Pre-authorization, sometimes referred to as prior authorization, is the approval healthcare providers require from insurance carriers before delivering certain services or prescriptions to patients. While you can still get the service without pre-authorization, you’ll be responsible for the full cost. Also, prior authorization approval doesn’t guarantee coverage.
The waiting and uncertainty of the process can be frustrating, but insurance carriers use the pre-authorization process to assess whether the treatment being sought is safe and cost-effective.
Medicare Advantage (MA) enrollees are familiar with prior authorizations, as 99% are required to get prior authorization for at least some services — usually more expensive services like inpatient hospital stays and chemotherapy. But effective January 1, 2026, CMS will roll out a pre-authorization pilot program in six states for Original Medicare (Part A and Part B) enrollees.
If you live in one of these six states or generally have questions about pre-authorization for Original Medicare, keep reading to learn what it means.
What is the Medicare pre-authorization program?
From January 1, 2026, to December 31, 2031, CMS will implement the Wasteful and Inappropriate Service Reduction (WISeR) Model, a pre-authorization pilot program for Original Medicare (Part A and Part B) aimed at limiting wasteful healthcare spending on services deemed vulnerable to fraud.
The pilot program will run in six states:
- New Jersey
- Ohio
- Oklahoma
- Texas
- Arizona
- Washington
The WISeR Model will use AI and machine learning technology to review the medical necessity of service claims for certain services that:
- Could create additional health concerns if delivered inappropriately
- Have existing publicly available coverage criteria
- May involve prior reports of fraud, waste, and abuse
In the pilot program, a small number of services will be subject to the tech-driven, clinician-reviewed pre-authorization process. The goal is to reduce waste in healthcare, which accounts for about a quarter of U.S. healthcare spending, and to prevent patients from receiving treatments that may ultimately do more harm than good.
Which Medicare services require pre-authorization?
The 17 services that now require pre-authorization under the WISeR Model:
- 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
These services are seen as both expensive and high-risk, making them more susceptible to fraud and waste. Earlier in 2025, over 300 defendants were charged in connection with over $14 billion in alleged fraud, some of which included these services. CMS believes that putting these under pre-authorization can reduce health spending without impacting the quality of care.
How to prepare for the new pre-authorization requirements
If you’re enrolled in Medicare Advantage (MA), the pre-authorization pilot program won’t apply to you. But if you live in any of the six states rolling out this program in the new year, the process for getting any of those 17 services on the list will be a little more complicated. Here’s how to prepare:
- Plan ahead: These new processes may mean you and your doctor need extra time to obtain necessary approvals. This can mean a longer lead time before getting a procedure, so it’s important to look ahead with your doctor and assess how quickly you’ll need to act to get care on time.
- Keep your documents: To get a pre-authorization decision, providers need to submit requests to the WISeR Model participant in your state. You’ll need medical records and supporting documents to prove you need the procedure. Double-check with your provider that your health records are up to date and easily accessible.
- Know your rights to appeal: You have the right to appeal if your pre-authorization request is denied. But if you’ve submitted a claim and it hasn’t been answered, you can resubmit your claim with updated information as many times as needed.
There will be a learning curve, so it’s essential that Original Medicare enrollees stay organized, ask questions, and don’t hesitate to advocate for themselves throughout the process.
