Prior authorizations required in Traditional Medicare in 2026 (for unlucky residents of 6 states.)

[pnwmom]

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."

SNIP

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

https://www.kiplinger.com/retirement/medicare/prior-authorization-coming-to-traditional-medicare

[W_HAMILTON]

1. Oh, fuck off.

Anyone that has had to go through this nonsense before realizes that it just serves as yet another hoop people have to jump through to get the care they need. The hope is that people will just give up in anguish and forego necessary care. The fraudsters will still find a way to defraud the system regardless.This will just hurt regular people and some will surely die because of it.

[Fiendish Thingy]

2. I predict a sudden surge in opioid addiction and deaths in those states

Many of those procedures are related to pain management, and if patients are denied those procedures, they will find doctors more than willing to prescribe opioids as a band aid symptom management.

[BidenRocks]

10. Like all that Fentanyl from Canada!

Eh?!

[Buddyzbuddy]

11. Either or are quite acceptable to the Republican party.

Death is inevitable per Republican Joni Ernst. Probably preferable.

[Silent Type]

4. Although they did not specify services, pre-authorizations were proposed in last months of Biden admin.

There actually are some medical services that are abused for provider profits. In any event, I’d rather see more services than really “needed” than less from restrictive precerts.

[SickOfTheOnePct]

5. Pre-approval for many services...

…is the backbone of a universal, government funded healthcare system. If we want such a system, we’re going to have to accept that pre-approvals are part of that.

[Silent Type]

6. +1. If we were willing to make certain compromises, I think there is a chance to enact universal coverage.

[pnwmom]

16. All this is about is coercing Traditional Medicare people to switch to for-profit Advantage plans.

Advantage plans ALREADY have half of the Medicare business, and they already use AI. That would be the perfect group of test subjects for any study of how well AI was working.

But Traditional recipients are paying HIGHER PREMIUMS -- and rejecting freebies like gym memberships -- in order to NOT have the for-profit insurers deciding on their care, rather than their doctors. Why should any Traditional Medicare recipients have to continue to pay Traditional premiums while being switched to AI-driven prior-authorization processes -- the thing they were trying to avoid when they chose a more expensive Traditional plan?

It seems to me that this is just all a way to get more people to switch to Advantage plans. If they're going to be forced to get prior authorizations anyway, they might as well take the freebies.

[Silent Type]

17. People take M Advantage because they think it's best for them. Since more than half choose MA, that

means you and I are in minority.

Personally, I’m not for taking that away from people who think it’s better for them. Nor, do I think I know better than them. I suspect at some time, I’ll be forced into MA. If Kaiser were in my area, I would have switched long ago.
.

[pnwmom]

8. We DON'T have to accept that pre-approvals using artificial intelligence will ONLY be tested

in the Traditional Medicare recipients -- not in Medicare advantage. And we DON'T have to accept that our premiums will remain just as high as in the 45 other states that WON'T require pre-approvals for Traditional Medicare recipients.

[Silent Type]

18. Actually, Medicare has used algorithms to audit doctors and other providers for decades. AI

is just another algorithm that focuses on services subject to over utilization when docs profit directly.

[LudwigPastorius]

7. Trump Death Panels

While not actually sentencing anyone to death yet, they'll deny pain-relieving procedures so that you'll wish you were dead.

[BurnDoubt]

9. That may be OK, but only if it applies to...

Congress-people and ALL the Executive Branch.
I believe that's the only way we will get the best health care... If We Get What They Get.

[markodochartaigh]

12. Well,

practically all of this executive branch should be getting their health care through the prison system.

[BurnDoubt]

15. Yep!!!

[OrangeJoe]

13. Congressional health care

I've posted on this subject before, but here goes again. Congressional members and staff (I'm a former Senate staffer) get the essentially the same health care as every other federal worker. The Republicans insisted members had to enroll in Obamacare as if that was going to be a huge penalty. It wasn't and that's the only real difference with the policy offered to other feds.

There is a huge myth about their health care and retirement benefits. These lies, along with the mistrust in electoral integrity, are all part of the multi decade effort to delegitimize representative democracy and push the idea that democracy is corrupt and the only solution is a benevolent dictatorship.

Here's a couple of studies that give the FACTS about federal health benefits and pensions.
https://www.opm.gov/retirement-center/publications-forms/benefits-administration-letters/2013/13-204attachment2.pdf
https://www.cbpp.org/blog/no-health-reform-doesnt-give-congress-special-treatment
https://www.congressionalinstitute.org/2018/09/27/busting-congressional-myths/

Please educate yourself do not continue to post inaccurate comments on this subject. It only feeds the anti-democracy trolls.

[SickOfTheOnePct]

14. I've posted the same thing in past years...

...but I think a lot of people still don't know about it.

I took the DRP, my retirement starts on October 1, and I'm glad that I get to take my health insurance into retirement. It will kind of suck next year when I turn 65, as I'll need to keep the federal insurance for another five years to cover my wife and pay higher Medicare premiums due to the two year "look back" on income, but between Medicare, my federal insurance, and TriCare for Life (military retiree), I'll be in a good place for medical coverage.

[Horse with no Name]

19. Because this is what I do for a living

This is protective of seniors and it is very helpful.
Some of the devices are used for off label uses and it is IMPOSSIBLE to request a device for an off label use because the CPT codes are automatically approved on the front side but run a high risk of being declined on the backside. I don’t mind doing an appeal and submitting records for patients to get what they need.
You can’t even request a review.
Conversely, there are a lot of practitioners who use this to their advantage and deliberately miscode.
I do like this.