Digital advocacy org sues Medicare for access to AI model records

SAN FRANCISCO (CN) — A digital advocacy nonprofit sued the U.S. Centers for Medicare & Medicaid Services Wednesday for access to records regarding a multistate program that utilizes artificial intelligence to assess requests for medical care.

The Electronic Frontier Foundation filed for injunctive relief under the Freedom of Information Act in the Northern District of California federal court after a Jan. 29 request to find out more about a program called WISeR, or Wasteful and Inappropriate Service Reduction, because “there is little information about how the AI algorithms used in WISeR model work, including what training data they rely on," was not answered by the federal agency.

“Health care experts, care providers, and lawmakers have raised alarm that the model may cause serious harm to patients by relying on AI to make important coverage decisions, potentially without the safeguards necessary to do so safely,” the foundation said in its complaint.  “Despite this widespread criticism, the model has been used in six states since Jan. 1, 2026.”

Arizona, Oklahoma, Ohio, New Jersey, Texas and Washington are currently the states where WISeR will be used for six years.

The foundation said the program uses AI to evaluate prior authorization requests from Medicare beneficiaries, but it’s unclear “whether this program includes meaningful safeguards against algorithmic bias, privacy violations, and wrongful denials of care.”

The program, announced last year by CMS Administrator Dr. Mehmet Oz, sidesteps advance approval from health insurers that was previously necessary as a condition of coverage in prior authorizations by medical providers before treating patients.

According to the foundation, CMS has not responded to its request for records and exceeded two deadlines to respond to the request, including one for expedited processing, “because of the urgent need to inform the public about the serious risks of AI-driven prior authorization determinations.”

“The public has a right to know more about the algorithms driving decisions around their healthcare,” Tori Noble, staff attorney at EFF, said in a statement. “Without greater transparency, patients, providers, and policymakers will continue to be left in the dark.”

Additionally, the WISeR model’s prior authorization decisions often result in delays or denials of care, the foundation said, which can sometimes be classified as discriminatory or “inappropriate” denials for medical care.

“The WISeR model also creates perverse financial incentives for contracted companies to deny prior approval against the best interests of patients,” the EFF said. “Vendors are compensated, in part, on the volume of healthcare services they deny; they are entitled to as much as 20% of the associated savings.”

Noble said in an email to Courthouse News that the agency did not provide a reason for the delay in access to the records, and the delay “unduly impedes the public’s right to know.”

The CMS information page about WISeR on its website says the model “helps reduce clinically unsupported care by working with companies experienced in using enhanced technologies to expedite and improve the review process for a pre-selected set of services that are vulnerable to fraud, waste and abuse.”

It lists Cohere Health Inc., Genzeon Corporation, Humata Health Inc., Innovaccer Inc., Virtix Health LLC and Zyter Inc. as model participants.

CMS declined to comment on pending litigation.