167 
‘‘(9) The term ‘New York City disaster 
area’ means the area within New York 
City that is— 
‘‘(A) the area of Manhattan that is 
south of Houston Street; and 
‘‘(B) any block in Brooklyn that is 
wholly or partially contained within 
a 1.5-mile radius of the former World 
Trade Center site. 
‘‘(10) The term ‘New York metropoli-
tan area’ means an area, specified by the 
WTC 
Program 
Administrator, 
within 
which eligible WTC responders and eligi-
ble WTC community members who reside 
in such area are reasonably able to ac-
cess monitoring and treatment benefits 
and initial health evaluation benefits 
under this title through a Clinical Cen-
ters of Excellence described in subpara-
graphs 
(A), 
(B), 
or 
(C) 
of 
section 
3006(b)(1). 
‘‘(11) Any reference to ‘September 11, 
2001’ shall be deemed a reference to the 
period on such date subsequent to the 
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terrorist attacks on the World Trade Cen-
ter on such date. 
‘‘(12) The term ‘September 11, 2001, 
terrorist attacks on the World Trade Cen-
ter’ means the terrorist attacks that oc-
curred on September 11, 2001, in New 
York City and includes the aftermath of 
such attacks. 
‘‘(13) The term ‘WTC Health Program 
Steering Committee’ means such a Steer-
ing Committee established under section 
3003. 
‘‘(14) The term ‘WTC Program Admin-
istrator’ means the individual responsible 
under section 3001(f) for the administra-
tion of the WTC program. 
‘‘(15) The term ‘WTC-related health 
condition’ is defined in section 3012(a). 
‘‘(16) The term ‘WTC Scientific/Tech-
nical Advisory Committee’ means such 
Committee 
established 
under 
section 
3002. 
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‘‘Subtitle 
B—Program 
of 
Moni-
toring, Initial Health Evalua-
tions, and Treatment 
‘‘PART 1—FOR WTC RESPONDERS 
‘‘SEC. 3011. IDENTIFICATION OF ELIGIBLE WTC RESPOND-
ERS AND PROVISION OF WTC-RELATED MONI-
TORING SERVICES. 
‘‘(a) ELIGIBLE WTC RESPONDER DEFINED.— 
‘‘(1) IN GENERAL.—For purposes of this 
title, the term ‘eligible WTC responder’ 
means any of the following individuals, 
subject to paragraph (5): 
‘‘(A) CURRENTLY
IDENTIFIED
RE-
SPONDER.—An 
individual 
who 
has 
been identified as eligible for medical 
monitoring under the current consor-
tium arrangements (as defined in sec-
tion 3008(4)). 
‘‘(B) RESPONDER
WHO
MEETS
CUR-
RENT
ELIGIBILITY
CRITERIA.—An indi-
vidual who meets the current eligi-
bility criteria described in paragraph 
(2). 
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‘‘(C) RESPONDER WHO MEETS MODI-
FIED
ELIGIBILITY
CRITERIA.—An indi-
vidual who— 
‘‘(i) performed rescue, recov-
ery, demolition, debris cleanup, 
or other related services in the 
New York City disaster area in re-
sponse to the September 11, 2001, 
terrorist attacks on the World 
Trade 
Center, 
regardless 
of 
whether such services were per-
formed by a State or Federal em-
ployee or member of the National 
Guard or otherwise; and 
‘‘(ii) meets such eligibility cri-
teria relating to exposure to air-
borne toxins, other hazards, or 
adverse conditions resulting from 
the September 11, 2001, terrorist 
attacks on the World Trade Cen-
ter as the WTC Program Adminis-
trator, after consultation with the 
WTC Responders Steering Com-
mittee and the WTC Scientific/ 
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171 
Technical 
Advisory 
Committee, 
determines appropriate. 
The 
WTC 
Program 
Administrator 
shall not modify such eligibility cri-
teria on or after the date that the 
number of certifications for eligible 
responders has reached 80 percent of 
the limit described in paragraph (5) 
or on or after the date that the num-
ber of certifications for eligible com-
munity members has reached 80 per-
cent of the limit described in section 
3021(a)(5). 
‘‘(2) CURRENT
ELIGIBILITY
CRITERIA.— 
The eligibility criteria described in this 
paragraph for an individual is that the 
individual is described in either of the 
following categories: 
‘‘(A) FIRE
FIGHTERS
AND
RELATED 
PERSONNEL.—The individual— 
‘‘(i) was a member of the Fire 
Department of the City of New 
York (whether fire or emergency 
personnel, active or retired) who 
participated at least one day in 
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the rescue and recovery effort at 
any of the former World Trade 
sites 
(including 
Ground 
Zero, 
Staten Island land fill, and the 
NYC Chief Medical Examiner’s of-
fice) for any time during the pe-
riod beginning on September 11, 
2001, and ending on July 31, 2002; 
or 
‘‘(ii)(I) is a surviving imme-
diate family member of an indi-
vidual who was a member of the 
Fire Department of the City of 
New York (whether fire or emer-
gency personnel, active or re-
tired) and was killed at the World 
Trade site on September 11, 2001; 
and 
‘‘(II) received any treatment 
for a WTC-related mental health 
condition described in section 
3012(a)(1)(B) on or before Sep-
tember 1, 2008. 
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‘‘(B) LAW
ENFORCEMENT
OFFICERS 
AND
WTC
RESCUE, 
RECOVERY, 
AND 
CLEAN-UP WORKERS.—The individual— 
‘‘(i) worked or volunteered on- 
site in rescue, recovery, debris- 
cleanup or related support serv-
ices in lower Manhattan (south of 
Canal 
St.), 
the 
Staten 
Island 
Landfill, or the barge loading 
piers, for at least 4 hours during 
the period beginning on Sep-
tember 11, 2001, and ending on 
September 14, 2001, for at least 24 
hours during the period begin-
ning on September 11, 2001, and 
ending on September 30, 2001, or 
for at least 80 hours during the 
period beginning on September 
11, 2001, and ending on July 31, 
2002; 
‘‘(ii)(I) was a member of the 
Police Department of the City of 
New York (whether active or re-
tired) or a member of the Port 
Authority Police of the Port Au-
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beginning on September 11, 2001, 
and ending on September 30, 
2001; or 
‘‘(IV) participated on-site in 
rescue, recovery, debris clean-up, 
or related services in lower Man-
hattan (south of Canal St.) for at 
least 80 hours during the period 
beginning on September 11, 2001, 
and ending on July 31, 2002; 
‘‘(iii) was an employee of the 
Office of the Chief Medical Exam-
iner of the City of New York in-
volved in the examination and 
handling of human remains from 
the World Trade Center attacks, 
or other morgue worker who per-
formed similar post-September 11 
functions for such Office staff, 
during the period beginning on 
September 11, 2001 and ending on 
July 31, 2002; 
‘‘(iv) was a worker in the Port 
Authority Trans-Hudson Corpora-
tion tunnel for at least 24 hours 
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176 
during the period beginning on 
February 1, 2002, and ending on 
July 1, 2002; or 
‘‘(v) 
was 
a 
vehicle-mainte-
nance worker who was exposed to 
debris from the former World 
Trade Center while retrieving, 
driving, cleaning, repairing, and 
maintaining 
vehicles 
contami-
nated by airborne toxins from the 
September 11, 2001, terrorist at-
tacks on the World Trade Center 
during a duration and period de-
scribed in subparagraph (A). 
‘‘(3) APPLICATION PROCESS.—The WTC 
Program Administrator in consultation 
with the Coordinating Centers of Excel-
lence shall establish a process for indi-
viduals, other than eligible WTC respond-
ers described in paragraph (1)(A), to 
apply to be determined to be eligible 
WTC responders. Under such process— 
‘‘(A) there shall be no fee charged 
to the applicant for making an appli-
cation for such determination; 
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‘‘(B) the Administrator shall make 
a determination on such an applica-
tion not later than 60 days after the 
date of filing the application; and 
‘‘(C) an individual who is deter-
mined not to be an eligible WTC re-
sponder shall have an opportunity to 
appeal such determination before an 
administrative law judge in a manner 
established under such process. 
‘‘(4) CERTIFICATION.— 
‘‘(A) IN
GENERAL.—In the case of 
an individual who is described in 
paragraph (1)(A) or who is deter-
mined under paragraph (3) (con-
sistent with paragraph (5)) to be an 
eligible WTC responder, the WTC Pro-
gram Administrator shall provide an 
appropriate certification of such fact 
and of eligibility for monitoring and 
treatment benefits under this part. 
The Administrator shall make deter-
minations of eligibility relating to an 
applicant’s compliance with this title, 
including the verification of informa-
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tion submitted in support of the ap-
plication, and shall not deny such a 
certification to an individual unless 
the Administrator determines that— 
‘‘(i) based on the application 
submitted, the individual does not 
meet the eligibility criteria; or 
‘‘(ii) the numerical limitation 
on eligible WTC responders set 
forth in paragraph (5) has been 
met. 
‘‘(B) TIMING.— 
‘‘(i) CURRENTLY IDENTIFIED RE-
SPONDERS.—In the case of an indi-
vidual who is described in para-
graph (1)(A), the WTC Program 
Administrator shall provide the 
certification under subparagraph 
(A) not later than 60 days after 
the date of the enactment of this 
title. 
‘‘(ii) OTHER
RESPONDERS.—In 
the case of another individual 
who is determined under para-
graph (3) and consistent with 
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paragraph (5) to be an eligible 
WTC responder, the WTC Pro-
gram Administrator shall provide 
the certification under subpara-
graph (A) at the time of the deter-
mination. 
‘‘(5) NUMERICAL
LIMITATION
ON
ELIGI-
BLE WTC RESPONDERS.— 
‘‘(A) IN GENERAL.—The total num-
ber of individuals not described in 
subparagraph (C) who may qualify as 
eligible WTC responders for purposes 
of this title, and be certified as eligi-
ble WTC responders under paragraph 
(4), shall not exceed 15,000, subject to 
adjustment under paragraph (6), of 
which no more than 2,500 may be in-
dividuals certified based on modified 
eligibility criteria established under 
paragraph (1)(C). In applying the pre-
vious sentence, any individual who at 
any time so qualifies as an eligible 
WTC responder shall be counted 
against such numerical limitation. 
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‘‘(B) PROCESS.—In implementing 
subparagraph (A), the WTC Program 
Administrator shall— 
‘‘(i) limit the number of cer-
tifications provided under para-
graph (4) in accordance with such 
subparagraph; and 
‘‘(ii) provide priority in such 
certifications 
in 
the 
order 
in 
which individuals apply for a de-
termination under paragraph (3). 
‘‘(C) CURRENTLY
IDENTIFIED
RE-
SPONDERS
NOT
COUNTED.—Individuals 
described in this subparagraph are 
individuals who are described in 
paragraph (1)(A). 
‘‘(6) POTENTIAL ADJUSTMENT IN NUMER-
ICAL LIMITATIONS DEPENDENT UPON ACTUAL 
SPENDING
RELATIVE
TO
ESTIMATED
SPEND-
ING.— 
‘‘(A) INITIAL CALCULATION FOR FIS-
CAL YEARS 2009 THROUGH 2011.—If the 
WTC Program Administrator deter-
mines as of December 1, 2011, that 
the 
WTC 
expenditure-to-CBO-esti-
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181 
mate percentage (as defined in sub-
paragraph (D)(iii)) for fiscal years 
2009 through 2011 does not exceed 90 
percent, then, effective January 1, 
2012, the WTC Program Adminis-
trator may increase the numerical 
limitation under paragraph (5)(A), the 
numerical limitation under section 
3021(a)(5), or both, by a number of 
percentage points not to exceed the 
number of percentage points speci-
fied in subparagraph (C) for such pe-
riod of fiscal years. 
‘‘(B) SUBSEQUENT CALCULATION FOR 
FISCAL YEARS 2009 THROUGH 2015.—If the 
Secretary determines as of December 
1, 2015, that the WTC expenditure-to- 
CBO-estimate percentages for fiscal 
years 2009 through 2015 and for fiscal 
years 2012 through 2015 do not ex-
ceed 90 percent, then, effective Janu-
ary 1, 2015, the WTC Program Admin-
istrator may increase the numerical 
limitation under paragraph (5)(A), the 
numerical limitation under section 
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3021(a)(5), or both, as in effect after 
the application of subparagraph (A), 
by a number of percentage points not 
to exceed twice the lesser of— 
‘‘(i) the number of percentage 
points specified in subparagraph 
(C) for fiscal years 2009 through 
2012, or 
‘‘(ii) the number of percentage 
points specified in subparagraph 
(C) for fiscal years 2012 through 
2015. 
‘‘(C) 
MAXIMUM
PERCENTAGE
IN-
CREASE IN NUMERICAL LIMITATIONS FOR 
PERIOD OF FISCAL YEARS.—The number 
of percentage points specified in this 
clause for a period of fiscal years is— 
‘‘(i) 
100 
percentage 
points, 
multiplied by 
‘‘(ii) one minus a fraction the 
numerator of which is the net 
Federal WTC spending for such 
period, and the denominator of 
which is the CBO WTC spending 
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estimate under this title for such 
period. 
‘‘(D) DEFINITIONS.—For purposes 
of this paragraph: 
‘‘(i) NET
FEDERAL
SPENDING.— 
The term ‘net Federal WTC spend-
ing’ means, with respect to a pe-
riod of fiscal years, the net Fed-
eral spending under this title for 
such fiscal years. 
‘‘(ii) CBO WTC SPENDING ESTI-
MATE UNDER THIS TITLE.—The term 
‘CBO WTC medical spending esti-
mate under this title’ means, with 
respect to— 
‘‘(I) 
fiscal 
years 
2009 
through 2011, $900,000,000; 
‘‘(II) 
fiscal 
years 
2012 
through 2015, $1,890,000,000; 
and 
‘‘(III) 
fiscal 
years 
2009 
through 2015, the sum of the 
amounts 
specified 
in 
sub-
clauses (I) and (II). 
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‘‘(iii) 
WTC 
EXPENDITURE-TO- 
CBO-ESTIMATE
PERCENTAGE.—The 
term 
‘WTC 
expenditure-to-esti-
mate percentage’ means, with re-
spect to a period of fiscal years, 
the ratio (expressed as a percent-
age) of— 
‘‘(I) the net Federal WTC 
spending for such period, to 
‘‘(II) the CBO WTC spend-
ing estimate under this title 
for such period. 
‘‘(b) MONITORING BENEFITS.— 
‘‘(1) IN GENERAL.—In the case of an eli-
gible 
WTC 
responder 
under 
section 
3011(a)(4) (other than one described in 
subsection (a)(2)(A)(ii)), the WTC pro-
gram shall provide for monitoring bene-
fits that include medical monitoring con-
sistent with protocols approved by the 
WTC Program Administrator and includ-
ing clinical examinations and long-term 
health monitoring and analysis. In the 
case of an eligible WTC responder who is 
an active member of the Fire Department 
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185 
of the City of New York, the responder 
shall receive such benefits as part of the 
individual’s periodic company medical 
exams. 
‘‘(2) PROVISION
OF
MONITORING
BENE-
FITS.—The 
monitoring 
benefits 
under 
paragraph (1) shall be provided through 
the Clinical Center of Excellence for the 
type of individual involved or, in the case 
of an individual residing outside the New 
York metropolitan area, under an ar-
rangement under section 3031. 
‘‘SEC. 3012. TREATMENT OF CERTIFIED ELIGIBLE WTC RE-
SPONDERS FOR WTC-RELATED HEALTH CON-
DITIONS. 
‘‘(a) WTC-RELATED HEALTH CONDITION DE-
FINED.— 
‘‘(1) IN GENERAL.—For purposes of this 
title, the term ‘WTC-related health condi-
tion’ means— 
‘‘(A) an illness or health condition 
for which exposure to airborne tox-
ins, any other hazard, or any other 
adverse condition resulting from the 
September 11, 2001, terrorist attacks 
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on the World Trade Center, based on 
an examination by a medical profes-
sional with experience in treating or 
diagnosing the medical conditions in-
cluded in the applicable list of identi-
fied WTC-related conditions, is sub-
stantially likely to be a significant 
factor in aggravating, contributing to, 
or causing the illness or health condi-
tion, as determined under paragraph 
(2); or 
‘‘(B) a mental health condition for 
which such attacks, based on an ex-
amination by a medical professional 
with experience in treating or diag-
nosing the medical conditions in-
cluded in the applicable list of identi-
fied WTC-related conditions, is sub-
stantially likely be a significant fac-
tor in aggravating, contributing to, or 
causing the condition, as determined 
under paragraph (2). 
In the case of an eligible WTC responder 
described in section 3011(a)(2)(A)(ii), such 
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term only includes the mental health con-
dition described in subparagraph (B). 
‘‘(2) DETERMINATION.—The determina-
tion of whether the September 11, 2001, 
terrorist attacks on the World Trade Cen-
ter were substantially likely to be a sig-
nificant factor in aggravating, contrib-
uting to, or causing an individual’s illness 
or health condition shall be made based 
on an assessment of the following: 
‘‘(A) The individual’s exposure to 
airborne toxins, any other hazard, or 
any other adverse condition resulting 
from the terrorist attacks. Such expo-
sure shall be— 
‘‘(i) evaluated and character-
ized through the use of a stand-
ardized, population appropriate 
questionnaire approved by the Di-
rector of the National Institute 
for 
Occupational 
Safety 
and 
Health; and 
‘‘(ii) assessed and documented 
by a medical professional with ex-
perience in treating or diagnosing 
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medical conditions included on 
the list of identified WTC-related 
conditions. 
‘‘(B) The type of symptoms and 
temporal sequence of symptoms. Such 
symptoms shall be— 
‘‘(i) assessed through the use 
of a standardized, population ap-
propriate medical questionnaire 
approved by Director of the Na-
tional Institute for Occupational 
Safety and Health and a medical 
examination; and 
‘‘(ii) 
diagnosed 
and 
docu-
mented by a medical professional 
described in subparagraph (A)(ii). 
‘‘(3) LIST
OF
IDENTIFIED
WTC-RELATED 
HEALTH
CONDITIONS
FOR
CERTIFIED
ELIGI-
BLE
WTC
RESPONDERS.—For purposes of 
this title, the term ‘identified WTC-re-
lated health condition for eligible WTC 
responders’ means any of the following 
health conditions: 
‘‘(A) AERODIGESTIVE DISORDERS.— 
‘‘(i) Interstitial lung diseases. 
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‘‘(4) ADDITION
OF
IDENTIFIED
WTC-RE-
LATED
HEALTH
CONDITIONS
FOR
ELIGIBLE 
WTC RESPONDERS.— 
‘‘(A) IN
GENERAL.—The WTC Pro-
gram Administrator may promulgate 
regulations to add an illness or health 
condition not described in paragraph 
(3) to be added to the list of identified 
WTC-related conditions for eligible 
WTC responders. In promulgating 
such regulations, the Secretary shall 
provide for notice and opportunity 
for a public hearing and at least 90 
days of public comment. In promul-
gating such regulations, the WTC Pro-
gram Administrator shall take into 
account 
the 
findings 
and 
rec-
ommendations of Clinical Centers of 
Excellence 
published 
in 
peer 
re-
viewed journals in the determination 
of whether an additional illness or 
health condition, such as cancer, 
should be added to the list of identi-
fied WTC-related health conditions 
for eligible WTC responders. 
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‘‘(B) PETITIONS.—Any person (in-
cluding the WTC Health Program Sci-
entific/Technical 
Advisory 
Com-
mittee) may petition the WTC Pro-
gram Administrator to propose regu-
lations described in subparagraph 
(A). Unless clearly frivolous, or initi-
ated by such Committee, any such pe-
tition shall be referred to such Com-
mittee for its recommendations. Fol-
lowing— 
‘‘(i) 
receipt 
of 
any 
rec-
ommendation of the Committee; 
or 
‘‘(ii) 180 days after the date of 
the referral to the Committee, 
whichever occurs first, the WTC Pro-
gram Administrator shall conduct a 
rulemaking proceeding on the mat-
ters proposed in the petition or pub-
lish in the Federal Register a state-
ment of reasons for not conducting 
such proceeding. 
‘‘(C) 
EFFECTIVENESS.—Any 
addi-
tion under subparagraph (A) of an ill-
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193 
ness or health condition shall apply 
only with respect to applications for 
benefits under this title which are 
filed after the effective date of such 
regulation. 
‘‘(D) 
ROLE
OF
ADVISORY
COM-
MITTEE.—Except with respect to a reg-
ulation recommended by the WTC 
Health Program Scientific/Technical 
Advisory Committee), the WTC Pro-
gram Administrator may not propose 
a regulation under this paragraph, 
unless the Administrator has first 
provided to the Committee a copy of 
the proposed regulation, requested 
recommendations and comments by 
the Committee, and afforded the 
Committee at least 90 days to make 
such recommendations. 
‘‘(b) COVERAGE OF TREATMENT FOR WTC-RE-
LATED HEALTH CONDITIONS.— 
‘‘(1) DETERMINATION BASED ON AN IDEN-
TIFIED WTC-RELATED HEALTH CONDITION FOR 
CERTIFIED ELIGIBLE WTC RESPONDERS.— 
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‘‘(A) IN GENERAL.—If a physician at 
a Clinical Center of Excellence that is 
providing monitoring benefits under 
section 3011 for a certified eligible 
WTC responder determines that the 
responder has an identified WTC-re-
lated health condition, and the physi-
cian makes a clinical determination 
that exposure to airborne toxins, 
other hazards, or adverse conditions 
resulting from the 9/11 terrorist at-
tacks is substantially likely to be a 
significant factor in aggravating, con-
tributing to, or causing the condi-
tion— 
‘‘(i) 
the 
physician 
shall 
promptly transmit such deter-
mination to the WTC Program Ad-
ministrator and provide the Ad-
ministrator with the medical facts 
supporting such determination; 
and 
‘‘(ii) on and after the date of 
such transmittal and subject to 
subparagraph (B), the WTC pro-
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gram shall provide for payment 
under subsection (c) for medically 
necessary treatment for such con-
dition. 
‘‘(B) REVIEW; 
CERTIFICATION; 
AP-
PEALS.— 
‘‘(i) REVIEW.—A Federal em-
ployee designated by the WTC 
Program Administrator shall re-
view determinations made under 
subparagraph (A) of a WTC-re-
lated health condition. 
‘‘(ii) CERTIFICATION.—The Ad-
ministrator shall provide a certifi-
cation of such condition based 
upon reviews conducted under 
clause (i). Such a certification 
shall be provided unless the Ad-
ministrator determines that the 
responder’s condition is not an 
identified 
WTC-related 
health 
condition or that exposure to air-
borne toxins, other hazards, or 
adverse conditions resulting from 
the 9/11 terrorist attacks is not 
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substantially likely to be a signifi-
cant factor in significantly aggra-
vating, contributing to, or causing 
the condition. 
‘‘(iii) 
APPEAL
PROCESS.—The 
Administrator 
shall 
provide 
a 
process for the appeal of deter-
minations under clause (ii) before 
an administrative law judge. 
‘‘(2) DETERMINATION
BASED
ON
OTHER 
WTC-RELATED HEALTH CONDITION.— 
‘‘(A) IN GENERAL.—If a physician at 
a Clinical Center of Excellence deter-
mines pursuant to subsection (a) that 
the certified eligible WTC responder 
has a WTC-related health condition 
that is not an identified WTC-related 
health condition for eligible WTC re-
sponders— 
‘‘(i) 
the 
physician 
shall 
promptly transmit such deter-
mination to the WTC Program Ad-
ministrator and provide the Ad-
ministrator with the facts sup-
porting such determination; and 
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‘‘(ii) the Administrator shall 
make a determination under sub-
paragraph (B) with respect to 
such physician’s determination. 
‘‘(B) REVIEW; CERTIFICATION.— 
‘‘(i) USE OF PHYSICIAN PANEL.— 
With respect to each determina-
tion relating to a WTC-related 
health 
condition 
transmitted 
under subparagraph (A)(i), the 
WTC Program Administrator shall 
provide for the review of the con-
dition to be made by a physician 
panel with appropriate expertise 
appointed by the WTC Program 
Administrator. Such a panel shall 
make recommendations to the Ad-
ministrator on the evidence sup-
porting such determination. 
‘‘(ii) REVIEW
OF
RECOMMENDA-
TIONS
OF
PANEL; CERTIFICATION.— 
The Administrator, based on such 
recommendations 
shall 
deter-
mine, within 60 days after the 
date of the transmittal under sub-
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paragraph (A)(i), whether or not 
the condition is a WTC-related 
health condition and, if it is, pro-
vide for a certification under 
paragraph (1)(B)(ii) of coverage of 
such 
condition. 
The 
Adminis-
trator shall provide a process for 
the appeal of determinations that 
the responder’s condition is not a 
WTC-related health condition be-
fore an administrative law judge. 
‘‘(3) REQUIREMENT OF MEDICAL NECES-
SITY.— 
‘‘(A) IN
GENERAL.—In providing 
treatment for a WTC-health condi-
tion, a physician shall provide treat-
ment that is medically necessary and 
in accordance with medical protocols 
established under subsection (d). 
‘‘(B) MEDICALLY NECESSARY STAND-
ARD.—For the purpose of this title, 
health care services shall be treated 
as medically necessary for an indi-
vidual if a physician, exercising pru-
dent clinical judgment, would con-
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sider the services to be medically nec-
essary for the individual for the pur-
pose of evaluating, diagnosing, or 
treating an illness, injury, disease or 
its symptoms, and that are— 
‘‘(i) in accordance with the 
generally accepted standards of 
medical practice; 
‘‘(ii) clinically appropriate, in 
terms of type, frequency, extent, 
site, and duration, and considered 
effective for the individual’s ill-
ness, injury, or disease; and 
‘‘(iii) not primarily for the 
convenience of the patient or phy-
sician, or another physician, and 
not more costly than an alter-
native service or sequence of 
services at least as likely to 
produce equivalent therapeutic 
or diagnostic results as to the di-
agnosis or treatment of the indi-
vidual’s illness, injury, or disease. 
‘‘(C) DETERMINATION
OF
MEDICAL 
NECESSITY.— 
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‘‘(i) REVIEW OF MEDICAL NECES-
SITY.—As part of the reimburse-
ment payment process under sub-
section (c), the WTC Program Ad-
ministrator shall review claims 
for reimbursement for the provi-
sion of medical treatment to de-
termine if such treatment is medi-
cally necessary. 
‘‘(ii) WITHHOLDING OF PAYMENT 
FOR
MEDICALLY
UNNECESSARY 
TREATMENT.—The 
Administrator 
may withhold such payment for 
treatment that the Administrator 
determines is not medically nec-
essary. 
‘‘(iii) REVIEW
OF
DETERMINA-
TIONS OF MEDICAL NECESSITY.—The 
Administrator 
shall 
provide 
a 
process for providers to appeal a 
determination under clause (ii) 
that medical treatment is not 
medically 
necessary. 
Such 
ap-
peals shall be reviewed through 
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the use of a physician panel with 
appropriate expertise. 
‘‘(4) SCOPE OF TREATMENT COVERED.— 
‘‘(A) IN
GENERAL.—The scope of 
treatment covered under such para-
graphs includes services of physi-
cians and other health care pro-
viders, 
diagnostic 
and 
laboratory 
tests, prescription drugs, inpatient 
and outpatient hospital services, and 
other medically necessary treatment. 
‘‘(B) PHARMACEUTICAL COVERAGE.— 
With respect to ensuring coverage of 
medically necessary outpatient pre-
scription drugs, such drugs shall be 
provided, under arrangements made 
by the WTC Program Administrator, 
directly through participating Clin-
ical Centers of Excellence or through 
one or more outside vendors. 
‘‘(C) TRANSPORTATION
EXPENSES.— 
To the extent provided in advance in 
appropriations Acts, the WTC Pro-
gram Administrator may provide for 
necessary and reasonable transpor-
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tation and expenses incident to the 
securing of medically necessary treat-
ment involving travel of more than 
250 miles and for which payment is 
made under this section in the same 
manner in which individuals may be 
furnished necessary and reasonable 
transportation and expenses incident 
to services involving travel of more 
than 250 miles under regulations im-
plementing section 3629(c) of the En-
ergy Employees Occupational Illness 
Compensation Program Act of 2000 
(title XXXVI of Public Law 106–398; 42 
U.S.C. 7384t(c)). 
‘‘(5) PROVISION OF TREATMENT PENDING 
CERTIFICATION.—In the case of a certified 
eligible WTC responder who has been de-
termined by an examining physician 
under subsection (b)(1) to have an identi-
fied WTC-related health condition, but 
for whom a certification of the deter-
mination has not yet been made by the 
WTC Program Administrator, medical 
treatment may be provided under this 
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subsection, subject to paragraph (6), until 
the Administrator makes a decision on 
such certification. Medical treatment pro-
vided under this paragraph shall be con-
sidered to be medical treatment for 
which payment may be made under sub-
section (c). 
‘‘(6) PRIOR APPROVAL PROCESS FOR NON- 
CERTIFIED NON-EMERGENCY INPATIENT HOS-
PITAL
SERVICES.—Non-emergency 
inpa-
tient hospital services for a WTC-related 
health condition identified by an exam-
ining physician under paragraph (b)(1) 
that is not certified under paragraph 
(1)(B)(ii) is not covered unless the serv-
ices have been determined to be medi-
cally necessary and approved through a 
process established by the WTC Program 
Administrator. Such process shall pro-
vide for a decision on a request for such 
services within 15 days of the date of re-
ceipt of the request. The WTC Adminis-
trator shall provide a process for the ap-
peal of a decision that the services are 
not medically necessary. 
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