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GOLD-CON-17

Conflicting evidence · gold-v0.1

Case inputs

As of
2026-06-20
Patient
59 years, SC
Request
Immunara for rheumatoid arthritis
Insurance
Northstar, Northstar Choice
Policy
immunara-v0.1
Inputs
sha256:d8b283ddecf8…

Documents 3

Physician note

problem_list
SYNTHETIC RECORD - Example Copperfield Rheumatology - Problem List Update - 2026-06-15
Patient reference SYN-8890. 59-year-old woman.

- Seropositive rheumatoid arthritis, diagnosed 2019, followed at this practice since.
- Methotrexate 20 mg weekly from 2026-01-07 to 2026-06-10, discontinued for inadequate response.
- Osteoarthritis of the knees, managed conservatively.
- Plan: discuss Immunara given the inadequate response to methotrexate.

Medication history

medication_history
SYNTHETIC RECORD - Example Copperfield Rheumatology - Medication History - 2026-06-16
Patient reference SYN-8890.
METHOTREXATE 20 MG PO WEEKLY - status: inactive - start 2026-01-07 - end 2026-06-14 - reason: inadequate response
FOLIC ACID 1 MG PO DAILY - status: inactive - start 2026-01-07
NAPROXEN 250 MG PO AS NEEDED - status: active

Fax cover

fax_cover
SYNTHETIC RECORD - Example Copperfield Rheumatology - Fax Cover Sheet - 2026-06-18
To: Northstar Choice Pharmacy Benefits
Re: Prior authorization request for Immunara
Patient reference SYN-8890. Member ID: not provided; our office does not have this on file for the patient. Pages: 1 of 1.

Decisions by provider

REQUEST_INFOcorrect

Decided by: documentation gate · auto_process 0.89

Judgments

p_yes for yes/no questions; ticks are the thresholds a gate compares each one with.

Diagnosis supported
0.970
Step therapy met
0.980
Documentation complete
0.050
Material contradiction
0.140
Missing evidence
INSURANCE_INFORMATION 1.000
Gate path· 7 gates, in engine order
  1. providerpassed

    all five decisions present and well-formed

  2. agepassed

    patient.age=59, policy min_age=18

  3. contradictionpassed

    p_yes(material_contradiction)=0.140, review at >= 0.8

  4. documentationFIRED → REQUEST_INFO

    p_yes(documentation_complete)=0.050, request info below 0.6

  5. missing_evidencenot reached
  6. auto_processnot reached
  7. default_reviewnot reached

passed = the gate checked and did not fire; not reached = an earlier gate decided.

  • documentation is likely incomplete (p_yes=0.050)
  • most likely missing: insurance information (p=1.000)
Run details· q-v0.2

run_20260925T170857Z_b95be9 · q-v0.2 · immunara-v0.1 (v0.1)

auto_process 0.89, chosen on gen-v0.2-dev.

questions: q-v0.2 →

Show expected answer (evaluation only)