The medical care delivery system in California workers’ compensation has becomevery challenging for the injured worker.  First, the worker has to pick a doctor from the insurance company Medical Provider Network [MPN]; after that, any treatment requested by that doctor is normally sent to Utilization Review [UR] which is another insurance doctor looking over the shoulder of the MPN doctor.  If UR denies the care, the worker must appeal to Independent Medical Review [IMR].  IMR presently has about a 90% denial rate for requested medical care.

Given the high denial rate for IMR, it is important for the practitioner to know when and how to appeal a bad IMR decision.  Labor Code Section 4610.6(h) authorizes the Appeals Board to review an IMR determination.  The IMR determination is presumed correct and can only be set aside by clear and convincing evidence of one of the following: (1) The Administrative Director [AD] acted in excess of his powers; (2) The IMR decision was procured by fraud; (3) The IMR doctor had a conflict of interest; (4) The IMR doctor was biased against the worker due to the workers’ race, age sex or religion etc; (5) The determination was the result of a plain factual mistake – not subject to expert review.

Since the worker does not know the identity of the IMR doctor, the only provable IMR offenses are (1) where the AD acts in excess of his powers and (5) where there is a clear factual error.

In Bowen v. County of San Bernardino [ADJ156419] the W.C.A.B. overturned an IMR denial of care saying that the IMR doctor had ignored the facts of the case.  The W,C,A,B, stated: “The IMR physician is obligated to look at all the submitted reports, and is obligated to consider the entire record.  The IMR reviewer may not pick and choose portions of the required accompanying documents.”  Specifically there was a prior IMR in the case which had authorized the use of NORCO noting functional improvement.  The primary treating physician [PTP] also noted evidence of functional improvement which the 2nd IMR doctor disregarded.

The moral of the story is that when we get an IMR decision which denies medical care, we must look to make sure it is based on the facts of the claim and not some made up fantasy the IMR doctor concocted to justify the denial.   If you have any questions about IMR feel free to call me at 619.338.90012 or e-mail at Jack@SDworkcompattorney.com.