Prior Authorization Coming to Traditional Medicare Starting in 2026

(Image credit: Getty Images)

published 7 July 2025

Traditional Medicare, also known as Original Medicare, has historically required little in the way of pre-authorization for beneficiaries seeking services; pre-authorization was typically the domain of Medicare Advantage. But that's about to change, as the Centers for Medicare and Medicaid Services (CMS) announced that it will implement prior authorization requirements for certain traditional fee-for-service Medicare services in six states starting next year.

This change will go into effect on January 1, 2026, when the CMS starts to "test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars," per a CMS press release. The model being implemented in 2026 builds on a change to prior authorizations rolled out by the Department of Health and Human Services (HHS) and CMS on June 23, 2025.

Six states — New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — will begin using the Wasteful and Inappropriate Service Reduction (WISeR) Model to perform prior authorization evaluations, CMS announced in a Federal Register notice. This will apply to 17 services that CMS says "are vulnerable to fraud, waste and abuse."

From just $107.88 $24.99 for Kiplinger Personal Finance

Be a smarter, better informed investor.

CLICK FOR FREE ISSUE

https://cdn.mos.cms.futurecdn.net/hwgJ7osrMtUWhk5koeVme7-200-80.png

Sign up for Kiplinger’s Free Newsletters

Profit and prosper with the best of expert advice on investing, taxes, retirement, personal finance and more - straight to your e-mail.

Profit and prosper with the best of expert advice - straight to your e-mail.

The Trump Administration's continuing fight against fraud, waste and abuse

The beginning of the second Trump administration brought the inception of DOGE and its tech-savvy staff tasked with finding fraud, waste, and abuse in government, including Medicare and Social Security.

HHS and CMS appear to be continuing DOGE's mission with the introduction of an agreement among private insurance companies to "pledge to streamline and improve the prior authorization processes for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace and commercial plans covering nearly eight out of 10 Americans." Humana recently announced a plan to reduce prior authorizations by one-third and reduce wait times for others.

The introduction of the short list of Medicare services for prior authorization will test how well technologies such as machine learning and AI can streamline the prior authorization process. “CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz.

As part of the goal of rooting out waste and fraud, the Justice Department conducted a 2025 National Health Care Fraud Takedown. Results were released on June 30, 2025, and included charges against more than 300 defendants who were accused of a range of health care fraud schemes.

One particular indictment can provide some insight as to how or why some of the procedures/services were selected for the list. In one particular case, three defendants in Arizona allegedly conspired to give elderly Medicare recipients unnecessary skin grafts, known as "amniotic wound allografts." The defendants allegedly pocketed millions of dollars and billed for "more than over $1 billion in false and fraudulent claims to Medicare and other health benefit providers for these medically unnecessary allografts." To make matters worse, according to the indictment, the defendants are alleged to have targeted Medicare beneficiaries, many of whom were terminally ill in hospice care.

The WISeR Model and how the program will work

The WISeR Model (Wasteful and Inappropriate Service Reduction) is meant to test the use of enhanced technologies, such as AI and machine learning, to decrease "certain wasteful or low-value services shown to have little to no clinical, evidence-based benefit." CMS chooses services that "have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use."

Medicare beneficiaries should know that AI will not be determining if a procedure is approved or denied; a human being will be reviewing the information. "...while technology will support the review process, final decisions that a request for one of the selected services does not meet Medicare coverage requirements will be made by licensed clinicians, not machines," CMS explained.

The use of the model will not alter Medicare coverage or payment rules. While other services may be added later to the model, it explicitly "excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed," according to the CMS fact sheet.

Providers and suppliers of the services to be included in the prior review process will be allowed to either submit a prior authorization request for the model’s selected items and services or go through a post-service/pre-payment medical review.

17 services to be subject to prior authorization

Here is the list of services that will go through a prior authorization process in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, between January 1, 2026, and December 31, 2031.

Electrical nerve stimulators
Sacral nerve stimulation for urinary incontinence
Phrenic nerve stimulator
Deep brain stimulation for essential tremor and Parkinson’s disease
Vagus nerve stimulation
Induced lesions of nerve tracts
Epidural steroid injections for pain management
- excluding facet joint injections
Percutaneous vertebral augmentation (PVA) for vertebral compression fracture
Cervical fusion
Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee
Hypoglossal nerve stimulation for obstructive sleep apnea
Incontinence control devices
Diagnosis and treatment of impotence
Percutaneous image-guided lumbar decompression for spinal stenosis
Skin and Tissue Substitutes
- Application of bioengineered skin substitutes to lower extremity chronic non-healing wounds
- Wound Application of cellular and/or tissue based products (CTPs), lower extremities

Critics come from both political persuasions

So far, there has been criticism from both the left and right, and for similar reasons.

"It's baffling how in one breath the administration is trying to take a victory lap on insurers streamlining prior authorization in Medicare Advantage, and in the other instituting the same delay tactics in traditional Medicare," Rep. Suzan DelBene (D-Wash.), whose state will be testing out the new model, told MedPage Today.

From the right, Michael Baker, director of healthcare policy at the American Action Forum, also hit President Trump on his promise to reduce prior authorizations and added a dose of skepticism about AI's ability to help the situation.

"Adding a duplicative third party to the already established Medicare Administrative Contractor network, particularly one that may be using untested artificial intelligence, machine learning, or algorithmic decision logic, may only increase the overall administrative burden and delay beneficiary care," Baker said to MedPage in an email.

How common are prior authorizations in Medicare and Medicare Advantage?

As it stands, traditional Medicare requires prior authorization for a substantially smaller set of procedures and services than most Medicare Advantage plans. Medicare services that typically require prior authorization include certain outpatient hospital services, non-emergency ambulance transport, and durable medical equipment. For 2023, just under 400,000 prior authorization reviews for traditional Medicare beneficiaries were submitted to CMS.

The situation is very different for Medicare Advantage plans. While they must cover all medically necessary services that Original Medicare covers, for some services, MA plans may use their own coverage criteria to determine medical necessity. Almost all Medicare Advantage enrollees — 99% according to KKF — must obtain prior authorization for some services. These are typically higher-cost services, such as inpatient hospital stays, skilled nursing facility stays and chemotherapy.

Donna joined Kiplinger as a personal finance writer in 2023. She spent more than a decade as the contributing editor of J.K.Lasser's Your Income Tax Guide and edited state specific legal treatises at ALM Media. She has shared her expertise as a guest on Bloomberg, CNN, Fox, NPR, CNBC and many other media outlets around the nation. She is a graduate of Brooklyn Law School and the University at Buffalo.