The California workers’ compensation system is facing renewed criticism as new data shows a sharp rise in Independent Medical Review (IMR) decision volume—while denial rates remain dangerously high.
Despite legislative promises of medical access under SB 863, workers are still being denied basic care at staggering rates. According to the California Workers’ Compensation Institute (CWCI), nearly 9 out of 10 treatment denials reviewed through IMR are still being upheld.
This surge in IMR activity is raising red flags across the legal and medical communities. While insurers and claims administrators point to medical guidelines, advocates for injured workers see a system that’s become more about delay and denial than healing and return to work.
IMR Volumes Are Surging — Again
After a five-year decline, IMR volume is climbing sharply:
- 2018: 184,735 IMR decisions (peak)
- 2022: 127,215 decisions (lowest)
- 2023: ↑ 2.9%
- 2024: ↑ 8.2%
- Q1 2025: ↑ 13% from Q1 2024
→ 38,393 decision letters issued, the highest first-quarter volume since 2019
“The trend is accelerating,” CWCI noted in Bulletin 25-09. “The volume of decision letters suggests a return to pre-pandemic utilization rates—but the uphold rate of denials remains stubbornly high.”
What Are Injured Workers Being Denied?
The majority of treatment denials involved non-invasive, conservative, and commonly prescribed therapies.
| Service | % of Q1 2025 IMRs |
|---|---|
| Prescription drugs | 30.6% |
| Physical therapy | 13.6% |
| Injections (epidural, nerve block) | 12.9% |
| Durable medical equipment (DME) | 9.7% |
| Acupuncture & chiropractic care | High volumes noted |
This data paints a stark picture: even basic pain relief, physical rehabilitation, and mobility equipment are frequently denied to injured workers, forcing delays and sometimes permanent impairments.
89% of Treatment Denials Are Still Being Upheld
The IMR process was billed as an objective way to resolve medical disputes. But the results have been anything but balanced.
In Q1 2025:
- 89.1% of utilization review (UR) decisions to deny or modify treatment were upheld by IMR doctors.
- This is up from 88% in 2024, showing no significant change in worker success rates.
Uphold Rates by Type of Service:
| Treatment Type | Uphold Rate |
|---|---|
| Acupuncture | 92.9% |
| Prescription medications | ~90% |
| Physical therapy | ~85% |
| Evaluation/management visits | 77.4% |
These are not outlier cases. This is the norm. Thousands of California workers are being denied treatment even when their own doctors say it’s necessary to heal.
Legal and Policy Perspective: What’s Going Wrong?
The IMR process was created by SB 863 to streamline care and reduce litigation. But in practice, it has become an opaque, bureaucratic tool that benefits insurance carriers.
Key Problems:
- No meaningful review of UR quality
UR decisions are rubber-stamped, not independently scrutinized. - Lack of transparency
IMR doctors are anonymous, and workers rarely receive a detailed explanation for denial. - Limited legal remedies
IMR decisions are final except in rare procedural violation cases under Dubon II. - Evidence-based medicine used rigidly
The Medical Treatment Utilization Schedule (MTUS) often fails to consider individual circumstances or new medical research.
As a result, thousands of workers find themselves stuck in a system where even legitimate care is delayed or denied—and there’s virtually no recourse.
Strategy: How Injured Workers Can Fight Back
At Employees First Labor Law, we’re using every available tool to challenge unfair denials. Here’s how we approach it:
1. Challenge the UR Process
If the insurance carrier missed deadlines, used an unqualified reviewer, or failed to notify properly, we may argue the UR is invalid under Labor Code § 4610 or Dubon.
2. Leverage QME/AME Reports
We work with qualified medical evaluators (QMEs) who provide strong narrative reports addressing causation, functional loss, and medical necessity.
3. Highlight Functional Impairment
IMR decisions often focus on clinical evidence—but ignore the worker’s ability to walk, sleep, work, or live independently. We focus our legal arguments on real-world impacts.
4. Escalate to the WCAB
In select cases, we can take IMR disputes to the Workers’ Compensation Appeals Board (WCAB) for review, especially when procedural rights have been violated.
The Bigger Picture: A System Out of Balance
California workers’ comp is supposed to “cure or relieve” industrial injuries. Instead, we’re seeing a system that:
- Over-relies on automated denials
- Dismisses treating physician opinions
- Favors rigid guidelines over individualized care
If IMR volume is rising—but nearly 90% of denials are still being upheld—the system is clearly not working for injured workers.
We Put Workers First—Always
At Employees First Labor Law, we’ve helped thousands of workers stand up to corporate giants. Whether it’s a workplace injury, unpaid wages, a retaliatory firing, or WARN Act violations, we have the experience to fight and win.
At Employees First Labor Law, we fight for workers across California to make sure your rights are respected, your body is protected, and your benefits are maximized.
