Appealing a denied imaging test based on semantics

Evening (suppose Morning)

I had a CT scan done at a large local hospital’s Imaging Center. The test was done at the hospital as the Imaging Center CT machine was down. It was initially scheduled for March 30th and rescheduled for April 4th. My insurance provider has denied the claim. I requested all the referrals and authorizations from my insurance provider, and of the three letters regarding this test, they all use different CPT codes, either incomplete or inaccurate testing reasons, but most cite that “It is common for people to have this test done outside of a hospital.” and “This service could be approved if given in a free-standing center”. All of these were sent out ON or A

I did it at this facility as the hospital (as a whole) is frankly a large bureaucratic nightmare to get anything to anyone internal or external. I want to debate semantics, specifically “free-standing center”. The Imaging Center is its own building, outside of the hospital entrance. I’m fairly certain it has its own foundation as well. Additionally the word “common” does not mean that its not uncommon to have it done at a hospital (which I’m not really going to argue, as I even less chances of winning based on the dictionary). The letters were sent out on April 10th, the original appointment (and estimate, which yes, I know its an estimate) was done on March 22nd.

This is a problem for several things. The estimate from the local hospital, puts Total (pre-insurance charges) at $4,738.00 while Negotiated Payer Rate at $697.72. Based on what I see so far, the claim being denied, results in even the negotiated payer rate not being available. The immediate cost of this is an issue, as this is an Auto Insurance claim. (which is limited to 25k and is in a long list of imaging, general and specialist doctors appointments).

The other issue is that I have an MRI lumbar spine, and the doctor was very adamant about ensuring that the MRI scan is done at the musculoskeletal institute as he knows the scanner is good. (Doctor did say, ask where is acceptable via the portal, after getting the acceptable list from the insurance provider, if needed). I know that from research for a previous MRI, that I had done at an Private Imaging Center back in January, Imaging Center equipment can be a hit or miss. I potentially have two additional MRIs in the near future, one of which would be for the same body part as the CT.

I do want to limit personal information, but I also want to give sufficient context. I am located in the Atlanta Metro. This should give an idea of the large local hospital.