{"schema_version":"0.10.0","id":"LR-2026-0805","record_version":1,"title":"WISeR AI program reportedly denied or delayed Medicare care for seniors in several states","verification":{"human_verified":false,"method":"automated_gate","auto_verified":true,"score":43.5,"score_breakdown":{"source_authority":12.1,"independent_corroboration":7.0,"implicated_party_confirmed":0.0,"citation_integrity":14.0,"specificity":0.0,"completeness":3.2,"unhedged_language":5.0},"checks":{"schema_valid":true,"every_field_cited":true,"quotes_verbatim":true,"source_fetched":true,"distinct_incident":true,"dates_plausible":true,"sources_agree":true,"source_describes_incident":true,"severe_backed_by_source":true,"record_integrity":true,"eligible":true,"about_this_case":true},"gate_version":"gate-2026-10-18.7","cross_check_model":null,"cross_check_agreement":null,"duplicate_of":null,"verified_by":null,"verified_at":"2026-11-01","extraction_run_id":null,"evidence_level":{"level":"preliminary","reason":"Publisher not yet named · subject to change","original_document":null,"reports_total":1,"reports_independent":0,"reports_derivative":0,"developing":true,"disputed":false,"rules_version":"evidence-2026-10-29.1","computed_at":"2026-11-01","history":[{"date":"2026-11-01","from_level":null,"to_level":"preliminary","reason":"Publisher not yet named · subject to change"}]},"sources_hash":"954934dac2556b14df63c7294aa0df04afaa9972b3a3c404d83bb14c17461b5a"},"system":{"model_name":null,"model_version":null,"developer":"unknown","harness":null,"tools_granted":[],"permissions_scope":null,"autonomy_level":"unknown","guardrails_present":[],"deployment_context":"production","tier":null,"lifecycle_stage":null,"integration_type":null,"intended_use":"Federal pilot program using AI to help decide which Medicare care is approved or denied","safeguard_state":null,"production_intended":null},"event":{"date_occurred":null,"date_disclosed":"2026-10-26","incident_class":"bias_disparate_impact","failure_class":null,"agent_involved":null,"secondary_failure_classes":[],"trigger":"unknown","duration":null,"detection_method":"unknown","summary":"A federal pilot program called WISeR uses artificial intelligence models to help decide whether Medicare requests for treatments and services are approved. The models are used at select clinics in six states: Texas, New Jersey, Oklahoma, Ohio, Washington and Arizona. A lawsuit by the Electronic Frontier Foundation alleges the models were denying care at disproportionately high rates. In Texas, the models approved care for 62% of patients, while humans approved 84%. The suit also reports that contracted vendors have financial incentives to deny prior approval. Physicians reported high denial rates and delays in approvals. The lawsuit sought records on whether the systems were tested for accuracy and bias. Whether the government audited or monitored performance is unclear. CMS plans a six-month performance report, but no date has been given.","tags":[],"date_detected":null,"near_miss":null,"root_cause":null,"root_cause_detail":null,"failure_class_detail":null,"responsible_party":null,"adversarial_actor":null,"input_provenance":null,"time_to_contain":null,"operations_paused":null,"remediation":null,"precursor_events":null},"impact":{"direct_loss_usd":null,"remediation_hours":null,"records_exposed":null,"third_parties_affected_count":null,"severity":"moderate","severity_because":"Moderate test: bounded scope stated (select clinics in six states); no third party count or unbounded scope stated","harm_class":[],"affected_description":null,"protected_class_involved":null,"data_categories_exposed":[],"loss_range_usd":null,"reversibility":null,"downstream_exposure_count":null},"evidence":{"sources":[{"url":"https://nypost.com/2026/10/26/lifestyle/federal-ai-agent-is-denying-seniors-medicare-report/","publisher":"New York Post","date":"2026-10-26","type":"press","title":"AI agent is denying seniors healthcare across several states — what recipients need to know - New York Post","archived_url":null,"attachment":"first_report"}],"per_field_confidence":{"system.intended_use":"C","system.deployment_context":"C","context.industry":"C","context.country":"C","event.incident_class":"D","impact.severity":"D","impact.severity_because":"D","event.summary":"C","system.autonomy_level":"D","event.trigger":"D","event.detection_method":"D","system.developer":"D","event.date_disclosed":"D","context.denominator_available":"D"},"field_citations":{"system.intended_use":[{"source_index":0,"quote":"The government is piloting a federal program that uses artificial intelligence to help decide what care to approve or deny."}],"system.deployment_context":[{"source_index":0,"quote":"These AI models are being used at select clinics in Texas, New Jersey, Oklahoma, Ohio, Washington and Arizona."}],"context.industry":[{"source_index":0,"quote":"The program’s administrator, Dr. Mehmet Oz, said WISeR would use AI to review Medicare requests for medical treatments and services."}],"context.country":[{"source_index":0,"quote":"The government is piloting a federal program that uses artificial intelligence to help decide what care to approve or deny."}],"event.incident_class":[{"source_index":0,"quote":"On page five of the 10-page lawsuit, the WISeR Model’s AI systems were “denying care at disproportionately high rates.”"}],"impact.severity":[{"source_index":0,"quote":"These AI models are being used at select clinics in Texas, New Jersey, Oklahoma, Ohio, Washington and Arizona."}],"impact.severity_because":[{"source_index":0,"quote":"These AI models are being used at select clinics in Texas, New Jersey, Oklahoma, Ohio, Washington and Arizona."}],"event.summary":[{"source_index":0,"quote":"The government is piloting a federal program that uses artificial intelligence to help decide what care to approve or deny."},{"source_index":0,"quote":"These AI models are being used at select clinics in Texas, New Jersey, Oklahoma, Ohio, Washington and Arizona."},{"source_index":0,"quote":"On page five of the 10-page lawsuit, the WISeR Model’s AI systems were “denying care at disproportionately high rates.”"},{"source_index":0,"quote":"For example, the AI models in Texas approved care for just 62% of folks, while humans approved 84%."},{"source_index":0,"quote":"The suit also found a couple of other important issues — a major contrast in approval numbers and a financial incentive to deny care to those people."},{"source_index":0,"quote":"The EFF originally filed the lawsuit to force the government to disclose records showing how — or if — the systems were tested for accuracy, bias and AI-generated errors."},{"source_index":0,"quote":"Additionally, it’s unclear whether or not the government audited or monitored the performance."},{"source_index":0,"quote":"An exact date for when the report will be dropped was not given."}]},"notes_on_gaps":"The source is one press article citing a lawsuit; no primary document was provided. Not stated: model name, version, developer, vendors, harness, tools, autonomy level, guardrails, or whether the system is an autonomous agent (agent_involved and failure_class omitted). Not stated: incident dates beyond the January 2026 launch, the lawsuit filing date, and the date of disclosure (the article date 2026-10-26 was not used as disclosure date). Root cause, responsible party, and reversibility are not stated. No control is confirmed as held, failed, got around or missing; the article only says testing and monitoring are unclear, so no control was linked. No remediation is reported; the CMS report is planned, not a change. Judgements made: incident_class as bias_disparate_impact based on the lawsuit's disproportionate-denial claim; detection_method as third_party because the EFF lawsuit surfaced the issues; deployment_context as production because the models are used at clinics; severity as moderate because the scope is bounded to select clinics in six states; harm_class as discriminatory; risk RK16 as most central. The 62% and 84% figures are the lawsuit's as reported by the press, not verified. [case created by the backfill: read by claude-haiku-5-5, backfill-2026-11-01.2, 2026-11-01; not yet reviewed] [2026-11-01: evidence level set: Preliminary (Publisher not yet named · subject to change)]"},"context":{"industry":"healthcare","org_size_band":null,"country":"US","denominator_available":false,"denominator":null,"related_incident_ids":[],"systemic_exposure":null,"shared_model_id":null,"upstream_incident_id":null,"incident_evidence":null,"regulatory":null,"coverage":null},"narrative":{"steps":[{"step":"doing","text":"A federal pilot program uses AI models to help decide which Medicare treatments and services are approved or denied.","quote":"The government is piloting a federal program that uses artificial intelligence to help decide what care to approve or deny.","source_index":0,"grade":"C"},{"step":"went_wrong","text":"The lawsuit says the AI models denied care at disproportionately high rates.","quote":"On page five of the 10-page lawsuit, the WISeR Model’s AI systems were “denying care at disproportionately high rates.”","source_index":0,"grade":"C"},{"step":"reached","text":"Providers reported high denial rates, delays in approval, and technical failures.","quote":"Physicians and other health care providers have reported unusually high denial rates, delays in care approval, technical failures, communication gaps, and administrative strain,","source_index":0,"grade":"C"}],"model":"claude-haiku-5-5","prompt_version":"backfill-2026-11-01.2","extracted_at":"2026-11-01","source_urls":["https://nypost.com/2026/10/26/lifestyle/federal-ai-agent-is-denying-seniors-medicare-report/"]},"analysis":{"sections":{"timeline":[{"text":"The WISeR program launched in January 2026.","quote":"After launching in January 2026, a lawsuit was filed against the Centers for Medicare and Medicaid Services (CMS), revealing a slew of issues within the first few months.","source_index":0,"when":"2026-01"},{"text":"A lawsuit was filed against CMS within the first few months after launch, revealing a slew of issues.","quote":"After launching in January 2026, a lawsuit was filed against the Centers for Medicare and Medicaid Services (CMS), revealing a slew of issues within the first few months.","source_index":0,"when":null},{"text":"Physicians and other providers reported high denial rates and approval delays, as stated in the lawsuit.","quote":"Physicians and other health care providers have reported unusually high denial rates, delays in care approval, technical failures, communication gaps, and administrative strain,","source_index":0,"when":null}]},"model":"claude-haiku-5-5","prompt_version":"backfill-2026-11-01.2","extracted_at":"2026-11-01","source_urls":["https://nypost.com/2026/10/26/lifestyle/federal-ai-agent-is-denying-seniors-medicare-report/"]}}