augmentation, approximately 58 additional deaths would occur in the first year and 79 additional deaths would occur by year five,” said Douglas P. Beall, MD, FSIR, an expert in musculoskeletal radiology and pain management, who practices in Oklahoma, where the model has taken effect.


The estimates cited by Dr. Beall and Dr. Lookstein also only reflect a fraction of the total Medicare population that undergoes vertebral augmentation each year. Scaling the impact across thousands of patients could result in hundreds to thousands of avoidable deaths nationwide.


Dr. Beall added that any delay whatsoever can worsen pain, disability and recovery—especially in patients with vertebral compression fractures, severe radiculopathy, discogenic back pain and chronic wound care. Delayed care is strongly associated with increased opioid use, more visits to the ER and prolonged morbidity, which makes some conditions more difficult to treat effectively over time.


“Prior authorization may appear to offer cost-containment advantages on paper, but its real-world implementation in critical procedures such as vertebral augmentation is ethically and clinically indefensible,” Dr. Lookstein wrote.


The risks of prior authorization Dr. Lookstein and Dr. Beall emphasized that not only is vertebral augmentation crucial to quality of life for some patients, but that prior authorization in general puts these patients at risk.


“Prior authorization has consistently been shown to impose excessive and often harmful bureaucratic barriers, particularly in specialty care such as interventional radiology, where timely access to image-guided, minimally invasive procedures is essential,” Dr. Lookstein wrote.


CMS says the aim is that by using artificial intelligence, prior authorization will be completed quickly; ideally within 72 hours.


However, this 72-hour turnaround time only applies to WISeR participants. Any facility or physician who has not opted into the model will go through a post service/pre-payment medical review.


CMS says the aim is that by using artificial intelligence, prior authorization will be completed quickly; ideally within 72 hours.


These reviews will still be handled by the contractors selected to handle the AI authorization, according to CMS. The companies contracted through each state will receive payments when they successfully reduce costs and will be penalized if they are found to be inappropriately denying coverage.


“The initiative also relies on automated review algorithms and predictive analytics that moves the interpretation of coverage rules into the hands of vendors using the algorithms,” Dr. Beall said. “This will inevitably produce denials based on incomplete documentation, as well as inconsistent review decisions, higher denial rates and reduced access for complex patients.”


Dr. Beall added that the patients at highest risk of denial are the elderly, frail,


multimorbid, disabled, or cognitively impaired beneficiaries who have unique medical needs. This may be compounded in rural areas, where providers may opt out of the model.


Because these procedures have not historically required prior authorization, the WISeR initiative also has the potential to erode the physician-patient relationship by introducing confusion and administrative barriers, Dr. Beall said.


According to CMS, certain guardrails have been set up to prevent delays in access to care, such as a “gold card” program which will exempt certain providers from prior authorizations if 90% of their requests are approved. Additionally, CMS says that all denials will be reviewed by a licensed clinician.


Speaking up Since announcing the launch of the WISeR model, CMS has removed deep- brain stimulation from the model after feedback from the physician community.


“In the example of deep-brain stimulation (DBS), patients with movement disorders will often need DBS to adequately function. There is no other


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