Medicare Will Require Prior Approval for Certain Procedures (AI will be used to help determine some approvals)

[Celerity]

A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.

https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.html

https://archive.ph/4mDE7

Frances L. Ayres worried that a new program under traditional Medicare will involve the types of pre-approval hassles for medical care that she had tried to avoid. Credit... Nick Oxford for The New York Times Reed Abelson

Like millions of older adults, Frances L. Ayres faced a choice when picking health insurance: Pay more for traditional Medicare, or opt for a plan offered by a private insurer and risk drawn-out fights over coverage. Private insurers often require a cumbersome review process that frequently results in the denial or delay of essential treatments that are readily covered by traditional Medicare. This practice, known as prior authorization, has drawn public scrutiny, which intensified after the murder of a UnitedHealthcare executive last December.

Ms. Ayres, a 74-year-old retired accounting professor, said she wanted to avoid the hassle that has been associated with such practices under Medicare Advantage, which are private plans financed by the U.S. government. Now, she is concerned she will face those denials anyway. The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives.

The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.

The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections. The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence.

snip

[leftstreet]

1. Thin end of the wedge

First they came for the incontinence treatment

then the hip replacement...

[TheBlackAdder]

23. Super efficient code: NOOP then RETURN

[Tumbulu]

2. Does it say which states anywhere?

Nightmare!!!!!

[Bayard]

5. I'm sure it will be blue states.

Just think--you can deal with this at the same time trump is sending troops into your city.

[Celerity]

8. New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington

https://finance.yahoo.com/news/trump-administration-tiptoes-into-testing-prior-authorization-in-traditional-medicare-143012089.html

[Tumbulu]

17. Thank you, pushing everyone onto Advantage plans

As there will essentially be no difference.

[Eliot Rosewater]

30. And will allow Medicare advantage insurance companies to drastically raise

Co-pays and deductibles So that our Medicare will be way more. Might as well not be a Medicare at that point which has been the whole point all along, Social Security is going also.

[Celerity]

7. New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington

https://finance.yahoo.com/news/trump-administration-tiptoes-into-testing-prior-authorization-in-traditional-medicare-143012089.html

[Native]

9. OK, AZ, WA, NJ, OH, TX

You really should read the article in full. People should be freaking out about this.

[Tumbulu]

18. Sorry, I thought one needed a subscription

to read the whole article.

But I guess it was a gift, and I did not check. The trouble is that the sort of state sponsored terrorism of the times is effecting me negatively.

Thank you for answering my question.

[Bayard]

3. Steroid Injections for Pain Management

That's my middle name.

The bean counters win if Medicare can make people pay for procedures themselves. You get to live in pain if you can't afford it.

I'm sure AI will make wise decisions.

[customerserviceguy]

10. We really need

to blow these AI computers up somehow.

[Bayard]

26. Yes

[I_UndergroundPanther]

37. Those injections

Keep me pain free for years. The last one was in 2018 and it’s still going strong.

[SickOfTheOnePct]

4. I know that people don't like to hear this...

...but if we ever get to a universal healthcare system, pre-authorization for expensive and/or specialized treatments is going to be necessary. It won't be based on a profit motive, obviously, but it will still be needed.

[customerserviceguy]

11. You're absolutely right

And I've long insisted that if the entire healthcare industry doesn't sit down and work out something fairer and way more transparent, rather than just pointing fingers at others in the industry, they'll all deserve it when single payer becomes the law of the land.

[SickOfTheOnePct]

12. Agree 100% on getting the industry together on something...

...but the people need to accept it too, and based on what I see here whenever pre-authorization for Medicare is mentioned, I think it's going to be a hard sell.

So many people seem to believe that universal healthcare will mean that every procedure, every drug, every treatment plan will be available to anyone who has a doctor that requests it, and that's simply not feasible.

[Native]

14. And the administrative burden is significantly less than what is happening here with private insurance companies.

[SickOfTheOnePct]

24. Absolutely

My point is just that with universal health care, pre-authorizations will be a necessity; the way so many react to something like the announcement that six states are going to do a trial with pre-authorization for some procedures doesn't instill a lot of confidence in me that people understand the need for pre-authorizations in a universal system.

[IbogaProject]

34. Also streamlining lots of other things

Liability insurance would be much cheaper and car insurance under universal health coverage.

[RobinA]

22. Anybody

who has a plan through their employer has most likely been dealing with this their entire working life. This pre-authorization complaint has been exaggerated by the pro-original Medicare crowd. Additionally, this really isn't anything new. A family member has original Medicare and they keep turning down her physician's attempt to get her a new non-opiate pain reliever.

[greatauntoftriplets]

6. Oh joy, more hoops to jump through.

My advice is to avoid getting a chronic illness at all costs. If anyone has any ideas about how to do that, please let me know.

[Skittles]

13. they're trying to turn it all into ADVANTAGE crap

profiting from rejections, it's just plain WRONG

[Native]

20. My guess is they will promote this as such a success in just a year or two that before the pilot's conclusion,

they will expand it & roll it out.

Remember how this Administration lied about all the money they were saving with their cuts to our agencies? They will lie about this and push it through. Their ultimate goal, and we all know it, is to privatize Medicare. What better way to worm their way in than by starting with a pilot program like this?

We need to start screaming from the rafters.

[Skittles]

21. BINGO

the ultimate goal is to throw it all to the wolves

then finally people will understand what the "savings" from "Advantage" bullshit truly cost us

[Intractable]

15. AI Death Panels!

Anyone remember the conservatives decrying the scary Obamacare death panels?

[Emile]

16. What six states are in this pilot program?

Never mind, I see in an earlier post in this thread it's OK, AZ, WA, NJ, OH, TX.

The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives.

[Silent Type]

25. Talk of prior approvals started in last months of Biden's term, but services weren't listed. Some of them are definitely

overutilized and are performed even when Medicare does not consider it medically necessary.

I'll bet money -- whether we like it or not -- they'll stop the test early and institute prior approval on highly questionable services after a year or two.

[Henry203]

27. I get the epidural shots for Stenosis

We can only get it 4 times a year. It's okay but crtainly not perfect. Stenosis is really hard on one.

[madinmaryland]

31. I have spinal stenosis and have epidural steroid shots since I have surgery

A year and a half ago. They work for a few months and then I need to go for another shot.

I had three disks replaced and fused which has helped. I’m still in pain, but I can still function, though my job is basically a desk job. I have issues lower in my back, but surgery is not something I want to do again. I’m taking the epidurals to hopefully reduce the swelling in my lower back.

[Henry203]

35. This has helped

I lost weight I ride a stationary bike for 30 minutes almost every day and then I then do 5 reps on a crunch machine. I do not pull my arms but I use the pads for the elbows.
I then take a steam. That really helps.
I was taking one pill of advil 3 times a day and when I was getting the shot my doctor said I should try 2 pills 3 times a day. It has helped.
This time I only got the left side done.My right side has been better. Because I only did one side he put in 40% more. Today is only day 2 so I won’t know how well it going to do. He did say if I want to do the right I could come back in 2 weeks. I am trying to avoid the surgery.

[relayerbob]

28. They already default to saying no

The AI is being used to determine who will sue and be successful.

[groundloop]

29. Fuck that, I'm paying more for Original Medicare to avoid that bullshit.

What REALLY stinks is that they're going to give the AI companies a bounty to refuse care. Sure, waste needs to be eliminated, but this is the WRONG way to do it. Whether or not I receive the care prescribed by my doctor shouldn't be dictated by the profit motive.

[Totally Tunsie]

32. Oh yeah?

Just wait until those limp dick Repugs are denied for the treatment of impotence...

[pinkstarburst]

33. Dumb question: Does medicare currently NOT require prior auths?

I ask this because I am chronically ill and have multiple meds that require prior auths every 6 months plus a recurrent procedure that requires it every 6 months.

It sucks, but being very sick sucks and some of these things are very expensive drugs and very costly procedures, so I get it.

I guess I am wondering why Medicare would not require prior auths for high cost procedures just like traditional insurance?

And I agree with another comment that if we ever make it to single payer insurance, everyone is going to be under a system of requiring "auths" for everything beyond pretty basic care.

[Emile]

36. Is the democratic leadership giving talking points

to all members in the party?

[canetoad]

38. So when AI gets it wrong

As it is bound to do, to whom does a patient go for an appeal or a review? I see grief ahead.