Aetna denied my wife's emergency appendectomy as 'not medically necessary' after she was already on the operating table. Need help with the appeal

Looking for some sanity check here because this whole thing feels surreal. My wife (34, no chronic conditions) woke up on April 28th with severe right lower quadrant pain. By 6am she was vomiting and could barely stand. I drove her to the ER at our in-network hospital. They did a CT scan, diagnosed acute appendicitis with early signs of perforation, and told us she needed surgery within hours or she was going to rupture.

The hospital called Aetna for pre-cert from the ER. Aetna told them they could not approve it without "additional documentation" and to proceed and bill afterward. Surgery happened at 11:47am. Standard laparoscopic appendectomy, no complications, she went home the next day. Total billed: $48,200. We expected to hit our $6,000 out of pocket max and be done with it.

Got the EOB last week. Aetna denied the entire surgical claim. Reason listed: "Inpatient admission and surgical procedure not medically necessary based on review of submitted records. Could have been managed with observation and antibiotics." The hospital and surgeon are now coming after us for the full balance because the denial transferred liability. We owe almost $50k for a routine emergency appendectomy that Aetna's own pre-cert nurse told the ER to proceed with.

I have already filed the first level internal appeal with copies of the CT report showing the inflamed appendix, the surgeon's op note describing what he found, and the discharge summary. Has anyone successfully fought a "not medically necessary" denial on something this clear cut? Do i need to skip ahead to external review? Should i be calling the state insurance commissioner now or after the second denial? Im honestly losing sleep over the bill and i dont know if im playing this right.