If you sustain an injury at work in California, getting medical treatment approved is not always easy. The insurance company may review your doctor’s recommendation and sometimes deny the request through a process called Utilization Review (UR). Understanding how this system works and what your next steps are can make all the difference in getting the care you need.
How the UR works
This is the process where an insurance company reviews a doctor’s treatment recommendation to see if it is medically necessary. In theory, the UR is supposed to help ensure that you receive appropriate care.
However, the reality is that the reviewing physician often never examines you directly and does not personally assess your condition. Instead, they make their decision by reviewing your medical records and comparing the requested treatment to California’s Medical Treatment Utilization Schedule (MTUS) guidelines.
Common reasons for denials
Your employer’s insurer usually denies your treatment request under the following circumstances:
- Case fails to meet the MTUS guidelines for being medically necessary
- Medical records do not clearly explain why the treatment is needed
- Treatment is considered experimental or not usual for the injury
While these may explain why your treatment request ended in denial during the UR, it is not always final. You can opt for an external state appeal to change that initial decision.
The independent medical review (IMR)
If the UR denies or changes your treatment, you have the right to request an IMR where the state chooses a neutral third-party organization to review your case. It is crucial to understand that the IMR is usually a paper-only just like the UR. The decision is based entirely on the documents you submitted, including:
- Medical records
- Physician notes
- Test results
- Explanation for treatment’s medical necessity
You also typically only have 30 days from the date of the UR denial to file for an IMR. Missing this deadline can mean you may need to wait a full year to request the same treatment again.
When taking action matters
A UR denial should not derail your recovery. Filing an IMR can be your chance to challenge that decision through a neutral, state-selected reviewer. A lawyer can ensure your medical evidence is strong while helping you file your appeal on time.