Anthem denied prior auth for my 9 year old's tonsillectomy/adenoidectomy after a sleep study showed severe pediatric OSA (AHI of 14) - genuinely stuck on what to do next

looking for advice from anyone who has been through a pediatric pre-auth denial. my son is 9, has been snoring loud enough to hear from down the hall for almost 2 years, sleeps with his mouth open, wakes up 4-5 times a night, falls asleep during dinner sometimes, and his teacher has flagged that he zones out by 10am most mornings. ENT we saw in march did a scope and said his tonsils are 3+ and adenoids are obstructing about 80% of his nasopharyngeal airway. he ordered an in-lab polysomnography because Anthem (our PPO through my wife's employer) requires it before pre-authing T&A in kids over 7.

we did the sleep study at the in-network pediatric sleep lab in late april. results came back showing AHI of 14.2 (severe by pediatric standards, where >10 is severe), oxygen nadir of 84%, and pretty significant sleep fragmentation. the sleep medicine doc and the ENT both wrote letters of medical necessity. ENT submitted the prior auth on may 6. Anthem denied it on june 2 with the explanation that "criteria for surgical intervention not met, recommend trial of conservative management including nasal steroids x 12 weeks and weight management." our kid is in the 45th percentile for weight, the ENT had already trialed fluticasone for 3 months in winter, and the sleep study was specifically ordered AFTER conservative management failed. like, the denial reads like it was generated without reading the chart.

questions for anyone who has fought this kind of thing:

1) what is the realistic timeline on a first-level appeal for a pediatric surgery prior auth at Anthem? our ENT is submitting one this week with all the documentation but i have read appeals can take 30-45 days and our kid is genuinely struggling. is there a way to flag this as urgent or expedited given the OSA severity?

2) if first-level appeal gets denied, do we go to external review through our state DOI, or is there a peer-to-peer step in between that is worth doing? i have heard mixed things about peer-to-peer (sometimes useful, sometimes a way for the insurer to "document" they tried).

3) anyone ever successfully gotten a pediatric T&A approved on appeal when the carrier insisted on more conservative management first? what was the magic argument?

4) do we have any leverage to push this faster, or is the answer "wait and pray"? watching him struggle with this is killing me and the ENT said every month of untreated severe OSA in a kid this age has long-term consequences.

thanks in advance. first time dealing with an actual denial and not really sure of the playbook.