How Justine defends against UR and IMR denials.

Utilization review and independent medical review decide whether injured workers get treatment, on deadlines that foreclose relief the moment they pass. Justine reads the denial against the treating physician’s request, tracks the Independent Medical Review appeal deadline, and starts the appeal from the treating physician’s own report — surfacing where the report already contains the documentation the reviewer claimed was absent. She tracks the statutory timelines and warns before a forfeiture date. The attorney chooses the route.

What WC does.

1. 01

   Justine tests the UR determination for the timeliness and procedural defects that, under Dubon, can return a medical-necessity dispute to the WCAB rather than leaving it to IMR.

2. 02

   She reads the denial against the treating physician’s request and the guideline the reviewer applied, surfacing where the documentation rebuts the stated basis or shows it was misapplied — without asserting a specific named guideline the software does not itself cite.

3. 03

   IMR appeal windows and RFA / UR response deadlines are tracked across the chain, so Justine warns the attorney before a forfeiture date, not after.

4. 04

   Where a fresh request is the better route, Justine drafts the renewed RFA with the clinical evidence the prior denial flagged as missing, for the treating physician and attorney to advance.

5. 05

   Every flag traces to the record; the attorney decides what is filed.

The AI reasons; the attorney decides.