September 25, 2025

Beginning January 1st, 2026, CMS is starting a 6-year pilot project called the Wasteful and Inappropriate Service Reduction (WISeR) Model in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington State). Information can be found at https://www.cms.gov/newsroom/press-releases/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare. Under this pilot project, certain outpatient services that are thought to be prone to fraud, waste, or low clinical value will require prior authorization using artificial intelligence (AI). This would apply to traditional Medicare beneficiaries only. Currently, no mental health conditions or procedures are included in this pilot. The Prior Approval Pilot is a small example of how AI can affect our practices in ways that may be harmful to our patients and best practices.

Many members of CSWA have reached out to express concern about how this pilot project may have an impact on coverage of mental health treatment. The project will require prior approval for 17 conditions before coverage is accepted. CMS has also stated that any denials identified by AI will then be reviewed by a human. To be clear, there are NO mental health services on this list at this time, but the possibility that our services may be added is cause for concern. CSWA is providing the following information to make LCSWs aware of the way this project could affect psychotherapy, not as an imminent threat to our practices.

Prior Approval Pilot Project

The project will begin on January 1, 2026 and be applied to conditions covered by traditional Medicare only in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington State, as well as Medigap plans, such as Plan G or Plan N, if they are using traditional Medicare coverage.

The conditions that will be governed by the project include the following:

• Facet joint procedures for back pain
• Nerve and muscle tests (electrodiagnostic testing)
• TENS units and similar electrical stimulation devices
• Hyperbaric oxygen therapy
• Spinal cord stimulators
• Deep brain stimulation (commonly for Parkinson’s)
• Sacral neuromodulation (for urinary conditions)
• Transcatheter aortic valve replacement (TAVR)
• Arthroscopic knee cleaning or debridement
• Vertebroplasty/kyphoplasty for spine fractures
• Epidural steroid injections
• Non-emergency ambulance transport
• Botox injections for medical issues
• Negative pressure wound therapy pumps
• Hernia repairs
• Lumbar spinal fusion
• Skin graft substitutes for chronic wounds

The stated reason for inclusion on this list is that these services are often flagged for being overused and/or not always medically necessary (https://www.resourcemedicare.com/post/new-medicare-changes-in-2026-prior-approval-required-for-these-17-services).

CSWA has been studying the impact of AI on the work of LCSWs for the past year and stands firmly against the use of AI or large language models as an LCSW providing therapy, diagnoses, or mental health treatment. The Prior Approval Pilot is a small example of how AI can affect our practices in ways that may be harmful to our patients and best practices.

The pilot project uses AI to identify diagnoses and streamline the prior authorization process, reflecting insurers’ long-standing goal of expanding prior approval whenever possible. Minimizing approval of mental health treatment, and many other conditions, is seen as reducing costs for insurers. Here is a summary from the New York Times about this project:

“…The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections. The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence…The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused.” (New York Times, “Medicare will Require Prior Approval for Certain Procedures,” 8/28/25, https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.html?smid=nytcore-ios-share&referringSource=articleShare) .

If this approach is extended to mental health conditions, this type of prior approval approach could have a serious impact on patients having access to mental health/substance use treatment.

CSWA encourages members in the Pilot states, and all others, to send the following message to their members of Congress and Insurance Commissioners: “I am a licensed clinical social worker, a constituent, and a member of the Clinical Social Work Association. I have concerns about letting artificial-intelligence (AI) systems make prior-authorization decisions for a particular procedure or therapy is likely to limit a person’s access to needed treatment. In mental health, for example, LCSWs use interactive engagement to expertly assess an individual’s responses and affect, in ways AI cannot. Currently AI cannot reliably understand emotional health, because it cannot determine and interpret facial expressions, body language, and words. Please leave treatment decisions to licensed professionals, not to AI, in the Prior Approval Project.” You can find emails for Congress at https://www.congress.gov/contact-us .

As always, please let Laura Groshong, LICSW, CSWA Director of Policy and Practice, know when you have sent your messages at lwgroshong@clinicalsocialworkassociation.org.