Wilderness Therapy denials in California external review
In the California DMHC record, independent physician reviewers decided 16 published external-review cases involving Wilderness Therapyand overturned the plan’s denial in 12.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Wilderness Therapy denials
| Category | Decisions | Overturned |
|---|---|---|
| Depression | 7 | 14.3% |
| Anxiety | 3 | 33.3% |
| Autism Spectrum Disorder | 3 | 0% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 22.2% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 7 | 0% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for any or all of the wilderness therapy. Wilderness treatment has evolved a great deal in the last decade, transitioning from an unregulated field with limited consistent evidence to a more standardized treatment option, termed outdoor behavioral health treatment, that is more well-accepted as particularly effective in adolescents with substance use disorders, legal issues, at risk for long-term criminal behavior, and with significant mental health issues impacting academic and family functioning. Current medical literature supports the results for these various specific populations. Wilderness therapy programs, or outdoor behavioral health programs, are now more strictly monitored, and there is an accreditation body to certify outdoor behavioral health programs.
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for wilderness therapy.Findings: Two of three physician reviewers found that the current medical literature supports the use of wilderness therapy in this clinical setting. Behrens and colleagues noted that a longitudinal outcome study of wilderness therapy programs has shown that youth in the study experienced significant decreases in suicidal ideation, anxiety, depression, substance abuse, social conflict, sleep disruption, violence, as well as an overall reduction in externalizing behaviors such as impulsivity, defiance, and hostility. Furthermore, these youth demonstrated improvements in work and academic functioning during the follow-up portion of the study.
Where the denial was upheld
Findings: The physician reviewer found that The patient has requested reimbursement for wilderness therapy services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for wilderness therapy services and/or residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Wilderness Therapy, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY