Medicare's new AI experiment sparks alarm among doctors, lawmakers

[Ms. Toad]

20. The problem isn't the availability of an appeal -

It is the denial in the first place.

One of those procedures in this new program is one I've had - for surgery on an extremely aggressive cancer. In my case, the tumor size doubled with 2-3 weeks. Appeals take months. I've had one take close to a year. Surgery could not proceed until all prior approvals were in place - OR - I agreed to pay for it myself. A delay of close to a year would have meant death.

Medicare has prior approval for treatments which are cosmetic in nature, but occasionally also medical. Although doctors should be able to determine with their patients what is medically necessary, it is understandable that - for example - the eyelid lift my spouse had because her eyelids were limiting her primary vision and were interfering with her peripheral vision - is also one my SIL wants for cosmetic reasons. Given the financial incentive for doctors to perform the surgery and call it medically necessary (rather than cosmetic - which would put it out of my SIL's budget), I can see wanting a second set of eyes on it. They should be real eyes, not AI eyes. But there is some actual basis for the procedures which currently require prior approval.

These new procedures are medically necessary - I didn't see any which were purely cosmetic. That, alone, makes it inappropriate as part of standard Medicare - even if the denials are done by humans. And even if there are appeals available. And even if there is a group willing to help with appeals.