California’s Department of Industrial Relations and Division of Workers’ Compensation released a report this week on the progress of their Independent Medical Review program. The report says treatment request denials for 2018 in the state’s comp system were overturned about 10.3 percent of the time. That means that almost 90 percent of medical review decisions were upheld. Specialist consultations, office visits and mental health services were the things more frequently overturned.

https://www.dir.ca.gov/dwc/imr/reports/2019_IMR_Annual_Report.pdf

In 2018 the department got 252,565 applications in their medical dispute resolution process, put in place with state reforms in 2013. The process was put in place to give comp stakeholders and injured workers a way to use medical expertise to obtain consistent, evidence-based decisions to determine whether treatment is medically necessary. Of the applications processed 185,783 (74 percent) were determined to be eligible for review.

Case decisions stayed similar when comparing different demographic categories, with average of 15,400 IMR decisions issued every month. The monthly average length of time to issue a decision after receiving all the medical records decreased to nine days by the end of 2018.

More than 40 percent of treatment requests sent for IMR were for pharmaceuticals, opioids comprised nearly one of every three pharmaceutical requests. Diagnostic tests (16 percent) and rehabilitation (15 percent) services comprised the second and third highest number of requests. Treatment denials overturned most often were for behavioral and mental health services (22 percent). Guidelines in the Medical Treatment Utilization Schedule remained the primary resource for determining medical necessity.

Read the full report here and the press release from the DIR here.