% 7%
Arthroscopic Surgery
2,933 90% 10%
Non-arthroscopic Surgery
4,298 89% 11%
Surgical Consult
1,776 92% 8%

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

September 2019