IMR update 2017

Case Decisions Issued

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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.

IMR Application Filings  2017

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 2017

**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

  • 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 Overtuned
Diagnostic Testing 25,307 91% 9%
DMEPOS 13,733 93% 7%
Evaluation and Management 3,291 83% 17%
Home Health & Transportation 832 93% 7%
Injection 11,649 89% 11%
Pharmaceuticals 73,887 82% 8%
Programs 1,626 89% 11%
Psych Services 2,437 82% 18%
Rehabilitation 24,592 94% 6%
Surgery 12,894 92% 8%

 

Pharmaceutical Subcategories
(Most Requested Medications)
Requests Upheld Overtuned
Opioids 22,064 90% 10%
NSAIDs 11,432 91% 9%
Muscle Relaxants 10,122 98% 2%
Topical Analgesics 5,656 98% 2%
Anti-Epilepsy Drugs 4,236 87% 13%
Proton Pump Inhibitors 3,996 93% 7%
Antidepressants 2,949 82% 18%

Decisions Issued Jan-Jun 2017

 

October 2017