IMR update 2018
Case Decisions Issued
"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.
**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.
*DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Treatment Request Outcomes (July 2018)
- 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 | 13,517 | 89% | 11% |
| Diagnostic Testing | 5,431 | 89% | 11% |
| Rehabilitation | 4,661 | 92% | 8% |
| DMEPOS | 2,804 | 91% | 9% |
| Injection | 2,225 | 88% | 12% |
| Surgery | 1,798 | 90% | 10% |
| Evaluation and Management | 1,273 | 82% | 18% |
| Psych Services | 360 | 76% | 24% |
| Programs | 311 | 81% | 19% |
| Home Health & Transportation | 206 | 92% | 8% |
| Pharmaceutical Subcategories
(Most Requested Medications) |
Requests | Upheld | Overturned |
|---|---|---|---|
| Opioids | 4,578 | 90% | 10% |
| Muscle Relaxants | 1,878 | 96% | 4% |
| Topical Analgesics | 1,665 | 95% | 5% |
| NSAIDs | 1,078 | 83% | 17% |
| Anti-Epilepsy Drugs | 990 | 77% | 23% |
| Sedative-hypnotics | 666 | 93% | 7% |
| Proton Pump Inhibitors | 549 | 72% | 28% |
| Antidepressants | 440 | 87% | 13% |
| Benzodiazepines | 364 | 96% | 4% |
August 2018