Question set
q-v0.3
19 questions, sent to Jev in one call per case under immunara-v0.1; the latest adopted set. 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
- sha256:4589d78b40d2be56216766beec111882b7f96c761be99d1f6ba218e3bfd2979cunder immunara-v0.1 and immunara-v0.2 (identical)
- Recorded
- the same hash is recorded in 100 committed gold and smoke traces
Why it changed from q-v0.2
q-v0.3 adds seven questions for an interrupted course, prompted by GOLD-TMP-17: q-v0.2 has one start and one end date, so it read that held-and-restarted course as one 133-day course and both Jev and Claude auto-approved it. q-v0.3 was developed on gen-v0.3-dev and evaluated once on gen-v0.3-holdout; gold is not a blind test for it on GOLD-TMP-17 and GOLD-TMP-18.
compare q-v0.2 → q-v0.3 →The 19 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 (a statement that the patient never took methotrexate counts as treatment history).
- 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 records do not say whether or when the patient took methotrexate. A record stating that the patient never took methotrexate counts as documented treatment history.
- 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 (the first time, if it was restarted)? 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 (the first time, if it was restarted)? 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 (the first time, if it was restarted)? 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) (the last time, if it was restarted)?
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 (the last time, if it was restarted)? 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 (the last time, if it was restarted)? 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 (the last time, if it was restarted)? 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.
13mtx_interrupted
yes/no · Noul
Do the documents describe the patient's own methotrexate being held, paused or stopped and later restarted?
- yes (true)
- A clinical record states that the patient's own methotrexate was held, paused or stopped, and that the patient later resumed or restarted it.
- no (false)
- The patient took one continuous course, never took methotrexate, or the hold and restart describe a relative or another person.
14mtx_pause_month
choice · Choice
In which month did the patient (not a relative or other person) first stop taking methotrexate before restarting it (a hold or pause counts as a stop)? Answer 'none' if the documents do not state the month, or if the course was never stopped and restarted.
Options: January … December, none
- none
- The documents do not state this, or the patient's course was never held, paused or stopped and then restarted.
15mtx_pause_day
choice · Choice
On which day of the month (1-31) did the patient (not a relative or other person) first stop taking methotrexate before restarting it (a hold or pause counts as a stop)? Answer 'none' if the day is not stated, for example when only a month is given, or if the course was never stopped and restarted.
Options: 1 … 31, none
- none
- The documents do not state this, or the patient's course was never held, paused or stopped and then restarted.
16mtx_pause_year
choice · Choice
In which year did the patient (not a relative or other person) first stop taking methotrexate before restarting it (a hold or pause counts as a stop)? Answer 'none' if no year is stated for this event, or if the course was never stopped and restarted.
Options: years found in the case, none
- none
- The documents do not state this, or the patient's course was never held, paused or stopped and then restarted.
17mtx_restart_month
choice · Choice
In which month did the patient (not a relative or other person) restart taking methotrexate after a hold, pause or stop? Answer 'none' if the documents do not state the month, or if the course was never stopped and restarted.
Options: January … December, none
- none
- The documents do not state this, or the patient's course was never held, paused or stopped and then restarted.
18mtx_restart_day
choice · Choice
On which day of the month (1-31) did the patient (not a relative or other person) restart taking methotrexate after a hold, pause or stop? Answer 'none' if the day is not stated, for example when only a month is given, or if the course was never stopped and restarted.
Options: 1 … 31, none
- none
- The documents do not state this, or the patient's course was never held, paused or stopped and then restarted.
19mtx_restart_year
choice · Choice
In which year did the patient (not a relative or other person) restart taking methotrexate after a hold, pause or stop? Answer 'none' if no year is stated for this event, or if the course was never stopped and restarted.
Options: years found in the case, none
- none
- The documents do not state this, or the patient's course was never held, paused or stopped and then restarted.
Step therapy under this set
Pause and restart segments: p = (1 − p_int) · P(first start → final end) + p_int · P(start → pause or restart → end), where p_int is p_yes of mtx_interrupted. The two segments are combined by inclusion-exclusion; an unknown pause or restart adds nothing. 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.