Medicare Advantage AI governance

A 0.985 denial score still needed a physician.

In a synthetic Medicare Advantage prior authorization case, the model strongly favors denial—but the patient's individual clinical factors account for only 22.06% of its attribution. CertaRoute holds the case for physician review and keeps the route inspectable.

Follow one case from initial assessment to the review gate and local record. The video shows the actual demonstration workflow.

Company walkthrough · 6 min 21 sec · Synthetic cases and records

01 / Initial assessment

DENY · 0.985

Stand-in model confidence for synthetic case A-4471.

02 / Individual evidence

22.06%

Share of absolute attribution from individual clinical factors; below the demo's configurable 35% floor for salient denials.

03 / Governance route

Physician review

The deterministic gate holds the case; its local technical record is marked NEEDS_PROOF.

A-4471 and every other case shown here are synthetic. The walkthrough demonstrates a governance mechanism, not a medical-necessity determination or a deployed payer workflow.

The question behind the demo

What did the model see—and what did it underweight?

A-4471 is a scripted post-acute skilled nursing extension case. The initial model assessment is a high-confidence denial. But the evidence that explains that score is weighted toward a recovery-timeline gap and prior utilization, while the member's individual clinical factors account for a much smaller share. The score alone cannot tell a reviewer whether those patient-specific facts received enough attention.

That distinction matters in Medicare Advantage. CMS's February 2024 guidance says coverage determinations must account for individual circumstances; an algorithm trained on a larger population cannot substitute for the patient's medical history, physician recommendations and clinical notes. CertaRoute demonstrates a control that exposes the mismatch and routes a case for human review. It does not decide medical necessity.

CertaRoute case file showing A-4471's factor-attribution bars and the pending physician-review state — **Frame 1 — Case evidence.** The amber bars represent population-weighted factors; teal bars mark individual clinical factors. Open the frame to inspect the application view at full size.

01 / Read the assessment

The high score is only the starting point.

The stand-in model issues an initial DENY assessment at 0.985 confidence. CertaRoute calculates exact Shapley attribution across ten model features so the reviewer can see which inputs drove that assessment. In A-4471, the two largest contributions are a recovery-timeline gap and prior utilization—not the patient's individual clinical indicators.

Recovery-timeline gap: ~49%
Prior utilization: ~19%
Individual clinical factors: 22.06%
Initial assessment: DENY

What to notice: high model confidence and strong patient-specific grounding are different properties. Attribution is a diagnostic view of this stand-in model, not a clinical judgment.

CertaRoute A-4471 case file with Individual clinical review marked FIRED and NEEDS PHYSICIAN PROOF shown as the route — **Frame 2 — Governance route.** The individual-clinical-review check is marked FIRED. The disposition is a physician-review queue label, not a finalized denial.

02 / Apply the boundary

A code gate holds the case before the model's denial becomes a decision.

For salient denials, this demo uses a configurable 35% floor for individual-clinical-factor attribution. A-4471's 22.06% is below that floor, so the deterministic gate fires the individual clinical review check and sets NEEDS_PHYSICIAN_PROOF. The local record is marked NEEDS_PROOF.

Routing authority stays in code. The default explanation is a deterministic template; optional model-generated wording can describe the result but cannot change the route.
The human step remains open. The displayed physician queue is a demo state. A qualified review and any final coverage determination are outside this demonstration.
The 35% floor is illustrative. It is a configured governance trigger in this synthetic run, not a clinically validated or CMS-prescribed threshold.

CertaRoute reconstruction dialog for A-4471 showing a locally verified hash chain with 253 of 253 records intact — **Frame 3 — Local reconstruction.** The app returns A-4471's technical record and verifies linked local hashes before the deliberate tamper test.

03 / Keep an inspectable trace

The route should be reconstructible, not just explainable.

The demo app appends each processed case to a local SQLite record whose hash includes the previous record's hash. The reconstruction view brings the inputs, attribution, route and record together for inspection. In the fixed 253-case synthetic run, all 253 local links verified before tampering.

One case, one technical trail. A reviewer can inspect the A-4471 record and the reason it was held.
Alteration becomes visible. The demo's tamper control changes a stored record without recomputing the hash; the verifier then reports a broken chain.
Custody remains separate work. Local hash verification is not immutable storage, independent notarization, a complete legal exhibit or proof that the clinical review occurred.

What this evidence does, and does not, establish

The mechanism is visible. Clinical and production validation are separate work.

Shown in the synthetic demo	Not established here
A code gate routes A-4471 to pending physician review when individual clinical attribution is below the configured floor.	A final coverage determination or clinically validated threshold.
253 of 253 fixed-run cases have a locally checkable hash-chained record before tampering.	Immutable custody, legal defensibility, or independent verification of every record field.
A planted dual-eligible denial-rate gap is flagged for review.	Bias or unlawful discrimination in a real health-plan population.
Source-system labels and an illustrative metrics panel show the proposed workflow.	Live payer connectors, staffed physician queue, Evidence of Coverage comparison, or CMS reporting compliance.

What this demo does not do: It uses synthetic cases, stand-in QNXT, Facets and HealthEdge labels, and a demo-only reviewer state. Its completeness flag is always passed as true in the current pipeline; it does not independently inspect every field. CMS-0057-F requirements are not implemented or certified by this panel.

Questions from health-plan teams

Can an algorithm deny Medicare Advantage coverage based on population data?

CMS says a Medicare Advantage coverage determination must account for the individual patient's circumstances. An algorithm drawing on a larger dataset cannot substitute for the patient's medical history, physician recommendations, and clinical notes. CertaRoute illustrates a review route; it does not make a medical-necessity decision.

What happens if a denial is confident but patient-specific factors have little weight?

In the synthetic A-4471 case, the initial denial has 0.985 model confidence, while individual clinical factors contribute 22.06% of absolute attribution. That is below the demo's configurable 35% floor for salient denials, so the deterministic governance gate marks the case NEEDS_PHYSICIAN_PROOF. The case remains pending physician review.

Does the AI explanation decide whether a case is approved or denied?

No. CertaRoute's code gate sets the demonstrated disposition independently of advisory text. The default explanation is a deterministic template, and an optional model-generated explanation can describe the route without authorizing it.

Does CertaRoute connect to our QNXT, Facets, or HealthEdge environment?

No live payer connection is shown. QNXT, Facets, and HealthEdge are source-system labels on synthetic cases, not working connectors. Production integration and access controls remain separate implementation work.

Is the hash-chained case record a legally defensible denial?

No. The demo stores local SQLite records whose hashes include the prior hash, and its verifier can detect a deliberate record alteration. That is a technical evidence example, not independently secured custody, a legal conclusion, or a final determination for a case pending physician review.

Does the dual-eligible gap prove bias in a health plan?

No. The displayed 54.5% versus 28.0% initial-denial rates come from a planted pattern in seeded synthetic cases. The plan-level test signals a reason to investigate a decision pathway; it does not establish discrimination in a real population.

Does the dashboard satisfy CMS prior authorization reporting requirements?

No. CertaRoute's dashboard includes illustrative indicators, including hard-coded synthetic turnaround values. It is not a CMS reporting implementation or certification, and the demo does not implement the required Prior Authorization API.

Technical Research

Explore related research for broader context on this demonstration.

Full solution

Explore the Medicare Advantage AI Governance solution →

Put the individual case at the center of AI governance.

We can examine where an automated assessment needs a human review boundary and a reconstructible record.

Bring your clinical, compliance and engineering teams to the same case-level conversation. We can discuss what a production design would have to validate beyond this synthetic demonstration.

Governance assessment

✓ Map model assessments to review decisions
✓ Examine patient-specific evidence handling
✓ Define clinical escalation criteria
✓ Review audit and reconstruction needs

Production design discussion

✓ Scope real payer data integration
✓ Plan clinical validation
✓ Design access and custody controls
✓ Separate reporting work from demo indicators

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