In the News

Recently released federal documents show the Trump administration planned an expansion of an AI-driven Medicare prior authorization program to millions more patients nationwide, drawing concern after early data from the pilot points to delays in care.

Internal communications from the Centers for Medicare & Medicaid Services surfaced by a FOIA request from the Electronic Frontier Foundation show how the administration planned to expand its Wasteful and Inappropriate Service Reduction (WISeR) Medicare pilot beyond the handful of states now testing it.

The program uses artificial intelligence to screen whether costly procedures such as knee surgeries and steroid injections are medically necessary. Private insurance and Medicare have used this system — known as prior authorization — for years to control costs, though critics say the practice can delay necessary medical care, increase administrative burdens on providers, and compromise patient health outcomes.

The document, a June 2025 investment plan for the pilot, says the prior authorization model is intentionally designed for expansion to drive savings on low-value services without adversely affecting the quality of care. The CMS said in the document that the model would scale well to a larger population because prior authorization has been effectively demonstrated in other areas.

The pilot, which runs until 2031, is currently in place across Texas, New Jersey, Oklahoma, Ohio, Washington, and Arizona, and affects nearly 6.5 million patients on traditional Medicare.

The administration’s plan to expand the program nationwide has drawn pushback from lawmakers, since preliminary quality reporting data the Electronic Frontier Foundation analyzed in the released documents found coverage delays, increased denials, and physician complaints of patient harm.

Center for Medicare and Medicaid Innovation Director Abe Sutton said in a panel discussion with conservative health leaders in September that the agency had led several conversations with lawmakers about the demonstration program

“My hope is that we’ve been able to reassure folks that this has been well designed,” said Sutton, and “that we are going to closely monitor it and learn from its lessons before we look to expand.”

The CMS uses pilots to test ways to lower costs and improve quality of care in the Medicare program. Generally, Medicare law allows the agency to permanently adopt these pilots if they are proven to reduce spending without harming quality or if they improve quality without increasing costs.

The CMS in the Investment Plan said that if the “model is successful at reducing Medicare expenditures,” it believed that “this historical precedent and evidence would directly factor into a certification analysis and would strengthen the case for certification, regardless of evaluation results.”

The language came as a surprise to Rep. Greg Landsman (D-Ohio), who called the plans unlawful overreach by the agency.

“I don’t believe this is in their authority to do. I think that’s one of the reasons why they have been very cagey with us,” Landsman said in an interview.

A CMS spokesperson said in a statement the paragraph pertained to a specific component of the evaluation process and does not encompass all that goes into the decision to expand.

The agency said it “will consider evaluation findings related to quality of care, beneficiary access, or other model outcomes when considering whether WISeR should be expanded.”

Access Concerns

The program was originally billed by the agency as a method to provide an “improved and expedited prior authorization process” relative to original Medicare’s existing process.

CMS Administrator Mehmet Oz said the goal was to “bring Medicare into the 21st Century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”

So far, WISeR has yet to accomplish those goals, according to the recently released documents. Records released by EFF found prior authorization request delays, with many taking longer than the 72 hours the agency promised.

Some doctors reported these delays have led to patients calling offices crying in pain because their procedures were postponed.

The CMS told Bloomberg Law that it took concerns of beneficiary access seriously but cautioned that some of the early data from specific months can often be accounted for by reporting issues that do not impact beneficiary access.

The agency said it will be releasing its own six-month analysis of outcomes data, prepayment review volumes, turnaround times, and preliminary data on accuracy in the months ahead.

Under current law, CMS expansion authority insulates the agency from litigation over the substance of a certification, said Jeff Wurzburg, a former attorney at the Department of Health and Human Services.

Challenges could instead focus on whether the agency followed the correct procedural processes.

“Any sort of challenge judicially is going to have to be pretty narrow. So in terms of APA challenges, it’s really going to be based on the record that the secretary provides in that rulemaking,” referring to the Administrative Procedure Act. “Perhaps if evidence demonstrates delayed or denied medically necessary care or CMS fails to adequately consider beneficiary access consequences,” he said.

Legislative Pushback

Both lawyers and lawmakers say that it may ultimately take an act of Congress to prevent the CMS from continuing its plans to expand WISeR across the country. That said, while there are some Republicans joining Democrats in urging caution, efforts to repeal the program have stalled.

In May, Landsman, along with Sen. Ron Wyden (D-Ore.) and Rep. Suzan DelBene (D-Wash.), introduced a Congressional Review Act resolution to axe the pilot. The Senate voted 46-50 along party lines to keep the program in place.

House appropriators also added language to a Health and Human Services Department funding bill that would block funding for the CMS model.

Landsman said a win in the midterm elections could be what it takes to get a repeal of the program across the finish line.

“We need folks who will stand up to Big Tech, and in this case, pause or end WISeR and require CMS to be fully transparent about what they are doing here.”