Paper on a desk with the wording, Prior Authorization Form

Changes to Medicare’s Prior Authorization Coming in 2026

July 11, 2025 Medicare

🩺 Medicare Changes Coming in 2026: Prior Authorization for Some Services

Starting January 1, 2026, people on Traditional Medicare in six states will need prior authorization for certain medical services. This means your doctor must get Medicare’s approval before providing these services—otherwise, Medicare might not pay. This also impacts people with Medigap Plans like Plan G, or Plan N who use Traditional Medicare.

This is part of a new program called WISeR (Wasteful and Inappropriate Services Reduction), aimed at cutting down on unnecessary care and fraud.

📍 Which States Are Affected?

If you live in one of these six states, this change applies to you:

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

📝 What Services Will Require Prior Authorization?

There are 17 services that will need prior authorization. These are often procedures that may be overused or not always necessary. Here’s the full list:

  1. Facet joint interventions (used to treat back pain)
  2. Electrodiagnostic testing (tests nerves and muscles)
  3. Electrical stimulation devices (like TENS units)
  4. Hyperbaric oxygen therapy (used for wound healing)
  5. Spinal cord stimulators
  6. Deep brain stimulation (used for Parkinson’s and other conditions)
  7. Sacral neuromodulation (used for bladder issues)
  8. Transcatheter aortic valve replacement (TAVR)
  9. Knee arthroscopy with lavage and/or debridement
  10. Vertebroplasty/kyphoplasty (used for spinal fractures)
  11. Epidural steroid injections
  12. Non-emergency ambulance transportation
  13. Botulinum toxin injections (Botox for medical reasons)
  14. Negative pressure wound therapy pumps
  15. Hernia repair
  16. Lumbar spinal fusion
  17. Skin substitute products for chronic wounds

Doctors will need to submit paperwork before these services are provided. If not approved first, they risk not getting paid—or patients getting stuck with the bill.

💡 Why Is Medicare Doing This?

The goal is to:

  • Stop overuse of risky or costly treatments
  • Reduce fraud and waste
  • Use new tools like AI to review requests faster (though human doctors will still decide)

⚠️ What This Means for You

  • Your doctor may need more time to get approvals
  • You might have delays before getting certain services
  • Paperwork and wait times could increase

This change will be tested from 2026 through 2031, and if it works well, it could expand to other states or include more services.

✅ Pros and Cons

Pros:

  • Helps reduce fraud and waste
  • Makes sure care is truly needed
  • Encourages use of safer or cheaper options first

Cons:

  • Could delay needed care
  • Adds more paperwork
  • May frustrate patients and doctors

🎥 Want a Quick Summary?

Watch this short video that explains everything simply:

👉 Click here to watch

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