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/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 (January 2019)

  • 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 11,619 90% 10%
Diagnostic Testing 4,800 89% 11%
Rehabilitation 4,949 91% 9%
DMEPOS 2,775 89% 11%
Injection 2,181 90% 10%
Surgery 1,557 88% 12%
Evaluation and Management 1,210 81% 19%
Psych Services 335 78% 22%
Programs 279 85% 15%
Home Health & Transportation 185 90% 10%

 

Pharmaceutical Subcategories
(Most Requested Medications)
Requests Upheld Overturned
Opioids 3,726 74% 26%
Muscle Relaxants 1,575 95% 5%
Topical Analgesics 1,518 94% 6%
Anti-Epilepsy Drugs 968 84% 16%
NSAIDs 850 80% 20%
Sedative-hypnotics 592 93% 7%
Antidepressants 473 74% 26%
Proton Pump Inhibitors 341 90% 10%
Benzodiazepines 291 97% 4%
Laxative 170 83% 17%

February 2019