Insurance Change over

Hi all – hoping someone can help/provide feedback as my wife and I are at wits end:

My wife is a school teacher in NJ for over 20 years, and we’ve been on a Choice POS plan through Aetna/First Health since her school district switched over to them a few years ago. (We were promised at level or better service… POS seems like an appropriate acronym…)
She’s been dealing with severe issues in her lower back over the last two years – shooting pain up and down her legs, weakness in her lower half, difficulty climbing stairs or bending over. It’s completely limited her quality of life. As a teacher she needs to be on her feet all day in the classroom. By the time she gets home from work, she can’t manage much more than climbing the stairs to our house and laying in bed.

Over the summer, she consulted with a spinal surgeon who did some work on me a few years ago. He had MRIs taken to confirm severe spinal stenosis, gone through two separate bouts of PT (until they were so painful that she got them to write her out) and has gone through 3 rounds of steroid shots in her back/spine that have each provided relief for less than a week.

At this point, her surgeon concluded that she would require a three-level spinal fusion to fix these issues, and she was originally scheduled for surgery in late August. She pursued an additional diagnosis, which reinforced our surgeon’s original conclusion.

Aetna has refused her request for approval twice now, on the grounds that she doesn’t fulfill the criteria for surgery which include: photographic evidence of severe spinal compression (check), debilitating physical pain that limits her ability to live a normal pain-free life (check) and lack of responsiveness to other methods of treatment (check and check)

She’s had multiple 2+ hour phone calls with Aetna over the past few weeks to try to understand why we’re being denied, and how she can get the process back on track. No one can answer any of our questions, and the operators have hung up on her on multiple occasions (and she wasn’t being angry or abusive on the call, just firm) We’ve submitted multiple 50+ page briefs outlining her PT history, the history of her shots, current conditions, etc.

One additional point; the insurance company has requested a 1-1 consult with our surgeon and one of their medical professionals. He’s refused to do so, and we haven’t been able to get a reason why. Should we be concerned about this, or does he know something we don’t about how that conversation might get used/twisted to continue to deny service?

This feels like criminal neglect. She’s terrified of what work is doing to her body, and that she might have a fall or accident that will significantly impact her quality of life. She doesn’t WANT the surgery, but it’s the only path for her to a better quality of life.

What should we do next? I know approval processes can be brutal, but is it normal for an approval like this to take so long?

Thanks in advance for any advice you can provide.