New Medicare Pilot for Prior Approval in 2026
Key Takeaways
Medicare will require prior authorization for select procedures in six states starting January 2026.
The WISeR pilot aims to reduce overuse, fraud, and unnecessary services.
Providers should expect added administrative steps and potential delays in care.
Strong, well-supported documentation will be essential for approval.
Beneficiaries with Traditional Medicare will require prior approval in the following six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. This initiative is a part of the WISeR (Wasteful and Inappropriate Services Reduction) pilot program, which is designed to curb medical overuse and detect potential fraud. The requirement will begin on January 1, 2026.
The services affected by this new pilot program are as follows:
Facet joint procedures for back pain
Nerve and muscle tests (electrodiagnostic testing)
TENS units and similar electrical stimulation devices
Hyperbaric oxygen therapy
Spinal cord stimulators
Deep brain stimulation (commonly for Parkinson’s)
Sacral neuromodulation (for urinary conditions)
Transcatheter aortic valve replacement (TAVR)
Arthroscopic knee cleaning or debridement
Vertebroplasty/kyphoplasty for spine fractures
Epidural steroid injections
Non-emergency ambulance transport
Botox injections for medical issues
Negative pressure wound therapy pumps
Hernia repairs
Lumbar spinal fusion
Skin graft substitutes for chronic wounds
This new initiative was set in motion to lower healthcare costs by avoiding fraud and waste. There has been concern regarding the performance of high risk procedures considered un-necessary. Artificial intelligence will be used to prescreen and streamline requests; however final decisions will have a human hand.
This will impact beneficiaries with Traditional Medicare and those with Medigap plans such as Plan G or Plan N. Potential for delays in receiving needed treatments and added administrative work for healthcare providers will likely result.
Best Practice for Providers – When submitting a request for prior authorization make certain to explain why the treatment under review is necessary, include any co-morbid conditions that drive the decision to perform the procedure under review versus another procedure. Submit patient records that support the aforementioned assertions and any relevant clinical data/studies that support your decision.
This pilot is slated to go on for 6 years. It will most likely be the first step in more restrictions for Seniors who have chosen Traditional Medicare because it allows for more freedom to access to care.
Ensource: YOUR trusted source for education
At Ensource, we’re committed to helping medical coders excel at every stage of their careers. Stay ahead of the curve by subscribing to our email list—you’ll be the first to know when we release new blogs, resources, and webinars offering AHIMA- and AAPC-approved CEUs, all completely free.
Join Our Community Today!