Report Shows California Workers’ Comp Medical Review Denials Still Rarely Overturned

The rate of California workers’ compensation medical treatment request denials being overturned was up slightly last year, but they are still a relatively rare occurrence, a new report shows.

Denials were overturned at a rate of 12.7%, an increase from the previous year’s 10.2% rate, according to a report from the California Department of Industrial Relations and its Division of Workers’ Compensation.

The annual report on the Department’s Independent Medical Review program, the medical dispute resolution process for the state’s workers’ comp system, describes IMR program activity in 2024, the twelfth year since the program was implemented.

The organization administering the program, Maximus Federal Services Inc., reported receiving 199,651 IMR applications and issuing141,621 Final Determination Letters addressing one or more medical necessity disputes. Throughout the year, the Maximus issued decisions on average six to seven days after receipt of all medical records.

Some highlights from the report include:

• Nearly 90% of all unique IMR filings were deemed eligible for review, slightly less than the annual percentage for those filed in 2023.
• Pharmaceutical requests accounted for 33% of all treatment requests sent for IMR, a slightly higher proportion of total service requests than in previous years.
• Opioids comprised 24% of all pharmaceutical requests.

Treatment request denials were overturned at an overall rate of 12.7% last year. The denials that were overturned most often were for evaluation and management services, followed by other programs such as Functional Restoration program, Brain Injury program, Weight loss program and behavioral and mental health service, the report shows.

Topics California Workers' Compensation