Independent Medical Review (IMR) Update 2020

Case Decisions Issued

Month Total Issued Average Age from
Assigned Date
(in days)
Average Age from
Complete Medical
Records (in days)
January 12,495 26 8
February 10,653 27 8
March 13,721 25 8
April 13,800 25 12
May 9,629 24 9
June 10,104 24 9
July 10,640 24 9
August 10,391 25 9
September      
October      
November      
December 91,433 - -

"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 14,176 14,954 14,999         122,595
Total Number of Unique Applications 13,961 13,636 13,951 11,450 10,235 11,561 12,197 12,411         99,402
Total Number of Eligible Applications 12,792 12,654 12,951 10,622 9,596 10,980 11,691 12,066         93,355

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) 2,618
No Signature 540
No UR Attached 1,303
Untimely 723
Other 863
Total 6,047

**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 (August 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 286 78% 22%
Evaluation & Management
118 78% 22%
Therapies
150 77% 23%
DIAGNOSTIC TESTING 3,483 88% 12%
EMG/NCV/NCS
351 88% 12%
Imaging, Radiology
1,330 88% 12%
Lab & Pathology
1,374 87% 13%
Other Diagnostic Tests
428 89% 11%
* DMEPOS 2,091 92% 8%
Durable Medical Equipment
961 94% 6%
Electrical Stimulation
392 92% 8%
Prosthetics / Orthotics
294 90% 10%
Supplies
444 90% 10%
EVALUATION & MANAGEMENT 771 85% 15%
Dental Services
42 83% 17%
Evaluation & Management
117 79% 21%
Medical Specialties
612 86% 14%
HOME HEALTH/TRANSPORTATION 131 89% 11%
Home Health
111 88% 12%
Transportation
20 90% 10%
INJECTIONS 1,632 93% 7%
Peripheral
635 91% 9%
Spine
845 94% 6%
Other Injection
152 94% 6%
PHARMACEUTICALS 6,944 92% 8%
Antidepressants
231 74% 26%
Anti-Epilepsy Drugs
640 89% 11%
Benzodiazepines
155 97% 3%
Muscle Relaxants
1,111 97% 3%
NSAIDs
551 84% 16%
Opioids
2,078 93% 7%
Proton Pump Inhibitors
210 88% 12%
Sedative/Hypnotics
375 95% 5%
Topical Analgesics
946 94% 6%
Other Pharmaceuticals
647 91% 9%
PROGRAMS 138 83% 17%
REHABILIATION 3,197 90% 10%
Acupuncture
545 86% 14%
Chiropractic
352 90% 10%
Physical Therapy / Occupational Therapy
1,840 90% 10%
Other Therapies
460 92% 8%
SURGERY 1,160 89% 11%
Adjunct Surgical Services
321 95% 5%
Arthroscopic Surgery
288 87% 13%
Non-arthroscopic Surgery
392 89% 11%
Surgical Consult
159 85% 15%

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

September 2020