Page:United States Statutes at Large Volume 124.djvu/3670

 124 STAT. 3644 PUBLIC LAW 111–347—JAN. 2, 2011 provide the Administrator with the facts supporting such determination; and ‘‘(ii) the Administrator shall make a determination under subparagraph (B) with respect to such physi- cian’s determination. ‘‘(B) PROCEDURES FOR REVIEW, CERTIFICATION, AND APPEAL.—The WTC Program Administrator shall, by rule, establish procedures for the review and certification of physician determinations under subparagraph (A). Such rule shall provide for— ‘‘(i) the timely review of such a determination by a physician panel with appropriate expertise for the condition and recommendations to the WTC Program Administrator; ‘‘(ii) not later than 60 days after the date of the transmittal under subparagraph (A)(i), a determination by the WTC Program Administrator on whether or not the condition involved is described in subsection (a)(1)(A) and is medically associated with a WTC- related health condition; ‘‘(iii) certification in accordance with paragraph (1)(B)(ii) of coverage of such condition if determined to be described in subsection (a)(1)(A) and medically associated with a WTC-related health condition; and ‘‘(iv) a process for appeals of determinations relating to such conditions. ‘‘(C) INCLUSION IN LIST OF HEALTH CONDITIONS.—If the WTC Program Administrator provides certification under subparagraph (B)(iii) for coverage of a condition, the Administrator may, pursuant to subsection (a)(6), add the condition to the list in subsection (a)(3). ‘‘(D) CONDITIONS ALREADY DECLINED FOR INCLUSION IN LIST.—If the WTC Program Administrator publishes a determination under subsection (a)(6)(B) not to include a condition in the list in subsection (a)(3), the WTC Program Administrator shall not provide certification under subparagraph (B)(iii) for coverage of the condition. In the case of an individual who is certified under subparagraph (B)(iii) with respect to such condition before the date of the publication of such determination the previous sentence shall not apply. ‘‘(3) REQUIREMENT OF MEDICAL NECESSITY.— ‘‘(A) IN GENERAL.—In providing treatment for a WTC- related health condition, a physician or other provider shall provide treatment that is medically necessary and in accordance with medical treatment protocols established under subsection (d). ‘‘(B) REGULATIONS RELATING TO MEDICAL NECESSITY.— For the purpose of this title, the WTC Program Adminis- trator shall issue regulations specifying a standard for determining medical necessity with respect to health care services and prescription pharmaceuticals, a process for determining whether treatment furnished and pharma- ceuticals prescribed under this title meet such standard (including any prior authorization requirement), and a process for appeal of a determination under subsection (c)(3). Deadline. Regulations.