Medicare Pilot Program Will Use AI To Decide If Pain Treatments Are Worth the Cost

By Pat Anson

Medicare patients in six states who need epidural steroid injections, cervical fusions, spinal cord stimulators, arthroscopic knee surgery and other treatments for chronic pain will soon have their prior authorization requests reviewed by artificial intelligence (AI) to decide whether the treatments are worth the cost.

The Centers for Medicare & Medicaid Services (CMS) is launching a 6-year pilot program on January 1, 2026 called the Wasteful and Inappropriate Service Reduction Model --- known as “WISeR” for short.

WISeR will cover Original Medicare patients in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington who seek treatment for chronic pain, impotence, incontinence, and burns or wounds needing skin and tissue substitutes.

WISeR will review over a dozen treatments that CMS considers low-value, potentially unsafe, or suspicious because of prior reports of fraud and wasteful spending. The low-value treatments alone cost Medicare nearly $6 billion in 2022.

“CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” CMS Administrator Dr. Mehmet Oz said in a press release. “Combining the speed of technology and the experienced clinicians, this new model helps 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.”

Under traditional or Original Medicare, most covered services do not require prior authorization, but Medicare Advantage (MA) plans often do. For that reason, CMS is partnering with private MA plans that have more experience using AI and other advanced technologies to process prior authorization requests. If a request is denied by WISeR, the agency says it will then be reviewed before a final decision “by licensed clinicians, not machines.”

CMS claims that WISeR will “expedite decision making” and not change coverage for traditional Medicare beneficiaries, who “retain the freedom to seek care from their provider or supplier of choice.”

Those providers, however, will be incentivized with higher Medicare payments if they participate in WISeR and show they can reduce the use of low value treatments and help lower Medicare spending.  

Pain treatments that will be reviewed under the WISeR Model include these procedures:

• Electrical Nerve Stimulation  

• Deep Brain Stimulation for Essential Tremor and Parkinson's Disease

• Vagus Nerve Stimulation

• Surgical Removal or Ablation of Nerves

• Epidural Steroid Injections (excluding facet joint injections)

• Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fractures

• Cervical Fusions  

• Arthroscopic Surgery for Knee Osteoarthritis

• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis

Many of these treatments have already drawn scrutiny for being ineffective or costly. Studies have found that spinal cord stimulation, for example, has no benefit for back pain; while epidural steroid injections, nerve blocks and nerve ablation have been found to have little or no benefit.

‘Perverse Incentives’

Not surprisingly, the WISeR Model has drawn criticism from physicians who perform the procedures, who decry the use of AI and algorithms to make healthcare decisions.

“We firmly believe that (WISeR) will jeopardize patient access to care, create more administrative burdens for physicians, offer perverse payment incentives for third-party vendors, and represent a substantial reversal of progress toward this Administration’s goal of prioritizing patients over paperwork,” a coalition of 23 neurosurgeon organizations wrote in a letter to Dr. Oz.

“Decision criteria to be used by participating vendors — including algorithms, scoring models, and evidence-based guidelines — remain a “black box,” leaving stakeholders with little to no insight into how prior authorization determinations will be made.”

Patient rights groups and some politicians say WISeR will create new roadblocks for Medicare patients needing treatment.

“While prior authorization is often described as a cost-containment strategy, in practice it increases provider burden, takes time away from patients, limits patients’ access to life-saving care, and creates unnecessary administrative burden,” Rep. Ami Bera (D) and Rep. Suzan DelBene (D) said in a recent letter to Dr. Oz.

“The use of prior authorization in Medicare Advantage shows us that, in practice, WISeR will likely limit beneficiaries’ access to care, increase burden on our already overburdened health care work force, and create perverse incentives to put profit over patients.”

About 12% of prior authorization denials by Medicare Advantage insurers were appealed in 2023, and more than 80% of them were overturned, according to the Center for Medicare Advocacy.

An HHS Inspector General's report in 2018 found “widespread and persistent” problems involving denials of care by Medicare Advantage. Another report in 2022 found 13% of denied requests actually met Medicare’s rules and should have been approved.

“(WISeR) is) a backdoor way of putting everybody in a Medicare Advantage plan,” Carrie Graham, executive director of the Medicare Policy Initiative told Cleveland.com. “It’s a first step to getting rid of, or downgrading, the freedom that traditional Medicare provides.”

Older Americans Feel Trapped in Medicare Advantage Plans

By Sarah Jane Tribble, KFF Health News  

In 2016, Richard Timmins went to a free informational seminar to learn more about Medicare coverage.

“I listened to the insurance agent and, basically, he really promoted Medicare Advantage,” Timmins said. The agent described less expensive and broader coverage offered by the plans, which are funded largely by the government but administered by private insurance companies.

For Timmins, who is now 76, it made economic sense then to sign up. And his decision was great, for a while.

Then, three years ago, he noticed a lesion on his right earlobe.

“I have a family history of melanoma. And so, I was kind of tuned in to that and thinking about that,” Timmins said of the growth, which doctors later diagnosed as malignant melanoma. “It started to grow and started to become rather painful.”

Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.

But he can’t. And he’s not alone.

RICHARD TIMMINS

“I have very little control over my actual medical care,” he said, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”

Low Premiums and Extra Benefits

Enrollment in Medicare Advantage plans has grown substantially in the past few decades, enticing more than half of all eligible people, primarily those 65 or older, with low premium costs and perks like dental and vision insurance. And as the private plans’ share of the Medicare patient pie has ballooned to 30.8 million people, so too have concerns about the insurers’ aggressive sales tactics and misleading coverage claims.

Enrollees, like Timmins, who sign on when they are healthy can find themselves trapped as they grow older and sicker.

“It’s one of those things that people might like them on the front end because of their low to zero premiums and if they are getting a couple of these extra benefits — the vision, dental, that kind of thing,” said Christine Huberty, a lead benefit specialist supervising attorney for the Greater Wisconsin Agency on Aging Resources.

“But it’s when they actually need to use it for these bigger issues,” Huberty said, “that’s when people realize, ‘Oh no, this isn’t going to help me at all.’”

Medicare pays private insurers a fixed amount per Medicare Advantage enrollee and in many cases also pays out bonuses, which the insurers can use to provide supplemental benefits. Huberty said those extra benefits work as an incentive to “get people to join the plan” but that the plans then “restrict the access to so many services and coverage for the bigger stuff.”

Switching Plans

David Meyers, assistant professor of health services, policy, and practice at the Brown University School of Public Health, analyzed a decade of Medicare Advantage enrollment and found that about 50% of beneficiaries — rural and urban — left their contract by the end of five years. Most of those enrollees switched to another Medicare Advantage plan rather than traditional Medicare.

In the study, Meyers and his co-authors muse that switching plans could be a positive sign of a free marketplace but that it could also signal “unmeasured discontent” with Medicare Advantage.

“The problem is that once you get into Medicare Advantage, if you have a couple of chronic conditions and you want to leave Medicare Advantage, even if Medicare Advantage isn’t meeting your needs, you might not have any ability to switch back to traditional Medicare,” Meyers said.

Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage, he said. In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care, Meyers said.

To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage.

But, Meyers said, there’s a catch: While beneficiaries who enrolled first in traditional Medicare are guaranteed to qualify for a Medigap policy without pricing based on their medical history, Medigap insurers can deny coverage to beneficiaries transferring from Medicare Advantage plans or base their prices on medical underwriting.

Only four states — Connecticut, Maine, Massachusetts, and New York — prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.

Paul Ginsburg is a former commissioner on the Medicare Payment Advisory Commission, also known as MedPAC. It’s a legislative branch agency that advises Congress on the Medicare program. He said the inability of enrollees to easily switch between Medicare Advantage and traditional Medicare during open enrollment periods is “a real concern in our system; it shouldn’t be that way.”

The federal government offers specific enrollment periods every year for switching plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.

Medicare Advantage enrollees can also switch plans or transfer to traditional Medicare during another open enrollment period, from Jan. 1 to March 31.

“There are a lot of people that say, ‘Hey, I’d love to come back, but I can’t get Medigap anymore, or I’ll have to just pay a lot more,’” said Ginsburg, who is now a professor of health policy at the University of Southern California.

Timmins is one of those people. The retired veterinarian lives in a rural community on Whidbey Island just north of Seattle. It’s a rugged, idyllic landscape and a popular place for second homes, hiking, and the arts. But it’s also a bit remote.

While it’s typically harder to find doctors in rural areas, Timmins said he believes his Premera Blue Cross plan made it more challenging to get care for a variety of reasons, including the difficulty of finding and getting in to see specialists.

Nearly half of Medicare Advantage plan directories contained inaccurate information on what providers were available, according to the most recent federal review. Beginning in 2024, new or expanding Medicare Advantage plans must demonstrate compliance with federal network expectations or their applications could be denied.

Amanda Lansford, a Premera Blue Cross spokesperson, declined to comment on Timmins’ case. She said the plan meets federal network adequacy requirements as well as travel time and distance standards “to ensure members are not experiencing undue burdens when seeking care.”

Traditional Medicare allows beneficiaries to go to nearly any doctor or hospital in the U.S., and in most cases enrollees do not need approval to get services.

Timmins, who recently finished immunotherapy, said he doesn’t think he would be approved for a Medigap policy, “because of my health issue.” And if he were to get into one, Timmins said, it would likely be too expensive. For now, Timmins said, he is staying with his Medicare Advantage plan.

“I’m getting older. More stuff is going to happen.”

There is also a chance, Timmins said, that his cancer could resurface: “I’m very aware of my mortality.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.