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More archives for:
PRIRA Cases: 2011 | 2010 | 2009 | 2008 | 2007 | 2003 | 2002

2011:			August - July - June - May - April - March - February - January
	August
		• 31 -	BCBSM 120097 - Covered benefit; medical food
		• 31 -	BCBSM 119873 - Mental health treatment; eligible provider
		• 31 -	Priority Health 120122 - Covered benefit; HPV vaccination for male
		• 26 -	United Health Care 120749 - Experimental drug; anakinra
		• 26 -	Time 119863 - Out-of-network service; MRI
		• 26 -	BCBSM 120484 - Covered benefit; durable medical equipment; vehicle wheelchair lift
		• 26 -	PHPMM 122340 - Medical necessity; orthognathic surgery
		• 26 -	BCBSM 119862 - Investigational treatment; mobile cardiac telemetry monitoring
		• 26 -	BCBSM 117759 - Prescription drug coverage; deductible requirement
		• 26 -	BCBSM 120173 - Durable medical equipment; comfort and convenience item; wheelchair seat lift
		• 26 -	BCBSM 119930 - Experimental surgery; artificial disc replacement
		• 26 -	BCBSM 119221 - Covered benefit; claims paid in error
		• 26 -	BCBSM 121264 - Durable medical equipment; comfort and convenience item; wheelchair seat lift
		• 23 -	BCN 119967 - Preventive service; application of deductible
		• 23 -	BCBSM 120026 - Durable medical equipment; copayment requirement
		• 23 -	BCBSM 119966 - Durable medical equipment; comfort and convenience item
		• 23 -	BCBSM 120026 - Durable medical equipment; copayment requirement
		• 23 -	BCBSM 119968 - Nonpanel deductible
		• 23 -	BCBSM 119973 - Application of deductible and copayment
		• 23 -	BCN 119967 - Preventive service; application of deductible
		• 22 -	BCBSM 119964 - Coordination of benefits; Medicare-eligible person
		• 22 -	Aetna 120800 - Medical necessity; decompressive diskectomy
		• 22 -	BCBSM 119284 - Covered benefit; allergy testing
		• 22 -	BCBSM 112363 - Out-of-network surgery; outside U.S.
		• 22 -	BCBSM 119747 - Mental health treatment; level of care
		• 22 -	BCN 119931 - Breast reduction surgery; copayment requirement
		• 20 -	BCBSM 119932 - Medical necessity; durable medical equipment; standing wheelchair
		• 15 -	Humana 119711 - Medical necessity; physical therapy
		• 12 -	Priority Health 119518 - Wellness program participation
		• 12 -	Priority Health 122683 - Out-of-network service; network adequacy
		• 12 -	Priority Health 121423 - Prescription drug coverage; formulary exception
		• 12 -	Guardian 119324 - Dental necessity; placement of crown
		• 12 -	BCN 119972 - Out-of-network surgery; prior authorization
		• 12 -	US Health & Life 119709 - Out-of-network surgery; outside U.S.
		• 12 -	Priority Health 122683 - Out-of-network service; network adequacy
		• 12 -	BCBSM 119861 - Home health care; participating provider
		• 12 -	BCBSM 119602 - Occupational therapy; approved facility
		• 08 -	BCBSM 119349 - Covered benefit; medical food
		• 08 -	BCBSM 119135 - Mental health treatment; level of care
		• 05 -	BCBSM 118870 - Experimental device; neuromuscular stimulator
		• 05 -	Humana 119417 - Experimental surgery; X-Stop system
		• 04 -	BCBSM 119029 - Covered benefit; dental care
		• 04 -	BCBSM 118891 - Experimental treatment; pulsed radiofrequency ablation
		• 04 -	BCN 119458 - Infertility treatment; application of copayment
		• 04 -	BCBSM 119260 - Covered benefit; orthodontia
		• 04 -	PHPMM 119034 - Covered benefit; temporomandibular joint treatment
		• 04 -	John Alden (Assurant) 119509 - Pre-existing condition
		• 03 -	BCBSM 117901 - Experimental treatment; intravascular stent
		• 03 -	BCBSM 118916 - Prescription drug coverage; self-administered drug
		• 03 -	Conn Gen. 118816 - Experimental surgery; Salto ankle
		• 01 -	PHP 118911 - Out-of-network service; CT scan
		• 01 -	USHL 118897 - Out-of-network service; ambulance transport
		• 01 -	PHP 118670 - Out-of-network service; surgery
		• 01 -	UHC 118519 - Medical necessity; physiotherapy
		• 01 -	PHPMM 122516 - Experimental surgery
		• 01 -	BCBSM 118928 - Occupational therapy; application of deductible
		• 01 -	BCBSM 118685 - Medical necessity; skilled nursing care
	July
		• 25 -	BCBSM 118153 - Experimental medical device, heart monitor
		• 25 -	BCBSM 118500 - Maternity benefit, midwife services
		• 25 -	BCN 119408 - Physical therapy, no-network provider
		• 25 -	BCBSM 118496 - Amount paid, air ambulance
		• 25 -	Aetna 118914 - Policy limitation, durable medical equipment
		• 25 -	Assurity 121623 - Policy exclusion, surgical procedure
		• 25 -	BCBSM 118510 - Policy limitation, durable medical equipment
		• 19 -	Humana 119525 - Pre-existing condition, physician treatment
		• 19 -	BCN 118632 - Policy exclusion, infertility treatment
		• 19 -	Humana 120481 - Emergency care, no-network provider
		• 19 -	BCBSM 118152 - Amount paid, out-of-network surgery
		• 19 -	BCBSM 118663 - Medical necessity, inpatient mental health treatment
		• 19 -	BCN 118416 - Policy exclusion, dental implants
		• 19 -	BCBSM 118381 - Laboratory tests, deductible
		• 19 -	Priority Health 117701 - Policy exclusion, fetal reduction
		• 19 -	BCBSM 118155 - Policy exclusion, bariatric surgery
		• 19 -	BCBSM 118340 - Laboratory tests, preventive care
		• 19 -	Priority 120503 - Coverage criteria, hand surgery
		• 19 -	American Community 118232 - Medical necessity, back surgery
		• 12 -	Priority Health 121666 - Home health care, eligibility
		• 12 -	BCBSM 117973 - Medical necessity, eyebrow surgery
		• 12 -	Wayne State 118310 - Emergency care, eligibility
		• 11 -	BCBSM 112419 - Experimental surgical procedure
		• 11 -	Celtic 116891 - Pre-existing condition, surgery
		• 11 -	BCN 118032 - Wellness program, eligibility
		• 08 -	BCBSM 117775 - Experimental device, heart monitor
		• 08 -	BCBSM 118102 - Surgery, cosmetic
		• 08 -	Priority Health 119707 - Network coverage, emergency treatment
		• 08 -	PHPMM 120683 - Unproven medical treatment
		• 08 -	Aetna 11940 - Policy exclusion, dental implants
		• 08 -	Humana 120560 - Copayment, emergency surgery
	June
		• 30 -	BCN 117941 - Durable medical equipment; insulin pump
		• 30 -	BCBSM 118100 - Occupational therapy; nonparticipating facility
		• 30 -	BCBSM 117638 - Mental health services; copayment
		• 30 -	Aetna 117802 - Network services; deductible
		• 30 -	BCN 117438 - Covered benefit; multifetal pregnancy reduction
		• 30 -	Time 119174 - Pre-existing condition
		• 23 -	BCN 120336 - Prescription drug coverage; excluded drug
		• 23 -	BCBSM 112443 - Covered benefit; chiropractic manipulation under anesthesia
		• 23 -	Priority Health 119235 - Out-of-network provider; physical therapy and occupational therapy
		• 23 -	American Community 119105 - Covered benefit; newborn child coverage
		• 23 -	BCN 118098 - Physical therapy; visit limitations
		• 23 -	BCBSM 118134 - Covered benefit; dental care
		• 23 -	Aetna 118345 - Medical necessity; CT scan
		• 23 -	BCBSM 116946 - Medical necessity; inpatient substance abuse treatment
		• 23 -	BCN 119130 - Out-of-network substance abuse treatment; prior authorization
		• 23 -	Priority Health 118095 - Out-of-network provider; mental health therapy
		• 23 -	PHPMM 117694 - Covered benefit; cranial helmet
		• 23 -	BCBSM 118545 - Experimental treatment; osteochondral graft
		• 20 -	Priority Health 117066 - Medical necessity; panniculectomy
		• 20 -	Priority Health 119626 - Prescription drug coverage; formulary exception
		• 20 -	BCBSM 119038 - Cosmetic dental treatment; veneer
		• 20 -	United Healthcare 118874 - Out-of-network services; PET and CT scan
		• 20 -	United Healthcare 118135 - Out-of-network surgery
		• 20 -	Priority Health 118096 - Out-of-network services
		• 20 -	Priority Health 119231 - Out-of-network emergency care
		• 20 -	BCBSM 117717 - Covered benefit; dental care
		• 20 -	PHPMM 120361 - Experimental device; implantable pain pump
		• 20 -	BCBSM 117613 - Application of deductible
		• 20 -	BCBSM 117654 - Out-of-network surgery; payment level
		• 20 -	Aetna 117851 - Covered benefit; additional payment for complicated surgery
		• 20 -	BCBSM 118028 - Covered benefit; compression garment
		• 20 -	Priority Health 120123 - Out-of-network provider; vagus nerve stimulator
		• 20 -	Guardian 117614 - Medical necessity; dental crown
		• 20 -	BCBSM 117402 - Medical necessity; skilled nursing care
		• 20 -	PHIC 117637 - Covered benefit; CT scan
		• 10 -	BCBSM 117471 - Durable medical equipment; neck orthotic
		• 10 -	BCBSM 117266 Medical necessity; myocardial perfusion imaging
		• 06 -	HAP 116963 - Bariatric surgery; medical criteria
		• 01 -	BCBSM 121624 - Medical necessity; skilled nursing care
	May
		• 26 -	Priority 120391 - Experimental surgery, disk replacement
		• 19 -	HAP 115786 - Review request not accepted, internal grievance not completed
		• 19 -	USHL 120157 - Medical necessity, DNA testing
		• 19 -	USHL 120160 - Medical necessity, surgery
		• 19 -	BCBSM 117469 - Medical necessity, abdominoplasty
		• 19 -	Unitedhealthcare 117058 - Dental surgery, deadline to complete procedures
		• 18 -	BCBSM 118693 - Experimental care, gastric electrical stimulators
		• 10 -	Humana 118390 - Pre-existing condition, surgery
		• 10 -	Principal Life 118470 - Policy exclusion, autism therapy
		• 09 -	BCBSM 117757 - Experimental surgery, disk replacement
		• 09 -	BCBSM 117719 - Amount paid, non-participating provider
		• 09 -	BCBSM 117774 - Amount paid, air ambulance by non-participating provider
		• 09 -	BCBSM 116993 - Pre-existing condition waiting period, creditable coverage
		• 03 -	Humana 117566 - Experimental surgery, spinal disk replacement
		• 03 -	BCN 120099 - Dental care exclusion, sinus surgery
		• 02 -	American Community 117689 - Pre-existing condition limitation
		• 02 -	Companion life 114549 - Policy exclusions, treatment for weight loss and sexual dysfunction
		• 02 -	Guardian 115174 - Dental necessity, crown build-up
		• 02 -	BCBSM 114715 - Policy exclusion, dental services
		• 02 -	BCBSM 110934 - Occupational therapy, non-participating facility
		• 02 -	BCN 117293 - Wellness program, eligibility
	April
		• 28 -	HAP 116844 - Wellness program participation
		• 28 -	Guardian 114645 - Medical necessity; dental crown buildup
		• 28 -	PHPMM 115016 - Unproven medication; hormone replacement therapy
		• 28 -	Paramount 114997 - Bariatric surgery; copayment
		• 28 -	Priority Health 113576 - Medical necessity; neuropsychological evaluation
		• 28 -	PHPMM 114499 - Physical therapy; visit limitation
		• 28 -	BCBSM 114547 - Covered benefit; office visit limitation
		• 28 -	Priority Health 116657 - Covered benefit; out-of-network services
		• 28 -	BCBSM 111247 - Investigational service; breast specific gamma imaging
		• 28 -	BCBSM 113580 - Medical necessity; skilled nursing care
		• 28 -	BCBSM 116854 - Experimental drug treatment; out-of-network services
		• 28 -	PHPMMF 116855 - Covered benefit; speech therapy
		• 28 -	HAP 114998 - Wellness program participation
		• 28 -	BCBSM 116653 - Medical necessity; prescription drug
		• 28 -	BCBSM 112212 - Medical necessity; breast reduction surgery
		• 28 -	Priority Health 113577 - Medical necessity; neuropsychological evaluation
		• 28 -	BCBSM 116921 - Mental health services; eligible provider
		• 28 -	Principal Life 112107 - Medical necessity; PET scan
		• 28 -	Guardian 113868 - Medical necessity; periodontal scaling and root planing
		• 28 -	BCBSM 113989 - Residential substance abuse treatment; out-of-network facility
		• 28 -	Priority Health 114495 - Out-of-network services
		• 28 -	American Community 115211 - Out-of-network services
		• 27 -	BCBSM 116921 - Mental health services; eligible provider
		• 27 -	BCBSM 117013 - Medical necessity; residential substance abuse treatment
		• 27 -	Assurity Life 118245 - Covered benefit; speech therapy
		• 27 -	BCBSM 114547 - Covered benefit; office visit limitation
		• 27 -	Midwestern Dental 116656 - Covered benefit; crown buildup
		• 08 -	BCBSM 114681 - Mental health services; nonparticipating facility
		• 01 -	City of Melvindale 119479 - Experimental drug
		• 01 -	Golden Rule 118546 - Waiting period
		• 01 -	Guardian 114110 - Medical necessity; dental crown buildup
	March
		• 25 -	BCBSM 116641 - Medical necessity, infant formula
		• 25 -	Priority Health 117612 - Policy limits, physical therapy
		• 25 -	BCBSM 116649 - Deductible, physical therapy
		• 25 -	Guardian 113635 - Dental care, dental necessity
		• 25 -	BCN 117890 - Medical necessity, ADD medication
		• 25 -	BCBSM 111656 - Surgery, non-participating hospital
		• 25 -	Principal Life 117297 - Experimental medication, injections for knee pain
		• 25 -	UHC 117062 - Policy exclusion, bariatric surgery
		• 18 -	UCH 117289 - Medical necessity, radiofrequency ablation
		• 18 -	Guardian 114471 - Dental care, dental necessity
		• 18 -	BCN 114996 - Psychiatric care, non-network provider
		• 17 -	Priority Health 119411 - Breast reconstruction, medical necessity
		• 09 -	HAP 112303 - Ear surgery, medical necessity
		• 09 -	BCBSM 110950 - Dental care, non-network provider
		• 09 -	Priority Health 112398 - Wellness program, eligibility
		• 09 -	BCBSM 112131 - Durable medical equipment, experimental device
		• 09 -	PHPMM 112281 - Experimental care, prescription drug
		• 09 -	BCN 112353 - Wellness program, eligibility
		• 07 -	PHP 110072 - Physical therapy, qualification for in-home care
		• 04 -	BCBSM 114548 - Payment amount, non-network surgery
		• 04 -	BCBSM 113066 - Well child visits, annual policy limits
		• 04 -	BCBSM 112080 - Medical necessity, inpatient rehabilitation
		• 04 -	BCN 118342 - Experimental care, cancer treatment
	February
		• 23 -	PHP Mid-MI 107894 - Experimental service; genetic test
		• 23 -	BCBSM 112537 - Covered benefit; home infusion therapy
		• 23 -	Alliance Health 113566 - Pre-existing condition; carpal tunnel syndrome
		• 18 -	BCBSM 114653 - Covered benefit; out-of-network hospital
		• 17 -	United Healthcare 116967 - Covered benefit; hearing aid
		• 17 -	Guardian 114470 - Medical necessity; dental crown buildup
		• 17 -	BCBSM 113637 - Nonpanel deductible; emergency room care
		• 17 -	BCBSM 112943 - Nonpanel deductible; hospital care
		• 17 -	BCBSM 112002 - Covered benefit; physical therapy
		• 16 -	BCBSM 114678 - Out-of-network surgery; multiple surgeries on same day
		• 11 -	Medco 111109 - Medical necessity; prescription drug
		• 11 -	BCBSM 111935 - Durable medical equipment; neuromuscular electrical stimulator
		• 11 -	BCBSM 111793 - Medical necessity; inpatient mental health services
		• 11 -	BCBSM 118690 - Medical necessity; inpatient substance abuse treatment
		• 11 -	BCBSM 114116 - Covered benefit; bariatric surgery
		• 09 -	Priority Health 114682 - Off label drug use
		• 09 -	Aetna 113270 - Out-of-network services; anesthesia
	January
		• 31 -	BCBSM 111101 - Prescription drug coverage; nonpreferred drug
		• 31 -	MET LIFE 110694 - Covered benefit; dental services
		• 31 -	PHP-MID MI 109584 - Covered benefit; birthing services
		• 31 -	PRIORITY HEALTH 111985 - Copayment; rhinoplasty
		• 31 -	BCN 111103 - Covered benefit; speech therapy
		• 31 -	GRAND VALLEY 111648 - Medical necessity; autologous chondrocyte transplantation
		• 26 -	HAP 115960 - Autism treatment; hyperbaric oxygen therapy
		• 24 -	PHP-MID MI 111102 - Medical necessity; abdominoplasty
		• 21 -	HUMANA 108341 - Application of deductible
		• 21 -	AETNA 108435 - Experimental test; lipoprotein test
		• 21 -	PHP-MID MI 113459 - Unproven service; radiofrequency ablation
		• 21 -	BCBSM 111201 - Covered benefit; emergency dental care
		• 21 -	PHP-MID MI 114498 - Medical necessity; genetic testing
		• 21 -	MOLINA 108470 - Medical necessity; bunionectomy
		• 18 -	TIME 107101 - Laboratory tests; included procedure
		• 14 -	BCN 107117 - Investigational drug; pain management
		• 14 -	BCBSM 107109 - Covered benefit; home health care
		• 14 -	BCBSM 106098 - Covered benefit; bariatric surgery
		• 12 -	USHL 77354 - Covered benefit; nonformulary drug
		• 06 -	PHP-MID MI 118180 - Covered benefit; nonformulary drug
		• 05 -	BCBSM 111862 - Experimental treatment; back surgery
		• 05 -	PRIORITY HEALTH 112913 - Policy exclusion; nontraditional medicine
		• 05 -	AETNA 111988 - Maternity care; deductibles
		• 05 -	PHP-MID MI 109973 - Policy exclusion; TMJ treatment
		• 05 -	AETNA 116451 - Policy limits; speech therapy
		• 05 -	BCN 113852 - Copayment; colonoscopy
		• 05 -	MIDWEST 111104 - Policy exclusion; lab tests
		• 05 -	BCBSM 110711 - Mail order drugs; approved vendor
		• 05 -	AETNA 109190 - Experimental treatment; blood test
		• 05 -	USHL 113153 - Experimental treatment; cancer
		• 05 -	BCBSM 109830 - Experimental treatment; back surgery
		• 04 -	MIDWEST 112320 - Deductible; lab tests
		• 04 -	TIME 110585 - Covered benefit; heart catheterization
		• 04 -	BCN 118132 - Drug coverage; proton pump inhibitor
		• 04 -	BCBSM 106346 - Covered benefit; infant food supplement
		• 04 -	HUMANA 118778 - Drug coverage; kidney disease


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