idea-008 · desirability deck
Every slide states a condition that would have to be true, then reports where it stands using the candidate file's own claim and its own confidence tag. A deck never upgrades a tag, invents a number, or recommends anything, and there is no ask slide.
The chair: the patient with grade II-III internal hemorrhoids who has failed conservative management, and the proceduralist deciding what to do with them in the office this afternoon.
How to read this: every slide is a condition, not a conclusion. A bracketed claim reference points into knowledge-base/candidates/idea-008.md. The number is the claim's position in its ## Claims list, and the tag is copied from that line and never adjusted here. A [no claim] marker means nothing in the file speaks to the condition at all. Where this deck needed a condition the file did not carry, it appended the condition to the file as an unverified claim before this deck was written. See docs/deck-spec.md.
Why this deck was rebuilt: the feasibility and viability decks went stale when the Verifier moved a tag on 2026-09-29, and their write-back moved the candidate's updated:. This deck is rebuilt from the file so that all three share one stamp. For this chair, the 2026-09-29 pass answered one proxy that earlier passes could not reach: no Medicare NCD (national coverage determination) or LCD (local coverage determination) in the cached index names 46930. The Verifier notes on claim 24unconfirmed and claim 15unconfirmed say plainly that this does not reach what patients face or what proceduralists would do. So nothing on this deck moved, and two patient-side conditions the file did not carry are now on record claim 76unverified, claim 77unverified. Rebuilt from the file, not patched.
Would have to be true: There would have to be a steady flow of grade II-III patients who have failed conservative management and are treated in an office. For them, recurrence after office treatment would have to be what pushes them on to repeat banding or to an operating room.
Where it stands: The volume is a verified floor. Medicare FFS (fee-for-service) billed 4,911 services for 46930, 3,259 of them in the office claim 7verified, claim 29verified. It is a floor and not a market, because this disease skews younger than Medicare. The recurrence that would drive escalation is sourced and unconfirmed pending appraisal. At grade III, ligation recurred at 47.5% at 12 months against 6.1% for hemorrhoidectomy claim 59unconfirmed, and office ligation recurred at 32.8% at grade III against 14.6% at grade I-II claim 60unconfirmed. Whether recurrence is actually what drives the referral is unbacked claim 24unconfirmed. So is what office proceduralists do with grade III today claim 48unconfirmed.
What would settle it: Chart review at practices already billing 46930, asking one thing: where their grade III patients go after the first recurrence. No connector reaches it.
If it's false: The obtainable share claim 9unconfirmed counts patients who were never in play. The case falls back to grade I-II, where a cleared bipolar RF (radiofrequency) device has been since 2012 claim 40verified.
Would have to be true: A colorectal surgeon, gastroenterologist or proctologist who owns and has paid off a banding or infrared instrument would have to start paying for a disposable on every grade II-III case. They would have to do it on a durability benefit that will not be proven at launch.
Where it stands: Unbacked, and the file records that no source can settle it. The Generator flagged it as an assumption claim 15unconfirmed. The research lane restated it against the measured grade III gap as evidence class 3, stakeholder future claim 63unconfirmed. Whether proceduralists see recurrence as a problem worth paying to fix is also unbacked claim 25unconfirmed. The pitch a salesperson would make is now mostly sourced: roughly half of grade III patients recur within a year after banding claim 59unconfirmed, and a 90-day global period means re-treatment inside three months is unpaid claim 57unconfirmed. What the pitch cannot yet say is what the kit costs. The viability deck carries that.
What would settle it: Interviews with practices billing 46930: what they own, what it cost, how often they re-treat, and what they would pay per case to re-treat less. It is commissioned primary research, and claim 63unconfirmed is the file's record that nothing else will do.
If it's false: The switch is decided before any cost comparison is reached. Factor 8 is already scored on a field of cheap, owned incumbents, and the economic argument never gets a hearing.
Would have to be true: The patient would have to accept an unsedated office RF procedure as readily as banding or infrared. Pain afterwards would have to be no worse than after banding. And a grade III patient who has been offered surgery would have to choose an office procedure whose durability is unproven. Separately, the practice's purchaser would have to accept a placed console and keep buying the kit as a kit.
Where it stands: Every one of these is unbacked. Sedation-free acceptance is recorded twice, the second time as evidence class 3 claim 26unconfirmed, claim 64unconfirmed. Pain relative to banding is this deck's write-back claim 76unverified; the file names pain only as a failure mode claim 12unconfirmed. The grade III choice against surgery is this deck's write-back claim 77unverified. Surgery's side of that choice is sourced: lowest recurrence, worst bleeding, retention and incontinence claim 61unconfirmed. On the purchaser side, console placement is unbacked claim 28unconfirmed, claim 66unconfirmed. The anoscope half of the kit faces a single-use anoscope already cleared through grade III claim 55verified, so unbundling is live claim 27unconfirmed.
What would settle it: A patient-preference study covering sedation and the surgery trade-off. Published pain comparisons for office RF against banding claim 76unverified, which are checkable in the literature. Practice-manager interviews on placement against purchase.
If it's false: If grade III patients who are offered surgery take it, the device is left with patients whom banding already serves. If the kit unbundles, the per-kit price that Factor 3 rests on claim 8unconfirmed falls with it.
Would have to be true: The kit would have to fit inside a fixed office payment that does not rise for a better device. And recurrence inside the global period would have to land on the physician, so that paying for durability pays the physician back.
Where it stands: The payment is checked: $249.07 non-facility, the higher of the two settings claim 58verified. That reverses the file's original read claim 5refuted. The global period that puts recurrence on the physician is sourced but not connector-checked claim 57unconfirmed, claim 2unconfirmed. The cost of the kit is unsourced claim 32unconfirmed. How much of the $188.99 practice-expense share claim 74verified is free to pay for the kit, rather than already spent on the session, is carried on the viability deck claim 80unverified. This deck does not repeat that working.
What would settle it: From this chair, one question in the Slide 2 interviews: what would a kit have to cost for you to use it on every grade II-III case? The payment-side reads are on the viability deck.
If it's false: If re-treatment inside 90 days were separately billable, recurrence would cost the physician nothing, and the durability pitch would lose its reason to exist. If the kit does not fit, the proceduralist on Slide 2 never gets to the durability question at all.
Would have to be true: The durability advantage at grade III would have to be shown to a proceduralist in a form they accept, against a bar that is rising, before the evidence the candidate concedes it will not have at launch exists.
Where it stands: This device's durability is unbacked claim 33unconfirmed. The bar is numeric: 47.5% at 12 months claim 59unconfirmed or 32.8% at a median 14.3 months claim 60unconfirmed. The bar is also moving: modified ligation reported 5.4% against 13.6% at 3 months, and no delayed massive bleeding in 149 cases claim 62unconfirmed. The only verified clinical-adjacent fact is that this modality is cleared for this anatomy at grade I-II claim 52verified.
What would settle it: A comparative study at grade III, which the file prices outside the clearance budget claim 72unconfirmed. Before that, bench data showing a dose consistency that banding cannot match. That is a feasibility-deck item, and it persuades engineers before it persuades clinicians.
If it's false: The product becomes a more expensive way to do what banding does, and the modified technique may close the gap first.
Would have to be true: Twenty interviews with practices already billing 46930, plus a literature pass on pain after office RF, would have to be enough to tell whether proceduralists and patients want this at a price the payment allows.
Where it stands: Not booked. The file records twice, formally, that interviews are the only route for the behavioural half claim 63unconfirmed, claim 64unconfirmed. The pain comparison is the one patient-side condition here that literature could answer claim 76unverified.
What would settle it: The interviews: what they own, how often they re-treat, where their grade III patients go, and what a kit would have to cost. The literature pass on claim 76unverified, ending in a claim for the Verifier.
If it's false: The candidate stays what its own title says it is, a device sized to a payment rate claim 6unconfirmed, with the physician's actual decision never tested.
Every condition above with nothing verified behind it. Read the tags, not the count.
The verified claims this deck cites are volume, site of service, the payment rate, and other devices' cleared scope. Not one of the twenty-one verified claims in the file says a patient or a proceduralist wants this. The rubric does not score whether anyone wants it, so that absence is not a gap the pipeline was ever going to close on its own.
If only one thing from this chair could be checked: whether a proceduralist will trade an owned, paid-off instrument for a per-case disposable, on a grade III durability promise that is unproven at launch claim 15unconfirmed, claim 63unconfirmed.
It holds across this rebuild. The 2026-09-29 pass added nothing that reaches it. The Verifier records that the coverage result does not speak to switching behaviour, and this is still an adoption claim with no source. The question to put to proceduralists is sharper than it was. Your grade III patients recur about half the time within a year after banding claim 59unconfirmed. You are not paid again inside 90 days claim 57unconfirmed. The cleared bipolar device stops at grade II claim 52verified. What would a kit have to cost? The patient's answer sits behind it claim 77unverified. A proceduralist willing to switch still needs a grade III patient who prefers the office to the operating room.
Naming it is not a recommendation, a gate, or a kill.
_shared/plain-language.md