Appealing a claim denial that had prior authorization

I had a procedure done by a surgeon who is out of network and a hospital that was in-network on a Cigna PPO plan. Initially, when the surgeon submitted the Authorization request, it came back denied. I sent an appeal which was eventually approved before surgery, but because it took so long, my surgeon said that I had to pay the full surgeon’s fee amount upfront in order to keep the surgery date.

After the surgery, I was given an invoice, which I submitted as a claim. However, Cigna denied that claim. I ended up contacting their representatives, several of whom told me different things. Many of them also seemingly were unable to determine why the claim was denied. The first several times I had called, they seemed to assume the CPT codes didn’t match (because the EOB said: “HEALTH CARE PROVIDER: YOUR CLAIM WAS RECEIVED WITH A MISSING OR INVALID CPT/HCPCS PROCEDURE CODE BASED ON THE DATE OF SERVICE. PLEASE CORRECT THE INFORMATION AND RE-SUBMIT THE CLAIM”)

After a few more calls, I was able to verify that there was nothing wrong with the CPT codes, and that they did match the procedures that were approved on the authorization.

The representatives that did go in to check and verify that the CPT codes did indeed match, sent the claim back to reprocess. But it came back denied again. This process happened multiple times, all with zero success.

I then had several representatives say that the dates didn’t match (despite this being easily verifiable info). And then there were issues with the Tax IDs not matching, which eventually lead to a representative finding out what I assume was the correct issue.

The representative that eventually took on the case said the reason seemed to be because the prior auth was submitted as the hospital (which incidentally also had its claim in the mid six figures denied) and not the surgeon and that the surgeon had also needed to submit another authorization. When I checked with the surgeon, his office says that what they did is standard practice.

Whether or not it was the correct way to submit it, I’m not sure how I could have possibly known about this very specific detail, which the majority of the representatives who I contacted at Cigna were also unaware of. Even if I had known it had to have been submitted as the surgeon, on the Cigna portal, the prior authorization shows the surgeon’s name and not the hosptial’s. It also doesn’t show what tax id was submitted with the request. It also seems excessive for me to have to know to do this (and to also have to know what the surgeon’s tax id vs the hospitals tax id is before this process). Also, in the past I have had this exact same situation (provider out of network, hospital in network) covered just fine with only one prior authorization.

At this point, the representative has recommended that I send in an appeal. Does anyone have any recommendations on what I should put into the appeal or if there is any action I should take before initiating the process? And does it even have a reasonable chance of success?