top of page

New Medicare Changes in 2026: Prior Approval Required for These 17 Services

Updated: Oct 8

Prior Authorization Form

Beginning January 1, 2026, certain medical procedures under Traditional Medicareย will require prior authorizationย in six U.S. states. This means your healthcare provider must obtain approval from Medicare beforeย performing specific servicesโ€”otherwise, coverage may be denied.

This update also affects individuals with Medigap plansย such as Plan Gย or Plan N, if they're using Traditional Medicare coverage.

The change is part of a pilot initiative called WISeRย (Wasteful and Inappropriate Services Reduction), which is designed to curb medical overuse and detect potential fraud.



๐Ÿ“ Which States Will See These Medicare Changes in 2026?

Residents in the following six states will be included in the initial rollout:

  • Arizona

  • New Jersey

  • Ohio

  • Oklahoma

  • Texas

  • Washington



๐Ÿ“ Which Medical Services Are Affected?

A total of 17 types of proceduresย will now need prior approval. These services are often flagged for being overused or not always medically necessary. Here's whatโ€™s on the list:

  • Electrical Nerve Stimulators

  • Sacral Nerve Stimulation for Urinary Incontinence

  • Phrenic Nerve Stimulator

  • Deep Brain Stimulation for Essential Tremor and Parkinsonโ€™s Disease

  • Vagus Nerve Stimulation

  • Induced Lesions of Nerve Tracts

  • Epidural Steroid Injections for Pain Management

  • Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture

  • Cervical Fusion

  • Arthroscopic Lavage and Arthroscopic Debridement for 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 (including bioengineered skin and CTP wound applications)


For these treatments, physicians will be required to submit documentation beforeย the service is performed. If approval isnโ€™t granted, coverage could be deniedโ€”leaving patients to pay out of pocket. Here is the official Federal Registry document.



๐Ÿ’ก Why Is This Happening?

The main goals of this policy include:

  • Preventing unnecessary or high-risk procedures

  • Lowering healthcare costs by avoiding waste

  • Combatting Medicare fraud

  • Using advanced tools, like AI, to streamline request reviews (with final decisions still made by human reviewers)



โš ๏ธ What It Could Mean for You

  • Doctors might need extra timeย to get necessary approvals

  • Some treatments could be delayedย due to administrative steps

  • Patients may face more paperworkย and longer wait times

The WISeR program is scheduled to run through 2031. If proven effective, it may be expanded to more states or additional services.



โœ… Key Takeaways: Pros & Cons

Benefits:

  • Helps eliminate fraudulent or unnecessary care

  • Encourages more appropriate and cost-effective treatment

  • May improve patient safety by requiring thorough review


Drawbacks:

  • Potential for delays in receiving needed treatments

  • More administrative work for healthcare providers

  • Could cause frustration for both patients and doctors

If you live in one of the six pilot states, now is a good time to talk with your healthcare provider about how this change might impact your future care. Planning ahead can help you avoid surprises once these new requirements go into effect.

bottom of page