Updated Coverage for Dental Services and Monoclonal Gammopathy of Undetermined Significance
Updated July 21, 2023 (Dental Services FAQ additions) / March 17, 2023
The World Trade Center (WTC) Health Program has released updated coverage details of the following:
- Dental services
- Monoclonal Gammopathy of Undetermined Significance (MGUS)
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:
- with a certified WTC-related head/neck cancer; and/or
- who will receive treatment for any certified WTC-related cancer; and/or
- with a planned WTC-related organ transplant.
The Program previously covered limited medically necessary dental care to restore function for members with certified WTC-related head/neck cancer only.
What dental services are covered?
Covered dental services are limited. They are only available prior to cancer treatment and/or organ transplant, with one exception. Members certified with WTC-related head/neck cancer may receive post-treatment dental care if medically necessary and needed because of the WTC-related treatment.
Covered dental services prior to treatment for any certified WTC-related cancer and/or prior to a planned WTC-related organ transplant include:
- a once-per-lifetime dental exam for eligible members based on the criteria above, potentially including a cleaning and all appropriate x-rays; and
- based on the exam results, follow-up medically necessary dental care (such as deep cleaning, fillings, and extractions) before an organ transplant and/or the start of chemotherapy or radiation.
Dental care is not covered if a member with a certified cancer has already received their one dental exam and the cancer returns following initial treatment. Dental care is also not covered when an eligible member has already received their once-per-lifetime dental exam and the cancer returns following initial treatment or becomes metastatic. Metastatic disease is when a cancer has spread to other parts of the body.
Additional dental care is available based on medical need for members with certified head/neck cancer.
Medically necessary dental care related to other certified WTC-related health conditions may be considered on a limited case-by-case basis.
Who can authorize dental services in the Program?
The Clinical Center of Excellence or Nationwide Provider Network Clinical Director can authorize the one-time dental exam prior to an organ transplant or start of chemotherapy/radiation.
Most follow-up dental care, such as deep cleaning, root canals, and fillings, require additional authorization from the WTC Health Program. The Program will work with the Clinical Center of Excellence or Nationwide Provider Network to ensure a dental treatment plan is developed and that all other criteria for coverage are met.
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:
- For Screening-Eligible Survivors, all MGUS services must be received in the initial health evaluation period. Responders and Certified-Eligible Survivors can receive the services whenever medically necessary.
- A health evaluation must show the potential existence of MGUS or there must be symptoms of a plasma cell neoplasm. A plasma cell neoplasm is a disease where there are abnormal changes with plasma cells.
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 member must be under the care of a Program provider,
- the services must be medically necessary, and
- there must be a plan of care in place.
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.