Aetna denied prior authorization for my wife's hip arthroscopy citing 'not medically necessary' despite 18 months of failed conservative treatment. Surgery is scheduled in 3 weeks. How do I escalate fast?

My wife is 41, had a labral tear on her left hip diagnosed by MRI back in November 2024. Since then she has done 14 months of physical therapy (3 separate scripts, 36 total sessions), two corticosteroid injections, an NSAID trial, and an unsuccessful PRP injection in December. Pain has progressed to the point she cannot sleep on that side and is missing about 1 day of work per week. The orthopedic surgeon at Hospital for Special Surgery in NYC recommended hip arthroscopy with labral repair and femoroacetabular impingement correction. Surgery is on the books for June 9.

Aetna denied the prior authorization yesterday. The denial letter says the requested procedure is "not medically necessary based on review of submitted documentation" and cites InterQual criteria. It also says we did not meet the requirement of "completion of conservative therapy" which is absurd because we sent them PT notes, injection records, imaging, and surgeon documentation. The reviewer was a non-orthopedic medical director per the bottom of the letter.

I have already called the surgeon's office and they are willing to do a peer to peer review with Aetna's medical director. The denial letter says we can request a peer to peer within 5 business days. We can also file an expedited internal appeal because surgery is scheduled within 30 days and a delay would cause continued pain and functional decline. After internal appeal we can go to external review through the New York Department of Financial Services.

My questions for anyone who has been through this. Does the surgeon's peer to peer typically reverse these denials or is it mostly a formality? Should I file the expedited internal appeal in parallel with the peer to peer or wait to see if peer to peer works? And how fast does NY DFS external review actually move when you tell them surgery is scheduled? I need to keep this surgery date if at all possible because rescheduling at HSS pushes us into late August.