# Diagnostic Essentials: Physical Health Condition s

G UIDANCE TO THE 

# V ICTIM 

# C OMPENSATION 

# F UND

FROM THE 

# W ORLD 

# T RADE 

# C ENTER 

# H EALTH 

# P ROGRAM

First Issued: 18 December 2013 Subsequently r evised: April 2 2014 , September 24, 2014
, October 3, 2014
, October 6, 2014
,

March 1, 2015
, March 2 8 , 2015 , & May 19, 2015



## Please note that the relevant policies pertaining to the medical professional determination on behalf of a claimant to the Victim Compensation Fund (VCF) may be found on the World Trade Center Health Program (WTCHP) website at http://www.cdc.gov/wtc/policies.html . The relevant policies include :

 Policy and Procedures to Certification of Physician Determination for Aerodigestive and Cancer Health Conditions

 Time I nterval s for New Onset Aerodigestive Disorders

 Rare cancers

 Minimum L atency & Types or Categories of Cancer

 Making a Determination about Exposure Aggravating Pre

- Existing Aerodigestive Disorders

 Health Condition s Medically Associated with WTC

- Related Health Conditions.



## In general, the diagnosis of a health condition depends on a combination of medical history, physical examination, various types of diagnostic testing, including radiographic and other types of imaging, spirometry, and various laboratory and pathologic analyses. The WTCHP has recommended that diagnostic information listed in th is document be utilized by the VCF to substantiate the diagnosis of claimed health conditions.

For each category of health conditions

, a star superscript (*) is listed next to th e types of information considered essential to support the medical professional determi nation of the underlying condition. In some categories, the clinician has a choice of which type of essential information is available in the medical record. Other clinical information that is not listed with a star superscript (*) may support a diagnosis of a health condition. The VCF will then have a licensed medical professional make a determination regarding the health conditions and attest to the linkage of the conditions to the individual’s 9/11

exposure s . The determination is then su b mitted for a verification decision by the WTCHP in accordance with the policies and procedures of the WTCHP. The VCF renders the final decision regarding condition eligibility and subsequent consideration for compensation.

### Health Condition

Category 1 

### Diagnostic Info rmation

Needed for Physician Determination Reference Guidelines Supporting the Medical Basis for Diagnostic Information

by Type of Condition Interstitial Lung
Disease 2 Pulmonary disease :

 History (Symptoms) & Physical
Exam Findings

 PFTs /Spirometry

 Radiographic /Imaging Evidence for lung findings *  American Thoracic Society (ATS) /European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias (2002)

http://www.thoracic.org/statements/resour ces/ interstitial

- lung

- disease/idio02.pdf

 An Official American Thoracic Society (ATS) /Euro pean Respiratory Society Statement: Update of the International Multidisciplinary Classification of the Idiopathic Interstitial Pneumonias (2013)

http://www.thoracic.org/statements/resour ces/ interstitial

- lung

- disease/classification

of

- IIPs.pdf

 ATS Statement on Sarcoidosis (1999) http://www.thoracic.org/statements/resour ces/interstitial

- lung

- disease/sarcoid1

- 20.pdf

 Vij R, Strek MA. Diagnosis and Treatment of
Connective Tissue Disease

- Associated Interstitial Lung Disease. CHEST 2013; 143(3):814

– 824.

 Casian A, Jayne D. Current modalities in the diagnosis of pu lmonary vasculitis. Expert Opin Med Diagn 2012; 6(6):499

- 516

.

1 The general categories of health conditions that are listed in this Table have been drawn from the List of Health Conditions for Responders found at 42 U.S.C . §§ 300mm

- 22(a)(3)(A) and 300mm

— 32(b)(1).

2 Interstitial lung disease (ILD) is a term used to describe the pulmonary manifestation of more than 100 health conditions. ILD is characterized by inflammation and/or fibrosis of the lungs. Some of the he alth conditions manifesting ILD may include, but are not limited to, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, sarcoidosis, eosinophilic granuloma, bronchiolitis obliterans, pneumoconioses and certain systemic autoimmune diseases such as the connective tissue diseases (CTD) , and small vessel vasculitides.Obstructive airways

disease , excluding asthma and reactive airways disease 3  History ( Symptoms) & Physical Exam Findings * and/or

 PFTs/Spirometry*

 Radiographic/imaging (required to support diagnosis of bronchiectasis 4 )

Note: For WTC

- exacerbated Chronic Obstructive Pulmonary Disease (COPD), there must be evidence that COPD was present prior to September 11, 2001 and worsened after exposure

. 5  Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper (2004) http://www.t horacic.org/statements/resou rces/copd/copdexecsum.pdf

 Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society (2011) http://www.thoracic.org/statements/resou

rces /copd/179full.pdf

Obstructive airways disease

— asthma and reactive airways disease only  History ( Symptoms) & Physical Exam Findings * and/or

 PFTs/Spirometry *  NIH National Heart, Lung and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma (National Asthma Education and Program (NAEPP)Expert Panel Report(EPR)

- 3, in 2007) http://www.nhlbi.nih.gov/health

pro /guidelines/current/asthma

- guidelines

3 Obstructive airways disease (OAD) is a broad category of respiratory diseases which are characterized by varying degrees of reversible and irreversible airways obstruction and include chronic respiratory disorder (fumes/vapors), chronic cough syndrome, WT C

- exacerbated c hronic obstructive pulmonary disease, a st hma, and reactive airways dysfunction s yndrome (RADS)

.

4 Bronchiectasis is certifiable as WTC

- related chronic resp iratory disorder (fumes/vapors) and/or as a medically associated health condition to a certifiable WTC

- related health condition under certain lung disease categories.

5 Evidence supporting a diagnosis of WTC

- exacerbated COPD consists of one or more of the following: (1) a record of physician diagnosis of COPD made prior to the individual’ s 9/11 exposure; (2) history of symptoms of chronic cough, sputum production and/or dyspnea experienced prior to the individual’s 9/11 exposure; (3) a history of recurrent bronchopulmonary infections experienced prior to the individual’s 9/11 exposure; (4) a record of pulmonary function tests showing chronic airways obstruction existing prior to the individual’s 9/11 exposure; and /or (5) a record of imaging studies consistent with COPD existing prior to the individual’s 9/11 exposure.Upper Airway

Inflammatory
D isorders 6  History (Symptoms) & Physical
Exam Findings *

 Radiographic/imaging ( CT of the sinuses )  American Association of Family Physicians Diagnosing Rhinitis: Allergic vs. Nonallergic (2006) http://www.aafp.org/afp/200 6/0501/p158 3.html

 American Academy of Otolaryngology/Head and Neck Surgery . Clinical Practice Guidelines on Adult Sinusitis (2007)

http://oto.sagepub.com/content/137/3/36 5.full Gastroesophageal Reflux D isorder  History (Symptoms) & Physical Findings * and/or

 Response to therapy * and/or

 Endoscopic evidence of

e sophagitis, stricture or Barrett’s metaplasia *  American Gastroenterological Association (AGA) Medical Position Statement on the Management of Gastroesophageal Reflux
Disease (2008) http://www.gastrojournal.org/article/S0016

- 5085(08)01606

- 5/fulltext

Sleep Apnea ( Obstructive Sleep Apnea ) " exacerbated by

, or related to

, a health condition " in Diagnostic Essentials

, --

- excluding M SD and Malignant Neoplasms

.  History (Symptoms) & Physical Findings

 Interpretation of a

p olysomnogram or sleep s tudy by a sleep medicine s pecialist or pulmonologist, showing evidence of Obstructive Sleep
A pnea *  American Academy of Sleep Medicine(AASM) Clinical Guideline for the Evaluation, Management and Long

- term Care of Obstructive Sleep Apnea in Adults (2009) http://www.aasmnet.org/Resources/clinical guidelines/OSA_Adults.pdf

Musculoskeletal Disorders (MSDs)

— Heavy Lifting or Repetitive Strain 7  History (Symptoms) & Physical Findings* and/or

 Radiographic/Imaging Evidence * and/or

 Electrodiagnostic testing (e.g., Electromyography and Nerve Conduction Velocity study) • A merican Academy of Orthopedic Surgeons (A AOS ) Endorsed Guideline

- American Pain Society Clinical Guideline for the Evaluat ion and Management of Low Back Pain ( Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society ) (2007) http://annals.org/article.aspx?article id=736814

6 Upper airway inflamm atory disorders is a broad category of health conditions ; however, for the purpose of verification for VCF claims, the category is limited to include only the following conditions: chronic rhinosinusitis or chronic rhinitis (either irritant or allergic), c hronic nasopharyngitis, chronic laryngitis, and u pper airway hyperactivity.

7 I n the case of a WTC responder only (i.e., not in the case of a survivor) who received any treatment for a WTC

- related musculoskeletal disorder on or before September 11, 2003 , the list of health conditions that can be verified includes: (1) low back pain; (2) carpal tunnel syndrome (CTS); and (3) other musculoskeletal disorders. The term ‘WTC

- related musculoskeletal disorder’ means a chronic or recurrent disorder of the muscul oskeletal system caused by heavy lifting or repetitive strain on the joints or musculoskeletal system occurring during rescue or recovery efforts in the New York City disaster area in the aftermath of the September 11, 2001, terrorist at tacks. See 42
U.S.C . § 300mm

- 22(a)(4).• American Academy of Orthopedic Surgeons(AAOS) Clinic al Practice Guideline on the Diagnosis of Carpal Tunnel Syndrome (2007) http://www.aaos.org/ research/guidelines/CTS_guideline.pdf

Malignant Neoplasm : General  History (Symptoms) & Physical Findings

 Radiographic/Imaging evidence

 Chemistry Laboratory

 Tissue biopsy or pathology report* Exception : Tissue bio psy is not required for certain neoplasm s. See NCCN guidelines for information about these neoplasms

.  National Comprehensive Cancer Network (NCCN) guidelines http://www.nccn.org/professionals/ physician_gls/f_guidelines.asp

 National Cancer Institute (NCI) http://www.cancer. gov/ cancertopics/factsheet/detection/pathology

- reports

 Borowitz M, Westra W, Cooley LD, et al. Pathology and laboratory medicine. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG, editors. Clinical Oncology . 3rd ed . London: Churchill Livingstone, 2004. Malignant Neoplasm:
In

- Situ Neoplasm  History (Symptoms) & Physical Findings

 Radiographic/Imaging evidence

 Chemistry Laboratory

 Tissue biopsy or pathology report*

All malignant in

- situ neoplasms are eligible for cer tification except the following: (1) lobular
carcinoma in

- situ of the breast (except pleomorphic lobular carcinoma); (2) in

- situ carcinoma of the gallbladder; (3) colorectal adenomatous polyp with area of
in

- situ carcinoma ; and (4) in

- situ carcinoma of the cervix.  National Comprehensive Cancer Network (NCCN) guidelines http://www.nccn.org/professionals/physicia n_gls/f_guidelines.asp

 National Cancer Institute (NCI) http://www.cancer.gov/cancertopics/factsh eet/detection/pathology

- reports

Malignant Neoplasm: Unknown primary  History (Symptoms) & Physical Findings

 Radiographic/Imaging evidence

 Chemistry Laboratory

 Tissue biopsy or pathology report* When the diagnosis under review
is a metastatic neoplasm of an unknown primary, a diagnostic work

- up summary is required to demonstrate that an appropriate  Ettinger DS, Agulnik M, Cates JM, Cristea M, Denlinger CS, Eaton KD, et al. Occult Primary. Clinical Practice Guideline s in Oncology. J Natl Compr Canc Netw. 2011;9(12):1358

- 95.search for the primary malignancy was done.

When the diagnostic work

- up does not reveal a primary site, the neoplasm shall be classified as a neoplasm of the metastatic site.

When the diagnostic work

- up does reveal a primary site, the neoplasm shall be classified as a neoplasm of the primary site.

T o ensure clarity about the condit ion for which verification is requested, t he medical determination should only state the final diagnosis and the date of this diagnosis

.