859 N.W.2d 672
Iowa Ct. App.2014Background
- Connor Gjerde, born 2003, has cerebral palsy and developmental delay and was insured under a UnitedHealthcare (United) policy that covers services that are “medically necessary.”
- In June–July 2011 Connor received fifteen intensive therapy sessions at Hyperbaric Healing Institute (HHI)/Beyond Therapy billed as physical therapy; sessions were ~3 hours each over three weeks and totalled $9,050.
- United denied reimbursement, determining the services were sensory integration therapy, therasuit use, and hyperbaric oxygen therapy —which United’s coverage policies describe as unproven/non-covered for cerebral palsy—and therefore not “medically necessary.”
- The Gjerdes exhausted internal appeals and sought external review under Iowa Code ch. 514J; the independent review organization (MAXIMUS) upheld United’s denial, finding the services were not physical therapy and that sensory/therasuit treatments were unproven.
- The district court, bound by MAXIMUS’s factual findings, affirmed the external review as to sensory integration and therasuit therapy but declined to affirm as to hyperbaric oxygen therapy because MAXIMUS’s findings on that treatment were unclear.
- Both parties appealed; the court of appeals affirmed the district court in full, holding the policy covers only medically necessary services consistent with accepted medical practice and MAXIMUS’s factual findings that sensory/therasuit treatments were unproven supported denial of coverage.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the intensive services at HHI are covered as "physical therapy" under the United policy | Gjerdes: bills/prescription labeled "physical therapy" and treatments were prescribed by pediatrician; thus covered | United: services were sensory integration, therasuit, and hyperbaric O2 —unproven/non-covered, not physical therapy | Held: MAXIMUS’s factual finding that services were sensory/therasuit (not physical therapy) is binding; denial affirmed for those services |
| Whether sensory integration and therasuit therapy are "medically necessary" under policy definition | Gjerdes: treating provider called therapy medically necessary and records describe physical therapy services | United: coverage criteria require consistency with generally accepted medical practice; policies classify sensory/therasuit as unproven/non-covered | Held: Court: lack of scientific evidence means not consistent with generally accepted practice; sensory/therasuit not covered |
| Whether the external reviewer considered required materials under Iowa Code §514J.107(12) | Gjerdes: MAXIMUS failed to consider requisite evidence and criteria | United: MAXIMUS reviewed medical records, provider letters, policy, and carrier materials per statutory list | Held: MAXIMUS considered the listed items; its review complied with §514J.107(7)–(12) |
| Whether denial as to hyperbaric oxygen therapy can be affirmed | Gjerdes: all services billed as PT; unclear whether HBO was provided or billed | United: HBO is unproven for cerebral palsy per its policy and was referenced in records | Held: Court of appeals: MAXIMUS’s factual finding that HBO was provided is binding though record is unclear; absence of billing/claims makes HBO a non-issue; affirmed district court’s disposition (no error) |
Key Cases Cited
- Boelman v. Grinnell Mut. Reins. Co., 826 N.W.2d 494 (Iowa 2013) (insurance policy interpretation reviewed for errors at law)
- Meier v. Senecaut, 641 N.W.2d 532 (Iowa 2002) (issues not raised and decided below are ordinarily not considered on appeal)