Regulation · Regulation
Medicare is testing AI to help decide whether some treatments get paid for
Medicare's WISeR model uses technology companies with AI tools to review requests for a short list of services, like knee arthroscopy for arthritis, before they're paid. It runs in six states from 2026 to 2031, and licensed clinicians make any 'no' decision. Rating: Announced only.
How far away is this?
This is a government programme description. No results on accuracy, delays or patient outcomes have been published yet. The tech companies are paid a share of the spending their reviews avert.
Get the weekly How Far
One email every Friday morning (Sydney time) on which medical AI actually reached patients, and what it means for you. Free, in plain English.
Where is it approved?
| Region | Regulator | Status | Notes |
|---|---|---|---|
| United States | FDA | Not applicable | Not a product; nothing to approve. |
| European Union | CE mark / EMA | Not applicable | Not a product; nothing to approve. |
| United Kingdom | MHRA | Not applicable | Not a product; nothing to approve. |
| Australia | TGA | Not applicable | Not a product; nothing to approve. |
Payment programme; not a product. "Register not searched yet" means we haven't searched that regulator's register; it doesn't mean the product is or isn't available. Approval in one country isn't approval in another.
What is it?
Prior authorisation means getting approval before a treatment is covered. Traditional Medicare has mostly not required it. WISeR tests it for selected services that CMS says often have little benefit.
What's the evidence?
WISeR runs from 1 January 2026 to 31 December 2031 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.[1]
Evidence stage: Announced only · #c1
Examples of services covered include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. Emergency and inpatient-only services are excluded.[1]
Evidence stage: Announced only · #c2
CMS says every recommendation not to pay is made by appropriately licensed clinicians, and Medicare coverage itself doesn't change.[1]
Evidence stage: Announced only · #c3
What does it mean for me?
If you have Original Medicare in one of the six states and need one of these services, your provider can either ask for approval first or have the claim reviewed before it's paid. Ask them which applies and how long it usually takes.
What could I ask my doctor?
- Does this treatment need prior approval under Medicare?
These are general starting points, not a recommendation to choose any particular test or treatment.
Short videos, under a minute
We make short, plain-English videos about AI in medicine, including what it can't do yet. Follow How Far for the next one.
Change history
- : First published.
General information only, not medical advice. Talk to your doctor about your situation. AI-assisted source check. Not clinically reviewed.
References
- CMS: WISeR (Wasteful and Inappropriate Service Reduction) Model. cms.gov. Official. https://www.cms.gov/priorities/innovation/innovation-models/wiser
Publisher shown as the website hosting each source. Dates are given where the source label includes them.