The RFK Jr. Medicare AI Program Already Denying Seniors Care in 6 States

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A 72-year-old in Phoenix needs a spinal cord stimulator for chronic back pain. Her surgeon orders the procedure. Before scheduling, the request now routes through an artificial intelligence vendor under contract with Medicare, which can recommend denial. Six months ago, that step did not exist in Original Medicare. Today it does, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

If you are on Original Medicare in one of those states, this article is for you. If you live anywhere else, or you are on a Medicare Advantage plan, the mechanic described here does not change your coverage.

What WISeR Actually Does

The Wasteful and Inappropriate Service Reduction Model, known as WISeR, launched on January 1, 2026 as a six-year pilot run by the Center for Medicare and Medicaid Innovation. It applies AI-driven prior authorization to a defined list of procedures in fee-for-service Medicare. Senator Maria Cantwell has publicly warned HHS Secretary Robert F. Kennedy Jr. that the program is delaying and denying procedures for seniors in the six pilot states.

The list of services subject to AI review includes skin and tissue substitutes, implantation of electrical nerve stimulators, sacral nerve stimulation for urinary incontinence, and certain knee arthroscopy procedures, among roughly a dozen others. Most are surgical, expensive, and not easily substituted.

Here is the part most beneficiaries miss. The outside vendors running the AI reviews are paid based in part on the savings they generate for Medicare. A denial is revenue for the contractor. That structure is the reason advocacy groups and physicians in all six states have reported approval rates lower than what beneficiaries see in Medicare Advantage, and turnaround times that in some cases exceed federal deadlines.

Why This Hits Original Medicare Enrollees Hardest

Many seniors picked Original Medicare specifically to avoid the prior authorization friction that defines Medicare Advantage. WISeR imports that friction into the program they paid extra for a Medigap policy to keep clean.

The financial mechanic is straightforward. If the AI vendor denies a procedure your physician recommends, you face three options. Proceed and pay the full cash price out of pocket. Appeal and wait, sometimes weeks, while your condition progresses. Or accept a substitute treatment the model approves, which may not be what your doctor wanted to do.

The dollars are real. A spinal cord stimulator runs $30,000 to $50,000 fully loaded. A course of skin substitute treatment for a chronic wound can exceed $25,000. Without Medicare coverage, those move from a $283 Part B deductible plus 20% coinsurance to the entire sticker price.

Background context matters too. Part B premiums already rose to $202.90 a month in 2026, up $17.90 from $185.00 in 2025. The 2026 Social Security cost-of-living adjustment is 2.8%, which does not cover that premium hike for most retirees. Adding denied procedures on top of that squeeze is what makes WISeR a household-budget event with real consequences for monthly cash flow.

What To Do If You Are in a Pilot State

Three concrete actions, in order of priority.

One. Confirm the prior authorization status before scheduling any procedure on the WISeR list. Ask your physician’s billing office whether the procedure code falls under WISeR and whether authorization has been submitted, approved, or denied. Do not let the surgery date be the first time you hear the word denial.

Two. If denied, file a Level 1 redetermination immediately. Original Medicare’s appeals process has five levels. You have 120 days from the denial notice to request redetermination by the Medicare Administrative Contractor. Roughly half of Medicare appeals at the higher levels succeed when beneficiaries push them through. Your physician’s office can submit the clinical documentation; you sign the request.

Three. Report the denial to your senator’s office and your state insurance commissioner. WISeR is a pilot. Pilots are politically reversible when constituent complaints accumulate. Cantwell’s pressure campaign on HHS has already pulled congressional attention to specific denials. Documented cases move policy faster than aggregate statistics.

If your procedure is not on the WISeR list, or you live in one of the 44 states outside the pilot, your Original Medicare coverage works exactly as it did in December. The trap is geographic and procedural, limited to specific states and procedure codes. Know which side of it you are on.

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