Independent Medical Review (IMR) Update 2021

Case Decisions

Month Total Issued Average Age from
Assigned Date
(in days)
Average Age from
Complete Medical
Records (in days)
January 2021 10,790 28 10
February 10,031 26 10
March 12,218 25 9
April 12,186 26 9
May 11,451 26 9
June 11,363 26 10
July 11,381 27 10
August 11,729 26 10
September 11,640 26 10
October      
November      
December      
Total 102,787 - -

"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

Jan Feb Mar Apr May Jun Jul Aug Sept
Oct Nov Dec Total
Total Number of IMR Applications Received 13,763 14,542 17,102 16,228 14,178 14,419 14,721 15,540 14,721       136,217
Total Number of Unique Applications 11,232 11,569 13,775 13,114 11,450 11,815 12,256 12,731 12,214       110,799
Total Number of Eligible Applications 10,579 10,856 12,917 12,365 10,745 11,167 11,144 12,083 11,854       104,670

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) 2,714
No Signature 663
No UR Attached 1,756
Untimely 11
Other 985
Total 6,129

**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 2,700 85% 15%
Evaluation & Management
1,027 85% 15%
Therapies
1,673 83% 17%
DIAGNOSTIC TESTING 37,615 93% 7%
EMG/NCV/NCS
3,205 92% 9%
Imaging, Radiology
14,177 92% 9%
Lab & Pathology
16,040 93% 7%
Other Diagnostic Tests
4,193 93% 7%
* DMEPOS 21,545 94% 6%
Durable Medical Equipment
9,118 95% 5%
Electrical Stimulation
3,787 93% 7%
Prosthetics / Orthotics
2,824 91% 9%
Supplies
5,816 92% 6%
EVALUATION & MANAGEMENT 8,725 88% 12%
Dental Services
569 85% 15%
Evaluation & Management
1,270 84% 16%
Medical Specialties
6,886 89% 11%
HOME HEALTH/TRANSPORTATION 1,317 93% 7%
Home Health
1,026 94% 6%
Transportation
291 93% 7%
INJECTIONS 16,656 95% 5%
Peripheral
6,470 93% 7%
Spine
8,962 96% 4%
Other Injection
1,224 92% 8%
PHARMACEUTICALS 61,727 93% 7%
Antidepressants 1,493 80% 20%
Anti-Epilepsy Drugs 5,577 91% 9%
Anti-Infectives 995 94% 6%
Benzodiazepines 1,065 97% 3%
Laxative 862 88% 12%
Muscle Relaxants 9,921 99% 1%
NSAIDs 5,804 87% 13%
Opioids 16,865 94% 6%
Proton Pump Inhibitors 2,088 90% 10%
Sedative / Hypnotics 3,382 95% 4%
Topical Analgesics 9,041 94% 6%
Other Pharmaceuticals 4,634 91% 9%
PROGRAMS 1,818 87% 13%
REHABILIATION 37,942 92% 8%
Acupuncture
6,712 90% 10%
Chiropractic
4,257 90% 10%
Physical Therapy / Occupational Therapy
21,259 93 7%
Other Therapies
5,714 92% 8%
SURGERY 11,894 92% 8%
Adjunct Surgical Services
3,515 94% 6%
Arthroscopic Surgery
2,825 88% 12%
Non-arthroscopic Surgery
3,997 91% 9%
Surgical Consult
1,557 95% 5%

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

October 2021