Medicare's New AI Screening Program Is Denying Claims in 6 States. Here's What Procedures It Targets.

Original Medicare launched a pilot program in six states that introduces AI-assisted reviews for common medical procedures. This initiative, titled the Wasteful and Inappropriate Service Reduction Model or WISeR, currently operates in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It focuses on 13 categories of service that federal officials claim are susceptible to excessive use or waste.

The list includes items like epidural steroid injections, specific nerve stimulators, and certain procedures for knee osteoarthritis. If you reside in one of these states and your doctor orders one of these treatments, the office must either seek prior authorization or submit the claim for a prepayment review. This changes the traditional fee-for-service workflow, as federal auditors now place an extra checkpoint before the agency releases payment.

Compensation structures for the private technology companies hired to perform these reviews create specific financial incentives. While CMS requires that a licensed clinician review each case, the vendors are paid based on savings tied to denied requests that do not eventually receive payment. This arrangement creates pressure on providers to ensure documentation is accurate to avoid claim rejection.

Patients can protect themselves by asking providers if their scheduled procedure falls under the WISeR list and whether the office has submitted an authorization request. If an authorization is denied, patients can ask for the clinical rationale in writing. While the pilot program is scheduled to run through 2031, federal authorities have not provided a timeline for a nationwide rollout. Keeping track of these requirements is essential for those who rely on Original Medicare for ongoing pain management or orthopedic care.