Proton Beam denials at external review

• the question matters

  The outcome turns on which question was put to the reviewer: 59.1% on medical necessity (n=115) against 29.3% on experimental/investigational (n=41) — a gap of 30 points inside the same treatment class.

• most-cited standard

  Reviewers named NCCN more than any other standard here — 77 decisions, which came out at 46.8%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

California requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.

Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.

• NCCN46.8%77
• American College of Rheumatology—2

A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.

• Cancer51.0%155
• CNS & neuromuscular—1

Browse all condition classes · Pick your own pair

• Prostate28.8%66
• Breast—25
• Brain—8
• Tumor—8
• Head/Neck/Throat—7
• Other—6
• Lymphoma—5
• Anal/Rectal—4

• Medical Necessity59.1%115
• Experimental/Investigational29.3%41

Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.