When Matthew Crooks, MD, interventional pain specialist in Phoenix, first heard about Medicare’s new prior authorization (PA) program, he was optimistic about its goal of reducing unnecessary care and controlling costs.
But nearly 3 months in, the reality is much different. Medicare has denied payment for any epidural steroid injections since the rollout, even for procedures with valid authorization numbers, Crooks said.
“This system is completely nonfunctional and unsustainable, and we have been given no guidance to navigate it,” Crooks said.
Many physicians and medical societies have reported delays, denials, and communication breakdowns since WISeR — the Wasteful and Inappropriate Service Reduction program — launched on January 1 in select states.
Now, a lawsuit against the Centers for Medicare & Medicaid Services (CMS) is underway.
Last week, the Electronic Frontier Foundation (EFF) filed a lawsuit seeking detailed information from CMS about how the program uses AI and third-party vendors for PA reviews, including financial incentives vendors receive and whether those could influence authorization decisions.
CMS did not respond to Medscape’s request for comment.
PAs for Select Services in Six States
WISeR marks a major change for traditional Medicare, which has historically allowed physicians to provide most covered services without authorization. The program applies to a subset of treatments — including nerve stimulators, epidural steroid injections, and some types of wound care — that CMS says may harm patients or involve fraud, waste, and abuse.
The pilot program, set to run through 2031, is now being tested in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It’s not clear whether the program will expand to more states or cover more treatments in the future.
Each state has been assigned a single contractor to review PA requests, and those vendors may use AI technology to automate parts of the process.
A spokesperson for Cohere Health, the WISeR vendor for Texas, told Medscape Medical News its technology is “never used to deny care but rather to automate approvals” for faster care decisions. More complex cases are reviewed by board-certified clinicians within 3 days, the spokesperson said.
Participation in WISeR is optional. Physicians can either submit PA requests through the program for the required services or have their claims routed for prepayment medical review. Providers who pursue the former can benefit by confirming coverage and payment upfront, and those with a strong track record of authorization approvals may earn a “gold card,” exempting them from future authorization and prepayment review requirements for some treatments.
‘Radical Change’ in Documentation
For Crooks, president of the Arizona Society of Interventional Pain Physicians, the program has been far from seamless. He said the authorization vendor and Medicare’s payment systems appear to not communicate well, with each side directing providers back to the other when claims are denied.
The result has been hundreds of delayed claims and a growing administrative burden that, he said, is affecting “every interventional pain practice I’ve spoken with in Arizona.”
“We initially saw wait times of 1-2 weeks to get an authorization decision, and denial rates of up to 30%-40%, even when Medicare Local Coverage Determination guidelines were being followed,” he said. Those rates have gradually improved as his practice adapted to a “radical change in documentation requirements,” which he said were necessary due to “AI being used to deny authorization.”
In some cases, they must now document that a patient’s primary care physician has been informed, as well as the specific type and dosage of medication planned for a future procedure, and “much, much more.” Despite these changes, he said some procedures are still denied for reasons that do not align with Medicare guidelines.
Arizona pain medicine physician William Thompson IV, MD, told Medscape Medical News some denials appear to reflect a “fundamental misunderstanding of the anatomy and technical aspects” of certain procedures.
At Northwest Endovascular Surgery in Richland, Washington, all authorization submissions since the program began have taken more than a week to generate a determination letter, well beyond the stated 3-day turnaround, Yasamin Alazawi, staff member who has been managing WISeR authorizations, told Medscape Medical News.
She said the office has had multiple claims denied, despite closely following CMS guidance and obtaining valid authorization numbers before submitting claims. “Because the claims are coded as ‘unprocessable,’ we have no right to appeal. No one can tell us what the error actually is,” she said.
Like Crooks, she described being caught between the vendor and the Medicare Administrative Contractor (MAC), with “no resolution in sight.” Alazawi estimated the practice’s staff has spent close to 100 hours navigating the portal, guidelines, and follow-up calls.
Concerns Grow Among Physician Groups
Several medical societies and physician groups told Medscape Medical News their members are experiencing similar delays and denials since WISeR’s launch.
Jason Jameson, MD, president of the Arizona Medical Association, said physicians are reporting more denials and longer wait times for peer-to-peer reviews, straining clinic resources and slowing access to care.
He’s also concerned about vendors’ use of AI, saying it should not replace physician judgment. Arizona, like many other states, has passed legislation limiting the role of AI in healthcare decisions, though Jameson said it does not apply to Medicare or Medicaid services.
In a March 26 letter to CMS, the Washington State Medical Association (WSMA) outlined similar issues affecting providers, including claims rejected despite valid authorization numbers, calling the situation “a systemic administrative disconnect…rather than a physician compliance issue.”
The state’s physicians have reported portal access issues, peer-to-peer scheduling delays, and inconsistent communication between vendors and MACs, said Jeb Shepard, WSMA’s director of policy, who noted “a real gulf in communication.”
The Society of Interventional Radiology raised concerns with CMS in September about WISeR’s proposed authorization requirements for vertebral augmentation. The organization said its members have voiced “overwhelmingly negative” since the program began, citing burdensome documentation requirements, vague criteria, unreliable technology, and minimal technical support.
Lawsuit: Calls for Transparency
Victoria Noble, JD, EFF staff attorney, told Medscape Medical News the WISeR model lacks transparency, which “increases the risk that unsafe uses will go unnoticed until it’s too late to protect people from harm.”
Earlier this year, EFF submitted a Freedom of Information Act request seeking records related to vendor payment agreements, algorithms, system testing, and data and privacy safeguards, but CMS has not provided them, according to the complaint.
Back in Arizona, Crooks said his group has begun warning Medicare patients about the delays.
“This is not in line with WISeR’s stated goal,” he said. “We have been trying to work through it, but as of now, our only choice is to inform our patients and ask that they reach out to their representatives.”
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