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Updated Coverage for Dental Services and Monoclonal Gammopathy of Undetermined Significance

March 17, 2023

The World Trade Center (WTC) Health Program has released updated coverage details of the following:

Dental Services

The WTC Health Program has updated the coverage policy for dental services.

Who is now eligible for limited dental coverage?

The WTC Health Program now covers limited pre-treatment dental services for members:

The Program previously covered limited medically necessary dental care to restore function for members with certified WTC-related head/neck cancer only.

Where can I get more information on dental service coverage?

Additional details on the update to dental services coverage is available in the WTC Health Program Administrative Manual – Dental Services.

Monoclonal Gammopathy of Undetermined Significance (MGUS)

The WTC Health Program had developed a new Medical Coverage Determination (MCD) for Monoclonal Gammopathy of Undetermined Significance (MGUS), outlining updated coverage details and criteria. Below is a summary. Full details and the official MCD are available in the Administrative Manual – MGUS.

What is MGUS?

MGUS is a condition in which an unusual level of certain proteins are found in the blood. When at unusual levels, these specific proteins–known as monoclonal or M proteins–can sometimes be a sign that cancer might develop in the future.

MGUS itself is considered a benign (not harmful) condition. It can, however, help a doctor detect cancer in the future. A doctor might monitor a patient with MGUS by regularly testing blood to check for any signs of cancer that could develop over time.

What MGUS services does the WTC Health Program cover?

Since MGUS is not a harmful condition, it usually does not require treatment on its own. However, the Program covers certain medical services related to MGUS because it might be a sign of a potential future cancer.

The WTC Health Program has covered and will continue to cover the diagnosis of MGUS as part of its standard cancer diagnostic coverage for all WTC Health Program members. This means a Program provider can check for and diagnose MGUS as part of testing for potential WTC-related cancer.

The WTC Health Program now also covers any necessary follow-up evaluations and ongoing monitoring for MGUS with the following limitations:

Routine screening of all members for MGUS is not medically necessary and will not be covered by the WTC Health Program. MGUS screening is also not recommended by the U.S. Preventive Services Task Force. However, the WTC Health Program will consider MGUS services for those without symptoms of a plasma cell neoplasm or signs of MGUS on a limited case-by-case basis.

Who can authorize MGUS services in the Program?

Initial tests for MGUS are covered by the Program as a standard diagnostic service when there is clinical evidence of MGUS or symptoms of a plasma cell neoplasm. These initial diagnostics do not require prior authorization from a Clinical Director or the WTC Health Program.

The six-month evaluation and ongoing monitoring for MGUS require authorization by a Clinical Center of Excellence or the Nationwide Provider Network Clinical Director.

In addition to Clinical Director approval:

The Program provider is responsible for gaining approval from the Clinical Director.

How long are MGUS services covered?

How long MGUS services are covered by the WTC Health Program depends on the type of member you are.

Screening-Eligible Survivors

MGUS initial diagnostics, six-month evaluation, and ongoing monitoring are available to Screening-Eligible Survivors during the initial health evaluation period only. Even if a Screening-Eligible Survivor is diagnosed with MGUS, the six-month evaluation or ongoing monitoring services are not available outside of the initial health evaluation period until the member is certified with a WTC-related health condition. Once certified, a Screening-Eligible Survivor becomes a Certified-Eligible Survivor.

Responders and Certified-Eligible Survivors

Responders and Certified-Eligible Survivors can receive initial diagnostics for MGUS whenever a Program provider finds it to be medically necessary. A six-month evaluation and ongoing monitoring can be authorized by a Program Clinical Director. For ongoing monitoring, the coverage authorization lasts for a period of three (3) years and must be reauthorized by the Clinical Director at the end of that period.

Can MGUS be certified?

No. The WTC Health Program will not certify MGUS.

However, the WTC Health Program covers the additional testing and monitoring of MGUS that may help a Program provider diagnose a WTC-related cancer in the future. A cancer may be eligible for certification once diagnosed if it meets all necessary certification criteria.