Treatment request denials for injured workers in California that were most often overturned in 2021 were for behavioral and mental health services, with 15% overturned, according to a report released Wednesday by the California Department of Industrial Relations, Division of Workers’ Compensation.
The annual report provides a snapshot of independent medical review under California law that requires reviewers to follow the guidelines of the state’s medical treatment schedule for assessing medical necessity when treating injured workers.
The program received 178,927 review requests in 2021. Overall, 7.2% of previous decisions denying treatment requests by physicians treating injured workers were overturned. The previous report in 2020 showed that 9.5% of decisions were overturned.
As in previous years, pharmaceutical inquiries accounted for the highest number of inquiries at 31%. This percentage continued the decline from 2020 (34% of all requests), 2019 (37%) and 2018 (42%). Of the 2021 figures, opioid prescriptions accounted for 27% of review requests. The second and third highest numbers of requests were for diagnostic tests, such as imaging and radiology, and rehabilitation requests, such as physical therapy and chiropractic care, each representing 19% of all services.
After behavioral and mental health services, rehabilitation programs and gym memberships were the next most overturned decisions, with 13% of reviews reversing previous denials. Assessment and management services, which include specialist consultations and dentistry, came third with a 12% drop.