About 1,000 pages of federal records show that vendors in Medicare's assisted prior authorization pilot often missed the program's 72-hour response goal during its first months. According to one internal status report, a request went unanswered for 83 days.
The Electronic Frontier Foundation (EFF), which sued the Centers for Medicare & Medicaid Services (CMS) in March under the Freedom of Information Act, published the records on Sept. 8. The documents include contracts with technology companies, internal status reports, and provider complaints about the Wasteful and Inappropriate Service Reduction (WISeR) model. The pilot began in January in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
Under WISeR, private companies hired by CMS use artificial intelligence to help evaluate prior authorization requests for certain services in Original Medicare. CMS says a qualified human clinician must review all denials. The services on the list include epidural steroid injections, implanted nerve stimulators, and vertebral augmentation. For Original Medicare patients in the six states, the records add documentation to complaints that had largely been anecdotal.
What Clinicians Told CMS
Some of the most detailed material comes from March 2026 responses to a feedback form about Innovaccer, the vendor handling requests in Ohio. Providers complained about poor communication, administrative problems, and long waits.
One respondent wrote that patients were "calling our offices crying in pain" because procedures were delayed while approvals were pending. Another described watching three patients cry at the bedside while waiting to hear back about a kyphoplasty procedure. A third reported waiting more than a month and a half for a tracking number to be generated while patients' surgeries were canceled.
These are provider accounts submitted to CMS, not verified medical records, and they describe one vendor in one state. They are consistent with other reports of Medicare patients left waiting in pain for approvals.
Delays, Denials, and Payment Rules in the Records
CMS says in its WISeR frequently asked questions that vendors should respond to prior authorization requests within 72 hours. Internal status reports from the program's first months show vendors missed that window for a significant number of requests. Timeliness data for two vendors in January 2026 show the same pattern.
Two companies together denied more than 20,000 prior authorization requests in the program's first three months, according to the records. One of them, Virtix, which CMS required to submit a corrective action plan, denied more requests than it approved during that period.
Those figures come from two vendors over a set period, so they cannot be read as a program-wide denial rate. Some denials may also be reversed on appeal.
The records also confirm how vendors are paid. They are paid for requests they deny, but not for denials that are reversed on appeal. CMS has said it guards against inappropriate denials by tying payment to quality scores that reflect timeliness and accuracy. However, the WISeR Data Reporting Guide included in the release shows that low quality scores reduce payments by only 5% to 10%.
What the Records Add and What They Leave Open
About a month before launch, Innovaccer told CMS it planned to go live with software that lacked full functionality and had not been fully tested. The company cited changing requirements, unclear governance processes, and a lack of time for end-to-end testing with providers. It said it would automatically approve all requests until the full system was ready, since CMS had decided not to delay the start date. An April 2026 status report shows that some features were still unfinished months into the program.
When MedicalDaily published its guide to the WISeR pilot in July, the known facts were mostly structural: the six states, the types of procedures, and expected decision times of about 72 hours for standard requests and 48 hours for expedited ones. CMS Innovation Center leader Abe Sutton had said contractors are rewarded for getting "the determination right,"not for denying claims. The new records add performance data and a vendor's own warning that its system was not ready.
The records do not show any change in Medicare coverage rules. CMS has said covered services remain covered, and providers keep their existing appeal rights. The problems described involve timing and process, not eligibility.
Major questions remain. Little is known about the AI systems vendors use. EFF's request sought records on testing for accuracy, bias, and hallucinations, along with audits and evaluations of the vendors. The organization says CMS is still producing documents in the EFF lawsuit.
The release also includes a June 2025 planning document that lists services that could be added in future years. Among them are services that would require faster prior authorization decisions, such as air ambulance transport, cancer treatment, MRI scans, and medications without publicly available coverage criteria. The document lists possibilities, not decisions.
Steps for Patients in the Six Pilot States
Patients should not delay or decline recommended care while an authorization is pending without talking with their clinician first. A pending decision is an administrative status, not a medical instruction.
Call the office that scheduled the procedure and ask three questions: whether the procedure is on the WISeR list, whether a request was submitted and on what date, and whether a decision has been made or the claim is going through prepayment review instead. Ask for the reason behind any denial, since a documentation problem can often be fixed, and ask whether the practice plans to resubmit or appeal.
Expedited review is available for urgent situations. Patients whose symptoms are getting worse while they wait should tell the practice directly. Keeping a written record of dates, names, and reference numbers can make an appeal easier.
The pilot is scheduled to run through 2031. Some members of Congress have asked House appropriators to block the model in the fiscal 2027 spending bill. MedicalDaily will report on further document releases.
Key Questions Answered
What do the new records show? They show that WISeR vendors missed the 72-hour response goal for a significant number of requests, that one request went unanswered for 83 days, and that one vendor warned CMS before launch that its software had not been fully tested.
Which states are affected? Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The pilot applies to Original Medicare, not Medicare Advantage.
Did Medicare coverage rules change? No. CMS has said covered services remain covered, and appeal rights are unchanged. The problems in the records involve timing and process.
How many denials were recorded? Two vendors together denied more than 20,000 requests in the first three months. One of them, Virtix, denied more requests than it approved.
Are vendors paid for denials? Yes. The records confirm vendors are paid for requests they deny, except for denials reversed on appeal. Low quality scores reduce payments by only 5% to 10%.
What should a patient do if a procedure is delayed? Ask the practice whether a request was submitted and when, what reason was given for any denial, and whether it will resubmit or appeal. Report worsening symptoms, since expedited review is available.
Could more services be added? A June 2025 planning document lists possibilities, including air ambulance transport, cancer treatment, and MRI scans. The document is a list of ideas, not a decision.
