Department of Managed Health Care Great Seal of the State of California

Physician Certification Form

In order to complete the application process for an IMR based on an experimental or investigational denial, a physician must provide the enrollee with a statement that confirms:

  1. the enrollee has a terminal medical condition, or a life threatening condition, or a seriously debilitating condition;


  2. an evaluation of "standard" therapies (that the standard therapies have not been effective in improving the enrollee's condition, or the standard therapies would not be medically appropriate for the enrollee; or there is no more beneficial standard therapy covered by the health plan than the therapy proposed);


    3. and

  3. that the requested therapy is likely to be more beneficial than any available standard therapy.

If a non-plan physician is requesting the treatment, the statement must also include copies or reference two documents from the medical and scientific evidence that the treatment is likely to be more beneficial for the enrollee than any available standard therapy.

The following medical and scientific evidence qualifies to support an Independent Medical Review request for treatment denied as experimental or investigational:

  • Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not a part of the editorial staff;


  • Peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institute of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline, and MEDLARS database Health Services Technology Assessment Research (HSTAR);


  • Medical journals recognized by the Secretary of Health and Human Services;


  • The following standard reference compendia: The American Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluation, the American Dental Association Accepted Dental Therapeutics, and the United States Pharmacopoeia-Drug Information;


  • Findings, studies and research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes including the Federal Agency for Health Care Policy and Research, National Institutes of Health, National Cancer Institute, National Academy of Sciences, Health Care Financing Administration, Congressional Office of Technology Assessment, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services; or


  • Peer-reviewed abstracts accepted for presentation at major medical association meetings.