Medicare Prior Authorization Update 2026

Starting January 1, 2026, Medicare is introducing something new: prior authorization for certain outpatient services under Original Medicare.

If you’re on Original Medicare in one of six states, some of your medical services will require approval before your doctor can provide them. This is part of a pilot program called WISeR — Wasteful and Inappropriate Service Reduction.

The goal? To cut down on fraud, waste, and unnecessary procedures that don’t help patients and sometimes cause harm.

But here’s what has people concerned: prior authorization can also delay care. It adds paperwork. And if you’re not prepared, it could mean waiting longer for treatment or facing unexpected denials.

I treat every client like I would my own parents. And if my parents were facing these changes, here’s exactly what I’d want them to know — what’s changing, who’s affected, and how to prepare.

What Original Medicare Covers and Why Prior Authorization Matters

First, let’s be clear about one thing: Medicare’s coverage rules aren’t changing.

Original Medicare still covers medically necessary services for diagnosis and treatment — hospital care, doctor visits, lab work, imaging, surgeries, and therapies. If your doctor says you need it and it meets Medicare’s medical necessity standards, it’s covered.

What’s changing is when Medicare verifies that the service is medically necessary.

In the past, most Original Medicare services didn’t require prior authorization. Your doctor ordered a test or procedure, you got it, and Medicare paid the claim after the fact.

Starting in 2026, certain services will require approval before they’re performed. Your doctor will need to submit documentation showing that the service is medically necessary, and Medicare (through a third-party company) will review it before you can proceed.

If the service is approved, you move forward. If it’s denied, you can appeal — but in the meantime, you’re waiting.

This is a big shift for Original Medicare. And if you’re in one of the six pilot states, it’s something you need to understand.

How Prior Authorization Works Today vs. What’s Changing in 2026

Right now, Original Medicare has very limited prior authorization. It’s mostly been used for certain durable medical equipment (DME) like power wheelchairs and hospital beds — things that have historically been targets for fraud.

For most services, there’s no prior approval needed. Your doctor orders it, you get it, Medicare pays.

But that’s changing in 2026.

Under the WISeR model, prior authorization will expand to 17 categories of outpatient services in six states. These are services that CMS (Centers for Medicare & Medicaid Services) has identified as high-risk for overuse, fraud, or abuse.

The process will work like this:

Step 1: Your doctor determines you need one of the 17 services that require prior authorization.

Step 2: Your doctor submits a prior authorization request to a third-party company hired by Medicare. This company uses AI and machine learning to screen the request.

Step 3: A licensed clinician reviews the request and makes the final decision — approved or denied.

Step 4: If approved, you proceed with the service. If denied, you can appeal.

This is similar to how Medicare Advantage plans already operate. But it’s new for Original Medicare, and it’s causing concern among patients and doctors alike.

Inside the WISeR Model: Goals, Scope, and Targeted Services

The WISeR model is a six-year pilot program running from January 1, 2026, through December 31, 2031.

Here’s what you need to know:

The Goal

Medicare wants to reduce fraud, waste, and abuse. They’re targeting services that have historically been overused or billed inappropriately — things like unnecessary imaging, pain procedures that don’t help, and surgeries that aren’t medically justified.

The program is designed to catch bad actors — providers who order services that patients don’t need, sometimes to inflate billing or commit outright fraud.

But here’s the concern: legitimate care could also get caught in the net. If the prior authorization process is slow or overly restrictive, patients who need care could face delays or denials.

The Scope

WISeR will launch in six states:

• Arizona
• New Jersey
• Ohio
• Oklahoma
• Texas
• Washington

If you live in one of these states and you have Original Medicare (not Medicare Advantage), you’ll be affected by this program.

If you live in any other state, WISeR doesn’t apply to you — yet. CMS could expand the program to more states after 2031 if the pilot is deemed successful.

The 17 Targeted Services

Here are the categories of services that will require prior authorization under WISeR:

• Skin and tissue substitutes (often used for wound care)
• Electrical nerve stimulator implants
• Knee arthroscopy for osteoarthritis
• Epidural steroid injections for pain management
• Cervical fusion (spine surgery)
• Deep brain stimulation for Parkinson’s disease
• Certain imaging services (MRI, CT scans, ultrasounds)
• Pain management procedures
• Orthopedic services
• Cataract-related items and services
• Durable medical equipment (DME)
• And several other high-volume outpatient procedures

These are services that CMS has flagged as historically prone to overuse or fraud. If you need one of these services in a pilot state, your doctor will need to get approval first.

AI and Human Review: Balancing Speed, Accuracy, and Patient Impact

One of the most talked-about parts of the WISeR model is the use of artificial intelligence (AI) to screen prior authorization requests.

Here’s how it works:

AI screens the request. When your doctor submits a prior authorization request, AI tools will scan it for red flags — things like ordering patterns that don’t match clinical guidelines, missing documentation, or services that don’t align with your diagnosis.

A clinician makes the final call. AI doesn’t approve or deny your care. A licensed clinician reviews the request and makes the final decision. That’s a safeguard CMS built in to prevent AI from making bad calls.

Fast reconsideration if denied. If your request is denied, you have the right to appeal. CMS is promising faster reconsideration pathways to reduce delays.

The idea is to make the process faster and more efficient than traditional manual reviews. AI can process requests quickly, flag outliers, and let routine, guideline-based requests move through without delays.

But there are concerns. AI isn’t perfect. It can flag legitimate care as suspicious. And if the appeals process is slow or difficult, patients could be stuck waiting for care they need.

State Rollout, Timeline, and What Participation Means for You

If you live in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, and you have Original Medicare, here’s what you need to know:

Your coverage isn’t changing. Medicare still covers the same services. You’re not losing benefits. What’s changing is the process for getting certain services approved.

Your doctors may participate — or they may not. Participation in WISeR is voluntary for providers. Some doctors and facilities will submit prior authorization requests. Others may choose to go through post-service review instead (which means they provide the service first and Medicare reviews the claim for payment afterward).

You may experience delays. If your doctor needs prior authorization for a service, it could take time to get approval. CMS is promising fast reviews, but in practice, delays are possible.

You still have appeal rights. If a service is denied, you can appeal. You’ll have the same appeal rights you have now under Original Medicare.

The program runs from January 1, 2026, through December 31, 2031. After that, CMS will evaluate the results and decide whether to expand it to more states or more services.

Practical Steps for Beneficiaries and Providers to Prepare

If you’re in one of the six pilot states, here’s what you should do:

For Beneficiaries

1. Confirm whether your doctors are participating in WISeR. Ask your primary care doctor and any specialists whether they’ll be submitting prior authorization requests or going through post-service review.

2. Ask how prior authorization will affect scheduling. If you need one of the 17 services, ask your doctor how long prior authorization typically takes and whether it will delay your care.

3. Keep updated lists of your medications, diagnoses, and imaging. Your doctor will need this information to submit prior authorization requests. Having it ready speeds up the process.

4. Request written explanations for any denials. If a service is denied, get the reason in writing. You’ll need it for your appeal.

5. Know your appeal rights. If you disagree with a denial, you can appeal. Ask your doctor for help and consider working with a Medicare agent who can guide you through the process.

For Providers

1. Map which services are affected. Review the list of 17 services and identify which ones you order frequently.

2. Designate a prior authorization lead. Assign someone in your office to handle prior authorization requests and track submissions.

3. Standardize documentation templates. Make sure your prior authorization requests include all the information Medicare requires — diagnosis, medical necessity, supporting clinical data.

4. Monitor AI flag patterns. If certain requests are getting flagged repeatedly, review your documentation to see if you’re missing key information.

5. Rehearse escalation pathways. Have a plan for what to do if a prior authorization is denied. Know how to file reconsiderations quickly.

Frequently Asked Questions

How will WISeR affect Medigap premiums or supplemental coverage options?
WISeR is unlikely to directly affect Medigap premiums or coverage. It’s focused on prior authorization, not benefit changes. Indirectly, if WISeR successfully reduces wasteful spending, it could slow Medicare Part B cost growth, which might temper future Medigap rate increases.

Can caregivers or proxies appeal WISeR-related denials on behalf of patients?
Yes. If you’re a caregiver or authorized proxy (with a HIPAA release or medical power of attorney), you can appeal WISeR-related denials on behalf of the patient. Follow Medicare’s standard appeals process and submit medical documentation within the required deadlines.

Will prior authorization decisions be visible in patient portals or EOBs?
Yes. Prior authorization decisions should appear in patient portals and Explanation of Benefits (EOB) statements, though timing may vary. You’ll see summary statuses and reason codes. For detailed explanations, you may need to request records from your provider or review appeal notices.

How are rural or critical-access hospitals treated under WISeR?
Rural and critical-access hospitals are subject to WISeR if they’re in one of the six pilot states and their providers order the targeted services. The model focuses on provider behavior, not patient location. Participation is voluntary, and human clinicians make the final authorization decisions.

What privacy safeguards protect data used by WISeR’s AI tools?
WISeR’s AI tools must follow HIPAA privacy rules. That includes using the minimum necessary data, encrypting data in transit and at rest, implementing role-based access controls, maintaining audit logs, de-identifying data for analytics, and using business associate agreements. CMS provides oversight and enforcement.

The Bottom Line: Stay Informed and Prepared

The WISeR model is Medicare’s attempt to reduce fraud, waste, and unnecessary care. The goal is good: protect patients from harmful procedures and save taxpayer dollars.

But prior authorization can also cause delays, add paperwork, and create frustration. If you’re in one of the six pilot states, you need to be prepared.

Talk to your doctors. Understand which services require prior authorization. Keep your medical records organized. And if a service is denied, know your rights and don’t be afraid to appeal.

This is a pilot program. It’s new, and there will be bumps along the way. But if you stay informed and proactive, you can navigate it without losing access to the care you need.

Need Help Navigating Medicare Changes?

If you’re in one of the WISeR pilot states and you’re not sure how these changes will affect you, let’s talk.

We’ll walk through your situation, answer your questions, and help you understand what to expect — without the confusion or pressure.

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Next step is simple: Book your free consultation, or reach out with questions. We’re here to help.