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.

**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
Pharmaceuticals 110,896 92% 8%
Diagnostic Testing 37,891 91% 9%
Rehabilitation 36,819 94% 6%
DMEPOS 20,582 93% 7%
Surgery 18,866 92% 8%
Injection 17,513 90% 10%
Evaluation and Management 4,829 83% 17%
Psych Services 3,636 81% 19%
Programs 2,392 90% 10%
Home Health & Transportation 1,302 93% 7%

 

Pharmaceutical Subcategories
(Most Requested Medications)
Requests Upheld Overtuned
Opioids 33,197 91% 9%
NSAIDs 17,053 91% 9%
Muscle Relaxants 14,882 97% 3%
Topical Analgesics 8,717 97% 3%
Anti-Epilepsy Drugs 6,429 87% 13%
Proton Pump Inhibitors 6,024 92% 8%
Antidepressants 4,397 82% 18%
Benzodiazepines 3,740 97% 3%
Sedative-hypnotics 3,624 97% 3%

November 2017