Appealing a Denied Treatment Through IMR

When your treating physician requests medical treatment for a work injury, California law requires that request to pass through a utilization review (UR) process before it is approved or denied. A UR reviewer, who is usually a physician hired by the insurance carrier, evaluates whether the requested treatment meets established medical necessity standards. When UR denies or modifies your doctor's request, that decision is not necessarily final. An Independent Medical Review (IMR) gives you the right to have the denial examined by an independent physician unconnected to the insurance company. But the window to request one is short, and missing it can leave the denial in place permanently.

The 30-Day Filing Window

Under California Labor Code Section 4610.5, you have 30 days from receiving the written UR determination to file an IMR application. The claims administrator is required to send you that written determination, and the DWC Form IMR application is typically included with it. If you do not receive the form or misplace it, contact your claims administrator for another copy or download it from dir.ca.gov/dwc. Missing the 30-day deadline generally forfeits your right to IMR for that denial, leaving the treatment unauthorized with limited recourse.

How to File the IMR Application

The process is straightforward but requires care to complete correctly:

1. Complete and sign DWC Form IMR — Fill in your name, claim information, date of injury, and details about the disputed treatment.
2. Attach a copy of the written UR determination — The denial or modification letter from the claims administrator must accompany the application.
3. Submit to MAXIMUS Federal Services — The state-contracted organization that conducts IMR reviews; mail or fax your completed application to DWC-IMR c/o Maximus Federal Services, Inc., P.O. Box 138009, Sacramento, CA 95813-8009. [Mailing address may be subject to change.]
4. Send a copy to your claims administrator concurrently — You are not required to include the UR determination with this copy, only with the MAXIMUS submission.
5. Submit any additional supporting documentation — You and your treating physician have the right to submit additional information supporting the treatment request, such as a letter from your doctor explaining why the treatment is medically necessary.

Expedited IMR for Urgent Medical Situations

If a delay in treatment poses an imminent and serious threat to your health, you may request an expedited IMR rather than the standard review. To qualify, your treating physician must submit a statement supported by medical records confirming the urgency of the situation. An expedited IMR is completed within three business days.

What the IMR Reviewer Evaluates

The independent reviewer evaluates the denied treatment against California's Medical Treatment Utilization Schedule (MTUS) and broader evidence-based medical treatment guidelines. The reviewer does not conduct a new physical examination and only reviews the documentation that has already been submitted. It is worth knowing that IMR uphold rates in California are notoriously high, meaning the reviewer sides with the UR denial in a majority of cases. This is not a reason to skip the IMR, though; it should be seen as a reason to work with an attorney who understands the process and can help take the stress out of navigating an already high-tension situation.

What to Expect After the Decision

If the IMR overturns the denial, the claims administrator is required to authorize the treatment without unreasonable delay. If the IMR upholds the denial, the decision is generally binding on both parties and cannot be appealed to the WCAB on medical judgment grounds. The grounds for challenging an IMR determination are narrow, such as being limited to issues like fraud, conflict of interest, or a material departure from evidence-based standards. If you believe the IMR process was conducted improperly, an attorney can review the record and assess whether any procedural grounds for challenge exist.

If your treatment has been denied through utilization review, time is already running. Pacific Workers', The Lawyers for Injured Workers offers free consultations to injured workers across California. Call us today at (888) 740-6434 and let us help you understand your options before the filing window closes.