A federal judge in Minnesota has ordered UnitedHealth Group to produce extensive documentation in an ongoing lawsuit alleging improper use of AI in Medicare Advantage coverage decisions.
The case centers on the use of nH Predict, a tool developed by the company’s Optum division (formerly naviHealth), which plaintiffs claim contributed to premature denials of post-acute care—particularly skilled nursing services. The lawsuit, filed by families of two deceased patients, argues that the tool may have overridden physician judgment in determining medical necessity.
Under the ruling, UnitedHealth must provide records dating back to 2017, including internal policies, analyses of the AI tool, documentation tied to its acquisition of naviHealth, and materials related to any government investigations into AI use in claims decisions. The order also requires disclosure of certain employee roles, internal review structures, and information related to specific denied cases tied to the proposed class action.
The court largely sided with the plaintiffs, allowing most discovery requests while rejecting efforts to limit the scope of documents based on timing. However, some requests—such as access to the algorithm’s source code and broader financial or personnel records—were denied.
Optum has maintained that the tool is designed to support care planning—not make final coverage decisions—and stated that medical necessity determinations are made by physicians in line with Centers for Medicare & Medicaid Services (CMS) guidelines.
UnitedHealth now has 21 days to comply with the order. The case reflects growing scrutiny around the role of AI in healthcare decision-making, particularly in Medicare Advantage, where regulatory and legal attention continues to increase.
Resource: Judge orders UnitedHealth to hand over documents in AI coverage denial case