Took my 8yo to the ER for severe stomach pain - turned out to be appendicitis. Aetna is denying the visit as 'non-emergency' because she didn't need IV pain meds before surgery.

Sunday around 11pm my daughter started crying about stomach pain that would not let up. By 1am she was pale, shivering, and could not stand up straight. The on call nurse line told us to go to the ER. We went to the closest hospital, which thankfully is in network. Five hours, two scans, and a surgical consult later they confirmed acute appendicitis and admitted her for surgery the next morning. Surgery went fine, she is home and recovering.

Two weeks later we got the explanation of benefits. Aetna paid the surgery and the hospital stay, but they denied the actual ER visit charges (about $4,200) as "did not meet medical necessity criteria for emergency care." Their reasoning, written verbatim in the letter: "patient was ambulatory upon arrival, vital signs were not critical, and patient did not require IV analgesia prior to imaging."

I am sorry, did they want me to wait until her appendix burst? Every single thing the nurse line told us to watch for was happening. The hospital actually admitted her and operated within 12 hours. How is that "non-emergency"?

Has anyone successfully appealed something like this? The hospital billing rep on the phone told me they get this from Aetna all the time and recommended I file the appeal myself first before they get involved. Is that the right move or should i be pushing the hospital to fight it on their end? I have 180 days but i want to do this right.