CMS Just Gave Medicare Prior Auth to an Algorithm. We Should Pay Attention.

The WISeR Model is live. As of January, CMS is running AI-assisted prior authorization in six states for three procedure categories: skin substitutes, nerve stimulator implants, and knee arthroscopy for osteoarthritis. The agency promises 72 hour coverage decisions and appropriately licensed clinician review on every denial. Here's the part worth watching: CMS plans to pilot a “goldcarding” feature by mid-2026 exempting providers with consistent approval histories from future prior auth requirements entirely. That's a genuinely interesting incentive design. Reward clean practice patterns and remove friction for the providers who don't need oversight. The tension is structural. AI-assisted prior auth is either a precision tool for reducing low-value care or a scalable mechanism for denying claims faster. The answer depends entirely on implementation, transparency, and whether "evidence-based" means the same thing to CMS's algorithm as it does to the surgeon holding the scalpel. Six states. Six years. Three procedure categories. This is how policy experiments begin.

What procedure categories do you think CMS adds next? I'd put money on imaging.