Pharmaceutical reviews accounted for more than a third of all of California’s independent medical review activity in 2019, according to a report released Friday by the California Department of Industrial Relations.

In 2012, Gov. Jerry Brown signed into law legislation creating an independent medical review program, which took effect Jan. 1, 2013.  The IMR program is available to all injured workers regardless of date of injury and is intended to expedite the resolution of disputes over workers compensation treatment. IMR reviewers follow guidance from the medical treatment utilization schedule and evidence-based medicine in their determinations, and employers bore the cost of the program.

According to data from the California DIR, the state processed more than 222,200 IMRs, a decrease of about 12% from 2018, and after excluding for duplications and ineligibility, the state issued nearly 164,000 final determination letters in an average of seven to eight days after receipt of all medical records for the review.

In 2019, more than 70% of IMR decisions were based on recommendations solely within medical treatment utilization schedule treatment guidelines, with just over a quarter based on recommendation outside of those guidelines.

About 10.4% of treatment request denials were overturned in the IMR program — with the reviewer finding that the treatment was medically necessary and appropriate — and specialist consultation, office visits and mental health services were among those issues most often overturned.

Requests with the fewest overturned utilization review denials included reviews of durable medical equipment, prosthetics, orthotics and supplies, and home health care and transportation.

Pharmaceutical requests accounted for about 36% of all IMR requests, down from 40% in recent years, with opioids involved in nearly a third of those pharmaceutical review cases. The DIR said the decrease may be attributed to the establishment of a drug formulary in 2018.