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GOLD-TRK-20

Tricky or ambiguous · gold-v0.1

Case inputs

As of
2026-06-10
Patient
71 years, TN
Request
Immunara for rheumatoid arthritis
Insurance
ExampleHealth, ExampleHealth Gold · EXH-609317
Policy
immunara-v0.1
Inputs
sha256:f4d19616e7cb…

Documents 2

Physician note

referral_letter
SYNTHETIC RECORD - Example Rosedale Rheumatology - June 10, 2026

Dear Claims Reviewer,

Patient reference SYN-7734. This 71-year-old man has an established diagnosis of seropositive rheumatoid arthritis, first documented in 2019, with persistent synovitis of the hands and feet despite his current regimen.

His only medication for joint inflammation has been methylprednisolone, used intermittently for flares; he has not taken methotrexate. Given his sustained disease activity, I am requesting Immunara.

Best regards,
The co-managing rheumatologist

Medication history

medication_history
SYNTHETIC RECORD - Example Rosedale Rheumatology - Medication History - 2026-06-09
Patient reference SYN-7734. Methylprednisolone 4 mg tapering dose, oral, 2026-01-05 through 2026-06-01, for symptomatic flare control. Current medications: lisinopril 20 mg daily, atorvastatin 40 mg daily.

Decisions by provider

HUMAN_REVIEWcorrect

Decided by: default_review gate · auto_process 0.89

Judgments

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

Diagnosis supported
0.980
Step therapy met
0.000
Documentation complete
0.940
Material contradiction
0.080
Missing evidence
TREATMENT_HISTORY 0.570
others: NONE 0.41 · DOSAGE 0.02
Gate path· 7 gates, in engine order
  1. providerpassed

    all five decisions present and well-formed

  2. agepassed

    patient.age=71, policy min_age=18

  3. contradictionpassed

    p_yes(material_contradiction)=0.080, review at >= 0.8

  4. documentationpassed

    p_yes(documentation_complete)=0.940, request info below 0.6

  5. missing_evidencepassed

    missing_evidence=TREATMENT_HISTORY (p=0.570), request info at >= 0.7

  6. auto_processpassed

    min(required p_yes)=0.000, auto at >= 0.89; p_yes(material_contradiction)=0.080, blocks at >= 0.2

  7. default_reviewFIRED → HUMAN_REVIEW

    case does not meet the autonomous-action bar

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

  • step_therapy p_yes=0.000 is below the 0.89 autonomous-action bar
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)