 One of the most frustrating aspects of California workers’ compensation is the Utilization Review process for medical treatment. That frustration is understandable: your treating physician believes you need care, so why won’t the insurance company authorize it? In short, under current law and regulations, your physician only recommends treatment for the insurance company to provide you. The insurance company then decides if they are going to authorize the recommended care or not. The process used to evaluate those recommendations is called Utilization Review (UR). When treatment is not approved through UR, the appeal process for that decision is called Independent Medical Review (IMR). Together, these systems frequently delay or deny medical care for injured workers.
What Are Utilization Review and Independent Medical Review? Utilization Review is the backbone of medical workers’ compensation medical treatment. In this system, treatment prescribed by your physician is only a recommendation rather than an order for insurance. The insurance company can dispute whether the recommended treatment is appropriate by challenging its medically necessary through UR. Labor Code § 4610(a). While most injured workers reasonably assume that treatment recommended by their doctor would clearly qualify as medically necessary, the phrase “medically necessary to cure or relieve the effects of the injury” is actually a legal term of art. Treatment must meet specific criteria before it is “medically necessary” will be authorized. Those criteria are set out in the Medical Treatment Utilization Schedule (MTUS). Labor Code § 4600(b)). The MTUS consists of treatment guidelines that outline when particular medical services are considered medically necessary for specific injuries. For example, the MTUS recommends cryotherapy for shoulder disorders when it is effective for temporary relief of acute, subacute, chronic, or peri‑operative shoulder pain. In plain terms, the MTUS finds an ice pack medically necessary for shoulder pain if it is helpful to you and used to treat short-term, long‑-term‑, or surgically related pain. The MTUS has guidelines for nearly every modern medical treatment from common pain medications like Advil to complex procedures such as spinal fusion surgery. Who Decides Whether Treatment Is Authorized? Whether a recommended treatment meets the MTUS guidelines is ultimately determined by the insurance company and a Utilization Review medical reviewer (UR Reviewer). The insurance company is not required to send any treatment recommendations to UR. Nothing prevents an adjuster from approving recommended treatment. However, if the adjuster disputes the recommendation, the decision to deny, modify (and approve) the recommendation, or seek additional information to determine necessity must be made by a UR Reviewer. (8 CCR § 9792.9.7(e)(1)). A UR Reviewer is a licensed medical professional, such as a surgeon, psychologist, optometrist, dentist, etc., who is competent to evaluate the dispute within their scope of practice. (8 CCR § 9792.6.1(v)). If the reviewer agrees with your physician that the treatment is medically necessary under the MTUS, the treatment will be approved and provided by the insurance company. If the reviewer agrees with the insurance, the recommendation will be denied or modified. A denial through Utilization Review has serious consequences. Once UR denies treatment, your physician generally cannot make the same recommendation again for 12 months, unless there is a material change in your condition. Labor Code § 4610(k). Appealing a UR Decision: Independent Medical Review If a Utilization Review denies or modifies your physician’s recommendation, that decision may be appealed through Independent Medical Review. IMR is the exclusive method for disputing UR determinations. (Labor Code § 4610.5(d)). IMR functions as a second UR review, conducted by a different medical reviewer (IMR Reviewer), to again determine whether the treatment meets medical necessity requirements under the MTUS. Labor Code § 4610.5(c). Importantly, a Workers’ Compensation Appeals Board judge generally cannot overturn a UR decision and order treatment for injured workers. Labor Code § 4610.5(e). The IMR Reviewer will either overturn the UR decision or uphold the UR decision. Overturning UR resulting in authorization of the recommended treatment. Uphold UR leaves the denial or modification in place, including the 12month bar on re‑-requesting‑ the recommended treatment. An IMR decision is final and binding as to medical necessity; there is not another level of appeal. Labor Code § 4610.6(g). If treatment is denied after an IMR appeal, an injured worker can self-procure the treatment. This means paying out of pocket, without the possibility of reimbursement, for the recommended treatment. Unfortunately the costs of treatment, often coupled with financial hardship of being out of work because of the injury, mean injured workers cannot afford to self-procure treatment. How Long Does the UR/IMR Process Take? Delays of approved treatment are another major source of frustration for injured workers. The UR/IMR process can take days, weeks, or even months to approve and provide injured workers recommended treatment. The process begins when your treating physician submits a Request for Authorization (RFA) with their treatment recommendations to the insurance company. From that point, the following timelines generally apply:
However, UR and IMR are either handled on a faster basis or retroactively if the medical condition poses an imminent serious risk to an injured workers’ health or is severe enough to warrant emergency treatment. How Often Are Treatment Requests Approved? UR and IMR are effective at limiting medical treatment. In 2024, daisyBill (a software system that handles RFAs and billing for workers compensation physicians) analyzed its RFA and UR data and found that 71% of treatment requests were approved and 22% were denied. However, denial rates varied widely by insurance companies, ranging from 8% to 34% for companies that had over 1,000 RFAs in daisyBill’s system. This shows that the insurance company and adjuster play a significant role in authorization outcomes. IMR rarely overturns UR denials. A 2025 state review found that only 12.7% of UR decisions were overturned. Certain treatments were more likely to be approved on IMR appeal, including psychological evaluations (30%), X-‑rays (29%), and crutches (22%). These statistics can be misleading. Denials occur less frequently than approvals, but their impact is far greater. A single denial comes up once and bars treatment for 12 months, while routinely approved treatments, such as medications, may be requested and approved multiple times each year. Conclusion Utilization Review is a process that is frequently harsh on injured workers. It makes physician prescriptions into recommendations that can be disputed and delayed for weeks or months at a time. If a treatment is denied, then it is effectively permanently denied because of the general 12-month bar on requesting the treatment again. A workers’ compensation attorney can help navigate UR and IMR. Just as an insurance adjuster influences approval decisions, your physician’s documentation plays a critical role. An attorney can help you find a knowledgeable physician who can improve the likelihood of approved recommendations by thoroughly documenting symptoms, precisely explaining medical necessity, and responding promptly to UR requests for information. An attorney can also dispute UR denials of treatment and file IMR appeals on your behalf. If you have trouble with workers’ compensation medical care, or a workers’ compensation case, please reach out to us. Comments are closed.
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