Medscape December 23, 2025
Medicare will significantly expand the use of prior authorization (PA) and post-service review for select services beginning next year, and private contractors will be permitted to use artificial intelligence (AI) and machine learning to make coverage determinations, according to the Centers for Medicare & Medicaid Services (CMS).
The change stems from the agency’s new Wasteful and Inappropriate Service Reduction (WISeR) Model, a pilot program designed to curb fraud, waste, and abuse associated with certain “low-value services,” such as nerve stimulators and steroid injections for pain management.
PA requirements have long been routine in Medicare Advantage, with nearly 50 million determinations in 2023, according to KFF. In contrast, Medicare had about 400,000 determinations that same year, reflecting the more limited...
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