Independent Medical Review update 2019

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

2019 IMR Filings Jan Feb March April May June July Aug Sept Oct Nov Dec Total
Total Number of IMR Applications Received 18,728 18,093 19,262 20,052 19,886 17,695 19,812 18,306 17,640 19,240 16,529 16,885 222,131
Total Number of Unique Applications 14,791 14,556 15,481 16,062 15,788 14,176 15,507 14,679 13,686 15,643 13,264 13,781 177,403
Total Number of Eligible Applications 13,747 13,639 14,948 15,095 14,815 13,279 14,510 13,690 12,823 14,532 12,328 13,148 166,188

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) 3,144
No Signature 908
No UR Attached 3,070
Untimely 2,726
Other 1,367
Total 11,215

**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 3,552 77% 23%
Evaluation & Management
1,713 78% 22%
Therapies
1,839 77% 23%
DIAGNOSTIC TESTING 54,382 91% 9%
EMG/NCV/NCS
5,808 85% 15%
Imaging, Radiology
21,184 88% 12%
Lab & Pathology
21,142 93% 7%
Other Diagnostic Tests
6,248 94% 6%
* DMEPOS 29,722 92% 8%
Durable Medical Equipment
11,874 93% 7%
Electrical Stimulation
6,757 91% 9%
Prosthetics / Orthotics
4,511 90% 10%
Supplies
6,580 92% 8%
EVALUATION & MANAGEMENT 13,306 84% 16%
Dental Services
708 79% 21%
Evaluation & Management
1,768 86% 14%
Medical Specialties
10,830 91% 9%
HOME HEALTH/TRANSPORTATION 2,213 91% 9%
Home Health
1,694 91% 9%
Transportation
519 92% 8%
INJECTIONS 23,933 89% 11%
Peripheral
8,939 87% 13%
Spine
13,288 92% 8%
Other Injection
1,406 90% 10%
PHARMACEUTICALS 117,355 90% 10%
Antidepressants
4,635 74% 26%
Anti-Epilepsy Drugs
9,395 82% 18%
Benzodiazepines
2,660 97% 3%
Laxatives 
1,486 84% 16%
Muscle Relaxants
16,853 96% 4%
NSAIDs
9,050 84% 16%
Opioids
37,403 89% 11%
Proton Pump Inhibitors
3,212 88% 12%
Sedative/Hypnotics
6,347 92% 8%
Topical Analgesics
15,039 94% 6%
Other Pharmaceuticals
11,275 89% 11%
PROGRAMS 3,020 84% 16%
REHABILIATION 54,773 91% 9%
Acupuncture
9,751 90% 10%
Chiropractic
6,269 90% 10%
Physical Therapy / Occupational Therapy
30,213 91% 9%
Other Therapies
8,540 90% 10%
SURGERY 17,687 91% 9%
Adjunct Surgical Services
4,647 93% 7%
Arthroscopic Surgery
4,275 90% 10%
Non-arthroscopic Surgery
6,182 89% 11%
Surgical Consult
2,583 92% 8%

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

January 2020