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GOLD-MIS-08

Missing information · gold-v0.1

Case inputs

As of
2026-07-15
Patient
40 years, CO
Request
Immunara for rheumatoid arthritis
Insurance
CivicCare, CivicCare Plus · CCP-991827
Policy
immunara-v0.1
Inputs
sha256:d41fe6282285…

Documents 2

Physician note

referral_letter
SYNTHETIC RECORD - Example Meridian Rheumatology - Referral Letter - 2026-07-10

Dear Pharmacy Benefits Reviewer,

This 40-year-old man carries an established diagnosis of seropositive rheumatoid arthritis, first seen at this practice in February 2026 after months of symmetric hand and foot swelling. He has since been maintained on a structured treatment plan.

For his complete methotrexate course, including start date, duration and the reason it was discontinued, please see the enclosed medication history from our electronic record. I believe he is an appropriate candidate for Immunara given his disease course, and I appreciate your review of the attached documentation.

Kind regards,
The treating rheumatologist

Fax cover

fax_cover
SYNTHETIC RECORD - Example Meridian Rheumatology - Fax Cover Sheet - 2026-07-10
To: CivicCare Plus Pharmacy Benefits
Re: Prior authorization request for Immunara
Patient reference SYN-1129. Member ID: CCP-991827. Pages 3-4 of 4 (the medication history) were not received on this transmission; please contact our office to resend if needed.

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
0.000
Documentation complete
0.080
Material contradiction
0.120
Missing evidence
TREATMENT_HISTORY 1.000
Gate path· 7 gates, in engine order
  1. providerpassed

    all five decisions present and well-formed

  2. agepassed

    patient.age=40, policy min_age=18

  3. contradictionpassed

    p_yes(material_contradiction)=0.120, review at >= 0.8

  4. documentationFIRED → REQUEST_INFO

    p_yes(documentation_complete)=0.080, 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=0.080)
  • most likely missing: treatment history (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)