In 2026, AI tools help with some Medicare prior authorization reviews. In Original Medicare, a pilot called WISeR uses AI plus doctors and nurses to review a short list of services. It runs in 6 states from 2026 to 2031: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. In Medicare Advantage, new rules say plans must decide urgent requests in 72 hours and others in 7 days. They must also tell you why they said no. You can always appeal.
Prior authorization means you need an okay before you get a service. Many people worry a computer will now say no to their care. Here is what really changed. It uses CMS’s WISeR Model page, the CMS prior authorization final rule fact sheet (CMS-0057-F), a CMS memo to Medicare Advantage plans on AI and coverage rules, and Medicare’s guide on how to appeal. I checked all of them on October 16, 2026.
I research Medicare rules for older adults. I am not a lawyer or licensed insurance agent.
Two very different systems
| Original Medicare (WISeR pilot) | Medicare Advantage | |
|---|---|---|
| Who it affects | People in 6 states, for a short list of services | Everyone in an Advantage plan |
| Who reviews | AI tools plus licensed clinicians at 6 tech companies | Your private plan |
| Dates | Jan 1, 2026 to Dec 31, 2031 | Ongoing; new time limits since 2026 |
| Decision time | Per the model’s rules | 72 hours urgent, 7 days standard |
| Denial reason | Non-payment set by licensed clinicians | Specific reason required since 2026 |
| Can you appeal? | Yes, normal Medicare appeals | Yes, plan appeals then outside review |
The WISeR pilot in Original Medicare
WISeR stands for Wasteful and Inappropriate Service Reduction. It is a CMS test that runs six years, from January 1, 2026 to December 31, 2031.
Where: six states, each with one technology company:
- Arizona: Zyter
- New Jersey: Genzeon
- Ohio: Innovaccer
- Oklahoma: Humata Health
- Texas: Cohere Health
- Washington: Virtix Health
What services: a short list that CMS says is prone to waste or fraud. Examples are skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis.
What’s left out: inpatient-only services, emergency services, and services that would put you at real risk if delayed.
How it works: your provider can either ask for prior authorization or skip it. If they skip it, the claim gets a medical review before Medicare pays. CMS says all recommendations for non-payment are made by licensed clinicians, not by the AI alone.
What doesn’t change: your Medicare coverage rules, your choice of provider, and what providers are paid. WISeR does not apply to Medicare Advantage.
Some people worry about how the companies are paid. They get a share of the money saved from care they help avoid. CMS adjusts that share using quality scores, such as how easy providers find the process.
If you live in a WISeR state
Live in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington and have Original Medicare? Ask these questions before a planned procedure:
- Is this service on the WISeR list?
- Will you ask for prior authorization first?
- If not, could the claim be held for review?
- Could I owe money if Medicare won’t pay?
- What will you do if the answer is no?
Most people will never touch WISeR. The list is short. But a planned knee scope or nerve stimulator is worth a quick call.
New rules for Medicare Advantage plans
Under CMS’s prior authorization rule (CMS-0057-F), starting in 2026, Medicare Advantage plans must:
- Decide urgent (expedited) requests within 72 hours.
- Decide standard requests within 7 calendar days.
- Give a specific reason for every denial, however the request was sent.
- Post prior authorization data on their websites each year. The first reports were due by March 31, 2026.
These rules do not cover prescription drugs.
From January 1, 2027, plans must also share your prior authorization records through a patient app link (called an API). Then you can see each request and decision.
Can an AI deny your Advantage plan care?
Not by itself. In a 2024 memo, CMS told Advantage plans they may use algorithms or AI to help with coverage decisions. But the choice must rest on your own health history, your doctor’s advice and your medical notes. Broad data is not enough. CMS also listed three things an algorithm can’t do alone. It can’t deny a hospital stay. It can’t switch you to observation status. And it can’t end your care in a skilled nursing facility. Your current health must be checked.
If you suspect a tool made the call, ask your plan for the reason and the rule it used.
What to do if you get a denial
- Read the notice. Find the reason and the deadline to appeal.
- Call your doctor. Many denials are fixed by sending missing records. Your doctor can also ask for a peer-to-peer talk with the plan’s reviewer.
- Ask for a fast decision if waiting could seriously harm your health. Your doctor’s support helps.
- File an appeal by the deadline on your notice. In Medicare Advantage, the first step is a plan reconsideration. If the plan still says no, the case goes to an independent reviewer.
- Keep copies of everything, with dates and names.
Our step-by-step guide on how to win a Medicare appeal has letter tips.
Free help
- SHIP: your State Health Insurance Assistance Program gives free one-on-one Medicare counseling.
- 1-800-MEDICARE (1-800-633-4227), 24 hours a day.
- Your doctor’s billing office. They handle prior authorization every day.
Should this change how you pick a plan?
Prior authorization is one of the biggest differences between Original Medicare and Advantage plans. If you see specialists often, compare each plan’s rules during open enrollment (October 15 to December 7). See Medicare Advantage vs Original Medicare and our 2027 open enrollment guide. If you might switch to Original Medicare, a Medigap plan can cover most of your share.
Common questions
Does Original Medicare now require prior authorization with AI?
Only in the WISeR pilot. It covers a short list of services in 6 states, from 2026 through 2031. Licensed clinicians make any non-payment decision.
Which services are in the WISeR model?
Examples include skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis. Emergency and inpatient-only services are excluded.
How fast must a Medicare Advantage plan decide prior authorization?
Within 72 hours for urgent requests and 7 calendar days for standard requests, starting in 2026. Drugs follow other rules.
Can a Medicare Advantage plan deny care using only AI?
No. CMS says decisions must be based on your own medical history and your doctor’s advice, not an algorithm alone.
What should I do if prior authorization is denied?
Read the reason, ask your doctor to send more records, and appeal by the deadline. Ask for a fast appeal if your health is at risk.
Written by Khasim Basha Shaik. I research Medicare rules and senior health topics. I am not a lawyer or licensed insurance agent. This article summarizes official CMS sources and is not legal or insurance advice. Last reviewed October 16, 2026.
