IMR update 2017

Case Decisions Issued

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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.

IMR Application Filings  2017

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.

**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/Service Categories

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.

IMR treatment request

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

Treatment Request Outcomes

  • 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.

Service Categories Requests Upheld Overturned
Pharmaceuticals 146,408 92% 8%
Diagnostic Testing 52,273 91% 9%
Rehabilitation 49,194 94% 6%
DMEPOS 27,943 93% 7%
Surgery 23,432 90% 10%
Injection 23,358 92% 8%
Evaluation and Management 8,299 83% 17%
Psych Services 4,083 83% 17%
Programs 3,213 89% 11%
Home Health & Transportation 1,708 93% 7%

 

Pharmaceutical Subcategories
(Most Requested Medications)
Requests Upheld Overturned
Opioids 43,633 91% 9%
NSAIDs 20,927 90% 10%
Muscle Relaxants 19,435 97% 3%
Topical Analgesics 14,047 97% 3%
Anti-Epilepsy Drugs 8,481 87% 13%
Proton Pump Inhibitors 7,850 92% 8%
Antidepressants 5,535 82% 18%
Benzodiazepines 5,189 96% 4%
Sedative-hypnotics 4,749 97% 3%

January 2018