What That Means — and What You Can Do About It
You’ve been injured at work. Your treating physician has evaluated you, reviewed your imaging, and made a clear recommendation: you need surgery. Maybe it’s a back fusion. Maybe it’s rotator cuff repair. Maybe it’s a knee replacement. Whatever it is, your doctor says it’s medically necessary.
Then you get a letter from the insurance company. Denied.
If this has happened to you, you are not alone — and you are not out of options. But you need to act fast.
Why Can an Insurance Company Overrule Your Doctor?
Under California workers’ compensation law, before the insurance company pays for any treatment, your doctor’s request goes through a process called Utilization Review — or UR.
A UR reviewer — often a physician hired by the insurer who has never examined you and may not even be licensed in California — compares your treating doctor’s request against a set of guidelines called the Medical Treatment Utilization Schedule (MTUS). If your case doesn’t fit neatly into those guidelines, the reviewer can deny or modify the request.
Your doctor, who has examined you, reviewed your MRI, and followed your case, says yes. A stranger on the phone says no. That’s the system. But it’s a system with a built-in remedy — if you use it in time.
The Remedy Is Called IMR — and You Have 30 Days
California Labor Code §4610.5 gives you the right to challenge any UR denial through a process called Independent Medical Review (IMR). IMR is handled by MAXIMUS Federal Services, an independent organization contracted by the state — not the insurance company.
An IMR reviewer examines your medical records and the UR denial and makes a binding determination. If they overturn the denial, the insurer must authorize the treatment. Period.
| ⏰ DEADLINE: You have 30 days from the date of the UR denial to request IMR. This deadline is hard. Miss it and you lose your right to challenge that denial through IMR — there is no extension, no grace period, and no do-overs. |
| ⚖️ The UR/IMR Process at a Glance
1. Your treating doctor submits a treatment request to the insurance company. 2. The insurer’s UR reviewer approves, modifies, or denies the request. 3. If denied or modified, you (or your attorney) request IMR within 30 days of the denial. 4. MAXIMUS assigns an independent medical reviewer — no financial ties to either side. 5. The reviewer examines your records and the denial rationale. 6. If the reviewer overturns the denial: the insurer must authorize treatment. 7. If the reviewer upholds the denial: the decision is binding, with very limited grounds for appeal. |
What Happens After IMR?
If IMR overturns the denial, the insurer must authorize your treatment — no further argument. If IMR upholds the denial, your appeal options are narrow. You can seek judicial review only on very limited grounds: fraud, conflict of interest, or that the IMR decision was clearly erroneous on a matter of law.
This is why getting IMR right the first time matters so much — and why an attorney who understands the process and the medical records can make a critical difference.
What About My Right to Medical Treatment Under the Law?
California Labor Code §4600 says your employer (through their insurer) must provide all medical treatment that is reasonably required to cure or relieve the effects of your work injury. Surgery your treating doctor has determined to be medically necessary falls squarely within that right.
A UR denial doesn’t erase that right. It triggers the process for enforcing it.
Don’t Let the Clock Run Out
We have seen injured workers lose their IMR rights simply because no one told them the 30-day deadline existed. The insurance company is not required to explain your rights to you. That’s what an attorney is for.
If your treatment has been denied — surgery, physical therapy, medication, specialist referrals, anything — call our office immediately. We track every UR denial and every IMR deadline as a matter of practice. We will fight to get you the treatment your doctor says you need.