Medicare AI Prior Authorization Program Delays Care for Seniors

A Medicare program using artificial intelligence to review medical procedures before approval has left patients waiting months for pain relief, according to doctors and lawmakers in Washington state who are now demanding the initiative be overhauled or eliminated.

The Wasteful and Inappropriate Services Reduction program, known as WISeR, launched in January 2026 across Washington and five other states. The Centers for Medicare and Medicaid Services designed the program to reduce unnecessary medical treatments by requiring prior authorization for more than a dozen procedures treating back pain, neck pain, arthritis, and incontinence.

Why it matters

This represents one of the first large-scale deployments of AI in Medicare coverage decisions, directly affecting when and whether seniors can access treatments their physicians recommend. The program's structure—which routes approvals through a third-party tech vendor that profits from denials—raises fundamental questions about how AI should be integrated into healthcare gatekeeping, especially when delays translate to extended suffering for elderly patients.

How the system works

Under WISeR, physicians must obtain approval from Virtix Health, a third-party technology company, before performing covered procedures. Previously, doctors could schedule treatments immediately and bill Medicare afterward. Now they risk non-payment if they proceed without authorization. Virtix receives a percentage of the money it saves Medicare through its review process.

Rep. Suzan DelBene announced at a Monday news conference at the University of Washington Medical Center that she has sponsored legislation to roll back the program. "Congress and the public deserve a full understanding of the impact this program is having on our seniors and our health care system," she said.

Patient experiences

Richard Badalamente, 88, has managed chronic back pain with epidural steroid injections since 2014, typically experiencing two years of relief per treatment. When his pain returned in February, his doctor submitted a request to Virtix. The request was denied, triggering an appeals process that stretched over two months.

During that period, Badalamente's condition deteriorated. He progressed from using a cane to two canes to a walker, while taking maximum doses of Tylenol and using pain patches. As primary caretaker for his wife Patricia, the delay affected his ability to provide care. He finally received the injection in late April.

Keith Magnuson, another patient facing similar delays for back pain treatment, ultimately paid out of pocket rather than continue waiting for approval. He received his procedure in April and is now pain-free.

Clinical pushback

Dr. Maheetha Bharadwaj, a urology resident at the University of Washington, described treating patients with overactive bladders who were denied sacral nerve stimulation—a treatment that significantly reduces daily incontinence episodes. "I don't want some AI program determining whether my patient, who is crying in front of me because she has several incontinence episodes a day, deserves a sacral nerve stimulator or not," she said.

Dr. Chris McMullen, who specializes in sports medicine and spine care at UW, reported that the program has overridden clinical judgments of multiple physicians. "We're seeing longer approval times, blanket denials and growing administrative burdens on physicians and staff," he said. "Most importantly, we see patients left waiting in pain."

The appeals process requires additional paperwork, further patient evaluations, and sometimes peer-to-peer phone reviews where doctors must justify their treatment decisions to Virtix-employed physicians.

Regulatory questions

In May, the Government Accountability Office determined that CMS should have submitted WISeR to Congress for review before implementation, which would have allowed lawmakers an opportunity to block it. CMS told The Seattle Times earlier this year that it was monitoring the program's performance and would take "corrective action" if it created inappropriate barriers to care. The agency did not respond to recent requests for comment.

Virtix stated in an email Monday that it issues decisions within "a few days," attributing delays to incomplete documentation from physicians or slow appeals submissions.

These details were first reported by Jessica Fu at The Seattle Times.