What Is an Independent Medical Review?

What Is an IMR?

An independent medical review is an evaluation of your denied claim by one or more physicians who are:

• Independent of your insurance company
• Board-certified in the relevant specialty
• Not involved in your care or the original denial

How IMR Works

1. You request IMR through your insurer or state insurance department
2. Your records are sent to the independent reviewer
3. The reviewer evaluates whether the denied treatment is medically necessary
4. A binding decision is issued (usually within 30-45 days)
5. If you win, the insurer must provide/pay for the treatment

Who Qualifies for IMR

You can typically request IMR when:

• Your internal appeal was denied
• The denial was based on medical necessity or experimental/investigational status
• You've exhausted internal appeal levels (or the insurer failed to meet timelines)

IMR vs External Review

In many states, IMR and external review are the same process. Some states have specific IMR programs (like California's DMHC IMR program) that are separate from standard external review. The key is that both involve independent physician review.

Success Tips

• Submit all relevant medical records
• Include current clinical guidelines supporting your treatment
• Include your doctor's letter of medical necessity
• Highlight any errors in the insurer's review