The federal government is preparing to roll out a controversial new policy that will bring prior authorization requirements — long associated with private insurers — into traditional Medicare.

Beginning next year, the Centers for Medicare and Medicaid Services (CMS) will launch a pilot program in six states, requiring pre-approval for certain medical procedures, including spine surgeries and steroid injections.

For many older adults who deliberately chose traditional Medicare to avoid the delays and denials that often come with Medicare Advantage plans, this shift is troubling.

Frances L. Ayres, a 74-year-old retired accounting professor from Oklahoma, is among those worried. “I picked traditional Medicare to avoid the hurdles of pre-approvals. Now it looks like I may face them anyway,” she said.

The system will rely heavily on artificial intelligence. CMS plans to contract private companies to review requests and determine whether procedures are medically necessary. Critics warn that these companies will be incentivized to deny claims since they stand to share in the government’s savings from reduced spending.

AI-driven prior authorization tools have already been at the center of lawsuits against private insurers, accused of enabling mass denials and cutting off patient care in rehabilitation facilities. Patient advocates fear that replicating this model in traditional Medicare could put vulnerable populations at greater risk of being denied timely care.

The debate comes at a sensitive time, as public trust in healthcare systems faces ongoing challenges. Prior authorization is widely criticized for delaying treatment, creating administrative burdens for doctors, and leaving patients uncertain about coverage.

While CMS argues that the pilot could help reduce unnecessary procedures and costs, critics maintain that the policy prioritizes savings over patient well-being. With Medicare covering more than 65 million Americans, the outcome of this pilot program could shape the future of healthcare access for seniors and people with disabilities nationwide.

What the new Medicare prior-authorization pilot (WISeR) means for U.S. residents

Below is a clear, practical breakdown of the pilot program CMS announced (often called the WISeR — Wasteful and Inappropriate Service Reduction — model), what it will do, who it affects, the risks and benefits, and what you can do to prepare if you or a family member are on Medicare. Sources are cited for the key factual points.

1) What is happening?

CMS will run a multi-year pilot that requires prior authorization (pre-approval) for a limited list of services delivered under traditional (Original) Medicare in six states. The program relies on technology — including AI and automated reviews — and will use private contractors to help decide whether specific procedures are medically necessary before Medicare will pay. CMS says the aim is to reduce waste, fraud and inappropriate services. CMS+1

Why it matters: Prior authorization has historically been much more common in Medicare Advantage (private plans). This pilot is the first time similar requirements will be tested within Original Medicare — potentially changing how quickly beneficiaries get approval for certain procedures.

2) Who will be affected?

• Beneficiaries on Original Medicare who receive care in the pilot states and who need one of the listed services. CMS has identified specific outpatient services (reports say 17 services initially) that will require prior authorization in the pilot.

  
  
  

• States initially expected or reported to be included (reporting sources): Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. If your provider or the place of service is in one of these states, you may be affected.

3) Timeline and scope

• The pilot was announced in mid-2025; it is scheduled to begin with a phased start (reports indicate activity beginning in January 2026 for selected services) and run for multiple years as a demonstration. CMS has published FAQs and a model page describing the rollout.

4) How the review process will work (high level)

• Technology + human review: Contractors will use technology (including AI/ML tools) to help screen and triage requests. CMS states licensed clinicians will be involved — but vendors’ automated systems will play a role in identifying cases for review and potentially streamlining decisions.

• Financial incentives: Contractors are expected to share in some savings generated from reduced payments for services deemed unnecessary. Critics worry this could create incentives to deny more claims. CMS frames it as incentive to reduce wasteful care.

  
  
  

5) Potential benefits (what CMS and supporters say)

• Lower wasteful spending: By screening services that are frequently overused or vulnerable to fraud, the program could reduce unnecessary procedures paid by Medicare.

• Standardization: Using evidence-based criteria and tech tools could standardize decisions and bring clinical review to services where variation is large.

6) Main concerns and risks (what critics, providers, and patient advocates warn)

• Delays in care: Prior authorization can add time between a doctor’s recommendation and treatment delivery — risking worse outcomes for time-sensitive conditions. This was the central criticism when private insurers used similar systems.

• Automated denials / biased incentives: When automated systems and contractor payments are tied to savings, critics fear an increased rate of denials or requests for more documentation, particularly if AI models are poorly calibrated or lack transparency. Lawsuits against private plans using similar tools have raised these concerns.

• Administrative burden on clinicians: Smaller providers and community clinics fear extra paperwork and time costs to appeal or supply additional documentation.

• Transparency & monitoring gaps: Advocates want strong reporting (how many approvals/denials, turnaround times, patient harm metrics) so CMS, Congress and the public can judge whether the pilot protects access to care.

7) Immediate practical effects for beneficiaries / families

• You may need pre-approval before Medicare will cover certain outpatient procedures if you live in (or receive care in) a pilot state. Ask your provider whether the service is on the pilot list.

• Turnaround time matters: Expect potential short delays while prior authorization is processed. CMS says clinicians will make final determinations for medical necessity, and vendors will use tech to speed reviews — but real-world turnaround times will vary.

8) What you should do now — a quick checklist

1. Check whether your state is in the pilot. (Published lists show AZ, NJ, OH, OK, TX, WA as likely participants — confirm with CMS updates or your provider.)

2. Ask your provider early: If a provider recommends a procedure, ask whether it’s on the list of services that will require prior authorization in the pilot. If so, ask who will submit the request and expected timing.

3. Get documentation: Keep copies of referral notes, test results, and the clinical rationale your clinician uses — this helps if more documentation is requested.

4. Know your rights to appeal: If Medicare (or a contractor) denies a request, you or your provider can appeal. Ask how to file an expedited (fast) appeal if care is urgent.

5. Track turnaround times: If you face long delays, note dates and communications — this information can be useful to ombudsmen, patient advocates, or lawmakers.

6. Contact your local SHIP or Medicare counselor (State Health Insurance Assistance Program) for free counseling about coverage, appeals, and next steps. (Search “SHIP + your state”.)

9) For clinicians and providers (brief)

• Prepare administrative workflows: designate staff to handle submissions and appeals, and ensure electronic records are organized.

• Engage with CMS materials: CMS has published model details and FAQs; review them to understand the evidence and documentation requested.

• Advocate for transparency: push for data on decision rates, appeal outcomes, and patient harm measures so the pilot can be evaluated fairly.

10) How the pilot will be evaluated (and what to watch for)

Key metrics that matter for judging the pilot’s success (and which advocates are demanding) include:

• Approval vs denial rates for the targeted services, and whether denials later get overturned on appeal.

• Turnaround times from request to decision (including expedited reviews).

• Patient outcomes and any evidence of harm or delay in care.

• Financial impacts — savings for Medicare vs costs (including administrative burdens on providers and appeals).

CMS will report on the demonstration; advocates and lawmakers will likely press for public, regular reporting. Watch CMS Innovation Center pages and major health-policy outlets for those updates.

11) Likely political and policy implications

• If the pilot shows reduced spending without harm, CMS could expand prior authorization to other services or states — effectively narrowing a historical difference between Original Medicare and Medicare Advantage. If the pilot shows harm or widespread delays, policymakers and courts could block or limit expansion. Expect debates in Congress, in state medical societies, and among patient groups.

12) FAQs — short answers

Q: Will AI alone decide whether I get care?
A: No. CMS says AI/technology will assist the process, but licensed clinicians will make final medical-necessity decisions. However, AI may triage and automate parts of the review.

Q: Can I appeal a denial?
A: Yes — there are existing Medicare appeal pathways. You can request expedited reviews for urgent cases; keep your clinician involved in appeals.

Q: Is this nationwide?
A: Not initially. It’s a pilot in six states; CMS may expand depending on results.