Medical Necessity
“Medically Necessary” or “Medical Necessity” shall mean health care services that a medical practitioner, exercising prudent clinical judgment, would provide to a Covered Individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Individual’s illness, injury or disease; and (c) not primarily for the convenience of the Covered Individual, physician, or other health care provider; (d) and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Individual’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors.
Detoxification – Patient has high potential for withdrawal, requires medical management of symptoms, 24 hr. nursing, daily doctor visits. La Hacienda provides this level of care.
Inpatient Rehabilitation – Patient has medical or psych-related issues that require 24 hr medical monitoring by nursing and daily doctor visits. La Hacienda provides this level of care.
Residential Treatment Center (RTC) – 24 hr. supervised living environment, no withdrawal symptoms, required doctor visit once weekly or as needed. These are considered long term programs. La Hacienda does not provide this level of care.
Partial Hospital Program (PHP) – also called “Day Treatment”. This is a medically monitored outpatient level of care providing 6 to 8 hours of service daily. The patient usually sleeps at home. La Hacienda provides this level of care with free boarding due to the location of the facility.
Intensive Outpatient (IOP) – This is a non-medically monitored outpatient level of care. Groups typically meet 3 to 4 nights a week for 3 to 4 hours, averaging 10 hours per week. An abuse diagnosis can qualify a patient for treatment at an IOP level of care. La Hacienda provides this level of care.
Outpatient Therapy – The patient meets with a therapist, as necessary, usually in an office setting once a week, every two weeks, monthly as determined by counselor and patient. La Hacienda does not provide this level of care.


