Prior Authorization Is Coming to Traditional Medicare: What You Need to Know
One thing I have held in high regard for traditional Medicare is the transparency and relative simplicity. Medicare has rules and regulations, and if I follow those as a physician, I know what I can and can’t order for a patient in need. However, starting in 2026, Traditional Medicare will begin requiring prior authorization for certain services—a major shift in how care is approved and delivered. While prior authorization has long been a feature of Medicare Advantage plans, this marks the first time it will be applied to Original Medicare in a meaningful way.
Let’s break down what prior authorization is, why it matters, and what this change means for older adults and healthcare providers.
📝 What Is Prior Authorization?
Prior authorization is a process where your healthcare provider must get approval from your insurance plan before performing a medical service or prescribing a medication. Without this approval, the insurer may refuse to pay—even if the service would otherwise be covered.
Also known as pre-approval or precertification, prior authorization is typically required for:
Expensive medications
Advanced imaging (like MRIs or CT scans)
Non-emergency surgeries
Durable medical equipment
Certain outpatient procedures
The goal is to ensure that care is medically necessary, cost-effective, and appropriate. But critics argue that it can delay treatment, add administrative burden, and create barriers to timely care.
🧓 What’s Changing in Traditional Medicare?
Historically, Traditional Medicare (Parts A and B) has required very little prior authorization. That’s about to change.
Beginning January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will launch a pilot program in six states:
New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
This program—called the WISeR Model (Wasteful and Inappropriate Service Reduction)—will require prior authorization for 17 outpatient services that CMS has flagged as vulnerable to fraud, waste, or abuse.
Examples include:
Epidural steroid injections
Cervical spinal fusion
Skin and tissue substitutes
Electrical nerve stimulators
Deep brain stimulation
Arthroscopic knee procedures
Wound grafts and bioengineered skin applications
These services were selected based on data showing overuse, questionable billing practices, or lack of clinical benefit in certain cases.
⚙️ How Will It Work?
Providers in the pilot states will have two options:
Submit a prior authorization request before performing the service
Proceed with the service, but undergo a post-service, pre-payment medical review
CMS says that licensed clinicians—not machines—will make final decisions, even though AI and machine learning may assist in streamlining the process.
Importantly, the program excludes emergency services and inpatient-only procedures, and aims to avoid delays that could harm patients.
💡 Why Is This Happening?
CMS is trying to balance two goals:
Protecting patients and taxpayers from unnecessary or inappropriate care
Preserving access to medically necessary services
In recent years, Medicare has faced billions in fraudulent claims—some involving procedures performed on terminally ill patients. The WISeR Model is designed to reduce waste and improve oversight, while testing whether technology can make the process more efficient.
🧾 What Does This Mean for You?
If you live in one of the pilot states and use Traditional Medicare:
You may need prior approval for certain services starting in 2026
Your provider will handle the paperwork—but delays are possible
If Medicare denies the request, you could be responsible for the full cost
Medigap plans won’t cover services denied by Medicare, so approval is key
Even if you’re not in a pilot state, this change could expand nationwide if successful. It’s a good time to talk with your provider about how prior authorization may affect your care. Prior authorization is coming to Traditional Medicare—and while it may help reduce waste, it also introduces new hurdles for patients and providers. Staying informed, asking questions, and planning ahead will be essential as this policy rolls out.
