Medicare to Launch AI Prior Authorization Pilot Program

September 18, 2025

Starting January 1, 2026, the Centers for Medicare and Medicaid Services (CMS) will launch a pilot program that will a) apply new prior authorization requirements to select services for traditional Medicare enrollees in six states and b) hire private companies to use AI in prior authorization determinations.  

The pilot program, officially named the “Wasteful and Inappropriate Service Reduction (WISeR) Model,” will be implemented in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington State.  

CMS stipulates that the program may only apply prior authorization requirements to items and services that “1) may pose concerns related to patient safety if delivered inappropriately; 2) have existing publicly available coverage criteria; and 3) may involve prior reports of fraud, waste, and abuse.” Moreover, CMS is clear that the model excludes “inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.” 

The impending program has received significant critical response from the AMA, state medical societies, and members of Congress on both sides of the aisle. On  September 10, the House Appropriations Committee adopted an amendment to the Health and Human Services funding bill that would block funding for the WISeR program. The amendment will now face a vote on the House floor.  

The MMA will continue to update its members on the WISeR program. For more information, contact Adrian Uphoff, manager of health policy & regulatory affairs.