AI Next WaveMedicare's AI Gatekeeper Is Slowing Care. Now Medicare Says So.
A pilot that puts AI-assisted review in front of back injections and spine procedures has piled up denials and weeks-long waits in six states. A senior Medicare official now admits much of it is broken, and Italy, starting today, writes the opposite rule for jobs.
The Short Version
Bill Curry raises cattle in rural Oklahoma and drives about two and a half hours to Oklahoma City for back injections every few months. Partway through his treatment this year, he learned Medicare now wanted to approve each one first. One trip became two, about ten hours on the road in all, KFF Health News reported in June. When his clinic asked for a third visit he thought was pointless, he skipped it, and he may move his care to Kansas.
Curry is living inside WISeR, a Medicare experiment that uses AI-assisted review to decide, before a procedure happens, whether Medicare will pay for it. Records pried loose by a lawsuit show thousands of denials and requests that sat for weeks. On October 15, a deputy administrator at the agency that runs Medicare said it out loud: "There are a lot of things about WISeR that are not working."
The pilot is scheduled to run through 2031. If you or a parent use traditional Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington, here is how it works, where it breaks, and what a family can do when an approval stalls.
How the Pilot Works
Traditional Medicare has generally paid for covered care without asking for approval first. WISeR, which started January 1, adds that approval step for a short list of services in six states.
CMS, the federal agency that runs Medicare, picked 13 services it considers prone to waste or fraud. They include epidural steroid injections for back pain, skin substitutes for chronic leg wounds, nerve stimulator implants, and some knee and spine procedures. Emergency care, inpatient-only services and any service where a delay would pose a substantial risk to the patient are left out.
Six private companies run the reviews, one per state. They use AI and machine learning to check each request against Medicare's coverage rules, and CMS says licensed clinicians make every recommendation to deny payment. The companies earn a percentage of the spending they avert, adjusted by performance measures that include how doctors rate the experience. The agency's innovation chief told KFF Health News the model "aims to reduce inappropriate care without delaying appropriate care."
The vendors say their systems mostly approve. Humata Health, which handles Oklahoma, told KFF Health News it gives an immediate yes in 88 percent of cases where the records support approval.
What the Records Show
In March, the Electronic Frontier Foundation sued CMS for the pilot's internal records. What came back is the clearest outside look so far. Two of the vendors denied 5,944 requests in the first three months. Virtix Health, the Washington vendor, denied more requests than it approved and was told to file a corrective action plan. Innovaccer, which handles Ohio, warned CMS a month before launch that its system wasn't ready and said it would approve every request automatically until it was. One request sat unanswered for 83 days, against the 72-hour turnaround CMS describes in public.
Those figures need a careful reading. The 5,944 count is requests, so it can't tell you how many patients were affected or how many denials were wrong. EFF has since corrected its denial figure and added that turnaround times cover the whole path of a request, including steps the vendors don't control.
Doctors and hospitals fill in what the counts leave out. In a provider feedback survey from Ohio found in the records, one provider wrote, "We have patients calling our offices crying in pain because their procedures are being delayed." In Washington, a hospital association survey of three health systems with 16 hospitals, released by Sen. Maria Cantwell in April, found that approvals which used to take about two weeks were taking four to eight, and that some patients turned to opioids while they waited.
The errors can be strangely specific. A Tulsa radiologist told KFF Health News that one patient's request was denied for numbness, even though he had documented four times that the patient had none. He described waits of six to eight weeks for payment on claims that should clear in about 15 days.
Who Gets Paid When the Answer Is No
Critics keep coming back to the payment design. Vendors earn money from the spending they avert, so a denial that sticks is worth something to them, while a denial reversed on appeal earns nothing, EFF reports. CMS points to quality scores as the safeguard, but the program's own reporting guide caps that penalty at 5 to 10 percent of a vendor's payment. The Medicare Rights Center adds that many people never appeal a first denial, so some bad denials are never corrected.
That's the backdrop for what Kim Brandt said in Santa Fe. Speaking at a conference on October 15, the CMS deputy administrator conceded the problems and said agency staff are committed to getting the pilot right. Her slides listed three lessons: the technology needs ongoing oversight, human clinical review is essential, and provider complaints are an early warning sign. She didn't say which parts are failing, and CMS hasn't published a full evaluation, so nobody outside the agency can yet count the harmful delays or the reversed denials.
Congress has split over what to do. The House Appropriations Committee voted unanimously in June to block funding for the pilot in next year's health spending bill, a step that would still need both chambers to become law. In July, the Senate rejected a resolution to cancel the pilot, 46 to 50, along party lines.
A Family Walks Through It
Picture a 72-year-old woman in Tulsa whose doctor recommends an epidural injection for back pain, and the son who drives her to appointments. Before anything is scheduled, the clinic sends a request to Oklahoma's reviewer, either directly or through Medicare's regional contractor. The first thing in place has to be the chart itself. Reviewers check the request against Medicare's coverage criteria, so the son can ask the clinic, before it submits, whether her notes show what she has already tried and why the doctor thinks the shot is the next step.
Then he sets a baseline. He writes down the date the request went in and asks the clinic to call when the written decision comes back. Every decision carries a tracking number, approved or not, so the number alone settles nothing; the clinic has to say whether the shot was affirmed. CMS says the reviewer typically answers within three days of receiving a request sent to its portal, and a request routed through the regional contractor can take longer. If a week passes in silence, he calls to ask whether the request is complete or stuck. That call is the new work this pilot hands to families, and it can repeat. If her doctor believes the wait could seriously harm her health, the clinic can ask for an expedited review, which CMS says is answered within two days once the reviewer confirms the risk.
If a denial arrives, the decision itself can't be appealed directly. The clinic can resubmit with missing records, or the doctor can ask for a peer-to-peer conversation with the reviewing clinician, which is the place to raise a denial that contradicts the chart. A doctor can also skip prior approval and send the bill through a review before payment, so the family should ask the office who pays if that review says no. Denied claims go through the standard Medicare appeals process.
The people with the power to fix a bad call are the reviewing clinician, her own doctor in that peer-to-peer call, and the Medicare appeals system after it.
Italy Puts a Name on the Decision
Starting today, Italy takes the opposite approach for jobs. Article 41 of Legislative Decree 179, published October 8, says the final decision on hiring, changing or ending someone's employment, including discipline and performance reviews, must rest with a person who holds real and independent authority. A dismissal that breaks the rule is void, and so are other employer decisions made in breach. A worker's consent doesn't waive it. On request, a person must explain how the AI system weighed in and which main factors it considered.
The rule has a gap. Candidate searches and CV screening sit outside it, even when software screens someone out before a human looks. It also binds only employers in Italy. AI Next Wave covered California's version of a human sign-off rule on October 2.
Both systems promise a human at the end, and Brandt's slides land on the same point about human review. My read is that the signature only protects people when the person signing has time, the full record and no stake in the answer. Italy wrote that into law with a penalty that undoes the decision. Medicare's pilot pays the vendor more when the answer is no and it sticks.
Opportunity Radar
Small pain, spine and wound-care practices in the six states now carry a paperwork job they never staffed. My hypothesis is that some would pay a service to own it: assembling records, tracking each request against the three-day target, setting up peer-to-peer calls and logging every denial with its reason. The pitch is fewer cancelled appointments and faster payment.
Test it with three practices for 60 days. Measure days from request to written decision, and the share of first requests affirmed, against the practice's own numbers from the months before you start. If you can't improve both meaningfully, or if CMS expands exemptions for doctors with strong approval records, or if Congress defunds the pilot, walk away.
What You Can Do With This
If you or a parent use traditional Medicare in the six states
Before you plan around a date, ask your doctor's office whether the procedure is on the WISeR list. If it is, ask when the request goes in, when the written decision comes back and whether it says yes, and note the dates yourself.
If you're the family member making the calls
When a denial arrives, ask the clinic to show you the exact reason and compare it with what the chart says. If they don't match, ask the doctor to request a peer-to-peer review or a resubmission. Log every call; the timeline is your best evidence in an appeal.
If you work at a small clinic in one of these states
Track your own numbers: days to decision, denials by reason and how many get reversed. Sen. Cantwell has demanded public denial counts, Brandt's slides call provider feedback an early warning sign, and a practice with clean records is in a stronger position to push back on a vendor or qualify for any exemption that comes.
If you manage people and use AI in HR decisions
In Italy, confirm today that a named person with real authority signs every hiring, discipline, review and dismissal decision, and that someone can explain the AI's role on request. It's a sound design anywhere you want decisions to hold up.
The Bigger Picture
WISeR is a pilot, and pilots exist to be scaled. A CMS planning document from June 2025, released in the EFF records, lists possible future additions including air ambulance transport, cancer treatment, MRI scans and some medications. An Oklahoma family physician put the stakes plainly to KFF Health News: "Everybody knows that if this pilot project works, it will be prior auth for basically all procedures." That makes the definition of "works" the decision that matters for the 2030s. If it means money averted, the current design passes. If it means care delivered on time to the people who need it, a senior official at the agency just told a conference that much of it doesn't yet. The next measure to watch is the one CMS hasn't published: how many denials are reversed when someone pushes back.
References
KFF Health News: Medicare's AI push snarls patients and doctors in errors and delays (June 23, 2026) Nextgov/FCW: CMS hopes to quadruple provider suspensions over next six months, official says (Oct. 15, 2026) Becker's Hospital Review: CMS wants to quadruple provider suspensions in 6 months (Oct. 16, 2026) Medical Daily: CMS official admits many parts of Medicare's AI-assisted WISeR prior authorization test are not working (Oct. 18, 2026) CMS: WISeR (Wasteful and Inappropriate Service Reduction) Model, page last modified Oct. 19, 2026 CMS: WISeR Model Frequently Asked Questions, page last modified Sept. 22, 2026 CMS: WISeR Provider and Supplier Operational Guide, Version 7.0 (July 24, 2026) Electronic Frontier Foundation: New records reveal problems with Medicare's AI prior authorization experiment (Sept. 8, 2026, corrected Oct. 9, 2026) Medicare Rights Center: New records show Medicare WISeR AI prior authorization model causing inappropriate denials of care (Sept. 24, 2026) Sen. Maria Cantwell: Letter to RFK Jr. demanding changes to AI-driven prior authorization program (Apr. 27, 2026) STAT: CMS WISeR program delays care at Washington state hospitals, senator says (Apr. 22, 2026) Healthcare Dive: House committee takes step toward blocking Medicare AI prior authorization pilot (June 10, 2026) Fierce Healthcare: Senate strikes down Democrats' move to overturn CMS' WISeR AI prior auth pilot (July 17, 2026) Decreto legislativo 7 ottobre 2026, n. 179, Gazzetta Ufficiale n. 234 of Oct. 8, 2026 (full text, via Orizzonte Scuola) ActuIA: Italy, from 23 October, AI hiring or firing requires a human decision-maker (Oct. 19, 2026) A&O Shearman: AI Act, Italy's implementing legislation (Oct. 13, 2026)