The Algorithm Deciding Whether Your Mother Gets Treatment

Somewhere in an office building in one of six states, software is reviewing your mother's treatment request.

Not a doctor. Not a nurse. Software, operated by a private contractor, deciding whether Medicare will pay for the imaging, the procedure, the equipment her physician ordered.

This is the WISeR model. It launched January 1 in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It's a six-year pilot, and its name stands for Wasteful and Inappropriate Service Reduction. That name tells you everything about its priorities.

What WISeR Actually Does

Here's how it works: Your parent's doctor orders a test or a treatment, maybe durable medical equipment. Under the old system, Medicare processed the claim after the service was provided. If there was a problem, it got flagged retroactively.

Under WISeR, certain services now require prior authorization before the care can happen. A private contractor reviews the request using artificial intelligence and clinical criteria. The contractor has 72 hours to respond (48 for expedited requests). If the request is denied, the care doesn't happen until someone overturns that denial.

The CMS fact sheet says coverage decisions will follow existing Medicare guidelines and that AI won't make final determinations. A human reviews the AI's recommendation.

But the structure creates incentives that should worry you. David Lipschutz of the Center for Medicare Advocacy has warned that the model "injects some of the worst of Medicare Advantage into traditional Medicare." His concern: the vendors running the AI reviews operate under contracts that create pressure to reduce spending. And reducing spending means reducing approvals.

How bad can it get? A Senate Permanent Subcommittee on Investigations report found that Humana's post-acute care denial rates, driven in part by AI tools, were over 16 times higher than its overall denial rates. UnitedHealthcare and CVS showed rates roughly three times higher.

17 Services That Now Need Prior Approval

Newsweek reported the initial list of services requiring WISeR pre-authorization. It includes:

- Certain imaging (MRI, CT scans)

- Cardiac procedures

- Orthopedic procedures including joint replacements

- Spinal surgeries

- Power wheelchairs and complex durable medical equipment

- Certain home health services

- Select outpatient procedures

If your parent lives in one of the six pilot states and needs any of these services through traditional Medicare, their doctor now has to get permission before proceeding. Sound familiar? It should.

This isn't how traditional Medicare has worked for 60 years. Prior authorization has been a hallmark of Medicare Advantage, the private-plan alternative. Bringing it into original Medicare is a fundamental shift.

How to Appeal a Denial

If your parent gets a denial, the appeal process matters. Here's the thing: most people don't appeal. The denial letter arrives, it looks official, and the family assumes the decision is final. They're wrong.

Level 1: Redetermination. Submit a written request to the contractor within 120 days of the denial. Include your parent's doctor's rationale for why the service is medically necessary. Ask the doctor's office for a letter of medical necessity. The contractor has 60 days to respond. Level 2: Reconsideration. If the redetermination is denied, request a review by a Qualified Independent Contractor (QIC). This is an independent entity, not the same contractor that issued the denial. You've got 180 days to file. The QIC has 60 days to respond. Level 3: Administrative Law Judge (ALJ). If you're still denied, you can request a hearing before an ALJ if the amount in controversy is at least $200 (in 2026). This is where success rates jump. HHS Office of Inspector General data has shown ALJ favorable decision rates of roughly 56%, and many categories see even higher overturn rates when strong documentation is provided. Level 4: Medicare Appeals Council. If the ALJ rules against you, you can appeal to the Medicare Appeals Council within 60 days. Level 5: Federal Court. For claims above $1,960, you can take the case to federal district court.

Most denials that get appealed get overturned. The system counts on you not appealing. Don't give it what it wants.

What You Can Do Before a Denial Happens

If your parent is in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, preparation matters.

Talk to your parent's physician about whether any upcoming procedures fall under WISeR's pre-authorization list. Ask the practice whether they've got staff experienced with prior authorization. Many do, because they've dealt with it in Medicare Advantage for years.

Keep copies of all medical records related to the requested service. If a denial comes, your appeal is only as strong as your documentation.

Consider contacting your State Health Insurance Assistance Program (SHIP). Every state has one. SHIP counselors are free, and they help Medicare beneficiaries understand their options and file appeals. They've been doing this long before WISeR existed.

And if your parent isn't in one of those six states? Pay attention anyway. This is a pilot. If CMS determines the model reduces spending (which is the stated goal), it will expand. The precedent being set in 2026 will shape Medicare for the next decade. Every state is one budget decision away from being state number seven.

Sources

1. Centers for Medicare and Medicaid Services. "Prior Authorization and Utilization Management Model for Traditional Medicare." CMS Fact Sheet, 2025.
2. U.S. Senate Permanent Subcommittee on Investigations. "Denial, Delay, Deny: How Medicare Advantage Organizations Use AI to Harm Seniors." October 2024.
3. Centers for Medicare and Medicaid Services. "Medicare Appeals." CMS.gov.
4. HHS Office of Inspector General. "Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials." OEI-02-19-00480.
5. Centers for Medicare and Medicaid Services. "Care Compare." Medicare.gov.
6. Medicare Rights Center. "WISeR Prior Authorization Model: What Beneficiaries Need to Know." 2025.
7. State Health Insurance Assistance Program (SHIP). "Free Medicare Counseling." SHIP National Technical Assistance Center.

This article is for educational and informational purposes only. It does not constitute medical or financial advice. Always consult qualified professionals for guidance specific to your situation.

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