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Calif. medical reviews volume hit all-time low in 2021

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medical reviews

The number of independent medical review decisions fell to an all-time low in 2021, largely due to a drop in pharmaceutical disputes after the state adopted a formulary and evidence-based standards for chronic pain, according to a California Workers’ Compensation Institute research update released Wednesday.

After peaking at 184,735 IMR determination letters in 2018, volume declined for three consecutive years, falling to 163,889 in 2019, 136,738 in 2020 and 133,494 in 2021.

The study found that much of the decline came after the Division of Workers’ Compensation incorporated chronic pain and opioid guidelines into the workers comp medical treatment schedule in late 2017 and implemented a prescription drug formulary in 2018, CWCI said in a statement.

The formulary identified drugs that were exempted from prospective utilization review when prescribed in accordance with the guidelines in the Medical Treatment Utilization Schedule. Drugs not labeled exempt, as well as those that are not listed in the formulary, continue to be subject to UR.

“In the wake of those changes, prescription drug disputes declined from 47.3% of all IMRs in 2017 to 34.9% of all IMRs in 2021, with much of that decline due to a reduction in opioid disputes, which fell from nearly a third of pharmaceutical IMRs in 2018 to just over a quarter of prescription drug IMRs last year,” CWCI said.

With pharmaceuticals accounting for a smaller share of IMR disputes, CWCI said the share of IMR decisions involving physical therapy, injections and durable medical equipment have all seen their share increase.

CWCI also reports an all-time high uphold rate in 2021, with 92% of IMR decisions affirming the utilization review determination that a requested treatment wasn’t medically necessary. CWCI noted that IMR decisions have consistently agreed with about nine in 10 UR decisions, with uphold rates between 2015 and 2020 ranging from 88.2% to 91.2%.

WorkCompCentral is a sister publication of Business Insurance. More stories here.

 

 

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