6 States to Pilot Prior Authorizations for Original Medicare

Takeaways

• A new pilot program will introduce prior authorizations for certain Original Medicare services in six states, effective January 2026.
• According to proponents, the program will reduce wasteful spending and unnecessary care by leveraging new technologies, including artificial intelligence, to expedite the prior authorization process. Critics are expressing concerns about potential limitations on patient access and an increased burden on health care providers.

In 2021, an Arizona couple pleaded guilty of defrauding Medicare and other health insurance companies of $1.2 billion dollars in false claims. They had targeted elderly and terminal patients for unnecessary and expensive skin grafts, ordering sizes larger than necessary to receive kickbacks.

A new pilot program by the Trump administration aims to prevent this kind of fraud and misuse of Medicare funds. According to a press release from the Centers for Medicare & Medicaid Services (CMS), the Wasteful and Inappropriate Service Reduction (WISeR) Model will evaluate whether new technologies, such as artificial intelligence (AI), can expedite the prior authorization process for services identified as vulnerable to fraud, waste, and abuse.

Effective January 2026, Original Medicare enrollees in six states will be subject to prior authorizations for certain services considered low-value.

Medicare and Prior Authorizations

As of May 2025, nearly 69 million people in the United States were enrolled in Medicare.

Among those with Medicare Part A and Part B, coverage (as of 2022) was about equally divided between those on Original Medicare and those enrolled in Medicare Advantage. The federal government administers Original Medicare, which has traditionally not included prior authorizations. Medicare Advantage is administered privately and includes prior authorization requirements.

Under the new pilot program, some Original Medicare recipients will now need to secure prior authorizations for certain services. Prior authorizations require that insurance approves treatments before patients receive them.

What Is the Purpose of the Pilot Program?

Per CMS, the program seeks to reduce spending on low-value services to safeguard federal taxpayer funds and help patients and providers avoid unnecessary care. Estimates suggest that up to $5.8 billion of Medicare spending in 2022 went to services with minimal benefit. In addition, CMS reports that an estimated 25 percent of health care spending may be wasteful.

Which States Will Take Part in the Pilot?

If you have Original Medicare and live in one of the following states, you will need to secure prior authorizations for select services starting in 2026:

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

What Services Will Require Prior Authorizations?

Medicare enrollees in these states won’t have to get prior authorizations for every service — just those deemed potentially inappropriate or wasteful by CMS.

According to Kiplinger, the following services will require prior authorizations.

• 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

What Will AI’s Role Be in the Pilot?

According to CMS, the pilot program will use AI but will not completely replace review by human clinicians. With AI, CMS seeks to speed up the prior authorization process, which can be lengthy and burdensome for patients seeking care.

What Are Critics of the Program Saying?

According to The Hill, Democrats are critical of the pilot program. They question the need for prior authorizations, which the Trump administration has sought to limit in Medicare Advantage.

In a letter to CMS administrator Mehmet Oz, 17 lawmakers wrote that “prior authorization has long been abused, and it is bad for patients and providers.” In the letter, they expressed concerns that prior authorizations will limit patient care access and burden health care workers.

How Could the Program Affect Patients?

The pilot program could help patients by preventing them from experiencing unnecessary services. However, it could also limit their access to desired services. Proponents say the program would act as a safeguard against unethical health care providers who encourage vulnerable patients, including seniors, to have medical treatments that they do not need.

Additional Reading

• Medicare Coverage Basics: What You Need to Know
• Don’t Make the Mistake of Not Signing Up for Medicare Supplemental Coverage
• Medicare’s Extra Help Program for Prescription Drug Coverage
• Pairing Medicare Coverage With Your Current Health Plan