Independent Medical Review (IMR) Update 2022

Case Decisions

Month Total Issued Average Age from
Assigned Date
(in days)
Average Age from
Complete Medical
Records (in days)
January 11,009 31 12
February 9,555 27 11
March 10,259 26 10
April 10,655 27 10
May 11,119 27 10
June 10,254 28 11
July 9,653 30 10
August 11,640 29 10
September 10,372 30 11
October 10,839 30 12
November 10,873 30 11
December 10,883 29 11
Total 127,111 - -

"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 Applications

Jan Feb Mar
Apr May Jun Jul 
Aug Sep Oct Nov Dec Total
Total Number of IMR Applications Received 12,641 13,005 15,674 14,887 14,422 14,695 14,159 15,689 13,936 14,364 13,882 13,496 170,850
Total Number of Unique Applications 10,388 10,641 12,899 12,163 11,770 12,040 11,463 12,777

11,625

11,890 11,533 11,235 140,397
Total Number of Eligible Applications 9,498 9,779 11,933 11,132 10,880 11,095 10,562 11,768 10,734 10,974 10,616 10,528 129,499

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 Total Count
Conditionally Non-Certified (CNC) 4,262
No Signature 1,074
No UR Attached 2,347
Untimely 2,114
Other 1,101
Total 10,898

**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
ACCOMMODATION 317 89%% 11%
BEHAVIORAL AND MENTAL HEALTH SERVICES 3,992 83% 17%
Evaluation & Management
1,165 85% 15%
Therapies
2,827 81% 19%
DIAGNOSTIC TESTING 43,181 91% 9%
EMG/NCV/NCS
3,798 93% 7%
Imaging, Radiology
18,102 92% 8%
Lab & Pathology
17,538 91% 9%
Other Diagnostic Tests
3,743 88% 12%
* DMEPOS 22,727 92% 8%
Durable Medical Equipment
7,338 95% 5%
Electrical Stimulation
4,336 93% 7%
Prosthetics / Orthotics
4,199 90% 10%
Supplies
6,854 90% 10%
EVALUATION & MANAGEMENT 10,383 86% 14%
Dental Services
491 80% 20%
Evaluation & Management
1,389 82% 18%
Medical Specialties
8,503 87% 13%
HOME HEALTH 1,383 93% 7%
INJECTIONS 20,631 96% 4%
Peripheral
9,006 93% 7%
Spine
11,590 98% 2%
Other Injection
35 89% 11%
PHARMACEUTICALS 71,512 92% 8%
Antidepressants 1,830 71% 29%
Anti-Epilepsy Drugs 6,519 92% 8%
Anti-Infectives 1,264 96% 4%
Benzodiazepines 1,096 97% 3%
Laxative 1,054 86% 14%
Muscle Relaxants 11,703 98% 2%
NSAIDs 7,240 83% 17%
Opioids 19,184 92% 8%
Proton Pump Inhibitors 2,175 84% 16%
Sedative / Hypnotics 2,003 93% 7%
Topical Analgesics 9,213 96% 4%
Other Pharmaceuticals 8,231 90% 10%
PROGRAMS 2,770 86% 14%
REHABILIATION 46,982 93% 7%
Acupuncture
8,773 94% 6%
Chiropractic
5,562 87% 13%
Physical Therapy / Occupational Therapy
26,318 93% 7%
Other Therapies
6,329 94% 6%
SURGERY 16,632 91% 9%
Adjunct Surgical Services
6,341 95% 5%
Arthroscopic Surgery
3,312 87% 13%
Non-arthroscopic Surgery
5,300 89% 11%
Surgical Consult
1,679 92% 8%
TRANSPORTATION 470 96% 4%

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

January 2023