# Medicare's WISeR model brings AI-assisted review to selected Original Medicare services > WISeR routes selected Original Medicare services in six states through AI-assisted review. CMS explains the provider choices and appeal path; early records document rollout problems but not current performance. By BIGCHANGE.AI Editorial Published: 2026-09-25T16:58:41.079Z Updated: 2026-09-25T16:58:41.079Z Canonical: https://bigchange.ai/blog/wiser-medicare-ai-prior-authorization ![Conceptual charcoal illustration of a clinical workstation holding a closed folder beside an empty outpatient exam room.](https://bigchange.ai/api/media/file/wiser-clinical-review-hero-v1.png) AI-generated conceptual illustration by BIG CHANGE. Since January 2026, a Medicare experiment called WISeR has routed selected services in six US states through technology-company review. The companies can use AI to help assess whether a service meets Medicare's existing coverage rules. A provider can seek a decision before treatment or deliver the service and have the claim reviewed before payment. [CMS lists the model as active](https://www.cms.gov/priorities/innovation/innovation-models/wiser), while [records obtained by the Electronic Frontier Foundation](https://www.eff.org/deeplinks/2026/09/new-records-reveal-problems-medicares-ai-prior-authorization-experiment) describe delays, technical problems and provider complaints during its first months. Those early records do not establish how the program performs now. ## The big change - **What changed:** Original Medicare is testing private companies' AI-assisted review for a defined set of services. The coverage rules remain Medicare's; the review now happens before treatment or before a claim is paid. - **Why it matters:** For affected patients and clinicians, a technology-supported recommendation can shape when a provider gets payment assurance. CMS requires a qualified human clinician to review a non-affirmation, but early operational records show that the path to a decision can still create delays. - **What to watch:** CMS's published timeliness and accuracy measures provide a way to judge the model beyond its design. The available early records identify problems, but do not show whether vendors meet those measures across all six states today. ## Who and what WISeR covers WISeR applies to selected **Original Medicare** services delivered in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. It does **not** apply to Medicare Advantage. [CMS's July 24 provider guide](https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf) says the place where the service is delivered matters; it identifies certain hospital outpatient departments, ambulatory surgery centers, homes and offices. It also excludes Railroad Medicare beneficiaries and specified providers under separate program integrity review. Section 5 says an exemption process began in July 2026: qualifying individual providers and suppliers can be exempt from both prior authorization and pre-payment review after demonstrating compliance. The exemption attaches to the individual provider identifier, not an entire facility. The affected procedures are narrower than all care in those states. [Appendix A of the current guide](https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf) lists the exact billing codes and conditions. Examples include certain skin substitutes, implanted nerve stimulators, knee arthroscopy for osteoarthritis, and vertebral augmentation. Some categories apply only to specified diagnoses or permanent implantation. CMS excludes emergency and inpatient-only services, and services that would pose a substantial risk if delayed. A patient or clinician should check the current Appendix A and the applicable diagnosis and setting, rather than assume every instance of a named procedure is included. CMS says WISeR leaves Original Medicare's coverage and payment policies in place. The change is the added review path for those services. The agency began accepting prior-authorization requests on January 5 for services furnished from January 15, after the model's January 1 start. Its planned end date is December 31, 2031. ## How the two review paths work For an in-scope service without an applicable exemption, the **provider or supplier** can send a prior-authorization request directly to the company assigned to its state or through its Medicare Administrative Contractor (MAC). The company reviews the clinical documentation and sends an affirmation or non-affirmation. An affirmation gives advance payment assurance only when the service, documentation, coding and claim meet Medicare requirements. The provider can instead deliver the service without prior authorization; its claim then goes through medical review **before Medicare pays it**. These are the two routes described in [sections 2 and 3 of CMS's operational guide](https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf). CMS says participating companies use enhanced technology, including AI, to support review. Its [FAQ](https://www.cms.gov/priorities/innovation/files/document/wiser-model-frequently-asked-questions) requires an appropriately licensed human clinician to make any recommendation against provisional affirmation, and the operational guide requires clinicians with relevant expertise to review non-affirmations before issuance. A company's AI can therefore influence the material a clinician reviews; the public documents do not show how often that happens, which system generated a given recommendation, or whether the human reviewer changed it. The MAC handles the later claim determination and appeals process. CMS's stated standard is a determination within three calendar days for ordinary requests, resubmissions and pre-payment reviews, and two days for qualifying expedited requests. The timing measure counts receipt as day one under [CMS's August 13 specifications](https://www.cms.gov/priorities/innovation/files/wiser-perf-msr-tech-spec.pdf). For pre-payment review, section 7.2 of the operational guide starts the three-day decision period after the reviewer receives all requested medical documentation; providers have up to 45 days to supply it. These standards do not describe the whole time a patient or provider may wait. EFF's September account cites one request unresolved for 83 days, and its correction explains that the reported turnaround times cover the full request pathway and are not solely controlled by vendors. The records and provider feedback document reported problems; they do not alone establish why every delay occurred or the program's current six-state performance. ## After a non-affirmation A non-affirmed **prior-authorization request is not itself an appealable claim denial**. According to [CMS's guide, sections 4.4 and 10](https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf), the provider or supplier can submit a complete revised request with supporting material, using the original tracking number, as often as needed before a claim is submitted and denied. On resubmission, the requester may seek a peer-to-peer discussion with a clinician who has relevant expertise. CMS says a non-affirmation does not prohibit furnishing the service and submitting a claim. The guide says a claim submitted with a non-affirmed decision on file will be denied by the MAC. That denial is an initial payment determination, and ordinary Medicare appeal rights become available to providers, suppliers and beneficiaries. The provider's decision about treatment and billing still needs to account for the specific case; a non-affirmation is not a promise that Medicare will pay. The [CMS WISeR page](https://www.cms.gov/priorities/innovation/innovation-models/wiser) names the company assigned to each state and links the operational guide, including contact information and the code list. For a specific service, the useful first check is whether the patient has Original Medicare, whether the service will be delivered in a WISeR state, whether its code and indication appear in the current guide, and whether an exemption applies to the provider. The treating provider or supplier handles the request and can explain the route it chose, the decision notice and any resubmission or claim appeal. ## What the early records can establish EFF [published its account in September](https://www.eff.org/deeplinks/2026/09/new-records-reveal-problems-medicares-ai-prior-authorization-experiment) with links to CMS records released through its information lawsuit. It reports that a vendor warned CMS before launch that some software functions were incomplete, and that an April status report still listed unfinished work. The same account cites early timeliness data, March provider feedback and 5,944 non-affirmed requests across two vendors in the first three months. That figure is a count for two vendors, not a program-wide denial rate, an AI-only decision count or a measure of medically incorrect decisions. EFF corrected an earlier version of its count. The early documents stop in April. CMS's later [technical specifications](https://www.cms.gov/priorities/innovation/files/wiser-perf-msr-tech-spec.pdf) define timeliness and accuracy measures, but are not a results report. The CMS model page, last modified September 10, still labels WISeR active. We found no comparable current public six-state results in these sources to show whether the early problems have persisted, improved or worsened. The model also faces a procedural dispute. In a [May 12 decision](https://www.gao.gov/products/b-337994), the Government Accountability Office concluded that CMS's 2025 WISeR notice is a rule subject to Congressional Review Act submission requirements. GAO's conclusion concerns the notice's status under that law. It is not a court order stopping WISeR, a ruling on any patient's claim, or proof that the model has ended; CMS still lists it as active. ## Sources - [CMS WISeR model page](https://www.cms.gov/priorities/innovation/innovation-models/wiser) — Page modified September 10, 2026. Official active status, six states, participants, scope and CMS design claims. Its stated goals are not measured outcomes. - [CMS WISeR FAQ](https://www.cms.gov/priorities/innovation/files/document/wiser-model-frequently-asked-questions) — Page modified September 22, 2026. CMS explanation of clinician review, prior authorization choice, non-affirmations, resubmission and appeals. Intended timing is not observed timing. - [CMS WISeR Provider and Supplier Operational Guide, version 7.0](https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf) — Version 7.0, July 24, 2026. The current procedural source for service codes, settings, effective dates, two review paths, resubmission and claims appeals. Appendix A should be checked for an individual service. - [CMS WISeR Performance Measure Technical Specifications](https://www.cms.gov/priorities/innovation/files/wiser-perf-msr-tech-spec.pdf) — August 13, 2026. Defines timeliness and audited accuracy measures for the first performance period. It does not report actual results. - [EFF WISeR FOIA reporting and linked records](https://www.eff.org/deeplinks/2026/09/new-records-reveal-problems-medicares-ai-prior-authorization-experiment) — September 2026. EFF reports early vendor readiness problems, delays and provider complaints, linking its CMS FOIA documents. Its corrected 5,944 count covers two vendors in the first three months; records discussed reach April, not current performance. The large combined PDF was inaccessible to this reader, so page-specific claims remain attributed to EFF. - [GAO decision B-337994](https://www.gao.gov/products/b-337994) — May 12, 2026. GAO concluded the CMS notice is subject to Congressional Review Act submission requirements. This is not a court injunction, an individual claim decision or a finding that the active model has ended.