Medical Policy



Subject: Wilderness Programs
Document #: MED.00122 Current Effective Date:    06/28/2017
Status: New Last Review Date:    05/04/2017

Description/Scope

This document addresses wilderness programs, including services such as adventure therapy or wilderness therapy when part of wilderness programs provided in an outdoor environment and proposed as a treatment option for a variety of medical conditions or behavioral health disorders.

Please see the following related documents for additional information:

Position Statement

Investigational and Not Medically Necessary:

Wilderness programs are considered investigational and not medically necessary for all indications.

Rationale

Wilderness programs offer a variety of different treatments in the outdoor setting. Adventure therapy (also known as wilderness adventure therapy or wilderness therapy) is one treatment option, providing an active, experiential and challenging approach to psychotherapy. Other services include education (known as, learning by doing), recreation, life skills training, counseling, and unique outdoor activities (for example, rock climbing, paddle boarding, surfing, hiking, ropes course, and kayaking) that are proposed to have a therapeutic impact. Wilderness programs are proposed to treat a variety of different medical conditions or behavioral health disorders. Individuals participate in individual, group, family and community activities with the aim of developing skills, self-confidence, decision making strategies, and a sense of purpose when tackling difficult tasks.

Wilderness programs are one of many strategies used in the treatment of medical conditions or mental health disorders. To date, wilderness programs have not been sufficiently studied to show effectiveness, safety, relevance, and/or reliability in peer-reviewed medical literature (Bowen, 2016; Cotton, 2013; Gelkopf, 2013; Schell, 2012; Shanahan, 2009; Zachor, 2017). Wilderness programs have not shown significant medical benefits for children, adolescents or adults with medical, including behavioral health, conditions.

Background/Overview

Wilderness programs have been proposed to be beneficial treatment for a variety of medical conditions, including behavioral health conditions. These programs have also been described as useful educational services and have been provided for individuals receiving attention through the criminal justice system. The merits of wilderness programs as an educational intervention or as services provided for individuals in the criminal justice setting are outside the scope of medical treatment.

Wilderness program treatment has been proposed to treat a wide range of medical conditions. Often the programs treat heterogeneous populations, complicating evaluation of effectiveness. The number of individuals receiving wilderness program treatment and reported in peer-reviewed medical studies is not sufficient to adequately evaluate either effectiveness or safety (Bowen, 2016; Cotton, 2013; Gelkopf, 2013; Schell, 2012; Shanahan, 2009; Zachor, 2017).

One particular condition that has received attention in the medical literature is traumatic brain injury (TBI). According to the Centers for Disease Control and Prevention (CDC), "a traumatic brain injury is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain" (CDC, 2016). These injuries are principally the result of motor vehicle accidents, violence, sports injuries, and falls. Individuals who have suffered a TBI often experience residual impairments affecting motor control, communication skills, social behavior and cognition. These deficits may result in a variety of alterations in the individual, including but not limited to changes in memory, language, attention and concentration, visual processing, reasoning, and problem-solving, as well as emotional and behavioral control. Psychosocial changes may include high levels of anxiety, depression and pervasive personal loss (for example, interpersonal relationships, social supports, employment, and leisure activity). Accordingly, TBI may have a profound effect on everyday functioning and independent living. The available medical literature does not show that wilderness program treatment of TBI is effective or safe.

Behavioral health disorders have been a focus of medical literature on the use of wilderness programs. The National Institute of Mental Health, in 2015 estimated that were nearly 9.8 million adults in the United States (U.S.) (4%) 18 years of age or older with severe mental illness (SMI), defined as a mental, behavioral or emotional disorder (excluding developmental and substance abuse disorders). According to the CDC approximately 9.4 million children (18%) aged 5-17 years in the U.S. have an emotional or behavioral difficulty reported by a parent to a health care provider or school staff. In June 2016, the American Psychiatric Association published an update to their Diagnostic and Statistical manual of Mental Disorders, Fifth edition (DSM-5). The update includes a definition for children/adolescents with serious emotional disturbances (SED), defined as children or/adolescents from birth to 18 years of age who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified. Psychiatric disorders can include a wide range of mental health diagnoses. The illnesses are described in current diagnosis sources (DSM-5, ICD-10-CM). The type of service needed reflects the gravity and acuity of symptoms. Determining the appropriate level and place of treatment is important for potential safety of the member as well as addressing the concerns of family members and society.

Residential treatment takes place in a structured facility-based setting with regular supervision by a treating psychiatrist. The outdoor environment characteristic of wilderness programs is distinct from the residential setting.  The wilderness program model includes community-based services with lodging options in the outdoors. Residential treatment is based on medically monitored treatment provided by a multidisciplinary team. Regular supervision by a psychiatrist is a critical aspect of residential care. Family involvement is characteristic of residential services. Wilderness programs do not meet the definition of clinical residential treatment centers, therefore are not considered residential treatment (American Academy Child & Adolescent Psychiatry [AACAP], 2010).

Definitions

Adventure therapy: Psychotherapeutic treatment that depends on an outdoor or especially physically taxing task to develop coping and life skills intended to improve the health, well-being and function of individuals with medical conditions or behavioral health disorders. As defined, synonymous with wilderness therapy.

Residential Treatment Center: Twenty-four (24) hours per day specialized treatment involving at least one physician visit per week in a facility-based setting.

Traumatic brain injury:  Damage to the brain caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Most instances of traumatic brain injury are the result of motor vehicle accidents, violence, sports injuries and falls.

Wilderness Program: A planned, systematic service approach that includes a variety of therapeutic services provided in the outdoor environment for individuals with medical conditions and behavioral health disorders.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

HCPCS  
T2036 Therapeutic camping, overnight, waiver; each session
T2037 Therapeutic camping, day, waiver; each session
   
Revenue Code  
1006 Behavioral Health Accommodations; Outdoor/Wilderness
   
ICD-10 Diagnosis  
  All diagnoses
   
References

Peer Reviewed Publications:

  1. Bowen DJ, Neill JT, Crisp SJ. Wilderness adventure therapy effects on the mental health of young participants. Eval Program Plann. 2016; 58:49-59.
  2. Cotton S. Outdoor adventure camps for people with mental illness. Australas Psychiatry. 2013; 21(4):352-358.
  3. Gelkopf M, Hasson-Ohayon I, Bikman M, Kravekz S. Nature adventure rehabilitation for combat-related posttraumatic chronic stress disorder: a randomized control trial. Psychiatry Res. 2013; 209(3):485-493.
  4. Mutz M, Muller J. Mental health benefits of outdoor adventures: results from two pilot studies. J Adolescence. 2016; 49:105-114.
  5. Ragsdale KG, Cox RD, Finn P, et al. Effectiveness of short-term specialized inpatient treatment for war-related posttraumatic stress disorder: a role for adventure-based counseling and psychodrama. J Trauma Stress. 1996; 9(2):269-283.
  6. Schell L, Cotton S, Luxmorre M. Outdoor adventure for young people with a mental illness. Early Interv Psych. 2012; 6:407-414.
  7. Shanahan L, McAllister L, Curtin M. Wilderness adventure therapy and cognitive rehabilitation: Joining forces for youth with TBI. Brain Inj. 2009; 23(13-14):1054-1064.
  8. Zachor DA, Vardi S, Baron-Eitan S, et al. The effectiveness of an outdoor adventure programme for young children with autism spectrum disorder: a controlled study. Dev Med Child Neurol. 2017; 59(5):550-556.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy Child & Adolescent Psychiatry. Practice Parameters for the assessment and treatment of children and adolescents with depressive disorders. 2007. Available at: http://www.jaacap.com/content/pracparam. Accessed on March 13, 2017.
  2. American Academy Child & Adolescent Psychiatry. Principles of care for the treatment of children and adolescents with mental illnesses in residential treatment centers. June 2010. Available at: https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/principles_of_care_for_children_in_residential_treatment_centers.pdf . Accessed on March 15, 2017.
  3. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on March 13, 2017.
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. DSM-5. Arlington, VA. 2016. Available at: http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. Accessed on March 14, 2017.
  5. Boston University Center of Psychiatric Rehabilitation. A Primer on the Psychiatric Rehabilitation Process. Available at: https://cpr.bu.edu/wp-content/uploads/2011/11/Primer-on-the-Psychiatric-Rehabilitation-Process.pdf . Accessed on March 14, 2017.
  6. National Committee for Quality Assurance (NCQA). Definition of severe and persistent mental illness (SPMI). 2014. Available at: http://app04.ncqa.org/faq/FAQReportList.asp?Product=146&PrintReport=Select+Report. Accessed on March 14, 2017.
Websites for Additional Information
  1. Centers for Disease Control and Prevention. National health statistics reports. November 2009. Available at: https://www.cdc.gov/nchs/data/nhsr/nhsr019.pdf . Accessed on March 15, 2017.
  2. Centers for Disease Control and Prevention. Traumatic brain injury & concussion. Updated February 9, 2016. Available at: https://www.cdc.gov/TraumaticBrainInjury/ . Accessed on March 16, 2017.
  3. National Institute of Mental Health (NIMH). Child and adolescent mental health. May 2016. Available at: https://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml . Accessed on March 15, 2017.
  4. National Institute of Mental Health (NIMH). Serious mental illness (SMI) Among U.S. Adults. Available at: http://www.nimh.nih.gov/health/statistics/prevalence/serious-mental-illness-smi-among-us-adults.shtml. Accessed on March 15, 2017.
  5. National Institute of Neurological Disorders and Stroke. Pervasive Developmental Disorders. Available at: http://www.ninds.nih.gov/disorders/pdd/pdd.htm. Accessed on March 15, 2017.
  6. World Health Organization. Fact sheets: mental disorders. Reviewed April 2016. Available at: http://www.who.int/mediacentre/factsheets/fs396/en/. Accessed on March 15, 2017.
Index

Adventure therapy
Outdoor behavioral therapy
Wilderness adventure therapy
Wilderness programs
Wilderness therapy

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History
Status Date Action
New 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review.
New 03/24/2017 Behavioral Health Subcommittee review. Initial document development.