Medicare’s New AI Screening Program Is Denying Claims in 6 States. Here’s What Procedures It Targets.

A retiree in Phoenix schedules an epidural steroid injection for chronic back pain. Her orthopedist calls back three days later: the procedure now faces a medical review conducted by a private contractor using AI-assisted technology. The office can request authorization first or perform the injection and wait for a prepayment review afterward. Either way, the paperwork now arrives before Medicare’s money does.

That is the new reality for Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, where the Centers for Medicare & Medicaid Services launched the Wasteful and Inappropriate Service Reduction Model, known as WISeR, at the start of 2026. Reviews began for services delivered January 15. CMS calls the model a possible roadmap for using private-sector technology elsewhere, though it has not promised a nationwide rollout.

If you are on a Medicare Advantage plan, WISeR does not touch you. Advantage plans already use prior authorization widely. This is about traditional, fee-for-service Medicare, which has historically relied more heavily on reviewing claims after care was delivered. That is changing for a specific list of procedures.

What Now Gets a Second Look

WISeR currently covers 13 categories of services CMS has flagged as prone to overuse, waste, or fraud. The list is narrow, but it hits procedures that older adults actually get. Among them:

• Implanted nerve stimulators, including certain electrical, sacral, vagus, phrenic, and hypoglossal devices
• Induced lesions of nerve tracts
• Epidural steroid injections for pain management
• Cervical fusion and percutaneous vertebral augmentation
• Arthroscopic lavage and debridement for the osteoarthritic knee
• Skin and tissue substitutes for chronic non-healing wounds
• Incontinence-control devices and certain procedures used to treat impotence

Deep brain stimulation and percutaneous image-guided lumbar decompression appeared in the original model list, but CMS delayed their implementation. They are not currently subject to WISeR review.

Emergency care, inpatient-only procedures, and services CMS determines could cause substantial harm if delayed are excluded from the list.

The Incentive That Should Worry You

The mechanic that makes WISeR different from ordinary prior authorization is how the reviewers get paid. CMS pays the technology companies a percentage of savings tied to non-affirmed requests that do not eventually produce a paid claim. If a claim is successfully appealed, the related payment can be clawed back, and poor quality scores can reduce the vendor’s compensation.

That is not a simple bounty for every denial. It still links the contractor’s payday to spending that never happens. A licensed clinician has to make every recommendation for nonpayment, and CMS says reviews must be evidence-based, but the underlying financial arrow points one direction.

That matters because these are not experimental treatments. Every procedure on the list already sits under a national or local coverage determination, meaning Medicare has agreed it is appropriate for defined patients. WISeR does not create a new coverage standard. It puts a new checkpoint in front of the existing one.

Providers can choose between submitting a prior authorization request before the service or accepting a prepayment review afterward. If they skip prior authorization, Medicare automatically holds the claim for review and requests the supporting medical records.

CMS has also implemented an exemption program for physicians whose requests meet a minimum 90% affirmation rate after at least 10 submissions. That rewards clean documentation, but it may also make doctors think twice before ordering anything near the line.

Why This Is Happening Now

CMS points to a familiar weakness in fee-for-service Medicare: providers are paid for the volume of care delivered, which can reward unnecessary services. WISeR moves the medical-necessity review toward the front of the process, where questionable care can be stopped before Medicare pays for it.

The model runs through December 31, 2031, and CMS can update its service list along the way. That makes the six states a testing ground. It does not make nationwide expansion a done deal.

What to Do Before Your Next Procedure

WISeR adds another set of eyes to the chart. Three moves can keep that review from turning into a surprise bill.

1. First, ask your provider whether the procedure is on the WISeR list and whether they have submitted prior authorization or plan to use prepayment review. If the office intends to proceed without an affirmative decision, ask whether you will receive an Advance Beneficiary Notice that could make you responsible for the bill.
2. Second, if the prior authorization is non-affirmed, request the specific clinical rationale in writing. The provider can resubmit the request an unlimited number of times and seek peer-to-peer review. A non-affirmed authorization cannot itself be appealed. The five-level Original Medicare appeals process begins only after a claim is submitted and formally denied.
3. Third, if you live outside the six pilot states, treat this as a development to watch, not a foregone conclusion. CMS can change the service list and has described WISeR as a roadmap, but it has not announced that the model will expand nationwide.

Original Medicare still lets you choose the doctor. WISeR adds someone looking over the doctor’s shoulder.

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