IMR Approved Your Medication, but the Insurer Still Won’t Provide It: What Can You Do?

If Independent Medical Review (IMR) approved your workers’ compensation medication or treatment and the insurer still won’t provide it, California law requires the claims administrator to authorize the treatment within five working days, or pay for treatment already provided within 20 days, counted from when it receives the decision. The exceptions are an appeal of the IMR decision or a dispute over liability, for a reason other than medical need, that already existed when the decision arrived. Otherwise, you can ask a workers’ compensation judge to order compliance, recover what you paid out of pocket and seek a penalty or sanctions; none of these happens automatically.

A utilization review (UR) approval is the administrator’s own authorization of a specific treatment. The reimbursement and enforcement remedies below can apply to it too, though the five-day and 20-day deadlines are written for IMR decisions. Under Labor Code section 4610.3, an employer cannot rescind or modify an authorization after the treatment has been provided; for a series of treatments, it may change only the part not yet provided.

What the claims administrator must do after IMR approves treatment

IMR decides only medical necessity, and its determination binds all parties. Under Labor Code section 4610.6(j) and California Code of Regulations, title 8, section 9792.10.7, the employer must promptly implement a decision that the treatment is necessary:

• Treatment not yet provided: the administrator must authorize it within five working days of receiving the written determination, or sooner if your condition requires, and tell you and your doctor it has been authorized.
• Treatment already provided: the administrator must reimburse the provider or the employee, whichever applies, within 20 days after receiving the determination, subject to any separate dispute over the amount.

Keep the IMR letter and its mailing date. The five-day and 20-day periods run from the administrator’s receipt of the determination, and the statutory 30-day appeal period runs from the mailing date.

Two lawful reasons for delay

An administrator may hold off for two reasons. First, either side can appeal an IMR determination to the Workers’ Compensation Appeals Board within the statutory 30-day period from mailing, subject to any applicable mailing extension. The appeal is narrow: the determination is presumed correct and can be set aside only on clear and convincing proof of listed grounds, such as fraud or a reviewer’s conflict of interest. Even a successful appeal sends the dispute back for a new review; a judge cannot substitute a different medical-necessity decision. Second, if the administrator was already disputing liability on other grounds when it received the determination, such as whether the injury or body part is covered, implementation waits until that dispute is resolved.

If neither applies, the approval should be honored. In Finander v. Los Angeles Unified School District, a WCAB panel decision issued October 23, 2026, the employer argued on reconsideration that pages were missing from the IMR decision. The trial judge, whose reasoning the Board agreed with, said its remedy had been to appeal; having not appealed, it could not dispute the determination later.

If you paid for the medication yourself

Under Labor Code section 4600(a), when an employer neglects or refuses reasonably to provide treatment, including medicines, it is liable for the reasonable expense the employee incurs. The IMR regulation also requires reimbursement to the employee for approved services already rendered.

Reimbursement is tied to approval. In Finander, the judge ordered repayment only for medications the employer, its UR or IMR had approved, and left the parties to calculate the amount.

Match each purchase to an approval

Our practical suggestion: keep a simple but specific record. A UR approval must identify the exact treatment approved, under Labor Code section 4610(i)(5), so compare it with what you bought. For each purchase, keep:

• the UR approval or IMR determination covering that drug, strength and quantity, including any “brand name only” wording and the number of refills;
• the pharmacy receipt showing date, drug and amount you paid;
• any denial or rejection from the pharmacy or the insurer’s pharmacy benefit manager; and
• your messages asking the adjuster to authorize the refill, and the replies.

A one-page list matching each receipt to its approval does the work that, in Finander, was left undone: the Board deferred the late-payment penalty because “it is not entirely clear which medications require payment.”

Ask a judge to enforce the approval

If a written request to the adjuster citing the approval does not work, a judge can be asked to resolve the dispute. In Finander, the employer agreed at a hearing to authorize the medication exactly as IMR had decided, and the judge ordered it to act within five working days; the worker still received the medication only once afterward. Those minutes later supported sanctions. In our view, it helps to bring every hearing order to the next hearing and point out each failure to follow one.

Separately, the IMR regulation directs the Administrative Director, on credible information that an administrator failed to implement a final determination, to begin a proceeding for administrative penalties, and section 4610.6(k) allows penalties of up to $5,000 for each day of noncompliance. That is an enforcement step against the administrator; it does not replace asking a judge for your own benefits.

Penalties and sanctions answer different questions

Under Labor Code section 5814, an unreasonably delayed or refused payment can be increased by up to 25 percent, capped at $10,000. It is measured against a particular delayed payment. Two traps: when a benefit is submitted for decision at a regular trial, any accrued penalty for it is conclusively presumed resolved unless the penalty is also submitted or expressly excluded, so make sure the penalty is on the list of trial issues. And a penalty claim cannot be brought more than two years after the payment was due.

Labor Code section 5813 sanctions address bad-faith actions or tactics that are frivolous or solely intended to cause unnecessary delay, with up to $2,500 payable to the state General Fund and reasonable expenses, including attorney’s fees, to the other party. They require more than a late payment. In Finander, failing to implement or appeal the IMR decision, after agreeing at a hearing to comply, supported $1,500 in sanctions.

If you are deciding whether to handle a hearing yourself, our guide to when a workers’ compensation attorney can help describes the signals. The full Finander analysis explains the Board’s reasoning.