Few California Workers’ Comp Treatment Request Denials Overturned

Few medical treatment denials in California workers’ compensation were overturned last year, a review released on Wednesday shows.

The California Division of Workers’ Compensation posted an annual report on the department’s Independent Medical Review program, which describes IMR program activity in 2021, the eighth year since the program was implemented.

The IMR program, the medical dispute resolution process for the state’s workers’ comp system that resolves disputes about the medical treatment of injured workers, received 178,927 IMR applications and issued 133,400 final determination letters addressing one or more medical necessity disputes.

Some highlights of the report include:

• Nearly 94% of all unique IMR filings were deemed eligible for review, the same annual percentage as for those filed in 2020.
• Pharmaceutical requests accounted for 31% of all treatment requests sent for IMR, a smaller proportion of total service requests than in previous years.
• Opioids comprised 27% of all pharmaceutical requests.
• Treatment request denials were overturned at a rate of 7.2%. Specialist consultants, office visits and mental health services were overturned most often.
• Guidelines contained in the Medical Treatment Utilization Schedule continue to serve as the primary resource for the determination of medical necessity.

The Division of Workers’ Compensation is part of the state’s Department of Industrial Relations. The report is posted on the DIR website.

Related:

• California Workers’ Comp Department’s Medical-Legal Evaluation Regulations OK’d
• California Workers’ Comp Benefits to Increase in 2023
• 178 Medical Providers Suspended from California’s Workers’ Comp System

Topics California Workers' Compensation