Medical report generation from medical images is a vital AI task that helps doctors with diagnosis and marks a significant step toward creating general AI-powered medical systems. However, previous methods either fail to optimize factual accuracy or heavily depend on expert preference data. To overcome these challenges, we propose MedQPA, an automatic and generalizable report evaluation technique that uses question proposing and answering to enable controllable, structured reasoning grounded in medical domain knowledge and the factual correctness of the report. Additionally, we design MedQPA-Gen, a medical report generation pipeline that maximizes the MedQPA score through prompt engineering and reinforcement learning with MedQPA as a reward signal. We demonstrate that MedQPA is an accurate evaluation metric that closely correlates with human preferences. More importantly, MedQPA-Gen achieves higher human preference scores and better performance on downstream tasks. We open-source code at this repo https://github.com/MedQPA-gen/MedQPA-gen.

While coronary imaging is widely used for anatomical assessment, CCTA reports play a distinct last-mile role in clinical care. Ratherthan serving as an intermediate signal, CCTA provides an assessment of coronary disease severity (known as the CAD-RADS score) toguide patient management. However, real-world clinical text exhibits substantial heterogeneity in terminology and structure, leadingto inconsistent interpretation by automated systems, even for clinically similar cases. Recent work leverages a direct application ofLLMs for automated CAD-RADS scoring, but is limited by small, non-public, and homogeneous clinical data. We introduce CCTA-RADS, the largest publicly available dataset of 940 real-world CCTA reports from a major cardiovascular center, each annotated with CAD-RADS scores. Our analysis reveals that direct approaches, including state-of-the-art LLMs (GPT-4o, GPT-o3) and fine-tuned BERT models underperform on diverse real-world clinical data. To address these limitations, we propose a two-stage pipeline that decouples structuring from classification: an LLM-based parser normalizes heterogeneous reports into structured format, followed by fine-tuned BERT classification. This approach substantially improves the F1-score by 6%-13% compared with direct methods. We deploy our system as an interactive web interface that allows clinicians to upload CCTA reports for automated CAD-RADS assessment with SHAP and LIME explainability visualizations.