chore: investigate demo procedure/payer selection for MVP

[rsalus]

Note for implementers: The design outlined here is a guideline, not a strict specification. Feel free to pivot from the suggested approach if you discover a better solution during implementation. Update the issue with your rationale when deviating significantly.

Summary

Determine the specific procedure and payer combination for the March 11, 2026 VC pitch demo at Pioneer Square Labs. This research/decision issue unblocks policy definition, form template selection, and data contract finalization for the MVP.

The architecture doc (Section 4.3, Section 5.1) explicitly marks procedure and payer as TBD. This decision must balance several factors: PA complexity (demonstrable value), data availability in Epic sandbox, policy documentation accessibility, and form availability.

Research Questions

1. Procedure Selection

Question	Considerations
What procedure codes best demonstrate PA value?	Should require meaningful clinical criteria
Which procedures have accessible policy documentation?	Public payer policies are easier to implement
Which procedures align with Synthea demo data?	Current config uses low back pain (M54.5) scenarios
Which procedures have standard PA forms available?	Form templates must be accessible

Candidate Procedures:

• Lumbar MRI (CPT 72148) - Common PA requirement, well-documented policies
• Physical Therapy (CPT 97110-97542) - Mentioned in architecture doc
• Spinal Injections (CPT 62322-62323) - Complex criteria, high PA burden
• Advanced Imaging (CT/MRI various) - Frequently requires PA

2. Payer Selection

Question	Considerations
Which payers have publicly accessible policy criteria?	Need explicit criteria for policy matching
Which payers have standardized PA forms?	PDF forms must be fillable/stampable
Which payers are in Epic FHIR sandbox?	Must be testable

Candidate Payers:

• Medicare (CMS) - Public policies, standardized forms
• Major commercial (Aetna, UHC, Cigna, BCBS) - Common but may have proprietary forms
• State Medicaid - Publicly documented policies

Decision Criteria

Criterion	Weight	Description
Demo Impact	High	Does it clearly demonstrate PA automation value?
Policy Accessibility	High	Are explicit clinical criteria publicly documented?
Form Availability	High	Is a fillable PA form available?
Sandbox Support	High	Can we test against Epic FHIR sandbox?
Data Generation	Medium	Can Synthea generate appropriate clinical scenarios?

Tasks

• Research candidate procedures for PA complexity and sandbox support
• Research candidate payers for accessible policy documentation
• Evaluate Epic FHIR sandbox capabilities
• Locate or create PA form template (fillable PDF)
• Extract and document policy criteria (thresholds, required documentation)
• Define specific demo patient clinical scenarios
• Update architecture doc sections 4.3 and 5.1

Downstream Dependencies (Blocked Issues)

Issue	What It Needs
#8 INT-003: Policy Matching	CPT codes, policy criteria, field mappings
#11 GW-004: PDF Form Stamping	PA form template PDF file
Data Contracts	Procedure-specific field requirements

Design References

• §4.3 Policy Definition - Policy structure with TBD fields
• §5.1 Synthetic Patient Generation - Demo patient scenarios
• §5.3 Truth Hierarchy - Data priority rules