Originally published on 12/29/25

The Center for Medicare and Medicaid Innovation (CMS) has officially announced which producers will require prior authorization under their new Wasteful and Inappropriate Service Reduction (WISeR) Model—a change that will affect people who look to the federal government program for health insurance. We share everything Medicare users need to know, including whether there are ways to opt out of the WISeR program, below.

What to know about the new Medicare AI program 

On January 1, 2026, Washington, Arizona, Ohio, Oklahoma, New Jersey and Texas will launch the WISeR Model, which allows AI to help determine whether or not users qualify for certain outpatient procedures. It will be the first time in history that something like this has happened for regular Medicare users, and is expected to impact around 6.4 million Americans.

One reason for the change? “CMS is committed to crushing fraud, waste and abuse, and the WISeR Model will help root out waste in Original Medicare,” CMS Administrator Mehmet Oz, M.D., said in a statement. “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.”

Following the announcement of the program, many experts voiced their concerns, stating that it would harm patient care rather than improve it. Others worried that the AI bot might make a mistake when it comes time for them to make a decision on who gets what care. 

“For the first time, seniors will need prior approval from private contractors (paid based on how many claims they deny) before accessing certain treatments,” Michael Ryan, a finance expert and the founder of MichaelRyanMoney.com, told Newsweek. “Traditional Medicare has operated without prior authorization for 60 years. This pilot introduces it.”

Despite the concerns, Dr. Oz stands by the decision, telling Morning in America earlier this week, “The purpose of these is not to deny care. It’s to make sure you get the care you need and deserve, not the care that some unscrupulous doctor wants to use on you because he can talk you into having spine surgery or knee surgery.” 

“We want AI to be used by the doctor, if the doctor wants, to help them take better care of patients, to allow the AI to help with scheduling tests, to give them some better ideas about a diagnosis,” he concluded. 

Full list of procedures requiring prior authorization

Currently, 17 outpatient producers will need prior authorization under the WISeR model. They include the following: 

1. Application of bioengineered skin substitutes to chronic non-healing wounds on lower limbs
2. Arthroscopic lavage and arthroscopic debridement for the knees of people with osteoarthritis
3. Cervical fusion surgery
4. Deep brain stimulation for the treatment of essential tremor and Parkinson’s disease
5. Diagnosis and treatment of impotence
6. Electrical nerve stimulators
7. Epidural steroid injections for pain management, excluding facet joint injections
8. Hypoglossal nerve stimulation for the treatment of obstructive sleep apnea
9. Incontinence control devices
10. Percutaneous image-guided lumbar decompression for spinal stenosis
11. Percutaneous vertebral augmentation
12. Phrenic nerve stimulator
13. Sacral nerve stimulation for the treatment of urinary incontinence
14. Skin and tissue substitutes
15. Surgically induced lesions of nerve tracts 
16. Vagus nerve stimulation
17. Wound application of cellular/tissue-based products for lower limbs

“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,” Abe Sutton, director of the federal Centers for Medicare and Medicaid Services’ Innovation Center, said in a statement. They also increase patient costs, while inflating health care spending.”

Who gets enrolled in the Medicare AI program?

If Medicare users live in one of the six states listed above and use Parts A and/or B of the government-issued insurance, they will automatically be enrolled in the new Medicare AI program for six years, when the pilot program stops. Once that period ends, it’s unclear if the CMS will decide to continue it. It’s also unclear how the CMS will measure whether the WISeR program is a success or a failure. 

Can you opt out of the Medicare AI program? 

As of publication, there is no way for Medicare users in Washington, Arizona, Ohio, Oklahoma, New Jersey and Texas to opt out of the WISeR program; however, people on the government-funded insurance program do have the option to appeal a decision made by the AI as long as they do so alongside their primary care physician. 

 “It is not unknown that private insurance companies are currently or will be using AI for their prior authorization process but there is an appeal process that is still very human which includes a peer-to-peer review,” Chris Fong, CEO of Smile Insurance and a Medicare specialist, told Newsweek. “We are unsure whether Medicare will have a similar appeal process. We are actively notifying our clients who are on traditional Medicare to be on the lookout for this new process and ensuring them that we will help them get through the prior authorization process.”

Link to original: https://www.womansworld.com/healthcare/medicare-ai-prior-authorization-model-sparks-concerns