UnitedHealth nH Predict Algorithm Lawsuit
System Description
NaviHealth nH Predict algorithm used to determine Medicare Advantage coverage duration for post-acute care
Authoritative Output Type
Coverage duration predictions determining when patients should be discharged from care
Missing Required State
Individual patient clinical assessment, treating physician input, actual recovery trajectory monitoring
Why This Is SAF
Algorithm allegedly produced coverage termination decisions based on population statistics while ignoring individual patient conditions; plaintiffs allege 90% error rate when decisions were appealed
Completeness Gate Question
Has this coverage decision incorporated the patient's individual clinical condition and treating physician's assessment?
Documented Consequence
Class action lawsuit allowed to proceed February 2025, CMS issued guidance February 2024 that algorithms cannot solely dictate coverage decisions
Notes
- **Verified**: 2025-12-19 - **Case**: 23-cv-3514 (D. Minn.) - **Filing Date**: November 2023 - **Notes**: Allegations include patient deaths following coverage denials; CMS issued responsive regulatory guidance
Prevent this in your system.
The completeness gate question above is exactly what Ontic checks before any claim gets out. No evidence, no emission.