Prior Authorization Coming to Original Medicare in 2026: What It Means for You

Original Medicare will change in a big way starting in 2026. This will affect how you get some medical services. For the first time, Medicare will not pay for some medical surgeries and treatments until you get permission first. This change, which mostly affects people with Original Medicare in some states, is meant to cut down on waste and services that are not needed by making sure that certain treatments are approved before they are paid. There will be prior authorization for Original Medicare in 2026. We will explain what it means, why it is happening, and what you can do to get ready.

What is the WISeR Model?

The WISeR Model, which stands for Wasteful and Inappropriate Service Reduction, is a new initiative introduced by the Centers for Medicare & Medicaid Services. Starting in 2026, this model will require prior authorization for certain medical services under Original Medicare.

How Does the WISeR Model Work?

In order to evaluate prior authorization requests for specific services, the WISeR Model makes use of AI and machine learning (ML). Anytime you need one of these treatments, your doctor will ask Medicare to cover it. AI will first look at the request to see if it meets the requirements for Medicare coverage. The AI will not automatically turn down the request if it thinks it may not satisfy the requirements. Instead, a real doctor or nurse will look over the request to make sure it fits with the rules and your medical needs. With both AI and human review, you can be sure that choices are made correctly and that you get the right care. This process also helps cut down on waste and fraud in the system.

Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington are the six states that will test the plan. More medical services and states may be added in the future if it works out well.

The 17 Services That Will Require Prior Authorization in 2026

17 specific services will now need prior authorization under Original Medicare as part of the WISeR Model. These services were chosen because they have been used too much in the past, cost a lot, or do not always provide clear health benefits. The services that will need prior authorization in 2026 are listed below:

• Electrical Nerve Stimulators
• Sacral Nerve Stimulation for Urinary Incontinence
• Phrenic Nerve Stimulator
• Deep Brain Stimulation for the Essential Tremor & Parkinson’s Disease
• Vagus Nerve Stimulation
• Induced Lesions of Nerve Tracts
• Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
• Epidural Steroid Injections for Pain Management, Excluding Facet Joint Injection
• Percutaneous Vertebral Augmentation for Vertebral Compression Fracture
• Cervical Fusion
• Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee
• Incontinence Control Devices
• Diagnosis and Treatment of Impotence
• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
• Skin and Tissue Substitutes
• Using Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
• Wound Application of Cellular and/or Tissue-Based Products, Lower Extremities

These services will require prior authorization starting in 2026, meaning that before receiving any of these treatments, your doctor will need to get approval from Medicare.

Why These Services Were Chosen

The choice of these services was based on worries about scams, overuse, and a lack of clinical proof to back their regular use. The reason for needing prior authorization is to make sure that only necessary treatments are given. This can help lower total healthcare costs and improve results for patients.

What Does This Mean for You and Your Medicare Plan?

For people with Original Medicare, these changes could affect how they get some medical care starting in 2026. Most services have not needed prior authorizations for Original Medicare in the past, which is why a lot of people choose it in the first place. But now that the WISeR Model is in place, you may have to go through more paperwork for some treatments.

How Will This Affect You?

• Increased Steps for Certain Services: If you need one of the 17 services that require prior authorization, your provider will need to get approval from Medicare before the service can be provided.
• Impact on Medigap Plans: If you have a Medigap plan (a supplement to Original Medicare), you are still covered for the services Medicare covers, but the prior authorization process will still apply. So, if you need one of the services in question, your provider will have to follow the new process for approval.
• Potential Delays: While the goal is to streamline the process, some people may experience delays as prior authorizations need to be processed before services are approved.

The Bigger Picture: WISeR’s Impact on Medicare Advantage

Even though these changes only affect Original Medicare, it is still important to know how they may affect Medicare as a whole. Over Original Medicare, Medicare Advantage is often the better choice for many people because it needs fewer administrative and management difficulties.

Medicare Advantage and Prior Authorization

This new rule for Original Medicare may cause some people to rethink their choices because Medicare Advantage plans already require prior authorization for many services. If you do not like the prior authorization process, Medicare Advantage might become more appealing. This is especially true as more services in Original Medicare may need prior authorizations in the future.

What Should You Do?

Stay Up to Date

The most important thing you can do is to stay informed about these changes. It is important to know which services will be affected, even if not all of them need prior authorizations. You will be helped by your service, but it is always good to know how the new method works.

Reach Out for Help

Feel free to contact LMS Insurance Group if you have any questions about how these modifications will affect your Medicare plan or if you need help with the new process. Our team can help you understand how the WISeR Model’s prior authorization works and give you advice that is specific to your case.

Conclusion

Prior authorization for Original Medicare will be required for some treatments starting in 2026. You may have to change how you get care because of this change, but the goal is to cut down on waste, scams, and services that are not needed, which will make the healthcare system better for everyone in the long run. LMS Insurance Group is here to help you if you need help with your Medicare plan or are worried about how these changes might affect you.

Do not hesitate to contact us immediately for further information.