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Vast majority of comp treatment denials upheld on review

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Nearly 90% of independent medical reviews for California workers compensation claims uphold utilization review medical decisions that deem a service for an injured worker as medically unnecessary, according to a study from the California Workers' Compensation Institute.

Out of 40,742 independent medical review decision letters issued in the first quarter of this year, 88.8% upheld treatment modifications or denials made by doctors under workers comp utilization reviews, the Oakland, California-based institute said in a report released Thursday.

The recent study tracks with previous findings from CWCI. In a report last year, the institute found that 88.6% of independent medical reviews upheld utilization review decisions. The uphold rate for 2014 was 91%, the report said.

“This consistently high uphold rate shows that the vast majority of the disputed modifications and denials made by utilization review physicians continue to be found to be in line with the evidence-based medicine guidelines,” the CWCI report said.

In the first quarter of 2016, almost half of the independent medical review decisions were for prescription drugs, CWCI said. Surgery accounted for less than 5% of the disputed service requests that went under review, the report said.

In nearly nine out of 10 of the cases involving opioids — 29% of all pharmaceutical requests — the independent medical review agreed with the utilization review doctor's determination that the “use, strength, quantity and durations of the opioid prescription was not medically necessary,” the report said.

Requests for physical therapy, durable medical equipment and injections remained near the top of the list of disputed medical services that undergo independent medical review, CWCI said. Independent medical review physicians found the services were not medically necessary about 90% of the time, according to the report.