Medicare's AI prior-authorization experiment left one request unanswered for 83 days — and the records are now public
About a thousand pages of internal CMS documents, pried loose by a Freedom of Information Act lawsuit, describe the first months of the WISeR model: missed deadlines, a vendor that approved everything because its software was not finished, and a payment formula that pays companies for saying no. If you have Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington, this is your prior authorization.
Prior authorization is the part of American health care that most people only learn about at the worst possible moment: the procedure is scheduled, the surgeon is ready, and someone at the front desk says the payer has not answered yet. Medicare beneficiaries were largely spared it. Original Medicare — Parts A and B, the government-run version — almost never made you ask permission first.
That changed on January 1 of this year in six states. And the internal record of how it went, released this month, is not reassuring.
- ~1,000 pages of CMS records released by the Electronic Frontier Foundation after a FOIA lawsuit filed in March
- 83 days — the longest single unanswered prior authorization request cited in an internal status report, against a stated 72-hour target
- 20,000+ requests denied by just two of the six vendors in the program's first three months; one of them, Virtix Health, denied more than it approved
- 5–10% — how much a bad "quality score" actually reduces a vendor's payment
- 6 states, 6 years: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, from January 1, 2026 through December 31, 2031
- Medicare Advantage members are not in this model — they have their own prior authorization
(Sources: Electronic Frontier Foundation, "New Records Reveal Problems with Medicare's AI Prior Authorization Experiment," September 8, 2026; STAT, September 15, 2026; CMS WISeR Model page, updated September 10, 2026.)
What WISeR is, in plain English
WISeR stands for Wasteful and Inappropriate Service Reduction — a CMS Innovation Center model that hires private technology companies to review whether certain Medicare procedures should be paid for. The companies use artificial intelligence and machine learning to screen the request; CMS says a licensed clinician must sign any recommendation against payment.
It applies to a short list of services CMS considers prone to overuse: skin and tissue substitutes, implanted electrical nerve stimulators, knee arthroscopy for osteoarthritis, and — per STAT's reporting — epidural injections for pain. Inpatient-only services and emergencies are excluded, as is anything CMS judges would be dangerous to delay.
Six companies each got a state: Cohere Health in Texas, Genzeon in New Jersey, Humata Health in Oklahoma, Innovaccer in Ohio, Virtix Health in Washington, Zyter in Arizona. Your doctor can skip the pre-approval, but then the claim gets reviewed before payment instead — which means the practice carries the risk of eating the cost. In practice, most will ask first.
The 72-hour rule and the 83-day request
CMS says vendors should answer within 72 hours. The internal status reports from the first months of the program, now public, show that a meaningful share of requests did not get an answer in that window. One request sat for 83 days.
The provider feedback forms in the release are blunter than any policy document. From clinicians reviewing Innovaccer's work in Ohio in March: "We have patients calling our offices crying in pain because their procedures are being delayed while awaiting approvals." Another wrote that they had watched three patients cry at the bedside waiting on authorization for a kyphoplasty — the injected-cement repair for a collapsed spinal vertebra. A third reported cases waiting over six weeks for a tracking number to even be issued, with surgeries cancelled in the meantime.
These are not appeals of denials. These are requests with no answer at all, which is the version with no deadline and nothing to appeal.
One vendor approved everything because the software wasn't finished
About a month before launch, Innovaccer told CMS it would go live with a version of its system that lacked full functionality and had not been fully tested end-to-end. Its stated fallback: auto-affirm every prior authorization request until the real product worked. In its own words in the documents, "Given CMS's decision not to delay the model start date, auto-affirming is the only path available."
Read that twice, because it cuts both ways. Ohio patients in those weeks got rubber-stamped approvals from a system that was not reviewing anything. Patients elsewhere got a system that was. Neither is medical review. The program was announced roughly six months before it started, and CMS declined to push the date when providers and at least one vendor said the runway was too short.
The part that should bother you most: how the vendors get paid
Model participants are paid a percentage of the spending they avert — the money Medicare does not spend because the review said no. Denials reversed on appeal do not count, which is the guardrail. The other guardrail is a "quality score" tied to timeliness and accuracy, and the newly released Data Reporting Guide puts a number on it: a low score trims payment by 5 to 10%.
So a company that denies too aggressively loses, at worst, a tenth of its rate. A company that approves generously earns nothing on those cases. You do not need a conspiracy to predict the direction of that math. CMS's position is that licensed clinicians make every non-payment call and that coverage rules have not changed. Both things can be true while the incentive still points one way.
Who this actually touches
If you have Medicare Advantage, WISeR does not apply to you — your plan already runs its own prior authorization, often on a much longer list of services. If you have Original Medicare outside the six states, it does not apply either. If you have Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington and your doctor proposes a nerve stimulator, a skin substitute, a knee scope for arthritis or an epidural injection for back pain, you are in it.
Nothing about your coverage changed on paper. What changed is who reads the file first, and how fast.
What to do if your procedure is in the pile
Ask three questions before you leave the office. Was a prior authorization submitted, and on what date? What is the tracking number? What happens if there's no answer in 72 hours? Write the answers down. A dated paper trail is the single most useful thing you can own in a delay, and it is free.
If the answer is a denial, appeal — the appeal rights are the ordinary Medicare ones, and they work. Our guide to prior authorization walks through the steps, the deadlines and the expedited route when waiting is itself the harm. If the wait is what is hurting you, ask your doctor's office to request an expedited review and to document the clinical reason in writing. And if you are weighing plans for next year, the trade-offs between the two systems are laid out in Medicare Advantage vs Original Medicare and in the broader Medicare guide.
You can also complain, in writing, to 1-800-MEDICARE and to your congressional office. Program feedback surveys are how those provider quotes ended up in a federal file in the first place.
CMS built WISeR to stop Medicare from paying for care that does not help. That is a real problem and a defensible goal. But the documents describe a program that shipped before it was ready, pays its referees for calling strikes, and left at least one person waiting 83 days for a yes or no. Fixing waste is not supposed to cost this much in weeks.