Medicare Spent Years Avoiding This. Now It's Testing It on You.

For most of its history, traditional Medicare did something private insurers never would: it largely left prior authorization alone. If your doctor ordered a procedure, you generally got it, and the paperwork came after. That quiet difference was one of the few places in American healthcare where the permission slip did not stand between you and your care.

This year, that changed. In mid-January, traditional Medicare began a pilot in six states — Oklahoma, Arizona, New Jersey, Ohio, Texas, and Washington — that requires preapproval for a list of thirteen medical services, from epidural spinal injections to a surgery for spinal fractures. The program is called the Wasteful and Inappropriate Service Reduction Model, or WISeR, and it leans on artificial intelligence to help flag which requests get a closer look (Centers for Medicare & Medicaid Services). The stated goal is to curb fraud and spare patients unnecessary procedures. The federal government says it is not meant to deny needed care.

The early experience, as reported by KFF Health News, has been rougher than that promise. In Oklahoma, a 65-year-old rancher named Bill Curry — who for years had driven two and a half hours to Oklahoma City for a routine spinal injection — was told this winter that he suddenly needed preapproval, then asked to make a third trip just to fill out a form describing how he felt. He hasn't gone back. Patients, doctors, and clinic staff across the pilot states described confusion, errors, and long waits; some called the rollout "horrendous" (KFF Health News). Early figures gathered from sixteen Washington hospitals suggest patients there have waited two to four times longer for care under the program (as reported by Fierce Healthcare). And a digital-rights nonprofit has gone to court, suing CMS for details about how the underlying algorithms were trained and what safeguards exist against wrongful denials (Healthcare Dive; Medscape).

The context worth understanding

Here is the part that my years in specialty pharmacy taught me to watch for. Prior authorization is not new — it is the daily reality for tens of millions of people with private and Medicare Advantage coverage, and surveys consistently find that patients and doctors regard it as the single most exhausting obstacle to getting care. What is new is the direction of travel. Even as the federal government tests this approval machinery inside traditional Medicare, the same administration has been pressing private insurers to scale prior authorization back. The right hand is loosening the screws while the left hand tightens them.

The other new element is the algorithm. An AI tool does not, on its own, make a denial illegitimate; used well, it can route the obvious cases through faster. The danger is the same one that recurs everywhere automated review touches care: speed without a meaningful human read. When a program is stood up quickly — WISeR was announced in June 2025 and live by mid-January, which contractors themselves called an aggressive pace — the rough edges land on patients first.

What it means for you

If you have traditional Medicare and you live in one of the six pilot states, the most important thing to know is that the old assumption no longer holds automatically. For certain procedures, your doctor may now need approval before you can proceed, and that step can add days — or, as in Mr. Curry's case, an extra trip — to care you have had without friction for years.

It also means something more durable, whatever happens to this particular pilot: the protection traditional Medicare once offered against the permission-slip system is no longer a given. The procedures on the list today are a narrow set. The precedent is not narrow at all.

What you can do today

Ask, before a procedure, whether it now requires prior authorization under your plan. If you have traditional Medicare in a pilot state, ask your clinic specifically about the WISeR list.

If care is delayed or denied, request the specific reason in writing, and ask whether a human clinician reviewed the decision. You are entitled to a real answer.

Know that a denial is appealable. A preapproval denial is a starting position, not a final verdict — the same as any other.

Keep your own record: dates of requests, who you spoke with, what you were told. Delays are easier to challenge when you can show them.

Ellen can help you read a denial, find the rule behind it, and build the appeal — whether the "no" came from a private insurer or from a new federal pilot still working out its kinks. The machinery is spreading into places it never used to reach. Knowing how it works is how you stay ahead of it.

Ellen does not provide medical advice. For treatment decisions, talk to your doctor.

Sources: KFF Health News, "Medicare's AI Push Snarls Patients and Doctors in Errors and Delays" (June 2026); Centers for Medicare & Medicaid Services, WISeR Model; Fierce Healthcare; Healthcare Dive; Medscape.