other than with respect to those covered under the 
arrangement with the Fire Department of the City 
of New York. 
‘‘(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 metropolitan area’ 
means an area, specified by the WTC Program Ad-
ministrator, within which eligible WTC responders 
and eligible WTC community members who reside in 
such area are reasonably able to access monitoring 
and treatment benefits and initial health evaluation 
benefits under this title through a Clinical Centers 
of Excellence described in subparagraphs (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 terrorist attacks on the 
World Trade Center on such date. 
‘‘(12) The term ‘September 11, 2001, terrorist 
attacks on the World Trade Center’ means the ter-
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rorist attacks that occurred on September 11, 2001, 
in New York City and includes the aftermath of 
such attacks. 
‘‘(13) The term ‘WTC Health Program Steer-
ing Committee’ means such a Steering Committee 
established under section 3003. 
‘‘(14) The term ‘WTC Program Administrator’ 
means the individual responsible under section 
3001(f) for the administration of the WTC program. 
‘‘(15) The term ‘WTC-related health condition’ 
is defined in section 3012(a). 
‘‘(16) The term ‘WTC Scientific/Technical Ad-
visory Committee’ means such Committee estab-
lished under section 3002. 
‘‘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): 
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‘‘(A) 
CURRENTLY
IDENTIFIED
RE-
SPONDER.—An individual who has been identi-
fied as eligible for medical monitoring under the 
current consortium arrangements (as defined in 
section 3008(4)). 
‘‘(B) RESPONDER WHO MEETS CURRENT 
ELIGIBILITY
CRITERIA.—An individual who 
meets the current eligibility criteria described in 
paragraph (2). 
‘‘(C) RESPONDER WHO MEETS MODIFIED 
ELIGIBILITY CRITERIA.—An individual who— 
‘‘(i) performed rescue, recovery, demo-
lition, debris cleanup, or other related serv-
ices in the New York City disaster area in 
response to the September 11, 2001, ter-
rorist attacks on the World Trade Center, 
regardless of whether such services were 
performed by a State or Federal employee 
or member of the National Guard or other-
wise; and 
‘‘(ii) meets such eligibility criteria re-
lating to exposure to airborne toxins, other 
hazards, or adverse conditions resulting 
from the September 11, 2001, terrorist at-
tacks on the World Trade Center as the 
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WTC Program Administrator, after con-
sultation with the WTC Responders Steer-
ing Committee and the WTC Scientific/ 
Technical Advisory Committee, determines 
appropriate. 
The WTC Program Administrator shall not 
modify such eligibility criteria on or after the 
date that the number of certifications for eligi-
ble responders has reached 80 percent of the 
limit described in paragraph (5) or on or after 
the date that the number of certifications for el-
igible community 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 PER-
SONNEL.—The individual— 
‘‘(i) was a member of the Fire De-
partment of the City of New York (wheth-
er fire or emergency personnel, active or 
retired) who participated at least one day 
in the rescue and recovery effort at any of 
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the former World Trade sites (including 
Ground Zero, Staten Island land fill, and 
the NYC Chief Medical Examiner’s office) 
for any time during the period beginning 
on September 11, 2001, and ending on 
July 31, 2002; or 
‘‘(ii)(I) is a surviving immediate fam-
ily member of an individual who was a 
member of the Fire Department of the 
City of New York (whether fire or emer-
gency personnel, active or retired) and was 
killed at the World Trade site on Sep-
tember 11, 2001; and 
‘‘(II) received any treatment for a 
WTC-related mental health condition de-
scribed in section 3012(a)(1)(B) on or be-
fore September 1, 2008. 
‘‘(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 services in lower Manhattan (south 
of Canal St.), the Staten Island Landfill, 
or the barge loading piers, for at least 4 
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hours during the period beginning on Sep-
tember 11, 2001, and ending on Sep-
tember 14, 2001, for at least 24 hours 
during the period beginning 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 retired) or a member of 
the Port Authority Police of the Port Au-
thority of New York and New Jersey 
(whether active or retired) who partici-
pated on-site in rescue, recovery, debris 
clean-up, or related services in lower Man-
hattan (south of Canal St.), including 
Ground Zero, the Staten Island Landfill or 
the barge loading piers, for at least 4 
hours during the period beginning Sep-
tember 11, 2001, and ending on Sep-
tember 14, 2001; 
‘‘(II) participated on-site in rescue, 
recovery, debris clean-up, or related serv-
ices in at Ground Zero, the Staten Island 
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September 11, 2001 and ending on July 
31, 2002; 
‘‘(iv) was a worker in the Port Au-
thority Trans-Hudson Corporation tunnel 
for at least 24 hours during the period be-
ginning on February 1, 2002, and ending 
on July 1, 2002; or 
‘‘(v) was a vehicle-maintenance worker 
who was exposed to debris from the former 
World Trade Center while retrieving, driv-
ing, cleaning, repairing, and maintaining 
vehicles contaminated by airborne toxins 
from the September 11, 2001, terrorist at-
tacks on the World Trade Center during a 
duration and period described in subpara-
graph (A). 
‘‘(3) APPLICATION PROCESS.—The WTC Pro-
gram Administrator in consultation with the Coordi-
nating Centers of Excellence shall establish a proc-
ess for individuals, other than eligible WTC respond-
ers described in paragraph (1)(A), to apply to be de-
termined to be eligible WTC responders. Under such 
process— 
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‘‘(A) there shall be no fee charged to the 
applicant for making an application for such 
determination; 
‘‘(B) the Administrator shall make a deter-
mination on such an application not later than 
60 days after the date of filing the application; 
and 
‘‘(C) an individual who is determined not 
to be an eligible WTC responder shall have an 
opportunity to appeal such determination before 
an administrative law judge in a manner estab-
lished under such process. 
‘‘(4) CERTIFICATION.— 
‘‘(A) IN GENERAL.—In the case of an indi-
vidual who is described in paragraph (1)(A) or 
who is determined under paragraph (3) (con-
sistent with paragraph (5)) to be an eligible 
WTC responder, the WTC Program Adminis-
trator shall provide an appropriate certification 
of such fact and of eligibility for monitoring 
and treatment benefits under this part. The Ad-
ministrator shall make determinations of eligi-
bility relating to an applicant’s compliance with 
this title, including the verification of informa-
tion submitted in support of the application, 
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and shall not deny such a certification to an in-
dividual unless the Administrator determines 
that— 
‘‘(i) based on the application sub-
mitted, the individual does not meet the 
eligibility criteria; or 
‘‘(ii) the numerical limitation on eligi-
ble WTC responders set forth in paragraph 
(5) has been met. 
‘‘(B) TIMING.— 
‘‘(i) CURRENTLY
IDENTIFIED
RE-
SPONDERS.—In the case of an individual 
who is described in paragraph (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 deter-
mined under paragraph (3) and consistent 
with paragraph (5) to be an eligible WTC 
responder, the WTC Program Adminis-
trator shall provide the certification under 
subparagraph (A) at the time of the deter-
mination. 
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‘‘(5) NUMERICAL
LIMITATION
ON
ELIGIBLE 
WTC RESPONDERS.— 
‘‘(A) IN GENERAL.—The total number of 
individuals not described in subparagraph (C) 
who may qualify as eligible WTC responders for 
purposes of this title, and be certified as eligible 
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 individuals certified based on modified 
eligibility criteria established under paragraph 
(1)(C). In applying the previous sentence, any 
individual who at any time so qualifies as an el-
igible WTC responder shall be counted against 
such numerical limitation. 
‘‘(B) PROCESS.—In implementing subpara-
graph (A), the WTC Program Administrator 
shall— 
‘‘(i) limit the number of certifications 
provided under paragraph (4) in accord-
ance with such subparagraph; and 
‘‘(ii) provide priority in such certifi-
cations in the order in which individuals 
apply for a determination under paragraph 
(3). 
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‘‘(C) CURRENTLY
IDENTIFIED
RESPOND-
ERS NOT COUNTED.—Individuals described in 
this subparagraph are individuals who are de-
scribed in paragraph (1)(A). 
‘‘(6) POTENTIAL ADJUSTMENT IN NUMERICAL 
LIMITATIONS DEPENDENT UPON ACTUAL SPENDING 
RELATIVE TO ESTIMATED SPENDING.— 
‘‘(A) INITIAL
CALCULATION
FOR
FISCAL 
YEARS 2009 THROUGH 2011.—If the WTC Pro-
gram Administrator determines as of December 
1, 2011, that the WTC expenditure-to-CBO-es-
timate percentage (as defined in subparagraph 
(D)(iii)) for fiscal years 2009 through 2011 
does not exceed 90 percent, then, effective Jan-
uary 1, 2012, the WTC Program Administrator 
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 specified in subparagraph 
(C) for such period of fiscal years. 
‘‘(B) SUBSEQUENT CALCULATION FOR FIS-
CAL YEARS 2009 THROUGH 2015.—If the Sec-
retary determines as of December 1, 2015, that 
the WTC expenditure-to-CBO-estimate percent-
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ages for fiscal years 2009 through 2015 and for 
fiscal years 2012 through 2015 do not exceed 
90 percent, then, effective January 1, 2015, the 
WTC Program Administrator may increase the 
numerical limitation under paragraph (5)(A), 
the 
numerical 
limitation 
under 
section 
3021(a)(5), or both, as in effect after the appli-
cation 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 INCREASE IN 
NUMERICAL LIMITATIONS FOR PERIOD OF FIS-
CAL 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 numer-
ator of which is the net Federal WTC 
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with respect to a period of fiscal years, the 
ratio (expressed as a percentage) of— 
‘‘(I) the net Federal WTC spend-
ing for such period, to 
‘‘(II) the CBO WTC spending es-
timate under this title for such period. 
‘‘(b) MONITORING BENEFITS.— 
‘‘(1) IN GENERAL.—In the case of an eligible 
WTC responder under section 3011(a)(4) (other 
than one described in subsection (a)(2)(A)(ii)), the 
WTC program shall provide for monitoring benefits 
that include medical monitoring consistent with pro-
tocols approved by the WTC Program Administrator 
and including clinical examinations and long-term 
health monitoring and analysis. In the case of an eli-
gible WTC responder who is an active member of 
the Fire Department 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 BENEFITS.— 
The monitoring benefits under paragraph (1) shall 
be provided through the Clinical Center of Excel-
lence for the type of individual involved or, in the 
case of an individual residing outside the New York 
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metropolitan area, under an arrangement under sec-
tion 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 condition’ means— 
‘‘(A) an illness or health condition for 
which exposure to airborne toxins, any other 
hazard, or any other adverse condition resulting 
from the September 11, 2001, terrorist attacks 
on the World Trade Center, based on an exam-
ination by a medical professional with experi-
ence in treating or diagnosing the medical con-
ditions included in the applicable list of identi-
fied WTC-related conditions, is substantially 
likely to be a significant factor in aggravating, 
contributing to, or causing the illness or health 
condition, as determined under paragraph (2); 
or 
‘‘(B) a mental health condition for which 
such attacks, based on an examination by a 
medical professional with experience in treating 
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or diagnosing the medical conditions included in 
the applicable list of identified WTC-related 
conditions, is substantially likely be a signifi-
cant factor 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 term only includes 
the mental health condition described in subpara-
graph (B). 
‘‘(2) DETERMINATION.—The determination of 
whether the September 11, 2001, terrorist attacks 
on the World Trade Center were substantially likely 
to be a significant 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 exposure shall be— 
‘‘(i) 
evaluated 
and 
characterized 
through the use of a standardized, popu-
lation appropriate questionnaire approved 
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by the Director of the National Institute 
for Occupational Safety and Health; and 
‘‘(ii) assessed and documented by a 
medical professional with experience in 
treating or diagnosing medical conditions 
included on the list of identified WTC-re-
lated conditions. 
‘‘(B) The type of symptoms and temporal 
sequence of symptoms. Such symptoms shall 
be— 
‘‘(i) assessed through the use of a 
standardized, population appropriate med-
ical questionnaire approved by Director of 
the National Institute for Occupational 
Safety and Health and a medical examina-
tion; and 
‘‘(ii) diagnosed and documented by a 
medical professional described in subpara-
graph (A)(ii). 
‘‘(3) 
LIST
OF
IDENTIFIED
WTC-RELATED 
HEALTH CONDITIONS FOR CERTIFIED ELIGIBLE WTC 
RESPONDERS.—For purposes of this title, the term 
‘identified WTC-related health condition for eligible 
WTC responders’ means any of the following health 
conditions: 
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‘‘(A) AERODIGESTIVE DISORDERS.— 
‘‘(i) Interstitial lung diseases. 
‘‘(ii) Chronic respiratory disorder- 
fumes/vapors. 
‘‘(iii) Asthma. 
‘‘(iv) Reactive airways dysfunction 
syndrome (RADS). 
‘‘(v) WTC-exacerbated chronic ob-
structive pulmonary disease (COPD). 
‘‘(vi) Chronic cough syndrome. 
‘‘(vii) Upper airway hyperreactivity. 
‘‘(viii) Chronic rhinosinusitis. 
‘‘(ix) Chronic nasopharyngitis. 
‘‘(x) Chronic laryngitis. 
‘‘(xi) Gastro-esophageal reflux dis-
order (GERD). 
‘‘(xii) Sleep apnea exacerbated by or 
related to a condition described in a pre-
vious clause. 
‘‘(B) MENTAL HEALTH CONDITIONS.— 
‘‘(i) Post traumatic stress disorder 
(PTSD). 
‘‘(ii) Major depressive disorder. 
‘‘(iii) Panic disorder. 
‘‘(iv) Generalized anxiety disorder. 
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‘‘(v) Anxiety disorder (not otherwise 
specified). 
‘‘(vi) Depression (not otherwise speci-
fied). 
‘‘(vii) Acute stress disorder. 
‘‘(viii) Dysthymic disorder. 
‘‘(ix) Adjustment disorder. 
‘‘(x) Substance abuse. 
‘‘(xi) V codes (treatments not specifi-
cally related to psychiatric disorders, such 
as marital problems, parenting problems 
etc.), secondary to another identified 
WTC-related health condition for WTC eli-
gible responders. 
‘‘(C) MUSCULOSKELETAL DISORDERS.— 
‘‘(i) Low back pain. 
‘‘(ii) Carpal tunnel syndrome (CTS). 
‘‘(iii) Other musculoskeletal disorders. 
‘‘(4) ADDITION OF IDENTIFIED WTC-RELATED 
HEALTH CONDITIONS FOR ELIGIBLE WTC RESPOND-
ERS.— 
‘‘(A) IN
GENERAL.—The WTC Program 
Administrator may promulgate regulations to 
add an illness or health condition not described 
in paragraph (3) to be added to the list of iden-
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tified WTC-related conditions for eligible WTC 
responders. In promulgating such regulations, 
the Secretary shall provide for notice and op-
portunity for a public hearing and at least 90 
days of public comment. In promulgating such 
regulations, the WTC Program Administrator 
shall take into account the findings and rec-
ommendations of Clinical Centers of Excellence 
published in peer reviewed journals in the deter-
mination of whether an additional illness or 
health condition, such as cancer, should be 
added to the list of identified WTC-related 
health conditions for eligible WTC responders. 
‘‘(B) PETITIONS.—Any person (including 
the WTC Health Program Scientific/Technical 
Advisory Committee) may petition the WTC 
Program Administrator to propose regulations 
described in subparagraph (A). Unless clearly 
frivolous, or initiated by such Committee, any 
such petition shall be referred to such Com-
mittee for its recommendations. Following— 
‘‘(i) receipt of any recommendation of 
the Committee; or 
‘‘(ii) 180 days after the date of the re-
ferral to the Committee, 
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whichever occurs first, the WTC Program Ad-
ministrator shall conduct a rulemaking pro-
ceeding on the matters proposed in the petition 
or publish in the Federal Register a statement 
of reasons for not conducting such proceeding. 
‘‘(C) 
EFFECTIVENESS.—Any 
addition 
under subparagraph (A) of an illness or health 
condition shall apply only with respect to appli-
cations for benefits under this title which are 
filed after the effective date of such regulation. 
‘‘(D) ROLE OF ADVISORY COMMITTEE.— 
Except with respect to a regulation rec-
ommended by the WTC Health Program Sci-
entific/Technical 
Advisory 
Committee), 
the 
WTC Program Administrator may not propose 
a regulation under this paragraph, unless the 
Administrator has first provided to the Com-
mittee a copy of the proposed regulation, re-
quested recommendations and comments by the 
Committee, and afforded the Committee at 
least 90 days to make such recommendations. 
‘‘(b) COVERAGE OF TREATMENT FOR WTC-RELATED 
HEALTH CONDITIONS.— 
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‘‘(1) DETERMINATION BASED ON AN IDENTI-
FIED WTC-RELATED HEALTH CONDITION FOR CER-
TIFIED ELIGIBLE WTC RESPONDERS.— 
‘‘(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 physician makes 
a clinical determination that exposure to air-
borne toxins, other hazards, or adverse condi-
tions resulting from the 9/11 terrorist attacks is 
substantially likely to be a significant factor in 
aggravating, contributing to, or causing the 
condition— 
‘‘(i) the physician shall promptly 
transmit such determination to the WTC 
Program Administrator and provide the 
Administrator with the medical facts sup-
porting such determination; and 
‘‘(ii) on and after the date of such 
transmittal and subject to subparagraph 
(B), the WTC program shall provide for 
payment under subsection (c) for medically 
necessary treatment for such condition. 
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‘‘(B) 
REVIEW; 
CERTIFICATION; 
AP-
PEALS.— 
‘‘(i) REVIEW.—A Federal employee 
designated by the WTC Program Adminis-
trator shall review determinations made 
under subparagraph (A) of a WTC-related 
health condition. 
‘‘(ii) CERTIFICATION.—The Adminis-
trator shall provide a certification of such 
condition based upon reviews conducted 
under clause (i). Such a certification shall 
be provided unless the Administrator de-
termines that the responder’s condition is 
not an identified WTC-related health con-
dition or that exposure to airborne toxins, 
other hazards, or adverse conditions result-
ing from the 9/11 terrorist attacks is not 
substantially likely to be a significant fac-
tor in significantly aggravating, contrib-
uting to, or causing the condition. 
‘‘(iii) APPEAL PROCESS.—The Admin-
istrator shall provide a process for the ap-
peal of determinations under clause (ii) be-
fore an administrative law judge. 
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‘‘(2) DETERMINATION BASED ON OTHER WTC- 
RELATED HEALTH CONDITION.— 
‘‘(A) IN GENERAL.—If a physician at a 
Clinical Center of Excellence determines pursu-
ant to subsection (a) that the certified eligible 
WTC responder has a WTC-related health con-
dition that is not an identified WTC-related 
health condition for eligible WTC responders— 
‘‘(i) the physician shall promptly 
transmit such determination to the WTC 
Program Administrator and provide the 
Administrator with the facts supporting 
such determination; and 
‘‘(ii) the Administrator shall make a 
determination under subparagraph (B) 
with respect to such physician’s determina-
tion. 
‘‘(B) REVIEW; CERTIFICATION.— 
‘‘(i) USE
OF
PHYSICIAN
PANEL.— 
With respect to each determination relat-
ing to a WTC-related health condition 
transmitted under subparagraph (A)(i), 
the WTC Program Administrator shall 
provide for the review of the condition to 
be made by a physician panel with appro-
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priate expertise appointed by the WTC 
Program Administrator. Such a panel shall 
make recommendations to the Adminis-
trator on the evidence supporting such de-
termination. 
‘‘(ii) REVIEW OF RECOMMENDATIONS 
OF PANEL; CERTIFICATION.—The Adminis-
trator, based on such recommendations 
shall determine, within 60 days after the 
date of the transmittal under subpara-
graph (A)(i), whether or not the condition 
is a WTC-related health condition and, if 
it is, provide for a certification under para-
graph (1)(B)(ii) of coverage of such condi-
tion. The Administrator shall provide a 
process for the appeal of determinations 
that the responder’s condition is not a 
WTC-related health condition before an 
administrative law judge. 
‘‘(3) REQUIREMENT OF MEDICAL NECESSITY.— 
‘‘(A) IN
GENERAL.—In providing treat-
ment for a WTC-health condition, a physician 
shall provide treatment that is medically nec-
essary and in accordance with medical protocols 
established under subsection (d). 
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‘‘(B) 
MEDICALLY
NECESSARY
STAND-
ARD.—For the purpose of this title, health care 
services shall be treated as medically necessary 
for an individual if a physician, exercising pru-
dent clinical judgment, would consider the serv-
ices to be medically necessary for the individual 
for the purpose of evaluating, diagnosing, or 
treating an illness, injury, disease or its symp-
toms, 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 
illness, injury, or disease; and 
‘‘(iii) not primarily for the conven-
ience of the patient or physician, or an-
other physician, and not more costly than 
an alternative service or sequence of serv-
ices at least as likely to produce equivalent 
therapeutic or diagnostic results as to the 
diagnosis or treatment of the individual’s 
illness, injury, or disease. 
‘‘(C) DETERMINATION
OF
MEDICAL
NE-
CESSITY.— 
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‘‘(i) REVIEW
OF
MEDICAL
NECES-
SITY.—As part of the reimbursement pay-
ment process under subsection (c), the 
WTC Program Administrator shall review 
claims for reimbursement for the provision 
of medical treatment to determine if such 
treatment is medically necessary. 
‘‘(ii) WITHHOLDING OF PAYMENT FOR 
MEDICALLY UNNECESSARY TREATMENT.— 
The Administrator may withhold such pay-
ment for treatment that the Administrator 
determines is not medically necessary. 
‘‘(iii) REVIEW
OF
DETERMINATIONS 
OF
MEDICAL
NECESSITY.—The Adminis-
trator shall provide a process for providers 
to appeal a determination under clause (ii) 
that medical treatment is not medically 
necessary. Such appeals shall be reviewed 
through the use of a physician panel with 
appropriate expertise. 
‘‘(4) SCOPE OF TREATMENT COVERED.— 
‘‘(A) IN
GENERAL.—The scope of treat-
ment covered under such paragraphs includes 
services of physicians and other health care pro-
viders, diagnostic and laboratory tests, prescrip-
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tion drugs, inpatient and outpatient hospital 
services, and other medically necessary treat-
ment. 
‘‘(B) PHARMACEUTICAL COVERAGE.—With 
respect to ensuring coverage of medically nec-
essary outpatient prescription drugs, such drugs 
shall be provided, under arrangements made by 
the WTC Program Administrator, directly 
through participating Clinical Centers of Excel-
lence or through one or more outside vendors. 
‘‘(C) TRANSPORTATION
EXPENSES.—To 
the extent provided in advance in appropria-
tions Acts, the WTC Program Administrator 
may provide for necessary and reasonable 
transportation and expenses incident to the se-
curing of medically necessary treatment involv-
ing 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 ex-
penses incident to services involving travel of 
more than 250 miles under regulations imple-
menting section 3629(c) of the Energy Employ-
ees Occupational Illness Compensation Program 
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Act of 2000 (title XXXVI of Public Law 106– 
398; 42 U.S.C. 7384t(c)). 
‘‘(5) PROVISION OF TREATMENT PENDING CER-
TIFICATION.—In the case of a certified eligible WTC 
responder who has been determined by an examining 
physician under subsection (b)(1) to have an identi-
fied WTC-related health condition, but for whom a 
certification of the determination has not yet been 
made by the WTC Program Administrator, medical 
treatment may be provided under this subsection, 
subject to paragraph (6), until the Administrator 
makes a decision on such certification. Medical 
treatment provided under this paragraph shall be 
considered to be medical treatment for which pay-
ment may be made under subsection (c). 
‘‘(6) PRIOR APPROVAL PROCESS FOR NON-CER-
TIFIED
NON-EMERGENCY
INPATIENT
HOSPITAL 
SERVICES.—Non-emergency inpatient hospital serv-
ices for a WTC-related health condition identified by 
an examining physician under paragraph (b)(1) that 
is not certified under paragraph (1)(B)(ii) is not 
covered unless the services have been determined to 
be medically necessary and approved through a proc-
ess established by the WTC Program Administrator. 
Such process shall provide for a decision on a re-
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quest for such services within 15 days of the date 
of receipt of the request. The WTC Administrator 
shall provide a process for the appeal of a decision 
that the services are not medically necessary. 
‘‘(c) PAYMENT FOR INITIAL HEALTH EVALUATION, 
MEDICAL MONITORING, AND TREATMENT OF WTC-RE-
LATED HEALTH CONDITIONS.— 
‘‘(1) MEDICAL TREATMENT.— 
‘‘(A) USE
OF
FECA
PAYMENT
RATES.— 
Subject to subparagraph (B), the WTC Pro-
gram Administrator shall reimburse costs for 
medically necessary treatment under this title 
for WTC-related health conditions according to 
the payment rates that would apply to the pro-
vision of such treatment and services by the fa-
cility under the Federal Employees Compensa-
tion Act. 
‘‘(B) PHARMACEUTICALS.— 
‘‘(i) IN
GENERAL.—The WTC Pro-
gram Administrator shall establish a pro-
gram for paying for the medically nec-
essary outpatient prescription pharma-
ceuticals prescribed under this title for 
WTC-related conditions through one or 
more contracts with outside vendors. 
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