AI Is Deciding Medicare Coverage · Hanh D. Brown

Medicare began an experiment this year. It put artificial intelligence (AI) inside its own approval process, in six states, on purpose, with a start date and an end date.

Artificial intelligence here means software trained to find patterns in large amounts of material, rather than software following a fixed list of instructions.

One question matters more than the rest. Can a machine turn down your care?

The rules answer it one way. The pilot answers it another. The difference between them is the reason this runs longer than a headline.

The answer is narrower than the headlines. It is also stranger.

It depends on which Medicare you hold. The first thing to know is that there are two.

What is the WISeR pilot and which states is it running in?#

The pilot has a long name and a short one. The long name is the Wasteful and Inappropriate Service Reduction model. The short name is WISeR.

It started on January 1, 2026. That is this year, not a proposal for some later one. It runs for six performance years.

Six states are in it. New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.

A person living in one of them may never notice. The change sits in the paperwork, not on the card in their wallet.

The Centers for Medicare and Medicaid Services (CMS) runs Medicare. It picked a short list of items and services. Each one has published coverage rules. Each one has a history of misuse.

Skin substitutes. Electrical nerve stimulators. Knee arthroscopy for osteoarthritis.

One fact is worth stating in plain words. WISeR covers Original Medicare only. The agency states that it does not apply to people in Medicare Advantage and will have no impact on them.

That matters, because a great many people on Medicare are in an Advantage plan rather than Original Medicare. For them this pilot is not the story. A different rule is.

Now the part worth turning over. The companies running the technology are paid a share of the savings their reviews produce.

Fewer approvals, more money. That is how two health economists who reviewed the design describe it.

That sentence needs care. A payment design is a fact about incentives, never by itself a fact about harm, and the difference matters when somebody is frightened.

One caution belongs here. That is a payment design, not evidence of harm. The agency also promises that every recommendation for non payment comes from an appropriately licensed clinician. Both things are true at once, and a reader deserves both.

Can AI deny a Medicare claim without a doctor looking at it?#

Under Medicare Advantage, no. The rule sits in the Code of Federal Regulations (CFR), the book where final agency rules live.

Its address is 42 CFR 422.566(d). It is unusually direct.

When a plan expects to issue an adverse decision based on medical necessity, that decision must be reviewed by a physician or other appropriate health care professional. That person must have expertise appropriate for the service. That person must also hold a current and unrestricted licence to practise.

Think of it as a signature line at the bottom of a form. Software can fill in everything above the line. The line still needs a hand.

The rule never mentions artificial intelligence. It works anyway, because it sets a requirement about who signs, and no program can hold a licence.

Under the WISeR pilot the protection is real. It is also a different kind of object.

The promise that licensed clinicians determine every recommendation for non payment sits in a model fact sheet. It does not sit in the regulation book.

A rule takes a rulemaking to change. A promise in a design document takes a decision. Knowing which one you are relying on is worth five minutes of anybody’s day.

What does a Medicare denial letter actually say?#

More than the envelope suggests. The page is dense. The type is small.

That envelope arrives on an ordinary day.

Five things are required.

• Approved language, readable and understandable.
• The specific reasons for the denial.
• Your right to a reconsideration.
• Both appeal routes, standard and expedited.
• Whatever else the agency requires.

Those five come from 42 CFR 422.568(e). Every one of them is yours by rule, and a notice that skips any of them is worth challenging on that ground alone.

The clocks are set by rule too. One of them changed this year.

A standard request for a service that needed permission in advance now gets an answer within seven calendar days. Other standard requests get fourteen. An urgent request gets seventy two hours. An urgent request for a Part B drug gets twenty four.

Those hours are not a courtesy. They are a deadline somebody owes you.

Here is the piece that gets missed. It is the most useful line in the whole rulebook.

If the plan fails to give you timely notice, that failure is itself an adverse decision. You can appeal it.

A notice that never arrives is like a referee who never blows the whistle. The rule treats the silence as a call, and it lets you argue with it. If you are still waiting past the deadline on the list above, you are not stuck. You have something to appeal.

Does Medicare have to tell you when AI was used?#

Read the five requirements again. They govern what the page must contain. They are specific.

Readable language. The specific reasons. Your appeal rights. The routes. Whatever else the agency adds.

The method is not among them. The rule asks for the reasons behind a decision. It does not ask for the tools used to reach it.

So the honest answer is this. What you are owed is a specific reason you can read and argue with. You are not owed a description of the software, and no line in that notice requirement asks for one.

One boundary belongs here. That is a statement about this rule. It is not a claim that no rule anywhere requires disclosure. States have been writing their own laws on this, and that map is uneven and moving.

What you can do is ask. Ask who reviewed it, by name and by role. Ask what criteria that person applied.

Do it on paper, not by phone, so the question and its date exist somewhere. Plans have to make their medical necessity criteria available on request.

Do AI assisted reviews raise denial rates?#

Nobody can answer that about this pilot yet, and anyone who does is guessing. The model began in January and its results are not published.

What is known is older and narrower. Researchers at a university health policy centre published a note in February. Past research shows that when insurers require prior authorization, the people they cover get fewer services. Their concern about this pilot is direct: if the method has trouble identifying necessary cases and denies them, people could lose access to care they need.

They make the fair point in the other direction too. The pilot could save money by cutting treatment that helps nobody.

Their conclusion is neither applause nor alarm. Watch it closely.

One detail in the model’s own design deserves a reader’s attention. The agency measures its participants partly on the number of non affirmations and favourable appeal decisions. In plain words, somebody is counting how often these reviews say no and how often that no gets overturned.

That is a good sign. It does not tell you the answer yet.

It tells you the answer is being collected.

How many Medicare Advantage denials get overturned on appeal?#

This piece gives no number, and the reason belongs in the open rather than in a hole. I could not pin a current year figure to a primary government source, and a stale percentage repeated confidently is exactly what this whole subject already suffers from.

What follows is better than a statistic, because it is a thing you can use.

When you appeal a Medicare Advantage denial, the plan reconsiders it. If the plan decides fully in your favour, it has to act. If the plan affirms its own denial in whole or in part, it does not get to end the matter there.

Under 42 CFR 422.590, the plan must prepare a written explanation and send your case file to an independent entity contracted by CMS, no later than thirty calendar days from the date it received your request.

It works like an automatic second opinion you never had to ask for. The plan that said no is required to hand your file to somebody who does not work for it. That happens because you appealed. It happens whether or not you know the rule exists.

What should you do if you think a machine denied your claim?#

Five steps. None needs a lawyer.

1. Check which Medicare you hold.
2. Read the notice for its specific reason.
3. Ask in writing who reviewed it.
4. Ask which criteria they applied.
5. Appeal before the deadline printed on the notice.

A word on each. Advantage and Original run on different rules, so step one decides everything after it. The reason in step two is required to be there, so its absence is itself an argument.

In step three, ask for the role and the credentials, not only a name. Appeal in step five even while you are still gathering paper. A late appeal forfeits the right, however good the case.

If the notice never came at all, that silence is appealable too. Put the date you asked and the date the deadline passed in your letter.

A machine did not sign your denial, if the rule was followed. A person did, and that person had to hold a licence. Asking who they were is not rude and it is not a long shot. It is the one question the rulebook already answers on your behalf.

Letters like that get read at the kitchen table, folded, and put back in the drawer. The family caregiver who opens it instead, and writes down one date, has done the hardest part of the whole process.

Two other programs handle this same moment differently. That map is in who decides what Medicare pays.

The approval gate itself gets taken apart in prior authorization by machine. To check any claim here against the rule, use check a policy claim.

CMS describes its own pilot on the CMS WISeR model page. The independent concerns are set out by researchers at the Schaeffer center.