The volume of medical reviews in California will reach an all-time low in 2021.

By Our Staff Reporter

According to a California Workers’ Compensation Institute research update released Wednesday, the number of independent medical review decisions will reach an all-time low in 2021, owing largely to a drop in pharmaceutical disputes following the state’s adoption of a formulary and evidence-based standards for chronic pain.

Following a high of 184,735 IMR determination letters in 2018, volume fell for three years in a row, falling to 163,889 in 2019, 136,738 in 2020, and 133,494 in 2021.

According to the study, much of the decline occurred after the Division of Workers’ Compensation incorporated chronic pain and opioid guidelines into the workers’ compensation medical treatment schedule in late 2017 and implemented a prescription drug formulary in 2018, as stated by CWCI in a statement.

The formulary listed drugs that were exempt from prospective approval.

When prescribed in accordance with the guidelines in the Medical Treatment Utilization Schedule, utilization review is performed. Drugs that are not labeled exempt, as well as those that are not on the formulary, are still subject to UR.

“As a result of those changes, prescription drug disputes fell from 47.3 percent of all IMRs in 2017 to 34.9 percent 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,” according to CWCI.

Despite the fact that pharmaceuticals account for a smaller proportion of IMR disputes, CWCI claims that the proportion of IMR decisions involving physical therapy, injections, and durable medical equipment has increased.

increase in market share

In addition, in 2021, CWCI reports an all-time high uphold rate, with 92 percent of IMR decisions affirming the utilization review determination that a requested treatment was not medically necessary. According to CWCI, IMR decisions have consistently agreed with roughly nine out of ten UR decisions, with uphold rates ranging from 88.2 percent to 91.2 percent between 2015 and 2020.