Beginning January 1st, 2026 some medical procedures under traditional Medicare will require Prior Authorization in six states before performing the service. Yes, Washington state has been selected. Arizona, New Jersey, Ohio, Oklahoma, and Texas.
This updates individuals with Medigap plans such as Plan G or Plan N, if they are using traditional Medicare coverages. While common in health plans and Medicare Advantage Plans these are new for original Medicare.
This change is part of a trial program called WISeR (Wasteful and Inappropriate Services Reduction). It is designed to curb medical overuse and detect potential fraud.
What Procedures will require a Prior Authorization?
There were 17 types of procedures that were flagged to now need approval. Here is what made the list.
- 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
Physicians will be required to submit documentation before the service is performed. If approval is not granted, coverage can be denied requiring the patient to pay out of pocket.
Who made this decision for Prior Authorization?
This was a rules change with the Centers for Medicare & Medicaid Services (CMS), Department of Health and Huma Services. Every administration picks there team to implement programs that they feel will have the biggest impact for consumers. They did a press release in June regarding this matter and it is estimating that they spent 25% of healthcare on services that had little to no clinical benefit. HHS Secretary Kennedy, CMS Administrator OZ pledge to fix Prior Authorization system.
At Wenatchee Insurance we do our best to lend a hand in understanding and enrolling in Medicare and insurance Programs. We are an independent insurance agency. If you are looking at supplemental policies then let us know and there are enrollment periods.
