Can AI Delay or Deny Your Original Medicare Procedure in 6 States?

If you have Original Medicare and live in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, a CMS model called WISeR can affect how some nonemergency procedures are reviewed before payment. That does not mean Medicare coverage rules changed across the board. It does mean a narrow list of services may go through prior authorization or pre-payment medical review.

The short answer is yes: WISeR can contribute to delays if review is still pending, and a claim can still be denied if Medicare requirements are not met. But CMS also says the model is limited. It applies only to selected services, does not apply to Medicare Advantage, does not change Medicare coverage rules themselves, and requires clinician review for non-payment recommendations and non-affirmations.

What WISeR is, in plain language

WISeR stands for Wasteful and Inappropriate Service Reduction. CMS says the model uses enhanced technology, including AI-assisted tools, to help review whether certain services meet existing Medicare coverage, coding, and payment rules before payment is made.

CMS describes WISeR as a six-year Innovation Center model that began January 1, 2026, and is scheduled to run through December 31, 2031. The agency says it focuses on a limited group of services that have raised concerns about inappropriate use, fraud, waste, abuse, or patient harm when used in the wrong setting or for the wrong indication.

Examples CMS lists include some skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis. This is not a new nationwide rule for every test, procedure, or treatment in Original Medicare.

Who is affected, and who is not

WISeR is limited to people in traditional fee-for-service Medicare, also called Original Medicare, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

CMS says Medicare Advantage enrollees are not part of WISeR. The agency also says patients in Original Medicare still keep the freedom to seek care from their provider or supplier of choice.

Just as important, WISeR does not apply to all services. CMS says it excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.

How the review process can affect a procedure

For selected WISeR services, a provider or supplier can submit a prior authorization request before the service. If they do not, the claim may instead go through post-service, pre-payment medical review.

If the provider uses prior authorization, the request can go through a WISeR participant portal or through the Medicare Administrative Contractor, often called the MAC. CMS says most portal responses should come within 72 hours, often faster. Requests routed through the MAC can take longer because information may need to be forwarded and returned between entities.

If waiting could seriously jeopardize the patient’s life or health, CMS says the requester can ask for expedited review. Even so, WISeR is aimed at nonemergency services, so urgent emergency care should not be delayed for this process.

In real life, delays can happen while records are being gathered, while a case is still under review, or while a provider is resubmitting documentation after an initial non-affirmation.

What a non-affirmation means

A non-affirmation means the future service was not shown to meet Medicare coverage, coding, or payment requirements based on the documentation submitted. CMS says every non-affirmation must be reviewed by a qualified human clinician.

A non-affirmation does not automatically mean the procedure is banned. Under the CMS FAQ, the provider can resubmit the request with more documentation. The provider can also still furnish the service and submit a claim, but if that claim is later denied, the usual Medicare appeals process applies.

CMS also says that if a service is non-affirmed during prior authorization, the physician must give the patient an Advanced Beneficiary Notice of Non-Coverage, or ABN, before furnishing the service. In plain language, that notice tells the patient Medicare may not pay and that the patient could be responsible for the bill if the claim is denied.

Why people are watching this closely

Concern about delay is not just political. A 2026 JAMA Health Forum study looked at prior authorization for branded prescriptions in the broader U.S. market, not WISeR specifically, and found that initial prior-authorization rejections were commonly tied to delays and many ended in denial. Because that study focused on pharmacy claims rather than Medicare procedures, it cannot predict exactly what WISeR will do. Still, it helps explain why any new prior authorization model gets close attention from patients, clinicians, and lawmakers.

AHRQ has also warned that when AI is used in healthcare, patients and families may need to ask basic safety questions: Was AI involved, how was the output reviewed, and who is accountable if something looks wrong? That framing is useful here because CMS says WISeR uses AI-assisted tools but still requires human clinical review for key non-payment decisions.

The policy fight around WISeR, as of June 8, 2026

The program is still active, but it is under legal and political scrutiny.

On May 19, 2026, the U.S. Government Accountability Office concluded that the WISeR notice is a rule for purposes of the Congressional Review Act and should have been submitted to Congress under that process. The next day, May 20, 2026, STAT reported that congressional Democrats moved to try to overturn the model. STAT also reported that CMS said WISeR remains an active Innovation Center model while the agency reviews the GAO opinion and considers next steps.

For patients, the practical takeaway is simple: as of June 8, 2026, WISeR has not been paused.

What patients and caregivers can do now

Ask whether the service is in WISeR. If you are in one of the six states and have Original Medicare, ask the scheduling office or clinician whether your planned procedure is on the selected WISeR list.
Ask who is reviewing it. Ask whether AI-assisted review is involved, how a clinician reviews the output, and who makes the final decision on non-payment recommendations.
Ask about timing. Find out whether the request is being sent through a WISeR portal or through the MAC, and whether any records are still missing.
Ask what a non-affirmation would mean for you. Specifically ask whether you might receive an ABN and what your estimated financial responsibility could be if Medicare does not pay.
Keep paperwork. Save letters, portal messages, the ABN if one is issued, and the names and dates from phone calls. That can help if a resubmission or appeal is needed.
Do not assume Medicare Advantage rules are the same. WISeR is limited to Original Medicare in six states. Medicare Advantage plans have separate rules.

When to escalate

If your clinician believes a delay could seriously jeopardize your life or health, ask whether expedited review applies. If you have emergency symptoms such as chest pain, stroke symptoms, severe trouble breathing, or heavy bleeding, seek emergency care right away. CMS says emergency services are excluded from WISeR.

If you are not in an emergency but think a review delay is putting you at risk, contact your clinician’s office promptly and ask what step is pending, whether more documentation is needed, and whether Medicare appeal rights may come into play.

Bottom line: WISeR does not put every Original Medicare procedure behind an AI gate. But for selected nonemergency services in six states, it can add a review step that may slow care, trigger an ABN, or lead to denial and appeal if Medicare requirements are not met. Knowing whether your service is included, who is reviewing it, and what happens after a non-affirmation can make the process easier to navigate.

Sources

Editorial note: Weence articles are researched from cited public-health, medical, regulatory, journal, and reputable news sources and may be drafted with AI assistance. They are checked for source support, clarity, and safety guardrails before publication.

This article is for general informational purposes only and is not medical advice. Research findings can be early or incomplete, and health guidance can change. Always talk with a qualified healthcare professional about personal symptoms, diagnosis, medications, vaccines, screenings, or treatment decisions. If you think you may have a medical emergency, call emergency services right away.