Necessity of Treatment in IMEs, Peer Reviews, and Functional Exams

Welcome back to our 26 in '26 Blog Series. Each post will address a top-of-mind topic in the clinical evaluation services sector. In the previous post we discussed Maximum Medical Improvement. This is the fourteenth post in our series and will detail Medical Necessities. 

Medical Necessity is one of the most contested issues in claims because it directly affects treatment authorization, benefit duration, and cost. Necessity is not a judgment about intent or motivation—it is an evidence-based assessment of appropriateness and expected benefit.

A Defensible Necessity Analysis asks whether the proposed treatment is reasonably expected to improve function, reduce impairment, or advance recovery for the condition at its current stage.

Key elements include appropriateness for the diagnosis, effectiveness demonstrated to date, reasonable duration and frequency, consideration of alternatives, and clearly defined goals or endpoints.

Guidelines such as ACOEM often inform necessity analysis, but guidelines are reference points—not mandates. Deviations may be appropriate and must be explained using patient-specific evidence.

Independent Medical Exams (IMEs) assess necessity by evaluating current clinical and functional status. Peer Reviews are particularly effective at identifying when care continues despite plateau or without measurable benefit.

Functional Capacity Exams  (FCEs) may demonstrate stable function despite prolonged therapy, informing decisions about necessity.

Fitness-for-Duty Exams (FFD) may indicate whether treatment affects safety-based capacity, but do not determine authorization.

Best Practice

Tie necessity opinions to measurable change: identify expected improvement, document progress or plateau, and define reasonable duration and endpoints.

Next in the Series

Next: O — Objectivity Standards: how neutrality is protected and demonstrated.