Clinical Criteria Medical Necessity Evaluation Engine
Payer-side prior-authorization clinical intelligence · Cohere Health
51 graded scenarios covering edge cases, failure modes, and quality checks.
About Cohere Health
Cohere Health is an AI company focused on clinical and healthcare applications, building tools that help medical teams triage patients, match clinical trials, and navigate complex care pathways more safely.
Sample tests· showing 3 of 51
Pass/fail checks, each adjudicated by an LLM judge.
| # | Input | Expected behavior | Check |
|---|---|---|---|
| 01 | The agent is processing a prior-authorization request for CPT 27447 (total knee arthroplasty) for a Medicare Advantage member with date_of_service 2026-03-15. The database contains exactly one criteria set mapped to this code for… | The tool response payload contains all five version-metadata fields alongside the criteria content: (1) criteria_set_id — a non-null unique identifier string; (2) version_number — the specific version designator of the criteria set in effect on 2026-03-15; (3) effective_date — the ISO 8601 date thi… | Pass / FailFactualitycritical |
| 02 | A payer is processing a retroactive authorization batch submitted 2026-05-24. CPT 43239 has two configured criteria set versions for the Commercial LOB: Version 1 (V1) was effective 2025-06-01 through 2025-12-31; Version 2 (V2) b… | The tool returns V1 of the criteria set — the version whose effective window (2025-06-01 through 2025-12-31) contains the date_of_service 2025-11-15. The response payload shows effective_date=2025-06-01 and expiration_date=2025-12-31. The response explicitly records date_of_service=2025-11-15 as th… | Pass / FailPolicycritical |
| 03 | At 09:00 the agent initiates a PA review workflow (ID: WF-20260524-00471) for CPT 70553, Medicare Advantage, date_of_service 2026-05-20. At initiation the active criteria set is Version 3 (V3, effective 2026-01-01, open-ended). T… | At initiation the system acquires a version lock on V3 and records a lock_acquired_at timestamp of 09:00 in the workflow audit log. Every subsequent tool call within workflow WF-20260524-00471 — evidence extraction, criteria question generation, criteria matching, determination generation — referen… | Pass / FailWorkflowcritical |
Rubric criteria
- Cohere Health
- Clinical
- Agentic
- Generated
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