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Mental treatment denials overturned most in medical necessity reviews

The treatment request denials for injured workers in California that were overturned most often 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 activity in accordance with California law that requires reviewers follow guidelines in the state’s Medical Treatment Utilization Schedule for determinations of medical necessity in treating injured workers.

The program received 178,927 requests for reviews in 2021. Overall, 7.2% of the earlier decisions that denied treatment requests made by physicians treating injured workers were overturned. The previous report in 2020 showed that 9.5% of decisions were overturned.

As with previous years, pharmaceutical requests accounted for the highest number of requests at 31%. This percentage continued the decrease from 2020 (34% of all requests), 2019 (37%) and 2018 (42%). Of the 2021 numbers, opioid prescriptions comprised 27% of review requests. The second- and third-highest number 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, functional restoration programs and gym memberships were the second most overturned decisions, with 13% of reviews reversing earlier denials. Evaluation and management services, which include specialist consultations and dental service, placed third at 12% overturned.

This article was first published in Business Insurance.

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