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 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, the tag is copied from it and never adjusted here. A [no claim] marker means nothing in the file speaks to the condition at all. See docs/deck-spec.md.
What changed since the 2026-08-25 build: the research lane measured the clinical gap this candidate is built around. Grade III recurrence after office rubber band ligation is now documented twice [claim 59: unconfirmed], [claim 60: unconfirmed], and the billing rule the whole durability argument depends on has a source [claim 57: unconfirmed]. Both are unconfirmed — a literature or dataset scan locates a fact and cannot verify a claim — and both change what this deck can say. Rebuilt from the file, not patched.
Would have to be true: There would have to be a real flow of grade II-III patients who have failed conservative management, and recurrence after office treatment would have to be the thing that pushes them onward to ligation or an operating room.
Where it stands: The recurrence half is now measured, and it is large. In a randomized multicentre noninferiority trial at grade III, rubber band ligation was not noninferior to hemorrhoidectomy on 12-month quality-adjusted life years, with a 12-month recurrence rate of 47.5% for ligation versus 6.1% for hemorrhoidectomy [claim 59: unconfirmed]. A single-centre cohort found the same gradient within office ligation itself: 32.8% recurrence at grade III against 14.6% at grade I-II, median follow-up 14.3 months [claim 60: unconfirmed]. And a network meta-analysis of 79 randomized trials (n=9,232) in grade II-III found closed hemorrhoidectomy had the lowest symptom-recurrence risk of 14 treatments compared, while the hemorrhoidectomy and stapled options carried the highest rates of postprocedural bleeding, urinary retention and bowel incontinence [claim 61: unconfirmed]. That is the clinical space this candidate is aimed at, described from the literature rather than asserted: office treatment recurs badly at grade III, surgery works but costs the patient more. What is still unmeasured is the flow — the volume [claim 7: unconfirmed] and what happens to those patients in practice [claim 48: unconfirmed].
What would settle it: Load data/medicare_procedure_volumes.csv and run procedures 46930, 46945, 46946 — read as a Medicare-FFS floor on US volume, never as a market. Then chart review at practices already billing the destruction code, asking specifically what happens to their grade III patients.
If it's false: Factor 3's obtainable-share assumption [claim 9: unconfirmed] is counting procedures that were never in play, and the desirability case collapses back to grade I-II — the band where a bipolar RF device has been cleared since 2012 [claim 40: verified].
Would have to be true: A physician would have to stop using an instrument they already own and have amortised, and start paying for a disposable on every case.
Where it stands: Still the candidate's own flagged assumption and still unbacked [claim 15: unconfirmed] — and the research lane has now written the specific version of it into the file: whether proceduralists would switch to a per-case disposable on the basis of the grade-III recurrence gap documented above [claim 63: unconfirmed]. That claim is evidence class 3, a stakeholder-future statement no source can settle, and the file says so. What the week supplied is the argument a salesperson would actually make, now sourced rather than assumed: 47.5% recurrence at 12 months [claim 59: unconfirmed], against a fixed payment [claim 5: unconfirmed] inside a 90-day global period [claim 57: unconfirmed].
What would settle it: Interviews with practices currently billing the destruction code — what instrument they own, what it cost, how often they re-treat, and what they would pay per case to re-treat less. No connector can reach any of that; it is commissioned primary research, and [claim 63: unconfirmed] is the file's own record that this remains true.
If it's false: Factor 8 (competitive intensity) is already scored on a field with cheap, owned, amortised incumbents, and the economic argument on Slide 4 never gets a hearing, because the switching decision is made before the cost comparison is reached.
Would have to be true: The practice's purchaser would have to accept a console-plus-disposable placement, and the patient would have to accept an unsedated office RF procedure at the rate they accept the office modalities they are offered today.
Where it stands: Both unbacked [claim 28: unconfirmed], [claim 26: unconfirmed], and the patient half is now formally recorded as unanswerable: the research lane wrote it up as evidence class 3 with "no source can settle this" [claim 64: unconfirmed]. The anoscope half of the kit faces an occupied position — a single-use disposable anoscope carrying a hemorrhoid indication through grade III is already cleared and recent [claim 44: verified], [claim 55: verified] — which is what makes unbundling a live risk [claim 27: unconfirmed].
What would settle it: Practice-manager interviews on capital placement versus outright purchase; a patient-preference study for the sedation question, which is the only way [claim 64: unconfirmed] ever moves; and the commercial trajectory of the already-cleared disposable anoscope, a trade-source question rather than a connector one.
If it's false: The kit unbundles — the practice buys the applicator and keeps its own anoscope — and the per-kit price assumption that Factor 3 rests on [claim 8: unconfirmed] falls with it.
Would have to be true: The per-case cost would have to fit inside a fixed payment that does not increase for a better device — and re-treatment inside the global period would have to land on the physician's own P&L.
Where it stands: The second half is now sourced, and it points the candidate's way. Under the CY2026 CMS Physician Fee Schedule, 46930, 46945 and 46946 each carry a 90-day global surgical period [claim 57: unconfirmed] — so re-treating a recurrence inside three months is work the physician has already been paid for. That is the mechanism the entire commercial logic depends on, and until this week it was an untested premise [claim 2: unconfirmed]. The setting also favours the office: the non-facility total RVU for 46930 is 7.42 against a facility total of 4.72, meaning the office is the higher-paying setting rather than the lower one [claim 58: unconfirmed]. What remains unmeasured is the other half of the subtraction — what a dosimetry-bearing disposable actually costs to make [claim 32: unconfirmed] — and the payment amount itself against primary CMS files rather than secondary reporting [claim 5: unconfirmed], [claim 6: unconfirmed].
What would settle it: A human attaching the CMS PFS file to data/hcpcs_payment_rates.csv and the CMS NCCI PTP quarterly edit-pair file to data/; plus AMA CPT Professional 2026 or a licensed vendor feed for the descriptor. The global-period question now has a source and needs confirming rather than discovering.
If it's false: If re-treatment inside the global period were separately billable, recurrence would cost the physician nothing and the strongest commercial logic in the file would disappear. On [claim 57: unconfirmed] that reading is now the less likely one — which is the single most favourable development on this candidate since the last build.
Would have to be true: A durability advantage at grade III would have to be demonstrable to the physician — and the candidate concedes it will not be proven at launch.
Where it stands: Unchanged for this device [claim 33: unconfirmed], and the bar it has to clear is now numeric rather than rhetorical. A competitor claim of "better than ligation at grade III" has to beat 47.5% recurrence at 12 months [claim 59: unconfirmed] or 32.8% at 14.3 months [claim 60: unconfirmed], and it has to do so without acquiring the complication profile that makes hemorrhoidectomy unattractive [claim 61: unconfirmed]. That is a well-defined target, and one caution belongs beside it: a modified ligation technique has been reported to cut 3-month recurrence to 5.4% from 13.6% and to eliminate delayed massive bleeding [claim 62: unconfirmed] — so the incumbent modality is itself improving, and the gap this candidate aims at may narrow without any new device.
What would settle it: A comparative durability study at grade III — the expensive answer — or, before that, ex vivo and animal thermal-spread data showing a dose consistency the incumbent modalities cannot match.
If it's false: Factor 6 has nothing behind it except the verified fact that this modality is cleared territory for this anatomy at grade II [claim 40: verified] — and the product is a more expensive way to do what the practice already does.
Would have to be true: Two file downloads plus a round of interviews with practices already billing the code would have to be enough to tell whether this is wanted and affordable.
Where it stands: The downloads are still unmade, and the caches they need were populated on 2026-08-30 and used to re-verify nine claims on idea-001 the same day — this candidate was never re-run against them. The interviews are still unbooked, and the file now records twice, formally, that they are the only route: [claim 63: unconfirmed] and [claim 64: unconfirmed] are both evidence class 3, with no source able to settle either.
What would settle it: The two CMS caches, then twenty interviews: what they own, how often they re-treat, where their grade III patients go, and what a disposable would have to cost.
If it's false: The candidate was designed backwards from a payment rate — its own title says "sized to the CPT 46930 non-facility payment" — and the physician's actual decision was never tested [claim 6: unconfirmed].
Every condition above with nothing verified behind it. Read the tags, not the count.
This is the best-evidenced regulatory position in the knowledge base — sixteen verified claims, including the modality's clearance history [claim 40: verified], the grade scope of every nearby IFU read verbatim [claim 42: verified], [claim 52: verified], codes and panels re-established [claim 45: verified], and the disposable anoscope class [claim 44: verified]. Every one of them is a regulatory-database fact about what somebody else was permitted to sell. Not one bears on whether a physician will switch or a patient wants this. What changed this week is that the clinical case is now evidenced too — and all of that evidence is unconfirmed, because literature and dataset scans cannot verify a claim.
If only one thing from this chair could be checked: whether a proceduralist will trade an owned, amortised instrument for a per-case disposable, on a durability promise that is unproven at launch [claim 15: unconfirmed], [claim 63: unconfirmed].
It survives, and the week's evidence has made it a much better-posed question rather than an easier one. Three things now support the pitch: the recurrence gap at grade III is measured at 47.5% versus 6.1% for surgery [claim 59: unconfirmed]; the 90-day global period means that recurrence is the physician's own cost [claim 57: unconfirmed]; and the office is the higher-paying setting, not the lower one [claim 58: unconfirmed]. That is a coherent commercial argument built out of sourced facts, which it was not at the last build.
Two things cut the other way and belong in the same breath. The incumbent modality is improving on its own — modified ligation reported at 5.4% 3-month recurrence against 13.6% [claim 62: unconfirmed] — so the gap may close without a new device. And the switching claim itself is now formally recorded as evidence class 3 [claim 63: unconfirmed]: no dataset, no literature, no connector will ever answer it. It requires proceduralists to be asked, and after this week the question to ask them is precise: your grade III patients recur about half the time within a year, you are not paid again for 90 days when they do, and the cleared bipolar device stops at grade II — what would a disposable have to cost?
Naming it is not a recommendation, a gate, or a kill. It is the answer to "check what first."