Is Medicare already using AI to decide what it pays for?

Part fifteen of Healthcare in Retirement. Two days ago I wrote about the AI on your phone. Today is about the AI on the government's side of the desk, because since January 1 of this year, Medicare has been using it in Arizona to help decide whether certain services get paid for. Most of the people I talk to have not heard of it. I am not an advisor and I am not a lawyer, so what follows is the program's own documents, the first independent reporting on it, the state law that sits next to it, and one question from my own working life that I cannot stop asking about it.

What is WISeR?

WISeR stands for Wasteful and Inappropriate Service Reduction, and it is a model run by Medicare's innovation center. Medicare's page describes it as running "from January 1, 2026 to December 31, 2031" in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. It applies only to Original Medicare, not to Medicare Advantage, and only to a short list of services the program considers prone to waste: skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis, among others. It excludes inpatient-only services, emergency services, and anything that "would pose a substantial risk to patients if delayed." For those services, in those states, a technology vendor now reviews the request before Medicare pays, which is the prior authorization Medicare Advantage members have lived with for years and Original Medicare, until January, mostly had not.

Scale, from KFF's analysis of February 10, 2026: of the 1.1 million Original Medicare beneficiaries who received one of these services in 2024, "roughly 207,500 (19.7%) were located in one of the six WISeR model states," and those services "accounted for 5.3% ($12.3B) of all Part B spending in traditional Medicare in 2024, up from 1.1% ($2.4B) in 2019." That growth is the government's stated reason for the program. KFF also notes how the vendors are paid: they "will be eligible to receive a share of the savings associated with services that are denied," and "may face penalties for inappropriate denials, such as negative payment adjustments or termination from the model." Both halves of that sentence matter, and I will come back to them.

Can a computer deny my care by itself?

Not according to the program's own rules. Medicare's WISeR questions-and-answers document says "A human clinician with relevant clinical expertise for selected items and services must review every non-affirmation," and, in another passage, that non-affirmations "cannot be performed solely by technology." The same document says decisions typically come within three days, two for expedited requests, and that "All appeals rights are preserved under WISeR and the provider and beneficiary have the right to appeal any denied claims." So the design is: the software screens, and a licensed human signs every no.

Here is the question. I have been the person who hands a report to a manager, and I have been the manager. Honestly now: when a trusted team hands you a finished recommendation, do you read every line, or do you trust the team you put in place? I did not read every line. Nobody does, past a certain volume, and the people who study this have a name for it. A 2012 systematic review in the Journal of the American Medical Informatics Association, by Kate Goddard, Abdul Roudsari, and Jeremy Wyatt, examined 74 studies and defined automation bias as "the tendency to over-rely on automation." It found the tendency rises with workload and task complexity. Does a clinician handed a screen that already says "deny," with a queue behind it, match the situation that review describes? I do not have the program's internal workflow to say. It is the question worth asking, and Medicare has the numbers to answer it by state, if it chooses to publish them. The software is the team. The clinician is the manager. Whether the manager reads every line is the whole question, and no promise in a program document answers it.

What do the first records show?

Delays, at least. On September 14, 2026, Newsweek's Suzanne Blake reported on documents obtained through a Freedom of Information Act lawsuit by the Electronic Frontier Foundation. The documents showed that at least one request went unanswered for 83 days against a 72-hour standard. Medicare's response, quoted in the piece: "CMS is firmly committed to ensuring timeliness, accuracy, and transparency under the WISeR model, and will take corrective actions as appropriate to ensure these goals are met." I will say two things about that. One request is one request, and a program this size will be judged on its averages, which have not been published by state. And a promise of a human reviewer does not help a patient whose request is sitting in a queue, because a delay is not a denial, and it is not an approval either. Ask a surgeon what an 83-day wait for a knee decision is. If you are in Arizona on Original Medicare and one of the listed services is in your future, this is now part of your planning.

Does Arizona have its own rule?

Yes, and it is worth reading exactly as written. Arizona's HB 2175, effective July 1, 2026, requires a medical director or a health care provider to "individually review" any denial of a claim or prior authorization that turns on medical necessity, and prohibits relying "solely on recommendations derived from any other source." The law never uses the words artificial intelligence. It does not have to; an algorithm is another source. Two cautions from an engineer who is not a lawyer. First, that statute governs insurers Arizona regulates. Original Medicare is federal, so WISeR runs under Medicare's rules, not Arizona's, and how far a state law reaches into Medicare Advantage is a question for counsel. Second, KFF's May 6, 2026 review of state laws written specifically about AI in prior authorization lists nine states as of April 28, 2026, and Arizona is not among them, presumably because HB 2175 is written about review, not about AI. Nevada does not appear in that review at all, but that is not the whole story. In 2025 Nevada lawmakers passed a bill that would have stopped insurers from relying solely on AI to deny a prior authorization, and the governor vetoed it. What Nevada does have is a rule on the books since 1997: when a managed care plan refuses to authorize a covered service your provider recommended, a Nevada-licensed physician or dentist who has reviewed your records has to make that call. Like Arizona's law, it never mentions AI, and the same two cautions apply. Have a different opinion? Let's talk about it. Email us at eddie@americanretire.com.

What about Medicare Advantage?

That is the older and larger story, and it is not WISeR. In October 2024 the Senate Permanent Subcommittee on Investigations reported on how the three largest Medicare Advantage insurers handled requests for care after a hospital stay. STAT's Bob Herman and Casey Ross summarized the finding: the insurers "increasingly refused to pay for rehabilitative care for seniors in the years after adopting sophisticated technologies to aid in their coverage decisions," turning down roughly a quarter of post-acute care requests by 2022. I am not naming the companies, because the point is not the company. The point is that a human reviewer was supposed to be in the loop there too, under the same kind of promise. Part ten of this series, on observation status and the three-day rule, is where that story lands for a real family. If you are on an Advantage plan, prior authorization with software in the loop is not coming. It is here, and it has been.

What should I do if a request is denied or stalls?

Three things, in order. Ask for the decision in writing and read the reason; under WISeR you are entitled to appeal, and the program says resubmission is allowed. Call the number on your Medicare card, or 1-800-MEDICARE, and ask where the request stands and what the turnaround standard is for your service. Then bring the letter to a person whose job is this. The one thing I would not do is accept a delay as an answer, because the documents released this month suggest that is exactly how some requests have been resolved.

What a Certified Medicare Planner® does differently

They can tell you whether a service you are facing is on that list, and whether your county is in the program, before you are standing in a clinic finding out. They know the difference between the federal promise of a human reviewer and a state law about individual review, and which one applies to the coverage you actually have. They read a denial letter for the reason, the deadline, and the appeal path, and they have seen enough of them to know a stall from a no. And they ask the manager's question on your behalf: who actually reviewed this, and can I see it? The advisors are at 602-281-3898.

Friday, October 2. Foothills Library, Glendale, 10:30 AM. Mustang Library, Scottsdale, 2:30 PM. No cost. Register at 123easymedicare.com/medicare-workshop or call (877) 220-1089.

Next in Healthcare in Retirement: still working at 65 for a small company? When your employer has fewer than 20 employees, Medicare generally pays first and the job's plan pays second, and that one rule changes the Part B decision.

This event is presented by 123EasyMedicare, a brand of American Retirement Advisors, an independent, private organization. It is not sponsored by, endorsed by, or affiliated with Medicare, the Centers for Medicare & Medicaid Services, the Social Security Administration, or any government agency. The libraries are not sponsors of, and are not affiliated with, this event. Educational only; not tax, legal, or insurance advice.

Disclaimer: This article is for educational purposes only. It is not sponsored, endorsed, or otherwise representative of Medicare or the federal Medicare program. American Retirement Advisors is not a government agency. For official Medicare information, visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227).