Retirement should bring peace of mind, not a new battle on medical services. However, the new pilot program may soon determine whether you are receiving pain treatment, not your doctor. The Centers for Medicare and Medicaid Services (CMS) have begun experimenting with AI to determine prior authorization approval. This means Medicare AI can have a final decision on the injection, surgery, or treatment recommended by your physician. Proponents claim this will reduce costs and increase efficiency, but critics fear patients will suffer while the algorithm tightens the numbers.
How Medicare AI works in practice
The program uses algorithms to analyze previous authorization requests for a specific treatment, including spinal injection and neural procedures. Instead of a human reviewer, AI checks the request and determines whether the coverage rules are compliant. Proponents believe that automation can reduce delays and provide patients with answers in minutes rather than weeks. But on the other hand, false denials may be just as fast. Once a decision is made, patients and doctors must fight the system.
Although efficiency sounds good in theory, doctors worry that this may mean faster rejection rather than faster care. They are not the only people they care about either. Charlotte Rudolph, executive director of the Ohio Global Medical Action Network, made a statement on technology changes and how they will affect patients. Ohio and five other states will launch a pilot program in 2026 called the “Waste and Inappropriate Service Reduction (Smart)” model.
“It will save money at the cost of patients,” Rudolph said. “Patients on Medicare are our most vulnerable Ohio people, just thinking about the storm they have on this procedure – it’s an inappropriate pressure that patients don’t even need to hear.”
Calls for Medicare decisions have already taken a lot of time and paperwork, and AI denies that it could increase that burden. Patients with pain may be stuck for weeks when trying to overturn the machine’s decision. This delay can worsen medical conditions, increase dependence on opioids and reduce quality of life. In practice, Medicare AI may bring speed without sympathy.
Doctors say AI destroys medical expertise
Many doctors believe that treatment decisions should be made by trained professionals who understand the patient’s unique medical history. They believe that there is no algorithm that can replicate nuances in the context of years of experience or individual cases. When AI refuses treatment, it may feel that the doctor’s judgment is ignored rather than to save costs. This shift creates tension between healthcare providers and insurers. Ultimately, Medicare AI has the potential to replace expertise with formulaic thinking.
Chronic pain conditions rarely fit neatly into standardized categories. Something that suits one patient may not work for another, and treatments usually require customization. However, AI relies on data patterns that may ignore these individual differences. Care can be denied simply because their profile does not match what the algorithm expects. For those with everyday pain, Medicare AI may mean more pain and fewer options.
Hidden bias can shape who gets approval
Artificial intelligence systems are only as fair as trained data. If past Medicare data contained discriminatory patterns, AI might strengthen them. This may mean that some demographics (e.g. women, minorities, or elderly patients) face higher denial rates. Without transparency, patients may never know if their care is judged. This raises the unsettling possibility: Medicare AI can inadvertently deepen existing health disparities.
Although CMS introduced the pilot, clear safeguards have not yet caught up with the technology. Patient advocates and lawmakers call for strict regulations on transparency, appeal rights and routine audits. Without strong supervision, the algorithm can be operated as an uncontrolled caregiver. The National Healthcare Association has raised alarms about the lack of accountability. Before the evolution of regulations, Medicare AI could be a system that patients take risks but cannot control.
Judith Stein, founder of the Center for Medicare Advocacy, is concerned about how the introduction of the technology will affect doctors’ relationships. The Medicare Advocacy Center aims to ensure that everyone entitled to Medicare has the best access to health care.
“Their doctors also have a lot of things to do, and are often out of (help) or not want to help,” Stan said. “It’s no surprise that the vast majority of people don’t challenge the previous authorization denial.”
It is worth noting that this technology is not completely unpromising. By reducing paperwork and inconsistent human decision-making, AI can simply simplify the process. Patients may receive faster approval of routine treatments that clearly meet coverage criteria. Doctors can spend less time on the table and spend more time with patients. If applied responsibly, Medicare AI can reduce the traditional tape, as long as it cannot completely replace human judgment.
The real danger is ignoring human factors
Pain management is personal, complex, and has a profound relationship with quality of life. Allowing algorithms to cover doctors has the risk of turning people into data points instead of patients. Bets are not abstract. They are about whether older people can get rid of the relief of conditions that make daily life unbearable.
“It creates a barrier between the orders of doctors and other healthcare providers and hopes to do medically necessary conditions for patients and what is provided based on algorithms,” Stan said.
Technology can be a powerful tool, but only if it supports rather than replaces the doctor’s relationship with the patient. Essentially, the debate about Medicare AI is about whether efficiency should be held before empathy.
Do you think Medicare should use AI to decide whether to get pain treatment? Or should the doctor always have the last word? Share your thoughts in the comments below!
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