How Justine will defend 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. A UR/IMR defense facet of Justine is designed to read the denial against the treating physician’s request and the MTUS the reviewer applied, then assemble the strongest available challenge — a procedural defect that voids the UR, an IMR appeal ground, or the medical evidence for a renewed RFA. The reasoning core is built to track the statutory timelines under SB 863 and surface where a late or defective determination opens a path back to the WCAB. The attorney chooses the route.
What WC is designed to do.
- 01
The facet is designed to test 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.
- 02
It will read the denial against the specific MTUS guideline and presumption the reviewer cited, surfacing where the treating physician’s documentation rebuts the presumption of correctness or shows the guideline was misapplied.
- 03
IMR appeal grounds are the design intent — the facet is built to identify the narrow statutory bases on which an IMR determination can be overturned and assemble the record support for each that applies.
- 04
Deadline tracking is planned across the chain — RFA, UR response window, IMR application, and appeal — so the facet warns the attorney before a forfeiture date rather than after.
- 05
Where a fresh request is the better route, the facet is designed to draft the renewed RFA with the additional clinical evidence the prior denial flagged as missing, for the treating physician and attorney to advance.
The AI reasons; the attorney decides.
JustineAI™ WC is coming next. This describes the workload it is built to carry. When it opens, founding-firm slots go to the workers’ comp attorneys who told us about their practice early.