Medicare Prior Approval Initiative Sparks Debate Over Patient Access and AI-Driven Screening

August 28, 2025 | Washington, D.C.

Federal regulators’ newly launched pilot program requiring prior authorization for selected Traditional Medicare services has ignited sharp criticism from Democratic lawmakers and healthcare providers, who warn it could hinder patient access and inflate administrative burdens. The Wasteful and Inappropriate Service Reduction (WISeR) Model, set to operate in six states beginning January 2026, leverages artificial intelligence (AI) for initial screening of claims but retains human clinicians for final coverage decisions.

Key developments announced today include:

  • Democratic Reps. Suzan DelBene (D-WA) and Ami Bera (D-CA) urged CMS to reconsider the pilot, arguing it risks delaying medically necessary care and undermines clinician autonomy.
  • CMS emphasized that AI-driven flags will only “flag wasteful services,” with all denial or approval determinations made by qualified reviewers.
  • Opponents warn rural hospitals may be disproportionately affected, given their reliance on Medicare reimbursement and limited administrative staffing to navigate added prior authorization requirements.
  • Supporters contend AI-assisted authorization could reduce fraud and unnecessary procedures, potentially yielding significant savings for the Medicare Trust Fund.

In a related development, the Journal of the American Medical Association published a Viewpoint today examining the WISeR Model’s design, noting that traditional Medicare’s prior authorization currently applies to less than 0.4% of Part B spending but could expand to cover up to one-quarter if MA policies were imposed; the article also flags concerns about potential delays averaging 4-6 days per review.

As CMS balances cost-containment goals with care quality, the pilot’s rollout and early performance metrics will be closely watched by policymakers, providers, and patient advocates alike.