His Back Injection Entered Original Medicare’s New AI Review. It Took a Lawsuit to Reveal 5,944 Denials and an 83-Day Wait

A 72-year-old retired carpenter in Washington has spinal stenosis, and every walk to the mailbox hurts more than the last one. His doctor recommends an epidural steroid injection. He chose Original Medicare partly to get away from the prior-authorization fights he had under Medicare Advantage. Then the scheduling office told him the request first had to clear a technology vendor.

He assumed Medicare made the call. In his state, a private company using AI and machine-learning tools reads his medical file before anyone books the procedure.

6 States Now Run Prior Authorization Inside Original Medicare

The Wasteful and Inappropriate Service Reduction Model, known as WISeR, began January 1, 2026 and is scheduled to run through 2031. It operates in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, potentially affecting roughly 6.4 million people with Original Medicare, and each state has its own vendor. The rules follow where the care is delivered, so even an out-of-state patient can be affected. Medicare Advantage is outside this model. In those six states, WISeR can apply to epidural steroid injections, cervical fusion, certain nerve stimulators, knee procedures and skin substitutes.

1,000 Pages of Lawsuit Records Expose the Denial Count

The Electronic Frontier Foundation filed a Freedom of Information Act request on January 29, 2026. As of March 24, 2026, CMS had released no records and had missed both the expedited and standard response deadlines, so EFF sued. Roughly 1,000 pages released through the case showed that two vendors denied or “non-affirmed” 5,944 prior-authorization requests during the first three months.

Washington’s vendor, Virtix Health, initially rejected more requests than it approved. CMS put it under a corrective action plan for delays. Virtix reportedly told Ars Technica its response times improved and the plan ended August 14. Across the released records, one request was still unanswered after 83 days. That measured the whole process, including steps outside the vendor’s control. Vendors generally have three calendar days after receiving a request to decide.

CMS requires a human clinician with relevant expertise to review every non-affirmation. The technology cannot make that call alone. The AI sorts and assesses files inside a system that produced high denial rates and long delays. Vendor pay explains why that matters: vendors can collect as much as 20% of associated savings from care the reviews avoid. CMS says it monitors denial patterns and cuts payments when vendors miss timeliness or accuracy measures.

Skipping Prior Authorization Still Routes You to the Reviewer

CMS calls the process voluntary. A provider can skip prior authorization and perform the injection, but Medicare then holds the claim in pre-payment review before it pays. Either path puts the service in front of a WISeR reviewer. Many practices refuse to schedule until they get an approval, and that is how a patient in pain ends up waiting.

Your Options After the First Non-Affirmation

A non-affirmation counts as a pre-service decision, so the standard Medicare appeals process stays closed at this stage. The provider can submit again as many times as needed, add medical records and request a peer-to-peer review with the vendor’s doctor. If waiting could seriously threaten the patient’s health or ability to recover function, the provider can request an expedited decision, which is generally due within two calendar days. If the procedure goes ahead and Medicare denies the claim, the patient gets full appeal rights.

The money risk sits in one form. An Advance Beneficiary Notice (ABN) asks whether he wants to proceed knowing Medicare may not pay. If he chooses treatment after receiving a valid notice, he may owe the listed charges. Choosing the option that bills Medicare preserves his appeal rights. Approval still leaves normal cost sharing, including any unpaid portion of the $283 Part B deductible for 2026. Medicare

Three Moves That Keep Your Procedure Alive

1. Get the paper trail. Ask for the procedure’s CPT or HCPCS code and whether WISeR covers it, the Unique Tracking Number on the request, and a copy of the approval or non-affirmation notice.
2. Push for a resubmission. Find out exactly which documentation the reviewer said was missing. Then ask your doctor to submit again with those records and request a peer-to-peer review. If your mobility is declining, ask for expedited handling.
3. Question any Advance Beneficiary Notice before you sign. Ask what the procedure costs in full and why the office expects Medicare to deny it.

He chose Original Medicare to keep an insurance company out of the space between him and the treatment chair. In six states, Medicare has put a new reviewer in that space, and it took a lawsuit for the public to see how often that reviewer said no.

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