📋 AI Prior Authorization Pilot Hits Original Medicare (AARP Article)

[SummerOnTheWay1]

FROM THE ARTICLE.

Original Medicare Tests Coverage

Preapprovals With an AI Twist.

Millions of beneficiaries in 6 states need artificial intelligence’s OK for 13 devices and procedures.

By Tony Pugh, AARP. Published February 19, 2026.

➡️[*** Key takeaways!

(1) 6.4 million people on Medicare are part of pilot program.

(2) 13 services in 6 states now have to pass an AI test.

(3) AARP opposes the preapprovals. Murky procedures prompt it.

(4) Medicare Advantage struggles with prior authorization.

(5) Some favor more accountability in original Medicare.

An estimated 6.4 million beneficiaries in six states now need approval before original Medicare will pay for certain equipment, services and supplies that their doctors recommend.

AARP and other groups are concerned that beneficiaries’ care could be delayed, denied or unduly influenced by technology-assisted coverage decisions in a pilot program that applies to nearly 1 in 5 original Medicare beneficiaries nationwide, according to estimates from McDermott+, a Washington, D.C.-based health care consulting firm.

USE LINK BELOW TO READ THE ARTICLE.

https://www.aarp.org/medicare/original-medicare-ai-prior-authorization-pilot/

[GailL1]

Personally, I think this is a good thing since we do need to start saving medical cost for things that are of LOW value to the patient or things that are of NO value to the patient.  

CMS is also modifying their guidelines when they find things that need to be changed.  Like this:

CMS.gov -Fact Sheets Dec 24, 2025 Final Local Coverage Determinations (LCDs) for Certain Skin Substi... 

Any AI recommendation is reviewed by a real person before any action is taken.

[SummerOnTheWay1]

📎  [2/23/26] Gail @GailL1 , my concern is that someone is going to "hack" into all this. And with all the "funding" issues doubt EVERYTHING produced by AI will be "reviewed" by someone who knows what they are doing. Geez, what's next. My Medicare Doctor will be some "robot" in the future. Nope, I luv my humans. Machines make mistakes. And yes humans do too. Lol, but I rather take my chances on a human.

Glad you stopped by,

Nicole 💛

[GailL1]

@SummerOnTheWay1 

You would be given your review by a human.  AI is there just to catch the parameters of the authorization for review.  If there is then a recommendation of denial, a human must review it before the denial is issued.

But even at that, your doc or even you can then appeal the decision.  

Understand that these prior approvals are only for a specific number of procedures - the ones that have been discovered to be low value to the patient or even no value to the patient.  And if found otherwise - CMS changes the rule.

The only reason that we may someday not have a human provider is because there are none available.  Yep, could happen - we need lots more personal care physicians, internist, family medicine physicians, even GYNs.  Other, more lucrative, specialties in medicine, slots are being filled but PCP’s not so much.  So we may get PA’s to file in and actually already have in many places.

[CBtoo · Accepted solution]

The human doing the review though is likely to be an RN and I trust the review of an MD who is a specialist in what is going on far more than an RN or any random non-specialist in that specialty MD. 

I would suspect this will have the same problems that advantage plans have which is high rejection rate and the decision is made in 30 seconds or less (and yes the humans have unrealistic quotas at most companies for how many cases to review in an hour).