Medicare tests AI prior authorization in six-state pilot

A 65-year-old cattle rancher in rural Oklahoma found himself making extra trips to Oklahoma City for epidural injections after Medicare began requiring preapproval for his care. Bill Curry was asked to return yet again just to fill out paperwork about how he felt, then did not come back.

His experience has become an early warning sign for a new federal experiment that brings prior authorization into traditional Medicare, where it has historically been rare. The Centers for Medicare & Medicaid Services launched the Wasteful and Inappropriate Service Reduction Model, known as WISeR, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. CMS said the model began in mid-January 2026 and will run for six performance years through December 31, 2031.

The agency says WISeR is meant to curb wasteful or inappropriate care by using artificial intelligence and machine learning alongside human clinical review. It is limited to 13 medical services or service categories that CMS says are vulnerable to fraud, waste and abuse, including skin and tissue substitutes, electrical nerve stimulator implants, knee arthroscopy for knee osteoarthritis, and certain spinal procedures such as epidurals and kyphoplasty. Emergency services, inpatient-only services and treatments that would pose substantial risk if delayed are excluded.

That design has not eased frustration for many patients and clinicians, who described the rollout as confusing, error-prone and slow. Todd Baker, who recently stepped down as chief executive of the Ohio State Medical Association, said the change was “quicker than normal” for the federal government. Jeb Shepard of the Washington State Medical Association said doctors had to “just sort of figure it out.” Jeremy Friese, chief executive of Humata Health, called it an “aggressive rollout.”

The pressure point is not only whether AI can screen claims faster, but who bears responsibility when it gets a decision wrong. CMS says participating companies must have clinicians with appropriate expertise to validate coverage determinations, but the model still puts an automated layer between patients and treatment in a system built to move quickly for people with cancer, pain, mobility problems and other serious conditions. For Curry, that meant more driving, more paperwork and one more missed appointment in a rural state where care already comes with a heavy logistical burden.

CMS has argued that the pilot could protect both beneficiaries and taxpayers, citing a Medicare Payment Advisory Commission estimate that as much as $5.8 billion in Medicare spending in 2022 went to services with minimal benefit. The agency also says waste may account for up to 25% of U.S. health care spending. Still, the policy lands in a system where prior authorization has already been widely criticized. The American Medical Association has said it can delay and disrupt care, and KFF found nearly 53 million prior authorization requests in Medicare Advantage in 2024, with 4.1 million denied.

The pilot also arrives alongside broader Medicare efforts to streamline prior authorization electronically. CMS finalized its interoperability and prior authorization rule in January 2024, with many API compliance deadlines generally set for January 1, 2027. Even so, WISeR has already drawn political resistance: the House Appropriations Committee approved an amendment in June 2026 that could block CMS funding for the model, setting up a fight over whether AI gatekeeping belongs in traditional Medicare at all.