AI Will Now Determine if Medicare Covers This Care

Access to healthcare is critical for retirees who often begin to develop age-related health issues. Medicare provides coverage for many older Americans, and while it has some significant coverage limitations and requires high out-of-pocket coinsurance costs, it also has some major benefits for retirees.

Traditionally, one of those benefits has been that preapproval isn’t typically required for Medicare services. However, that’s changing this year. Medicare is introducing new preapproval requirements in a pilot program that uses artificial intelligence (AI) to help determine if care should be authorized. If it’s viewed as successful, this pilot program could potentially lead to more restrictions on care without prior approval.

Unfortunately, not everyone is thrilled about the new limitations, and some points of potential concern relate to the fact that AI will be involved.

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Medicare is imposing preapproval requirements on these services

The new pilot program will run in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. The program is called the WISeR Model, which stands for Wasteful and Inappropriate Services Reduction, because it restricts access to 17 services considered to be presumptively “wasteful.”

The 17 services that will require preauthorization under the program include:

• Phrenic nerve stimulator
• Percutaneous image-guided lumbar decompression for spinal stenosis
• Electrical nerve stimulators
• Sacral nerve stimulation for urinary incontinence
• Deep brain stimulation for essential tremor and Parkinson’s disease
• Vagus nerve stimulation
• Surgically induced lesions of nerve tracts
• Hypoglossal nerve stimulation for obstructive sleep apnea
• Application of bioengineered skin substitutes to chronic non-healing wounds on lower limbs
• Epidural steroid injections for pain management (excluding facet joint injections)
• Percutaneous vertebral augmentation
• Cervical fusion surgery
• Arthroscopic lavage and arthroscopic debridement for the knees of people with osteoarthritis
• Incontinence control devices
• Diagnosis and treatment of impotence
• Skin and tissue substitutes
• Wound application of cellular/tissue-based products for lower limbs

The program began in January, so anyone using these services currently must get preapproval, which will involve an AI-assisted review process.

AI will help determine if Medicare beneficiaries can get care

Some advocates have expressed concern about how new preapproval requirements will affect the ability of Medicare beneficiaries to get essential care.

While the government may view these treatments as wasteful, retirees who have been taking advantage of these services probably don’t. Those seniors may have to choose between forgoing the care they need or paying out of pocket from their retirement plans.

Unfortunately, advocates are also concerned about how preapproval decisions will be made, as AI will play a critical role during the review process. While the “final decision” will be made by a human, according to CMS, “the WISeR Model tests the use of enhanced technology to decrease certain wasteful (low-value) services shown to have little to no clinical, evidence-based benefit. Technology companies participating in the model help streamline the review of medical necessity for select items and services…”

In other words, a key part of the goal is to test how AI and machine learning can be used to try to fight waste, fraud, and abuse. If the pilot program helps Medicare save money, it will likely expand – and if the government feels AI worked effectively, it’s likely to play an even larger role in later models. And those who don’t necessarily want a machine making choices about their medical care may not be very happy about that outcome.