Medicare Is Using AI to Deny Your Parent's Care. Here's How to Fight a Denial and Win

Marcus found out his mother's pain shot had been flagged the same week the cortisone was supposed to go in. Renata had been waiting on an epidural steroid injection for the nerve pain running down her leg, the kind of thing her doctor in Ohio had ordered a dozen times before without a second thought. This time a letter said the request was under review. Not by her doctor. By a contractor running software for Medicare, deciding whether the shot her physician already ordered would be paid for at all. If your parent is on traditional Medicare in one of six states, here is the part too few families hear in time: a flag is not a final no, and most denials that get appealed get reversed.

What landed on Renata is called the WISeR model. It started January 1, 2026 in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, and it runs as a six-year pilot. The name stands for Wasteful and Inappropriate Service Reduction.¹ That name tells you what it is built to do.

If nobody has walked your family through this, that is normal. It is brand new, and it is a real change in how original Medicare handles certain care. So here is the plain version: what the software actually does, which services it now touches, and the appeal process that quietly turns most denials around when a family knows to use it.

What does WISeR actually do?

Here is the mechanics of it. A doctor orders a test, a treatment, or a piece of equipment. Under the old way, Medicare paid the claim after the service happened, and any problem got sorted out after the fact. Under WISeR, certain services need prior authorization first, before the care can go ahead.

A private contractor reviews the request using artificial intelligence and clinical criteria. The contractor has 72 hours to answer a standard request, or 48 hours for an expedited one. If the answer is no, the care does not happen until someone overturns that no.¹

CMS says coverage decisions still follow existing Medicare rules, and that a human clinician, not the AI, makes any final denial.¹ That sounds reassuring on paper. The worry is about who that human works for, and how the contractor gets paid.

It injects some of the worst of Medicare Advantage into traditional Medicare.

David Lipschutz, Center for Medicare Advocacy

His concern is the money. The vendors running these reviews can earn a share of the savings from the care they deny, which means denials are tied to their pay.² We have seen where that road leads. A U.S. Senate investigation found that in 2022, Humana's denial rate for post-acute care, driven in part by AI tools, ran about 16 times higher than its overall denial rate, with UnitedHealthcare and CVS roughly three times higher.³

Which services now need prior approval?

WISeR does not touch everything. It starts with a list of about 17 items and services that CMS says have a higher risk of waste or overuse. The ones most likely to land on a family include:²

• Epidural steroid injections for pain, the kind Renata was waiting on.
• Electrical nerve stimulator implants.
• Skin and tissue substitutes for chronic wounds.
• Cervical spinal fusion for neck conditions.
• Knee arthroscopy and certain joint procedures.
• Incontinence control devices.
• Diagnosis and treatment for impotence.

If your parent lives in one of the six pilot states and needs any of these through traditional Medicare, the doctor now has to get permission before going ahead. That is not how original Medicare has worked. Prior authorization has been a hallmark of Medicare Advantage, the private-plan version. Bringing it into traditional Medicare is the real shift here.

How do you appeal a Medicare denial?

This is where families win or lose, and where most never even start. The letter arrives, it looks official, and the family assumes the decision is locked. It is not. Original Medicare has five levels of appeal, and the early ones are something a family can do on their own.⁴

1. Level 1: Redetermination. Submit a written request to the contractor within 120 days of the denial. Include the doctor's reasoning for why the service is medically necessary, and ask the office for a letter of medical necessity. The contractor has 60 days to respond.
2. Level 2: Reconsideration. If the first answer is still no, ask for a review by a Qualified Independent Contractor, a separate entity from the one that issued the denial. You have 180 days to file. They have 60 days to respond.
3. Level 3: Administrative Law Judge. If it is still denied, you can request a hearing before an ALJ when the amount in dispute is at least $200 in 2026.⁴ This is where a strong file, with that letter of medical necessity, tends to pay off.
4. Level 4: Medicare Appeals Council. If the ALJ rules against you, you can appeal to the Medicare Appeals Council within 60 days.
5. Level 5: Federal Court. For claims of at least $1,960 in 2026, the case can go to federal district court.⁴

The numbers favor families who push. When the federal watchdog looked at Medicare Advantage, the kind of prior-authorization setup WISeR borrows from, it found insurers overturned about 75 percent of their own denials once they were appealed, yet only about 1 percent of denials were ever appealed at all.⁵ The system is built around families not appealing.

What can you do before a denial happens?

If your parent is in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, a little preparation goes a long way. Ask the doctor whether any upcoming procedure is on the WISeR list. Ask the practice whether the staff have handled prior authorization before. Keep copies of every record tied to the requested service.

Consider calling the State Health Insurance Assistance Program. SHIP counselors are free, and they have helped Medicare beneficiaries file appeals for years, long before WISeR existed. Their directory lives at shiphelp.org.⁶

What if your parent is not in a pilot state?

Pay attention anyway. This is a pilot, and CMS will judge it on whether it cuts spending, which is the stated goal. If it does, expect it to grow. The precedent set in 2026 will shape Medicare for years, and every state is one budget decision away from being state number seven.

Frequently Asked Questions

Does a computer decide whether Medicare pays for my parent's care?

Under WISeR, AI software helps review prior-authorization requests, but CMS says a human clinician makes any final denial and decisions must follow existing Medicare rules. The concern is that the contractors can earn a share of the savings from denied care, which ties their pay to saying no.

How long does the contractor have to respond?

72 hours for a standard request and 48 hours for an expedited one. If the request is denied, the care does not move forward until that denial is overturned.

Is it worth appealing a denial?

Usually yes. In Medicare Advantage, the model WISeR borrows from, insurers overturned about 75 percent of their own denials once families appealed, but almost no one appealed. A strong file and a letter of medical necessity from the doctor make the biggest difference.

Where can my family get free help with an appeal?

Every state runs a free State Health Insurance Assistance Program. SHIP counselors help beneficiaries understand their options and file appeals at no cost. Start at shiphelp.org.

Renata got her shot. Marcus asked the doctor's office for a letter of medical necessity, sent in the redetermination with her records inside the 120-day window, and the denial came back overturned before the second level was even needed. It took a few phone calls and a stack of paper he had thought to keep. The flag was never the final word. It just looked like one.

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Sources

1. Centers for Medicare and Medicaid Services, CMS Innovation Center. "Wasteful and Inappropriate Service Reduction (WISeR) Model." cms.gov/priorities/innovation/innovation-models/wiser
2. Kaiser Family Foundation. "Examining the Potential Impact of Medicare's New WISeR Model." 2025. kff.org/medicare/examining-the-potential-impact-of-medicares-new-wiser-model
3. U.S. Senate Permanent Subcommittee on Investigations. "Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care." October 2024. hsgac.senate.gov
4. Medicare.gov. "Appeals in Original Medicare," and Federal Register, "Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026" (ALJ $200, federal court $1,960). medicare.gov/providers-services/claims-appeals-complaints/appeals/original-medicare
5. HHS Office of Inspector General. "Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials." OEI-09-16-00410, 2018. oig.hhs.gov
6. State Health Insurance Assistance Program National Technical Assistance Center. "Find Local Medicare Help." shiphelp.org/about-medicare/regional-ship-location

This content is for educational and informational purposes only. It is not a substitute for professional medical, legal, or financial advice. Always consult qualified healthcare providers, attorneys, or financial advisors for guidance specific to your situation. Statistics and policy details cited were accurate at the time of publication and may have changed.

© 2026 Aging Parent Care. All rights reserved. No portion of this article may be reproduced, distributed, or used in any form without the explicit written permission of Aging Parent Care.

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