Decertification Letter Template - Latency - Prostate Cancer

WTC Health Program

PO Box 7002

Rensselaer, NY 12144

Name

Address

Address

Re: 911XXXXXX

<Date>

Dear (Insert Member Name):

This letter is regarding your certification for (Insert Cancer Condition) as a World Trade Center (WTC)-related health condition eligible for treatment in the WTC Health Program. After reviewing your medical records at your Clinical Center of Excellence (CCE)/Nationwide Provider Network (NPN), (Insert CCE/NPN/), we have discovered an error in your certification determination. Upon further review of your records, the World Trade Center (WTC) Health Program has determined that your (Insert Cancer Condition) was a recurrence and not a second primary cancer. This information results in a revision to the date of diagnosis for your cancer and, consequently, your cancer does not meet the requirements for certification in the WTC Health Program.

In order for a cancer to be certified as a WTC-related health condition, the WTC Health Program requires that a minimum amount of time must have elapsed between the date of the member’s initial 9/11 exposure and the date of the initial date of diagnosis for the member’s cancer; this is called the “latency period.” The date of diagnosis used to determine the latency period is the date of the member’s original cancer occurrence, rather than the date of any recurrence. The latency period for your cancer has been recalculated based on the date of your original cancer diagnosis and is shorter than the minimum period of time specified by the WTC Health Program for certification of this type of cancer, which is four years. (See “Minimum Latency & Types or Categories of Cancer” available at: www.cdc.gov/wtc/policies.html).

According to the information submitted by your CCE physician, the date of your initial 9/11-related exposure was (Insert date) and the original date of diagnosis of your (Insert Cancer Condition) was (Insert date). The period of time between the date of your initial 9/11 exposure and the date of your diagnosis is (Insert timeframe). This period of time does not meet the minimum latency period required to certify your type of cancer, which is four years. In addition, due to the (Insert year) original diagnosis date not meeting the required minimum latency period, any recurrence of or metastasis from the malignant neoplasm of the prostate will not be considered for certification regardless of the amount of time that passes between remission of the pre-existing neoplasm and its recurrence or metastatic spread.

Based upon this new information, the WTC Health Program has decertified the following WTC-related health condition:

Date of Certification	Condition Category on List of WTC-Related Health Conditions*	Certification Category or Injury
(Effective Date)	Cancer- Malignant Neoplasm of Prostate	Cancer

* As listed in the James Zadroga 9/11 Health and Compensation Act of 2010 and/or 42 C.F.R. § 88.15

This decertification means that the WTC Health Program and your CCE will no longer be able to pay for any health benefits related to your (Insert Cancer Condition). Your CCE will work with you to transition the care of your (Insert Cancer Condition) to be reimbursed through your primary or other insurance. All health treatment claims submitted with a date of service on or after 120 days from the date of this letter will not be covered by the WTC Health Program.

You are still enrolled as a (RESPONDER/SURVIVOR) in the WTC Health Program and you remain eligible for monitoring and treatment benefits for the following certified health condition(s):

Date of Certification	Condition Category on List of WTC-Related Health Conditions*	Certification Category or Injury
(Effective Date)	(Insert Zadroga Term)	(Condition Category)

*As listed in the James Zadroga 9/11 Health and Compensation Act of 2010 and/or 42 C.F.R. § 88.15

The WTC Health Program will only provide payment for medically necessary treatment(s) authorized by your WTC Health Program physician for your certified health condition(s) by a WTC Health Program participating provider.

Appeal Rights

If you believe the decertification of your (Insert Cancer Condition) condition was made in error, you may request to appeal the decertification by sending a written letter to the following address or fax:

Appeal Coordinator

WTC Health Program

P.O. Box 7000

Rensselaer, NY 12144

Fax: 1.877.646.5308

The appeal request letter must be postmarked or faxed within 120 calendar days of the date of this letter. Your appeal request should include a complete explanation of the specific reasons you feel the decertification is incorrect. If you choose to make an oral statement as a part of your appeal and/or you would like to designate an individual to represent you during the appeal process, this information should also be included in your letter. Information about the oral statement and designating a representative can be found in the Overview of the Appeal Process for Denial of Health Condition Certification enclosed with this letter.

Please note that all appeal letters must be signed by you or your representative if you have designated one. Your signature on your appeal request letter indicates that the information provided is correct to the best of your knowledge. Should you have any questions about this letter or the appeal process, please send your questions to [email protected] or call the WTC Health Program at 1-888-982-4748 Monday through Friday, 9 AM to 5 PM (Eastern Standard Time), and ask to speak to the appeal coordinator.

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Copy to: Director, Clinical Center of Excellence