WA patients agonize as Medicare AI program continues to delay care

In early February, Michael Edgerly's doctor recommended that he get an epidural steroid injection.

Edgerly has degenerative disc disease and scoliosis, and suffers from low back pain. Over the past few months, the pain worsened to the point where he couldn't walk without a walking stick, and then a walker. Life contracted. Edgerly struggled to exercise, to do housework, to see friends.

It was depressing," he said in a phone call from his home in Cle Elum, Kittitas County, on Wednesday.

An epidural steroid injection is a common first-line treatment for low back pain. But in early March, Edgerly discovered that he'd been denied the procedure, despite it being covered by his traditional Medicare insurance.

Across Washington, Medicare patients are facing denials and delays getting treatment for back pain just like Edgerly.

In January, Medicare launched a pilot program that requires doctors to get approval from a third-party contractor using artificial intelligence technology before they can provide certain types of medical care. Epidural steroid injections are one of the procedures included in the pilot, which is being tested in Washington and five other states.

The time needed to complete certain procedures is now up to four times longer compared with before the implementation of the pilot, according to a new report citing hospital data.

Less than four months into the pilot's launch, lawmakers are demanding change.

During a series of congressional hearings over the past two weeks, Washington lawmakers questioned Secretary of Health and Human Services Robert F. Kennedy Jr. about the program's unintended consequences.

"What's happening is AI is being used as a denial device," said Democratic Sen. Maria Cantwell at a Senate Finance Committee hearing on Wednesday, citing Seattle Times reporting on the Medicare pilot program. "We have hospitals calling me about this, I have doctors calling me about this, I have patients calling me about this."

'Not the hospitals' fault'

The pilot program is called the "Wasteful and Inappropriate Service Reduction" - or "WISeR" for short - and is intended to save Medicare money by limiting unproven or unnecessary medical procedures.

But doctors and patients in Washington say that WISeR is issuing wrongful denials, creating barriers to care and prolonging pain for those who need certain types of treatment.

Medicare patients across the state, from Edmonds to the Olympic Peninsula to Yakima have shared stories with The Seattle Times detailing WISeR denials that take time and effort to overturn.

Cantwell called on Kennedy to shore up program oversight, including by speeding up response times and mandating that all denials come with an explanation written by a human.

The Centers for Medicare and Medicaid Services, which administers Medicare, said that it would make changes to the pilot if necessary, including by taking corrective action in response to inappropriate barriers to access.

"CMS is closely monitoring implementation in real time, including turnaround times, system performance, and denial patterns, and is actively addressing issues as they arise," a spokesperson wrote to The Seattle Times on Friday. "CMS does not have evidence of inappropriate denials currently."

In its response, the agency also addressed epidural steroid injections specifically.

"WISeR includes services such as epidural steroid injections because the clinical evidence shows that, while these procedures may offer short-term relief for certain patients, they also carry meaningful risks that can outweigh their benefits and are often overused in ways that do not improve long-term outcomes," the spokesperson wrote.

In Washington, the company contracted to administer the pilot program is a Phoenix-based tech firm called Virtix Health. Little information is publicly available about the company. Under WISeR, Virtix receives a portion of the money that it helps Medicare save.

Since the program launched, doctors' offices and patients have reported waiting through longer-than-standard response times from Virtix.

Virtix is supposed to either approve or deny a procedure within three days for standard requests, or within 24 hours for urgent requests.

In an email on Friday, Virtix acknowledged long turnaround times during the pilot's initial weeks, but disputed that the issue persists.

"That has improved significantly," the email read, adding that the company is currently meeting target turnaround times.

But staff at doctors' offices say they're still waiting. Three medical systems representing hospitals across Washington reported approval times are taking between 15 and 20 days, according to an April survey conducted by the Washington State Hospital Association. Cantwell's office shared the findings in a report on WISeR published this week.

"Hospitals are getting more patient complaints related to the delays and it's really not the hospitals' fault," said Jennifer Brackeen, senior director of government affairs at WSHA. "We're just trying to follow the rules."

'I'm not giving up'

Some Washington lawmakers are seeking an end to this pilot program.

"It is still critically important that Congress passes legislation to make it clear that the administration can't continue moving forward with this program," said Rep. Suzan DelBene, D-Medina, who sponsored a bill last November aimed to prohibit the pilot's launch.

Historically, traditional Medicare has not required patients to get prior authorization, a process through which a medical procedure must get insurer approval before a patient can get treated and a doctor paid.

DelBene warned that the WISeR pilot program could eventually lead to broadened prior authorization requirements across traditional Medicare.

That could mean more delays and denials.

Under the pilot, Medicare patients in Washington are now waiting two to four times longer for certain medical services than before, according to WSHA survey data.

Procedures that might typically take two weeks to complete now take up to eight since the launch of the pilot program, the organization reported based on hospital surveys.

That extended timeline is due to all the additional steps that a hospital or doctor's office might now have to go through, said Brackeen, such as submitting an approval request, waiting for a response, receiving a denial, requesting an appeal, coordinating a case review, obtaining additional documentation.

Those extra steps contributed to the extended wait that Edgerly of Cle Elum had to endure.

After the initial denial, Edgerly's doctor had to file an appeal. In late March, Edgerly's wife Carel called Virtix directly to inquire about his case. She was told that it was on track for approval. Edgerly was finally able to get the shot on March 30.

By then, seven weeks had passed since his doctor first recommended it. During that time, he'd became isolated from his friends and felt his muscles atrophy from inactivity.

"I really don't want AI deciding my medical care, Carel said. The couple pays around $400 per month in Medicare premiums.

The procedure didn't used to take this long to schedule.

Just last year, Edgerly had gotten the very same procedure. In late May, his doctor recommended an epidural steroid injection for low back pain. Two weeks later, he'd gotten the shot and felt significant pain relief for about three months.

Today, Edgerly is feeling much improved compared with how he felt before getting the shot on March 30.

He's trying to regain the strength he lost. He still experiences mild pain, and believes he may need to get surgery to address the problem in the long run. But for now, he's trying to stay hopeful.

"I know it's going to get better," he said. "So I'm not giving up."

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