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By Suzanne Blake
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Medicare is launching a new pilot program that will require prior approval for 17 health services using artificial intelligence tools.
The Wasteful and Inappropriate Service Reduction (WISeR) model is launching in six states starting next year. Under the program, health care providers will be required to obtain Medicare approval before patients can access a range of specific services.
Why It Matters
Nearly 70 million seniors rely on Medicare for their health insurance. Historically, traditional Medicare did not require prior authorization, but the new pilot program from the Centers for Medicare & Medicaid Services is adding this requirement for 17 services.
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What To Know
The new WISeR model pilot will require prior authorization for 17 services:
- Electrical nerve stimulators
- Sacral nerve stimulation for the treatment of urinary incontinence
- Phrenic nerve stimulator
- Deep brain stimulation for the treatment of essential tremor and Parkinson’s disease
- Vagus nerve stimulation
- Surgically induced lesions of nerve tracts
- Hypoglossal nerve stimulation for the treatment of obstructive sleep apnea
- Epidural steroid injections for pain management, excluding facet joint injections
- Percutaneous vertebral augmentation
- Cervical fusion surgery
- Arthroscopic lavage and arthroscopic debridement for the knees of people with osteoarthritis
- Incontinence control devices
- Diagnosis and treatment of impotence
- Percutaneous image-guided lumbar decompression for spinal stenosis
- Skin and tissue substitutes
- Application of bioengineered skin substitutes to chronic non-healing wounds on lower limbs
- Wound application of cellular/tissue-based products for lower limbs
The pilot will last six years. It begins on January 1, 2026, for those on traditional Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
The pilot aims to “help protect American taxpayers” by “helping patients and providers avoid unnecessary or inappropriate care,” according to CMS.
Across the six states affected, 6.4 million Americans are on traditional Medicare, according to consulting firm McDermott+.
The final decision on whether Medicare approves or denies coverage will come down to an employee, but many critics of the AI test pilot. The larger concern is that companies conducting the review process will be incentivized to deny coverage because they receive payments when they lower costs.
"For seniors, the impact could be substantial, especially when immediate care is critical," Kevin Thompson, CEO of 9i Capital Group and host of the 9innings podcast, previously told Newsweek.
"The current administration is focused on removing so-called waste, fraud, and abuse, pulling every lever to show their program is working. What used to require a single prior authorization could now face multiple layers, which means more delays and higher denial rates."
What People Are Saying
Abe Sutton, director of the federal Centers for Medicare and Medicaid Services’ Innovation Center, said in a statement: “Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress. They also increase patient costs, while inflating health care spending.”
CMS Administrator Dr. Mehmet Oz said in a statement: "CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare. Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures."
Alex Beene, a financial literacy instructor for the University of Tennessee at Martin, told Newsweek: “The initial announcement of prior authorization coming to select Medicare services was obviously met with tremendous concern, as many recipients grew fearful the development would make it more difficult to have procedures they need covered. However, recent clarification of prior authorization being limited to a six-year pilot program in six states and only being implemented for 17 services that the program sees as being overused and even abused could put some minds at ease.”
What Happens Next
While some details remain unclear about how the pilot program will work, many Americans have concerns about the AI aspect of the decision-making.
“It's still unclear how the pilot program that will be used in states like Ohio and Texas will fully operate and the frequency of prior authorization for these 17 services for state recipients,” Beene said. “As with most changes, recipients will have to stay informed to see what the timeline is for these changes taking effect.”
A 2024 Senate committee report found that AI tools have been linked to higher rates of care denial, 16 times higher than decisions made without the technology.
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