The government is piloting AI for insurance-coverage decisions through the WISe R program in six states, aiming to reduce wasteful spending in original Medicare. Prior authorization—insurer pre-approval for recommended care—often delays treatment, with a 2025 AMA survey showing 61 percent of physicians fear AI will worsen wrongful denials. Medicare Advantage plans, covering 55 percent of eligible seniors, issue millions of denials annually.

A Commonwealth Fund survey found roughly one in five American working-age adults with private insurance faced coverage denials for physician-recommended care in 2025, with 41 percent reporting delayed care and over a quarter saying their health worsened. The Biden administration's 2024 rule mandated 72-hour decisions for urgent requests and seven days for non-urgent ones, effective Jan. 1 for most public plans.

The Trump administration's WISe R model, running through December 2031, uses machine learning and human review to target services like skin substitutes and knee arthroscopy. Critics, including former Cigna executive Wendell Potter and researcher Zena Wolf, cite investigations showing care delays and denials in pilot states. Vendors earn a share of "averted expenditures," creating profit incentives for denials.

Lawmakers have introduced measures to block WISe R funding, citing patient access threats. Meanwhile, CMS Administrator Mehmet Oz has warned private insurers to ease prior authorization burdens or face federal regulation, prompting some compliance data releases.