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One of the major reforms in Senate Bill 863 was the creation of an Independent Medical Review (IMR) process in which medical doctors, relying on evidence-based treatment guidelines replaced judges as the final arbiters in resolving disputes over the necessity of recommended medical services. IMR has recently completed its second full year of operation.The CWCI compiled data from a study sample that encompassed IMR decisions in regard to 260,889 medical services requested for 76,718 injured workers.

A treatment request becomes eligible for independent medical review if it is denied or modified by a utilization review physician. With an estimated 75 percent of requests authorized after initial review, and 76.6 percent of the requests approved by the UR physician after elevated review, the overall approval rate for workers’ compensation medical service requests following the first two stages of UR is 94.1 percent, while only 5.9 percent — 1 out of 17 — requested medical services are modified or denied during UR. Thus, the vast majority of treatment requests are approved by UR, leaving only a small percentage in which the injured worker may choose to dispute the UR physician’s decision by applying for independent medical review.

Data on the IMR outcomes show that 91 percent of all IMR decisions upheld or agreed with the physician-level utilization review opinion, while conversely, 9 percent of medical service requests submitted for IMR after being modified or denied by a UR physician were approved by the independent medical reviewer. Requests for pharmaceuticals topped the list of services submitted for independent medical review, representing nearly 45 percent of the total. The uphold rates for the pharmaceutical IMRs varied based on the drug group and route of administration. Compound drugs accounted for 12 percent of all pharmaceutical requests submitted for IMR, and the independent medical reviewer upheld the UR physician’s denial or modification of those requests 98 percent of the time. No major differences in uphold rates were found based on year of injury. The authors also found that information made available after the UR decision can influence the IMR, and that while reviewers overwhelmingly rely on the Medical Treatment Utilization Guidelines (MTUS) for their decision-making, they frequently draw from additional sources to reach their final determination, though the frequency with which they do so depends on the service in question.

Although the volume of requests for IMR has far exceeded original projections, the study reveals that a relatively small number of physicians are responsible for the vast majority of requested medical services that result in IMR disputes, with the top 10 percent of all physicians named in the IMR decision letters (1,332 individual physicians out of approximately 13,000) accounting for 83 percent of all disputed treatment requests, while the top 10 individual physicians alone accounted for 15 percent of the disputed services submitted for independent medical review.

Along with pharmaceuticals, requests for durable medical equipment (DME); physical therapy; injections (primarily epidural injections), and diagnostic tests and measurements (including sleep studies and nerve conduction studies) rounded out the top 5 IMR service categories, each accounting for about 5 to 10 percent of the IMR cases. Together these five categories represented nearly three quarters of California workers’ compensation independent medical reviews conducted in 2014.

Approximately 12 percent of the pharmaceutical requests that were sent through IMR in 2014 were identified as compound drugs. After reviewing the injured workers’ medical records and the clinical evidence and recommendations in the treatment guidelines, the IMR physicians upheld the modification or denial of these requests 98 percent of the time.

After a medical service request is modified or denied by a UR physician, an IMR application may be submitted by the injured worker or their representative – usually the worker’s attorney or the physician who requested the service. The WCIRB estimated that 25.4 percent were filed by the employee, 5.2 percent by a provider and 69.9 percent filed by an attorney. Overall the percentage of treatment requests upheld following IMR was not materially different for applications submitted by injured workers, physicians and attorneys. The vast majority of 2014 IMR decisions addressed to someone other than the employee were addressed to only a small number of representatives, with the top 1 percent of representatives named on 18 percent of the decision letters last year, and the top 10 percent of representatives named on 65 percent of the letters.

Just as a small number of representatives were named in nearly two-thirds of the IMR requests, only a small number of medical providers were responsible for most of the requested medical services that resulted in IMR disputes. The top 1 percent of medical providers named in the 2014 IMR decision letters were linked to 44 percent of the letters responding to disputed medical service requests, while the top 10 percent were named in 83 percent of the IMR determination letters.