                   IN THE COURT OF APPEALS OF IOWA

                                  No. 13-1624
                           Filed November 13, 2014


RYAN GJERDE and JAMIE GJERDE,
Individually and as the Legal Representatives
of CONNOR GJERDE,
       Plaintiffs-Appellants,

vs.

UNITEDHEALTHCARE PLAN OF THE
RIVER VALLEY, INC. d/b/a UNITEDHEALTHCARE,
     Defendant-Appellee.
________________________________________________________________
     Appeal from the Iowa District Court for Polk County, Douglas F. Staskal,

Judge.



      Insureds appeal, and the insurer cross-appeals, the district court’s judicial

review decision of an external review decision under Iowa Code chapter 514J

(2013). AFFIRMED ON BOTH APPEALS.



      Michael S. Jones of Patterson Law Firm, L.L.P., Des Moines, for

appellants.

      Sarah E. Crane and Michael C. Richards of Davis, Brown, Koehn, Shors

& Roberts, P.C., Des Moines, and Archana Nath, Michael J. Vaneselow, and

Ranelle Leier of Oppenheimer Wolff & Donnelly LLP, Minneapolis, Minnesota, for

appellee.



      Heard by Danilson, C.J., and Doyle and Tabor, JJ.
                                        2


DOYLE, J.

       Ryan and Jaime Gjerde challenge the district court’s judicial review

decision under Iowa Code chapter 514J (2013) of an external review decision

upholding the denial of coverage by UnitedHealthcare Plan of the River Valley,

Inc., doing business as UnitedHealthcare (“United”), for certain intensive therapy

services for their son’s cerebral palsy and developmental delay. United cross-

appeals, challenging the district court’s failure to determine whether one of the

services at issue was covered under the insurance policy. Because the district

court committed no error in concluding the services at issue were not covered

under the United policy, we affirm on both appeals.

I.     Background Facts and Proceedings

       Ryan and Jaime Gjerde are the parents of Connor Gjerde. Connor was

born in 2003 and has cerebral palsy and developmental delay.          At all times

relevant to this proceeding, Connor was covered by a health insurance policy

from United, which Jaime obtained through her employment with the Ankeny

school district.

       The United policy provided coverage for health care expenses that were

“medically necessary.” The term “medically necessary” was defined in the policy

as meeting the following criteria:

               4.3.1 The service or treatment is consistent with generally
       accepted principles of medical practice for the diagnosis and
       treatment of the Member’s medical condition; and
               4.3.2 The service or treatment is performed in the most cost-
       effective manner in terms of treatment, method, setting, frequency
       and intensity, taking into consideration the Member’s medical
       condition.
                                          3


Section 8 of the policy listed “Exclusions,” including: “Any service or treatment,

Hospital, medical, or otherwise, which is not medically necessary as described

and defined in section 4.3 . . . .”

       In June and July 2011, Connor received fifteen “intensive physical

therapy” sessions at the Hyperbaric Healing Institute (“HHI”) in Kansas City,

Missouri.1     The treatments were prescribed by Connor’s Ankeny, Iowa,

pediatrician. The fifteen sessions at issue were approximately three hours each

and were scheduled five days each week for three weeks between June 13 and

July 1, 2011. HHI charged $650 for the initial session and $600 for each of the

following fourteen sessions, for a total of $9050.       Although United had paid

claims for similar treatments prescribed for Connor in the past,2 United refused to

reimburse the Gjerdes for Connor’s June and July 2011 therapy sessions at HHI

upon determining the services were not “medically necessary” within the terms of

the United policy.

       The Gjerdes appealed United’s denial, claiming that under the United

policy, Connor was entitled to sixty days of outpatient physical therapy. United

did not dispute the Gjerde’s coverage for physical therapy, but stated the

intensive therapy Connor had received at HHI was sensory integration therapy

and hyperbaric oxygen therapy—both of which were “unproven treatment for a

diagnosis of cerebral palsy and developmental delay,” not medically necessary,

and therefore excluded from coverage under the United policy.

1
  The Gjerdes refer to this healthcare service provider as “Beyond Therapy,” and state
that “[b]ills for treatment at Beyond Therapy were submitted through [HHI].” Connor’s
physical therapy evaluation and his physical therapy discharge summary are on “beyond
therapy” letterhead.
2
  According to United, it “only paid for [the prior] treatment due to oversight.”
                                          4


       Upon exhausting United’s internal grievance process, the Gjerdes

requested an external review of United’s decision with the Iowa Insurance

Commissioner pursuant to Iowa Code chapter 514J.3                  See Iowa Code

§§ 514J.105    (“A   covered    person    or   the   covered    person’s   authorized

representative may make a request for an external review of a final adverse

determination.”); 514J.102(1)(a) (“‘Adverse determination’ means a determination

by a health carrier that [a] health care service . . . that is a covered benefit has

been reviewed and, based upon the information provided, does not meet the

health carrier’s requirements for medical necessity, appropriateness, health care

setting, level of care, or effectiveness, and the requested service or payment for

the service is therefore denied . . . .”); see also id. § 514J.106(1) (providing that

in general, “a request for an external review shall not be made until the covered

person or the covered person’s authorized representative has exhausted the

health carrier’s internal grievance process and received a final adverse

determination”).      The   commissioner       assigned   an    independent    review

organization, MAXIMUS, Inc., to conduct the external review.                  See id.

§§ 514J.107 (providing standards for external review); 514J.111 (providing for

approval of independent review organizations); 514J.112 (listing requisite

qualifications for independent review organizations).


3
 “The purpose of this chapter is to provide uniform standards for the establishment and
maintenance of external review procedures to assure that covered persons have the
opportunity for an independent review of an adverse determination or final adverse
determination made by a health carrier . . . .” Iowa Code § 514J.101. “The health care
external review process, which the [Affordable Care Act] requires and Iowa codified in
Chapter 514J, provides significant consumer protections that will generally make it
easier and less costly for covered persons to challenge an insurer’s adverse benefit
determinations.” Wade S. Hauser, Does Iowa’s Health Care External Review Process
Replace Common-Law Rights?, 99 Iowa L. Rev. 1401, 1429 (2014).
                                          5


       Following its review under section 514J.107, MAXIMUS issued a written

decision regarding United’s denial of coverage. MAXIMUS found the services

Connor received at HHI were “hyperbaric oxygen therapy, therasuit[,] and

sensory integration,” which according to its “physician consultant[,] were not

physical therapy services.” MAXIMUS upheld United’s denial of coverage on the

basis that the “sensory services” provided to Connor by HHI were “unproven for

treatment of [Connor’s] condition” and therefore excluded from coverage under

the terms of the United policy.

       The decision of the independent review entity is binding upon the

insurance carrier. Id. § 514J.110(1). An insured, however, “may appeal the

external review decision made by an independent review organization by filing a

petition for judicial review” within fifteen business days of the review decision. Id.

§ 514J.110(2)(a). Here, the Gjerdes filed a petition for judicial review appealing

the external review decision.

       Following a hearing and receipt of the parties’ written arguments, the

district court entered a ruling on judicial review.    Quoting language from the

United policy, the district court observed the coverage question rested with

whether the services denied by United were medically necessary, i.e., whether

the particular forms of therapy at issue were “consistent with generally accepted

principles of medical practice for the diagnosis and treatment of [Connor’s]

medical condition.” Citing section 514J.110(2)(b), the court acknowledged it was

bound by MAXIMUS’s fact findings, and therefore its role was “limited to

determining whether the reviewer’s ultimate legal conclusion—that the United

Policy does not cover the services in question—is erroneous.”
                                           6


        With regard to sensory integration therapy and use of a therasuit, the court

acknowledged MAXIMUS’s finding of no scientific evidence to support the use of

these services for Connor’s condition, and stated, “[P]rescribing treatments for

whose efficacy there is ‘no scientific evidence’ cannot be ‘consistent with

generally accepted principles of medical practice.’” The court therefore affirmed

the external review decision concluding that “‘therasuit and sensory integration

therapy’ are not covered under the United policy.”

        With regard to hyperbaric oxygen therapy, however, the court noted its

review of the MAXIMUS decision left it unable to determine if MAXIMUS

specifically addressed whether hyperbaric oxygen therapy was covered under

the United policy. Ultimately, the court concluded it could not “affirm a review

decision on a particular treatment when it is not even clear that the reviewer

made a decision to review.” The Gjerdes appeal, and United cross-appeals, from

the district court’s ruling.4, 5




4
  After these appeals were filed, the Iowa Supreme Court entered an order, sua sponte,
directing the parties to brief the additional issues of whether Iowa Code section
17A.19(6) required records to be certified by the agency to the reviewing court when the
parties stipulated to shorten the record, or whether section 17A.19(6) required the
agency to participate in any stipulation to shorten the record. Although “[t]he
commissioner may adopt rules pursuant to chapter 17A to carry out the provisions of this
chapter,” see Iowa Code § 514J.117, “[t]he [chapter 514J] external review process shall
not be considered a contested case under chapter 17A.” Id. § 514J.110(1). Considering
these sections together, we conclude this proceeding is not subject to the section
17A.19(6) agency certification requirements.
5
  There are approximately 220 pages of documents in the parties’ appendix. In an
ordinary proceeding, these documents would have been marked, identified, offered, and
received as discrete exhibits, and those exhibits would have been identified by exhibit
number or letter and concisely described in the table of contents of the appendix. See
Iowa R. App. P. 6.905(4)(c). Such is not the case here because the documents were not
separately numbered or identified when submitted under chapter 514J procedures.
Nevertheless, it would have been helpful in our navigation of the appendix had the
parties listed and identified each document in the table of contents.
                                           7


II.    Scope and Standard of Review

       In an appeal under Iowa Code chapter 514J, “[t]he findings of fact by the

independent review organization conducting the external review are conclusive

and binding.” Id. § 514J.110(2)(b). As the district court aptly noted, “Chapter

514J otherwise establishes no standards whatsoever for review by the court of a

challenged external review decision.” “The external review process shall not be

considered a contested case under chapter 17A.” Id. § 514J.110(1). “We use

the errors at law standard when our decision rests upon the interpretation of an

insurance policy.” Boelman v. Grinnell Mut. Reins. Co., 826 N.W.2d 494, 500

(Iowa 2013). We review the district court’s ruling on judicial review for correction

of errors at law. Iowa R. App. P. 6.907.

III.   Discussion

       On appeal, the Gjerdes claim the medical bills denied by United “were for

physical therapy prescribed as medically necessary by Connor Gjerde’s

pediatrician and administered under the direction of a licensed physical therapist,

and therefore the trial court erred by not finding coverage under the United[]

policy which is supposed to pay for physical therapy.” The Gjerdes challenge the

external review decision by MAXIMUS finding the services provided to Connor

were not physical therapy.6      On cross-appeal, United challenges the district


6
  The Gjerdes point out that United “does not contend that the treatment in question is
experimental or investigational,” and therefore claims those grounds would not be a
basis to uphold United’s denial of coverage. We agree. Although “experimental or
investigational treatment” are recognized grounds to deny coverage, see Iowa Code
§ 514J.109, United has not relied on those grounds throughout these proceedings and
any such claim is therefore not preserved for our review. See Meier v. Senecaut, 641
N.W.2d 532, 537 (Iowa 2002) (“It is a fundamental doctrine of appellate review that
issues must ordinarily be both raised and decided by the district court before we will
decide them on appeal.”).
                                            8


court’s failure to determine whether coverage for hyperbaric oxygen therapy

received by Connor was properly denied under the United policy. We address

these issues together.

       In support of their contention that all services should be covered as

“physical therapy,” the Gjerdes point to documents from Connor’s treating

pediatrician in Iowa prescribing—in general terms—physical therapy for Connor

and describing the physical therapy as medically necessary for his condition.

They contend the bills that were submitted from HHI “were for physical therapy,

not hyperbaric oxygen treatments, therasuit[,] or sensory integration therapy.”

They further emphasize the health records from HHI contain detailed information

regarding the services performed on Connor, which they claim is “within the

ordinary meaning of ‘physical therapy.’”

       We observe the billing documents from HHI for Connor’s intensive therapy

services generally listed the “Type of Service” as “P/T Physical Therapy

(Unmodified).” The bills list codes for the procedures performed such as “97112”

and “97530.”7 Throughout these proceedings, the Gjerdes have taken an all-or-

nothing approach by relying on the presence of the term “physical therapy” on

documents from HHI and Connor’s pediatrician to claim the services should be

covered under the United policy.         Indeed, the United policy’s “Schedule of

Benefits” includes the following coverage for physical therapy:




7
  June 13 also listed a third code for “97001,” which was not on the billing documents for
the other days. Aside from general assertions, it does not appear either party presented
specific evidence to prove what these codes actually stand for.
                                           9


                              Benefits Through              Benefits Through Point-
Coverage Category             Network Providers             of-Service Providers

Outpatient Rehabilitative     90% of Allowed Charge         80% of Allowed Charge
Therapy (Physical/            after Deductible has been     after Deductible has been
Occupational/Speech)          met. Maximum 60               met. Maximum 60
                              outpatient Network and        outpatient Network and
                              Point-of-Service              Point-of-Service
                              treatment days per            treatment days per
                              calendar year. The 60         calendar year. The 60
                              outpatient Network and        outpatient Network and
                              Point-of-Service              Point-of-Service
                              treatment days are            treatment days are
                              combined.                     combined.

       Upon United’s receipt and inspection of the bills, however, it determined

the specific services provided at the sessions were sensory integration therapy

and hyperbaric oxygen therapy. For whatever reason, it appears in previous

years—when similar treatments for Connor were covered by United—they had

been coded solely as “physical therapy.” Prompted by an outside investigation

into its billing practices, however, HHI began coding the treatments as sensory

integration therapy and hyperbaric oxygen therapy.8

       In denying the Gjerdes’ appeal of its coverage decision, United stated in

part, “Hyperbaric Oxygen Therapy and Sensory Integration Therapy are

unproven treatment for a diagnosis of cerebral palsy and developmental delay.”

United further stated:

8
  As United points out in its brief, it appears portions of Connor’s treatment plan and
evaluation from HHI are missing from the record. Specifically, on the section of the
physical therapy evaluation form providing Connor’s specific treatment plan, several
boxes are checked, but the spaces corresponding to the checked boxes (to describe the
forms of treatment) are blank. This is in contrast to other sections of the same document
in which checked boxes correspond with textual descriptions. United suggests the HHI
“records were altered before they were submitted, in order to remove references to
treatments that would not be covered [United’s policy].” We also note references in the
record with regard to Jaime Gjerde’s contact with United during the internal grievance
process, during which she apparently questioned United whether it would pay for the
therapy claims “if they didn’t use the therasuit.”
                                        10


      The decision was made to deny your request to cover services
      received from Hyperbaric Healing Institute. This decision was
      based on your Certificate of Coverage with Preferred Family
      Pharmacy which states in Article 4.3 that benefits will be paid only
      for a service, procedure, treatment, supply, device, or item,
      Hospital, medical or otherwise, which is medically necessary.

      United relied on the policy criteria provided in sections 4.3.1 and 4.3.2 (set

forth above) requiring a service or treatment to be medically necessary for

coverage, and further stated, “Your contract also excludes services or treatments

which are not medically necessary as stated in Article 8.1, please refer to the

enclosed plan language which explains your benefits and the UHC coverage

policies on sensory integration and hyperbaric oxygen therapy.”

      It is not crystal clear from the record as to what was actually enclosed with

the denial letter to the Gjerdes, but the letter references “enclosed . . . [United]

coverage policies on sensory integration and hyperbaric oxygen therapy.”

United’s “Coverage Policy Library” describes specific services and treatments,

sets forth whether the specific services or treatments are covered or not covered,

and provides detailed “Coverage Rationale” to explain the coverage decision.

The listing for “Sensory Integration Therapy” states: “This policy describes the

use of sensory integration therapy for treatment of learning disabilities,

developmental delays, and putative sensory integration disorders. The goals of

this procedure vary but can include improvement of sensory integration function,

fine motor skills, locomotor abilities, behavior, and academic performance.” The

therapy description states that sensory integration therapy can use “weighted

vests and blankets [such as a therasuit] to encourage a noncognitive, creative,

and explorative process,” noting, “The Therasuit is a modification of a space suit
                                            11


. . . used to treat patients diagnosed with cerebral palsy . . . and many other

neurological disorders.” The “Coverage Status” for sensory integration therapy is

listed as “Non-Covered.”        The “Coverage Rationale” stated in part: “Sensory

integration therapy is unproven for the treatment of any condition . . . .”

       The Coverage Policy Library describes “Hyerbaric Oxygen Therapy and

Topical Oxygen Therapy” as “involv[ing] the systemic administration of pure

gaseous oxygen under pressures greater than 1 atmosphere.                  Hyperbaric

oxygen therapy is used for a variety of conditions, including carbon monoxide

poisoning and tissue injury due to thermal burns, radiation exposure, trauma,

surgery, or infection.” This type of therapy is listed as a treatment that “Requires

Prior Authorization,” with the “Coverage Rationale” stating in part: “Hyperbaric

oxygen (HBO) therapy is unproven for the following clinical conditions: . . .

cerebral palsy . . . .” No pre-authorization is disclosed in the record.

       As the independent review organization, MAXIMUS analyzed anew the

terms of coverage of the United policy at issue and United’s decision denying

coverage for Connor’s June and July 2011 therapy sessions. See Iowa Code

§ 514J.107(10) (“In reaching a decision the independent review organization is

not bound by any decisions or conclusions reached during the health carrier’s

internal grievance process.”).       As part of its review, MAXIMUS considered

medical records from the HHI detailing the treatment provided, letters from

Connor’s pediatrician and Connor’s mother describing the intensive therapy as

“medically   necessary     to    continue    his   progress,”   and   other   relevant

documentation submitted for review. In its written decision, MAXIMUS upheld

United’s denial of coverage on the basis that the “sensory services” provided to
                                            12


Connor by HHI were “unproven for treatment of [Connor’s] condition.”                   As

MAXIMUS’s external review decision stated in part:

              The MAXIMUS physician consultant explained that the
       services that the covered person received from 6/1/11 to 7/1/11
       were hyperbaric oxygen therapy, therasuit and sensory integration.
       The MAXIMUS physician consultant also explained that these
       services were not physical therapy services. The MAXIMUS
       physician consultant indicated that there is no scientific evidence to
       support the use of therasuit and sensory integration therapy for
       treatment of this covered person’s diagnosis. The MAXIMUS
       physician consultant also indicated that therasuit and sensory
       integration therapy would be considered experimental/
       investigational/unproven for treatment of the covered person’s
       diagnosis.      Therefore, the MAXIMUS physician consultant
       concluded that the sensory services that the covered person
       received from 6/1/11 to 7/1/11 were unproven for treatment of his
       condition.
              Accordingly, MAXIMUS upholds the Carrier’s denial of
       coverage for the sensory services that the covered person received
       from 6/1/11 to 7/1/11.[9]

9
  The record does not reflect that Connor actually received any hyperbaric oxygen
therapy during the fifteen physical therapy sessions at issue. The records for each
session make no reference to any such therapy, nor does the discharge summary, which
also describes the treatment Connor received. The only record reference to hyperbaric
oxygen therapy is from Dr. Schutte-Schenck, the Ankeny pediatrician who prescribed
physical therapy for Connor. Her plan, included in a pediatric office visit note dated June
1, 2011, states: “4 wks hyperbaric.” In a July 6, 2011 “to whom it may concern” letter,
Dr. Schutte-Schenck stated: “Connor is also undergoing physical therapy treatment at a
facility in Kansas City, in conjunction with hyperbaric oxygen treatments.”
          Furthermore, although the record does not enlighten us as to service descriptions
for the billing code numbers submitted by HHI in Connor’s case, it appears from the
record that when HHI ordinarily billed for hyperbaric oxygen therapy, it utilized the
number 99183, a billing code number not submitted by HHI in Connor’s case.
Additionally, in a March 9, 2012 letter to United’s appeal department, Connor’s mother
stated, “No claims for Hyperbaric Oxygen Therapy . . . were submitted.”
          We are statutorily bound by the external reviewer’s fact finding that Connor
received hyperbaric oxygen therapy during the sessions in question. Iowa Code
§514J.110(2)(b) (“The findings of fact by the independent review organization
conducting the external review are conclusive and binding on appeal.”) (emphasis
added). Nevertheless, we find MAXIMUS’s finding regarding hyperbaric oxygen
treatment to be highly suspect. The district court’s characterization of MAXIMUS’s
“sloppy use of language” is spot-on.
          At the end of the day, whether or not Connor received hyperbaric oxygen
treatment appears to be a non-issue. There is nothing in the record to indicate the
Gjerde’s were ever billed for such treatment, and in any event, there is nothing in the
record indicating such billing was submitted to United. With no bills for the treatment
                                         13


       Citing Iowa Code section 514J.107(12), the Gjerdes point to certain types

of information that “shall” be considered by the independent review organization

in determining whether an insured’s coverage decision is contrary to the terms of

the policy. That subsection provides:

       In addition to the documents and information provided to the
       independent review organization pursuant to this section [i.e.,
       information submitted by the insured, see subsection 514J.107(7);
       information submitted by the insurer, see subsection 514J.107(8)],
       the independent review organization shall, to the extent the
       information or documents are available and the independent review
       organization considers them appropriate, consider the following in
       reaching a decision:
               a. The covered person’s pertinent medical records.
               b. The treating health care professional’s recommendation.
               c. Consulting reports from appropriate health care
       professionals and other documents submitted by the health carrier,
       covered person, or the covered person’s treating physician or other
       health care professional.
               d. The terms of coverage under the covered person’s health
       benefit plan with the health carrier, to ensure that the independent
       review organization’s decision is not contrary to the terms of
       coverage under the covered person’s health benefit plan with the
       health carrier.
               e. The most appropriate practice guidelines, which shall
       include applicable evidence-based standards and may include any
       other practice guidelines developed by the federal government,
       national or professional medical societies, boards, and
       associations.
               f. Any applicable clinical review criteria developed and used
       by the health carrier.
               g. The opinion of the independent review organization’s
       clinical reviewer after considering the information or documents
       described in paragraphs “a” through “f” to the extent the information
       or documents are available and the clinical reviewer considers
       them relevant.




having been submitted, it is immaterial as to whether or not the treatment was covered
or not covered, or subject to pre-approval, under United’s policy, and it is therefore
immaterial to this appeal that MAXIMUS made no decision concerning United’s denial of
coverage for such treatment. Accordingly, we affirm on United’s cross-appeal of that
issue.
                                          14


Iowa Code § 514J.107(12). Insofar as the Gjerdes contend the external review

by MAXIMUS did not include a consideration of the requisite information, we

disagree.       At the outset of its external review decision, MAXIMUS listed the

“Documentation Submitted for Review,” including:

                Letter from the Iowa Insurance Division regarding the
                 Independent Review Organization [IRO] selection dated
                 4/6/12.
                Carrier coversheet.
                Letters from the member’s mother dated 3/8/12 and 4/10/12.
                Carrier correspondence about the appeals.
                Carrier Contact Service Form.
                Carrier screen prints.
                Member Appeal Request Form.
                Letter from Dr. Schutte-Schenck [Connor’s pediatrician]
                 dated 7/6/11.
                Copy of a prescription for physical therapy for the covered
                 person.
                Portions of the Carrier’s contract.
                Medical records.
                Carrier Claims inquiry screen prints.
                Health Insurance Claim forms.
                Carrier policy regarding sensory integration therapy.
                Carrier policy regarding hyperbaric oxygen therapy and
                 topical oxygen therapy.
                Carrier email.
                Carrier Appeal Summary.
                Carrier denial letter.
                Physical therapy records [from HHI].

We conclude MAXIMUS’s reviewed the requisite information as set forth in

section 514J.107(7)-(12) (describing the information an independent review

organization should consider in its review) in reviewing the Gjerdes’ claim.

      MAXIMUS found the services Connor received at HHI were “hyperbaric

oxygen therapy, therasuit[,] and sensory integration,” which according to its

“physician consultant[,] were not physical therapy services.” MAXIMUS found

the “sensory services” provided to Connor by HHI were “unproven for treatment
                                           15


of [Connor’s] condition.” MAXIMUS further found “there is no scientific evidence

to support the use of therasuit and sensory integration therapy for treatment of

[Connor’s] diagnosis.”      Judicial review of MAXIMUS’s findings is severely

circumscribed by statute.      “The findings of fact by the independent review

organization conducting the external review are conclusive and binding.”              Id.

§ 514J.110(2)(b).10 The district court concluded, “It is obvious that prescribing

treatments for whose efficacy there is ‘no scientific evidence’ cannot be

‘consistent with generally accepted principles of medical practice.’” We agree.

       As discussed above, the United policy provided coverage only for health

care expenses “consistent with generally accepted principles of medical practice

for the diagnosis and treatment of the Member’s medical condition.” The district

court did not err in affirming “the MAXIMUS review decision that ‘therasuit and

sensory integration therapy’ are not covered under the United policy.”

Consequently, we affirm the district court’s ruling.

       AFFIRMED ON BOTH APPEALS.




10
  While the external review process makes it easier and less costly for an insured to
challenge a denial of coverage, the process has its limitations. “[I]t does not contain a
procedure for depositions or live testimony. The external review process also likely
prevents a covered person from presenting additional evidence in the district court
demonstrating that the [IRO] erred.” See Hauser, 99 Iowa L. Rev. at 1428-29.
