Medicare Turns to AI for Claim Decisions in 6 States

New CMS program will use AI to approve or deny some Medicare claims, raising concerns about access to care.

Published on Feb. 26, 2026

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The Centers for Medicare and Medicaid Services (CMS) has launched a trial program in six states that will use AI and machine learning to approve or deny some Medicare claims for non-emergency health care services. The program, called the Wasteful and Inappropriate Service Reduction (WISeR) Model, aims to reduce waste and speed up the prior-authorization process, but experts and lawmakers are worried it could lead to denials of necessary care for Medicare beneficiaries.

Why it matters

If the AI-powered system can reduce unnecessary care, it could save Medicare millions of dollars and ease pressure on the federal budget. However, there are concerns that the automated system could wrongly deny or delay necessary care, especially for complex cases, shifting costs onto seniors who are often on fixed incomes.

The details

The WISeR Model will run through the end of 2031 and operate in Texas, New Jersey, Oklahoma, Ohio, Washington, and Arizona. Claims that need prior authorization will go through the AI system first, which will deny services that provide little clinical benefit or have a higher risk of waste, fraud, and abuse. Claims for emergency inpatient-only services and emergency services will not be processed by the AI. CMS says the updated technology will decrease waste and speed the prior-authorization process, but some experts and lawmakers are worried it will deny claims for services that should be covered by Medicare.

  • The WISeR Model was launched by CMS in February 2026.
  • The program is set to run through the end of 2031.

The players

Centers for Medicare and Medicaid Services (CMS)

The federal agency that oversees the Medicare program and has launched the WISeR Model trial program in six states.

Shannon Benton

The executive director of The Senior Citizens League, who has expressed concerns about the risks of the WISeR Model and the need for transparency, safeguards, and human oversight when using AI in Medicare claims decisions.

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What they’re saying

“AI could help Medicare process prior authorizations and claims more quickly and consistently, reducing delays and administrative burdens for beneficiaries and aiding in the fight against fraud and waste.”

— Shannon Benton, Executive Director, The Senior Citizens League (Email)

“However, risks are significant, as automated systems might wrongly deny or delay necessary care, especially in complex cases.”

— Shannon Benton, Executive Director, The Senior Citizens League (Email)

“Any use of AI would be subject to strict oversight to ensure transparency, accountability, and alignment with Medicare rules and patient protection.”

— CMS Spokesperson (Email)

“CMS remains committed to ensuring that automated tools support, not replace, clinically sound decision-making.”

— CMS Spokesperson (Email)

What’s next

CMS will monitor the timeliness and accuracy of prior-authorization review decisions made through the WISeR Model.

The takeaway

The use of AI in Medicare claims decisions raises concerns about the potential for wrongful denials of necessary care, especially for complex cases. Strict oversight, transparency, and human review will be crucial to ensure the system supports, rather than replaces, clinically sound decision-making and protects access to care for Medicare beneficiaries.