Independent Medical Exams: 5 Must-Have Records

When it comes to Independent Medical Exams (IMEs), the outcome is only as strong as the information provided to the physician. Without the right background, IME doctors may miss critical context, overlook pre-existing conditions, or fail to connect treatment patterns with the claimed injury. This could lead to boilerplate reports, unnecessary disputes, and weaker claim defensibility. For adjusters and claims teams, preparing a thoughtful, complete IME referral packet is one of the most important steps in medical case management.

Core Medical Records for Independent Medical Exams

The foundation of every IME is a complete and well-organized set of medical records. At a minimum, this should include:

• Treating provider notes and histories, including ER visits, primary care, and specialists.
• Diagnostic test results such as X-rays, MRIs, CT scans, EMGs, and lab results.
• Prescription history, with a focus on pain medications, opioids, and long-term therapies.

Without these documents, IME physicians are left to fill in the blanks about a worker’s care trajectory. Worse, gaps in records can open the door for credibility challenges if opposing counsel introduces documents that were not provided at the time of the exam.

According to the National Council on Compensation Insurance (NCCI), medical costs account for nearly 60% of total Workers’ Compensation claim costs, and prescription drugs, particularly opioids, remain a significant driver of both cost and complexity. By supplying a complete prescription history, adjusters help IME physicians evaluate not only the appropriateness of treatment, but also potential risks such as dependency, overutilization, or drug interactions.

Prior Injury or Condition Documentation

Separating pre-existing conditions from new injuries is one of the most challenging parts of medical case management, and it begins with the records provided to the IME physician. To make defensible causation determinations, physicians need clear documentation of:

• Prior claims or injuries involving the same body part.
• Chronic conditions that may affect healing, such as arthritis, diabetes, or obesity.
• Surgical history, particularly orthopedic procedures.

The Workers Compensation Research Institute (WCRI) 2025 report on Degenerative and Comorbid Conditions in Workers’ Compensation found that claims with one or more comorbidities incurred significantly higher medical payments and longer disability durations than those without. That means failing to provide prior medical history upfront directly undermines the credibility of causation opinions.

Employment and Functional Records for Independent Medical Exams

Independent medical exams aren’t just about pathology, they’re about function. For an IME physician to provide meaningful return-to-work (RTW) guidance, the referral packet should include:

• A current job description with physical demands (lifting requirements, repetitive motions, standing/sitting expectations).
• Employer incident reports and witness statements, which provide context for how the injury occurred.
• Any prior work restrictions or RTW forms, showing whether the employee has had modified duty or accommodations before.

These documents help the physician connect medical findings to the worker’s real-world capabilities. For example, a 20-pound lifting restriction is usually manageable for an office worker but could be disabling for a warehouse employee or delivery driver. Without this functional context, IME recommendations, such as “light duty recommended”, often become vague and less defensible in litigation.

The U.S. Bureau of Labor Statistics notes that musculoskeletal disorders remain a leading cause of lost workdays in physically demanding industries. Providing detailed functional records ensures the IME physician’s guidance is practical, defensible, and tailored to the employee’s actual role.

Treatment Timeline and Utilization History

Patterns are important. For an IME physician to assess whether care is appropriate, excessive, or out of line with guidelines, they need a clear treatment timeline. This should include:

• Chronological summaries of all treatment, from ER visit through current care.
• Physical therapy (PT) attendance and compliance records, including no-shows.
• Prior utilization review outcomes and authorization decisions, especially denied requests or modified treatment plans.

A well-documented timeline helps the IME doctor flag red flags such as excessive PT sessions, prolonged opioid prescriptions, or repetitive imaging with little clinical justification.

The WCRI has found that injured workers with longer-term opioid prescriptions had 251% higher indemnity costs compared to those without opioid use, a striking example of how unchecked treatment patterns can escalate claim costs and delay recovery. Similarly, missed PT appointments or repeated requests for non-guideline procedures may point to barriers that need addressing.

By supplying a complete utilization history, adjusters give IME physicians the tools to assess whether ongoing care aligns with evidence-based guidelines like the Official Disability Guidelines or American College of Occupational and Environmental Medicine. This makes the resulting report both stronger and more defensible.

Legal and Administrative Context in Independent Medical Exams

While clinical records form the backbone of any IME packet, the legal and administrative documents are just as important. Adjusters should always include:

• Claim forms, such as the First Report of Injury or state-specific filings.
• Litigation status, if the claim is contested or under review.
• The IME cover letter, which defines the scope and purpose of the exam.

The cover letter is especially critical because it frames the physician’s analysis. Vague requests like “Is this injury work-related?” often produce equally vague answers, leaving room for dispute. Instead, the best practice is to pose focused, defensible questions, such as:

• Did the workplace incident aggravate a pre-existing condition?
• Is the proposed surgery medically necessary and evidence-based?
• Has the worker reached maximum medical improvement?

Poorly crafted questions have been criticized in litigation for being overly broad or leading, while precise, medically grounded questions are more likely to yield clear, admissible answers. According to the National Association of Independent Medical Examiners, IME reports carry the greatest weight when they directly respond to well-structured referral questions and are backed by evidence-based guidelines.

By including the right administrative context and a strong set of referral questions, adjusters ensure the IME physician addresses the core issues driving claim resolution rather than providing boilerplate or incomplete opinions.

Independent medical exams are only as strong as the foundation they’re built on. Adjusters who provide comprehensive, relevant, and well-organized records set IME physicians up to deliver defensible, evidence-based opinions. That preparation not only reduces disputes but also improves worker outcomes, speeds claim resolution, and contains costs.

Want to set up your IMEs for success? Talk to us today. 

Check out our sources:

National Association of Independent Medical Examiners (NAIME). Guidelines for Independent Medical Examinations. NAIME, 2024.

National Council on Compensation Insurance (NCCI). “Inflation and Workers Compensation Medical Costs — Prescription Drugs.” NCCI, 28 Mar. 2023, https://www.ncci.com/Articles/Pages/Insights-Inflation-WorkersComp-Medical-Costs-Prescription-Drugs.aspx.

U.S. Bureau of Labor Statistics. “Nonfatal Occupational Injuries and Illnesses Requiring Days Away From Work, 2023.” U.S. Department of Labor, 7 Nov. 2024, www.bls.gov/news.release/pdf/osh2.pdf.

Workers Compensation Research Institute (WCRI). Degenerative and Comorbid Conditions in Workers’ Compensation. 27 Mar. 2025, https://www.wcrinet.org/reports/degenerative-and-comorbid-conditions-in-workers-compensation.