After suffering an injury on the job, the last thing you want to worry about is whether approval of your medical treatment is possible. In California, employers or claims administrators employ a Utilization Review (UR) to determine the necessity of the medical care your doctor recommends. They might approve some treatments, but they may deny yours. If this happens, you have the right to appeal.
Request for an IMR assessment
Independent Medical Review (IMR) aims to resolve disputes about your health care following a work injury. If a claim administrator disputes the necessity of a treatment recommended by your doctor, you can file for an IMR. In this process, another doctor reviews the need for the treatment you’re seeking.
When you should start the process
Doctors resolve disagreements over medical treatment decisions for work-related injuries through IMR. If the UR denies or modifies your treatment as not medically necessary, you can initiate an IMR. Upon receiving the decision, find the IMR form and a pre-addressed envelope included with it. To appeal, sign the form and mail it back within 30 days of receiving the UR decision. This swift action is crucial for securing an independent medical review.
The process requires multiple considerations
Challenging a UR decision involves more than just completing a form. The Administrative Director (AD) evaluates several factors to determine your case’s eligibility for IMR, such as the timeliness and completeness of your submitted form, including your signature and a copy of the UR decision. They also consider whether there’s been a previous IMR request for the same treatment. Furthermore, if they require additional information to assess if your treatment request qualifies for IMR, you have 15 days to provide it upon request. Given these complexities, it’s crucial to approach the appeal process with care. So, you should consider consulting with a workers’ compensation attorney to improve your chances of a favorable outcome.