Billed for add-on measurement that insurance isn’t covering. Pre-authorization and appeals questions.

I had COVID at the beginning of May. For over 4 months after that, I had intermittent chest pain basically every day. I went to my doctor in June and she ordered an echocardiogram, which I promptly scheduled and completed in July. The order listed on my notes was for echocardiogram and the appointment is listed an a Transthoracic Echocardiogram Complete. In addition to the echo, the provider billed for myocardial strain imaging using speckle tracking. This analysis or measurement isn't listed on the order by my doctor. Insurance is covering the echo, but not the myocardial strain imaging.

If it's helpful, I have BCBS Federal Employee Program, and it's pretty clear in their documents that this CPT code is not covered because it's considered "experimental."

I've had quite a few tests and procedures over the past two years including MRIs, CT scans, etc., and I've always been told by this medical provider while scheduling that they will call me if the procedures aren't pre-approved by my insurance, so I didn't think that I would have any surprises after the fact.

So I have a couple questions, I guess.

Can someone help me understand the process whereby pre-authorization happens? Would all the CPT codes be included when the medical provider is trying to get pre-authorization? If so, is it common that a CPT code would be added after the fact?

It does look like this CPT code is covered by CMS. Is it common or normal for CPT codes covered by the federal government to be considered "experimental" by other insurers? Especially insurers covering federal employees?

Are peer-to-peers common? The billing office at my medical provider said "we don't do that," but I feel like this is something I've heard happening before.

The first appeal where the insurer was sent my medical records was denied, so I'm just trying to gain as much info about this as possible before determining my next steps.

Thanks for reading.

submitted by /u/ReplacementPart
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