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 16,676                     34,041
Total Number of Unique Applications 13,965 13,798                     27,763
Total Number of Eligible Applications 12,815 13,264                     26,079

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) 645
No Signature 91
No UR Attached 299
Untimely 461
Other 188
Total 1,684

**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 511 82% 18%
Evaluation & Management
216 85% 15%
Therapies
295 79% 21%
DIAGNOSTIC TESTING 7,974 91% 9%
EMG/NCV/NCS
776 88% 12%
Imaging, Radiology
3,041 90% 10%
Lab & Pathology
3,280 91% 9%
Other Diagnostic Tests
877 93% 7%
* DMEPOS 4,189 93% 7%
Durable Medical Equipment
1,721 94% 6%
Electrical Stimulation
870 92% 8%
Prosthetics / Orthotics
610 92% 8%
Supplies
988 94% 6%
EVALUATION & MANAGEMENT 1,842 85% 15%
Dental Services
71 62% 38%
Evaluation & Management
251 83% 17%
Medical Specialties
1,520 86% 14%
HOME HEALTH/TRANSPORTATION 301 90% 10%
Home Health
223 89% 11%
Transportation
78 95% 5%
INJECTIONS 3,406 88% 12%
Peripheral
1,338 87% 13%
Spine
1,858 89% 11%
Other Injection
210 89% 11%
PHARMACEUTICALS 16,248 89% 11%
Antidepressants
545 77% 23%
Anti-Epilepsy Drugs
1,559 81% 19%
Benzodiazepines
344 97% 3%
Laxatives 
210 83% 17%
Muscle Relaxants
2,309 95% 5%
NSAIDs
1,276 86% 14%
Opioids
5,169 90% 10%
Proton Pump Inhibitors
489 88% 12%
Sedative/Hypnotics
781 94% 6%
Topical Analgesics
2,104 93% 7%
Other Pharmaceuticals
1,462 86% 14%
PROGRAMS 423 85% 15%
REHABILIATION 7,968 90% 10%
Acupuncture
1,415 88% 12%
Chiropractic
856 88% 12%
Physical Therapy / Occupational Therapy
4,449 91% 9%
Other Therapies
1,248 90% 10%
SURGERY 2,779 92% 8%
Adjunct Surgical Services
760 94% 6%
Arthroscopic Surgery
635 91% 9%
Non-arthroscopic Surgery
1,011 92% 8%
Surgical Consult
373 92% 8%

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

March 2020