Question set
q-v0.1
12 questions, sent to Jev in one call per case under immunara-v0.1. Question ids are for code and are not sent; the instructions and criteria below are. Year options are the years found in the case.
- question_set_hash
- sha256:b395531673a539ec02c1e66bb03d5952b8608eba15f041939549ece2617ac77aunder immunara-v0.1 and immunara-v0.2 (identical)
- Recorded
- the same hash is recorded in 10 committed gold and smoke traces
Replaced by q-v0.2 (compare) →
The 12 questions
01diagnosis_support
yes/no · Noul
Do the clinical documents establish a clinician-documented diagnosis of rheumatoid arthritis for this patient, as the policy requires?
- yes (true)
- A clinician states that the patient has rheumatoid arthritis as an established diagnosis.
- no (false)
- The diagnosis is absent, only suspected, pending workup, or describes someone other than the patient.
02documentation_complete
yes/no · Noul
Does this request include every item the policy lists under submission documentation?
- yes (true)
- The insurance member ID, a clinician note supporting the diagnosis, and the patient's treatment history (including whether and when methotrexate was taken) are all present.
- no (false)
- At least one required item is missing, unavailable, or marked as not provided.
03material_contradiction
yes/no · Noul
Do the case documents contain a material contradiction about the patient's diagnosis or treatment history that affects this authorization?
- yes (true)
- Two sources make incompatible claims about the same fact, for example one record shows a medication was taken while another says it was never tried.
- no (false)
- The sources agree, or differ only in wording, detail, or precision without conflicting.
04missing_evidence
choice · Choice
What is the most important information missing from this request for the policy decision, if any?
Options: DIAGNOSIS, TREATMENT_HISTORY, LAB_RESULT, DOSAGE, INSURANCE_INFORMATION, NONE
- DIAGNOSIS
- No established diagnosis of rheumatoid arthritis is documented.
- TREATMENT_HISTORY
- The patient's methotrexate treatment history (dates or outcome) is not documented.
- LAB_RESULT
- A lab result that the decision depends on is missing.
- DOSAGE
- The requested dose or regimen is missing.
- INSURANCE_INFORMATION
- The insurance member ID or plan information is missing.
- NONE
- Nothing that the policy requires is missing.
05mtx_start_month
choice · Choice
In which month did the patient (not a relative or other person) start taking methotrexate? Answer 'none' if the documents do not state the month.
Options: January … December, none
- none
- The documents do not state this, or the patient never took the medication.
06mtx_start_day
choice · Choice
On which day of the month (1-31) did the patient (not a relative or other person) start taking methotrexate? Answer 'none' if the day is not stated, for example when only a month is given.
Options: 1 … 31, none
- none
- The documents do not state this, or the patient never took the medication.
07mtx_start_year
choice · Choice
In which year did the patient (not a relative or other person) start taking methotrexate? Answer 'none' if no year is stated for this event.
Options: years found in the case, none
- none
- The documents do not state this, or the patient never took the medication.
08mtx_end_status
choice · Choice
What is the status of the patient's own methotrexate treatment (not a relative's)?
Options: ended, ongoing, not_stated
- ended
- The documents say the patient stopped taking methotrexate.
- ongoing
- The documents say the patient is still taking methotrexate.
- not_stated
- The documents do not say, or the patient never took methotrexate.
09mtx_end_month
choice · Choice
In which month did the patient (not a relative or other person) stop taking methotrexate? Answer 'none' if the documents do not state the month.
Options: January … December, none
- none
- The documents do not state this, or the patient never took the medication.
10mtx_end_day
choice · Choice
On which day of the month (1-31) did the patient (not a relative or other person) stop taking methotrexate? Answer 'none' if the day is not stated, for example when only a month is given.
Options: 1 … 31, none
- none
- The documents do not state this, or the patient never took the medication.
11mtx_end_year
choice · Choice
In which year did the patient (not a relative or other person) stop taking methotrexate? Answer 'none' if no year is stated for this event.
Options: years found in the case, none
- none
- The documents do not state this, or the patient never took the medication.
12mtx_inadequate_response
yes/no · Noul
Is it documented that the patient's own methotrexate treatment was ineffective (inadequate response) or was stopped because of intolerance or a contraindication?
- yes (true)
- A clinician documents that methotrexate did not adequately control this patient's disease, or that it caused intolerance or is contraindicated for this patient.
- no (false)
- There is no such documentation for this patient; statements about relatives or other people do not count, and neither does a different medication.
Step therapy under this set
One course: the first start to the final end, from mtx_start_*, mtx_end_status and mtx_end_*. An ongoing course ends at the request's as_of_date. Under immunara-v0.2 (max_days_since_therapy 365) the qualifying course must also be ongoing or have ended, at its earliest possible end, no more than 365 days before as_of. The rule applies on both paths; immunara-v0.1 has none. How every decision is composed.