The Centers for Medicare & Medicaid Services (CMS) launched the Wasteful and Inappropriate Service Reduction (WISeR) trial, a six‑state pilot that will test AI‑driven prior‑authorization for Original Medicare. Texas is one of the six participating states—alongside Arizona, New Jersey, Ohio, Oklahoma and Washington—where the program will roll out in 2025. The goal is to cut unnecessary spending by flagging high‑risk, low‑value services that are prone to fraud, waste or abuse .
Under WISeR, CMS partners with private technology vendors to apply artificial‑intelligence models that review claims data and predict the likelihood of a service being medically justified. The AI focuses on procedures such as skin‑and‑tissue substitutes, electrical‑nerve‑stimulator implants, knee arthroscopy, cervical fusion, steroid injections and impotence treatments. Emergency or urgent care services are excluded from the AI review to avoid treatment delays .
A key safeguard is that any coverage denial must be confirmed by a licensed human clinician, not the algorithm alone. Vendors are also barred from receiving payment tied to denial rates, aiming to keep financial incentives separate from clinical decisions. The pilot is scheduled to run through 2031, giving CMS time to assess whether AI can streamline the prior‑authorization process while maintaining patient safety .
If successful, the model could reshape how Original Medicare handles pre‑approval, moving from manual reviews to a more efficient, data‑driven workflow. However, critics warn that AI may amplify delays or biased denials, especially for high‑cost treatments. The outcome will likely influence future Medicare policy and may set a precedent for broader AI adoption in public health insurance programs .
