CMS, Independent Medical Review, Medicare Set-Aside Blog, Medicare Set-Asides, MSP News, Work Comp on June 21, 2017
Posted by Jean S. Goldstein, JD, CMSP

The California Supreme Court has determined that it will not review a case involving an injured worker who asserted that the Independent Medical Review (IMR) process was unconstitutional.  This is good news for California payers, furthering the defensive position that payers can continue to rely on both the Utilization Review (UR) and Independent Medical Review processes to resolve claims.

What is the UR/IMR Process?

In most cases, UR can be a helpful measure allowing for review and validation of medical treatment, as recommended by a physician.  Utilization review allows a payer to confirm the medical necessity of treatment utilizing mandated guidelines promulgated under the Medical Treatment Utilization Schedule (MTUS);  MTUS further provides an analytical framework for the evaluation and treatment of injured workers, and helps medical providers understand which evidenced-based treatments have been effective in providing improved medical outcomes to those workers. In some cases, based on the MTUS guidelines, the UR provides a payer with the ability to override recommended treatment.  An IMR takes the UR process one step further, allowing an injured worker to seek review of the UR determination in the form of an objective second opinion based upon the documentation supporting the requested treatment.  An IMR determination, pursuant to California Labor Code is binding, and in no event, may a determination contrary to an IMR be made; although certain grounds for appeal of a determination, such as bias of the reviewer exist. (See California Labor Code, 4610.6 (i)).  Both UR and IMR determinations are made by independent medical professionals.  These processes were instituted as such to transition decision-making regarding medical necessity of treatment out of the Workers’ Compensation Boards and placing such decisions in the hands of those well versed to make such medical determinations [1].  

The UR/IMR Process is Constitutional.

An injured worker, Daniel Ramirez, was involved in a workers’ compensation claim.  The matter settled, but additional treatment was requested by Mr. Ramirez’s physician.  Within the authorization request, the physician noted that Mr. Ramirez had missed work and that recommended treatment had previously helped in decreasing his pain, allowing him to be more functional.[2] Through the UR process, the treatment request was evaluated, and denied.  Ramirez subsequently sought review through the IMR process, which also yielded the conclusion that the treatment was not medically necessary.  Ramirez requested a hearing asserting that the UR decision was procedurally defective, requested disclosure of the IMR reviewer so that he could discover any potential bias, and further requested a hearing to determine the constitutionality of the IMR process.  Ramirez’s case was ultimately heard before the Court of Appeals, which concluded that the IMR process is constitutional, and that the appropriate means to challenge the validity of a UR decision is through the IMR process, such as the course stayed in Mr. Ramirez’s case.  Mr. Ramirez requested reconsideration of the Court of Appeals’ determination before the California Supreme Court, which was denied on June 14.

Why is the Recent California Supreme Court Decision Important to California Payers?

The UR and IMR processes provide the means for an objective review of an injured workers’ need for treatment in a non-judicial and efficient manner.  In Mr. Ramirez’s case, he followed both the UR and IMR processes which objectively reviewed and found the treatment to be medically unnecessary.  This means the primary payer in Mr. Ramirez’ case would not be required to pay for the treatment requested by the physician denied under the UR process.  However, when considering the effect of a UR/IMR on future medical treatment needs, there is one an additional aspect to consider.  Medicare must be the secondary payer when a primary payer, such as a carrier, has assumed liability for a claim.  With respect to considering future treatment denied via a UR determination, the treatment can be excluded from a Medicare Set-Aside based solely upon the UR denial.  However, if submitting a case to CMS, CMS does not generally provide significant weight to a UR.  In fact, CMS may defer to a treating provider’s recommendation for treatment, even if there exists a UR denial for the same.  Conversely, CMS views IMRs quite differently and usually applies the results of an IMR determination.

The California Supreme Court’s determination in refusing to review the Ramirez case is additional support that the UR/IMR process continues to be the most effective manner by which to address a dispute in treatment recommendations.  On its face, this may just appear to be yet another case addressing a dispute in treatment, but to the contrary- this is another example of the solvency of the UR/IMR process in California.  What was once designed to make the California Workers’ Compensation system more efficient, continues to be viewed as a constitutional and just process.

[1] See Opinion, Ramirez v. The Workers’ Compensation Appeals Board et. al (2017) Retrieved at:

[2] Id.