Trump Administration to Test AI-Powered Prior Authorization in Medicare
The Trump administration is preparing to introduce a pilot program that will use artificial intelligence (AI) to screen Medicare claims and potentially deny certain services. The initiative, called WISeR—short for Wasteful and Inappropriate Service Reduction—is scheduled to begin January 1 in 6 states: Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington. It will run through 2031 and represents the most significant federal expansion yet of prior authorization in traditional Medicare.
Prior authorization is common in private insurance and in Medicare Advantage, where insurers require providers to obtain approval before moving forward with certain treatments, tests, or prescriptions. In contrast, traditional Medicare has rarely used the process. That will change under WISeR, which aims to determine how much money can be saved by reducing “low-value” services flagged by AI algorithms.
The initial scope will include procedures such as skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy—areas the government considers particularly prone to fraud and waste. Emergency and inpatient-only services, along with procedures where delays could pose significant risk, will be excluded.
The pilot underscores a broader trend: the growing use of AI in coverage decisions. Insurers argue AI can streamline reviews, reduce human error, and cut costs. But opponents say it risks entrenching denial-focused systems that override clinical judgment.
The Centers for Medicare and Medicaid Services (CMS) has pledged safeguards. A spokesperson stressed that all denials will be reviewed by a qualified human clinician and that vendors are prohibited from payment structures tied directly to denial rates. Still, contractors will share in any savings produced by the program, raising concerns that financial incentives could bias decisions.
For payers and providers, WISeR raises several issues with direct relevance to future coverage debates. First, it will test whether AI-driven prior authorization can meaningfully reduce Medicare spending without worsening access or outcomes. Second, it will signal whether CMS intends to normalize practices that have long been unpopular with patients and providers alike.
Public opinion remains firmly against prior authorization: nearly three-quarters of Americans surveyed this summer by KFF labeled it a major problem. That distrust could deepen if the federal government is seen as adopting “delay-or-deny” tactics.
Ultimately, WISeR is a pilot, and lawmakers from both parties are already pushing to block funding. The program’s long timeline, stretching to 2031, means its results could shape Medicare’s approach to utilization management for the next decade.
Reference
Sausser L, Tahir D. Private health insurers use AI to approve or deny care. Soon Medicare will, too. NBC News. September 24, 2025. Accessed September 25, 2025. https://www.nbcnews.com/health/health-care/private-health-insurers-use-ai-approve-deny-care-soon-medicare-will-rcna233214
