AI enters Medicare’s review process—could it change your coverage?
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A new Medicare pilot program will soon change how certain medical procedures are reviewed for approval, and it could affect the way some seniors receive care.
Starting next year, artificial intelligence (AI) will help decide whether specific treatments are covered.
The initiative, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, is designed to speed up decision-making and cut down on waste and fraud.
But some experts say the move could also bring more denials and delays for patients.
Here’s a closer look at what’s planned, where it’s happening, and what you should know if you rely on Medicare.
How the program works
The Centers for Medicare & Medicaid Services (CMS) will use AI to assist with prior authorization—the process of approving or denying a procedure before it happens.
The agency says this will help identify unnecessary or overly expensive treatments more quickly, but promises that the final decision will still be made by a human reviewer.
While traditional Medicare has typically required fewer prior authorizations than Medicare Advantage, that could change under this pilot.
In 2023, the average Medicare Advantage enrollee needed two prior authorizations, compared to just one for every 100 traditional Medicare beneficiaries.
Also read: 600,000 UnitedHealthcare Medicare Advantage members to lose coverage in 2025
Why Medicare is turning to AI
CMS hopes AI can reduce costs, detect patterns of waste or fraud, and process requests faster.
However, critics point out that companies operating these systems could be paid more for cutting costs, which might encourage more denials, even for necessary care.
Procedures included
The WISeR Model will apply to select outpatient procedures, such as:
It will not apply to inpatient-only or high-risk procedures where delays could be dangerous.
Also read: Could you be charged extra for Medicare without realizing it?
Where it’s happening
The pilot program will launch in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
It’s scheduled to run for six years, with opportunities for evaluation and feedback along the way.
Concerns from experts
Healthcare advocates warn that adding AI to the process could result in:
Also read: Medicare price talks progress quietly as government targets costly prescriptions
Kevin Thompson, CEO of 9i Capital Group and host of the 9innings podcast, said:
“For seniors, the impact could be substantial, especially when immediate care is critical. What used to require a single prior authorization could now face multiple layers, which means more delays and higher denial rates… If contractors are rewarded for reducing or denying coverage, that’s exactly what will happen—more denials. Whether a treatment is truly necessary or not becomes secondary to the incentive structure.”
Alex Beene, a financial literacy instructor at the University of Tennessee at Martin, said many Americans already question the value of Medicare Advantage, as it hasn’t always delivered as promised.
He noted that adding AI to pre-authorization in six states could raise valid concerns, since recipients want fewer barriers, not more—even if AI might streamline the process.
Also read: Medicare grocery allowance: Are you missing out on this food benefit?
What Medicare says
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.”
Also read: Medicare may soon cover medications for weight loss—here’s what to know about the proposed program
Rising Medicare costs
At the same time, Medicare Part B premiums are set to increase from $185 per month in 2025 to $206.50 in 2026—an extra $21.50 a month for beneficiaries.
What you can do
If you live in one of the pilot states:
As the WISeR Model moves forward, Medicare beneficiaries—especially in the six pilot states—will want to watch closely for any changes to their coverage process.
Staying informed, keeping thorough records, and speaking up about concerns can help ensure that care decisions remain fair and timely.
The coming years will reveal whether AI truly streamlines Medicare or adds new hurdles for those who depend on it most.
Read next: Bigger benefits, smaller payoff? Medicare costs may cut into your next Social Security raise
Have you ever had a procedure denied by Medicare? Are you concerned about AI being part of the decision-making process for your healthcare? Share your experiences and concerns in the comments so others can prepare and learn from your story.
Starting next year, artificial intelligence (AI) will help decide whether specific treatments are covered.
The initiative, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, is designed to speed up decision-making and cut down on waste and fraud.
But some experts say the move could also bring more denials and delays for patients.
Here’s a closer look at what’s planned, where it’s happening, and what you should know if you rely on Medicare.
Medicare is testing new technology that could change how certain treatments are approved. Image Source: YouTube / CBS Philadelphia.
How the program works
The Centers for Medicare & Medicaid Services (CMS) will use AI to assist with prior authorization—the process of approving or denying a procedure before it happens.
The agency says this will help identify unnecessary or overly expensive treatments more quickly, but promises that the final decision will still be made by a human reviewer.
While traditional Medicare has typically required fewer prior authorizations than Medicare Advantage, that could change under this pilot.
In 2023, the average Medicare Advantage enrollee needed two prior authorizations, compared to just one for every 100 traditional Medicare beneficiaries.
Also read: 600,000 UnitedHealthcare Medicare Advantage members to lose coverage in 2025
Why Medicare is turning to AI
CMS hopes AI can reduce costs, detect patterns of waste or fraud, and process requests faster.
However, critics point out that companies operating these systems could be paid more for cutting costs, which might encourage more denials, even for necessary care.
Procedures included
The WISeR Model will apply to select outpatient procedures, such as:
- Skin and tissue substitutes used in wound care
- Electrical nerve-stimulator implants
- Knee arthroscopy for osteoarthritis
It will not apply to inpatient-only or high-risk procedures where delays could be dangerous.
Also read: Could you be charged extra for Medicare without realizing it?
Where it’s happening
The pilot program will launch in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
It’s scheduled to run for six years, with opportunities for evaluation and feedback along the way.
Concerns from experts
Healthcare advocates warn that adding AI to the process could result in:
- Delays — Additional review layers could slow down approvals, especially when immediate care is needed.
- Higher denial rates — A 2024 Senate report found AI systems have denied care up to 16 times more often than manual reviews.
- Financial conflicts — If contractors benefit from reducing coverage, necessary treatments could be rejected.
Also read: Medicare price talks progress quietly as government targets costly prescriptions
Kevin Thompson, CEO of 9i Capital Group and host of the 9innings podcast, said:
“For seniors, the impact could be substantial, especially when immediate care is critical. What used to require a single prior authorization could now face multiple layers, which means more delays and higher denial rates… If contractors are rewarded for reducing or denying coverage, that’s exactly what will happen—more denials. Whether a treatment is truly necessary or not becomes secondary to the incentive structure.”
Alex Beene, a financial literacy instructor at the University of Tennessee at Martin, said many Americans already question the value of Medicare Advantage, as it hasn’t always delivered as promised.
He noted that adding AI to pre-authorization in six states could raise valid concerns, since recipients want fewer barriers, not more—even if AI might streamline the process.
Also read: Medicare grocery allowance: Are you missing out on this food benefit?
What Medicare says
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.”
Also read: Medicare may soon cover medications for weight loss—here’s what to know about the proposed program
Rising Medicare costs
At the same time, Medicare Part B premiums are set to increase from $185 per month in 2025 to $206.50 in 2026—an extra $21.50 a month for beneficiaries.
What you can do
If you live in one of the pilot states:
- Keep track of any changes to your coverage.
- Save records for all treatments and procedures.
- Appeal any denials promptly—humans still have the final say.
- Contact your local Medicare office or advocacy groups if you have concerns.
As the WISeR Model moves forward, Medicare beneficiaries—especially in the six pilot states—will want to watch closely for any changes to their coverage process.
Staying informed, keeping thorough records, and speaking up about concerns can help ensure that care decisions remain fair and timely.
The coming years will reveal whether AI truly streamlines Medicare or adds new hurdles for those who depend on it most.
Read next: Bigger benefits, smaller payoff? Medicare costs may cut into your next Social Security raise
Have you ever had a procedure denied by Medicare? Are you concerned about AI being part of the decision-making process for your healthcare? Share your experiences and concerns in the comments so others can prepare and learn from your story.
