EFF publishes more than 800 pages of Medicare WISeR records

The Electronic Frontier Foundation released more than 800 pages of documents on Oct. 27, 2026 concerning Medicare’s WISeR prior-authorization program in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.p

The records came from a lawsuit EFF filed against the government in March 2026 concerning the Wasteful and Inappropriate Service Reduction model, WISeR’s formal name. About six months after announcing it, CMS launched WISeR despite provider calls to delay the rollout. The program began Jan. 1, 2026, and is scheduled to run through 2031. It potentially affects roughly 6.4 million people with Original Medicare.p

The release includes CMS requests for information and corrective action plans sent to four of six WISeR vendors, along with vendor responses, applications from 66 companies including the six selected firms, and task orders and contracts for evaluating, implementing or monitoring the program. CMS sent those requests to at least four of six vendors in the program’s first three months, and the rollout problems extended beyond one vendor or one state.p

More than 20,000 prior authorization requests were rejected by two vendors in the program’s first three months. Two vendors denied or non-affirmed 5,944 requests during the program’s first three months, according to roughly 1,000 pages of released records. Virtix turned down more requests than it approved in the program’s opening three months. One prior authorization request sat unanswered for 83 days.p

CMS’s standard is that vendors respond to requests within 72 hours. After receiving a request, vendors have three calendar days to reach a decision. The program also offers expedited review for urgent situations, generally due within two calendar days. Internal status reports show vendors fell outside the 72-hour window on a significant number of requests.p

CMS asked Virtix about slow turnaround times, inaccurate or inconsistent denials and inadequate customer service. CMS told Zyter, which relies on Palantir software, that reports showed untimely determination letters and weak escalation processes when providers raised concerns. Innovaccer received two corrective action plan requests and a noncompliance notice from CMS over an incomplete provider portal. Months before launch, Innovaccer told CMS it might not be ready, and about a month before launch it said its untested, incomplete software was planned to go live.p

Until the full system was ready, Innovaccer said it would approve requests automatically because the agency would not delay the start date. Some Innovaccer features were still unfinished months into the program, according to an April 2026 status report.p

Zyter acknowledged a payment backlog from April stretching to January, while the agency said it was resolving the backlogs. Earlier in 2026, nearly 100 University of Washington patients waited for epidurals because of WISeR delays. Doctors believe AI is behind many denials, including errors from AI hallucinations.p

Vendors are paid for denied requests, but not when denials are reversed on appeal. Vendors may collect up to 20 percent of the savings from care their reviews avoid, and low quality scores cut payments by only 5 percent to 10 percent.p

CMS requires that a human clinician review every non-affirmation; technology alone cannot make that call. At one company, reviewers could reject claims without opening patient files, spending an average of 1.2 seconds per case. EFF says the public cannot assess clinician review as meaningful oversight of WISeR AI systems.p

Vendor applications cite data sources including provider behavior and patient demographics along with historical claims data. CMS guidance cautions against coverage algorithms built on larger data sets instead of individual patient circumstances. A planning document from June 2025 lists possible future services such as air ambulance transport, cancer treatment or MRI scans.p

House appropriators were asked by some members of Congress to block WISeR in the fiscal 2027 spending bill. Some physicians say WISeR could expand prior authorization to basically all procedures if it saves money. CMS said it is not currently considering changes to the WISeR service list, though it continues to assess them. CMS leadership said prior authorization is not meant to deny care.p

Covered services include epidural steroid injections, nerve stimulators and vertebral augmentation, along with cervical fusion, knee procedures, skin substitutes and kyphoplasty. A January KFF poll found that prior authorization is considered a burden by 69 percent of insured adults. A 2025 survey found that AI tools are already used by 84 percent of commercial insurers. Spending on skin substitutes surged nearly 700 percent over two years, the Health and Human Services inspector general warned in September.p

Patients can ask whether a procedure is on the WISeR list, when a request was submitted and whether a decision was made. Patients should not delay or decline recommended care while waiting for an authorization without consulting a clinician. Cost sharing stays normal after approval, including any unpaid part of the 2026 Part B deductible of $283.p

At the non-affirmation stage, a non-affirmation counts as a pre-service decision while the standard Medicare appeals process remains closed. Providers can resubmit requests, add medical records or request peer-to-peer reviews with vendor doctors. An Advance Beneficiary Notice asks if the patient wants to proceed while noting Medicare may not pay.p

EFF argues AI has no place in consequential government decisions about rights or access to benefits. EFF says WISeR endangers seniors’ access to medical care because decisions shift to private AI firms that lack sufficient transparency, testing or legal limits. EFF urges Congress to put tougher legal limits on automated decision-making in Medicare. EFF says the WISeR payment structure pushes vendors to reject as many claims as they can.p