Table of Contents
- Understanding the Medicare Authorization Shift
- The Trump Administration’s Anti-Fraud Initiative
- WISeR Model Implementation Details
- Complete List of 17 Affected Services
- Political Response and Criticism
- Current Prior Authorization Landscape
- What This Means for Beneficiaries
Understanding the Medicare Authorization Shift
Traditional Medicare is undergoing its most significant operational change in decades. Starting January 1, 2026, the Centers for Medicare and Medicaid Services (CMS) will implement prior authorization requirements for certain traditional fee-for-service Medicare services across six states. This represents a fundamental shift from Medicare’s historically hands-off approach to service approvals.
Unlike Medicare Advantage plans, which have long required extensive prior authorizations, Original Medicare has traditionally operated with minimal pre-approval requirements. This freedom has been one of the key distinguishing features between traditional Medicare and Medicare Advantage plans, making the upcoming changes particularly noteworthy for millions of beneficiaries.
The Six-State Testing Ground
The initial rollout will target New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington as testing states for the new Wasteful and Inappropriate Service Reduction (WISeR) Model. These states were strategically selected to provide geographic diversity and varying healthcare utilization patterns, enabling CMS to gather comprehensive data on the program’s effectiveness.
This phased approach allows CMS to “test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars,” according to the official press release.
The Trump Administration’s Anti-Fraud Initiative
DOGE’s Influence on Healthcare Policy
The second Trump administration has made fraud, waste, and abuse elimination a cornerstone priority. The inception of the Department of Government Efficiency (DOGE) brought tech-savvy staff specifically tasked with identifying inefficiencies across government programs, including Medicare and Social Security.
This healthcare initiative represents a direct continuation of DOGE’s mission, with HHS and CMS spearheading efforts to streamline and improve prior authorization processes across multiple insurance sectors. The agreement among private insurance companies pledges to enhance authorization procedures for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace, and commercial plans covering nearly 80% of Americans.
National Health Care Fraud Takedown Results
The Justice Department’s 2025 National Health Care Fraud Takedown demonstrates the scope of the problem. Released on June 30, 2025, the results included charges against more than 300 defendants accused of various healthcare fraud schemes, validating the need for enhanced oversight measures.
A particularly egregious case from Arizona involved three defendants who allegedly conspired to provide unnecessary skin grafts to elderly Medicare recipients. These “amniotic wound allografts” generated over $1 billion in false claims to Medicare, with many victims being terminally ill hospice patients—highlighting the vulnerability of Medicare beneficiaries to fraudulent practices.
WISeR Model Implementation Details
Technology-Enhanced Review Process
The WISeR Model leverages cutting-edge technology including artificial intelligence and machine learning to identify and reduce wasteful or low-value services with little to no clinical, evidence-based benefit. However, CMS emphasizes that human oversight remains paramount in the decision-making process.
“While technology will support the review process, final decisions that a request for one of the selected services does not meet Medicare coverage requirements will be made by licensed clinicians, not machines,” CMS explained. This human-centered approach aims to address concerns about AI-driven healthcare decisions while maintaining efficiency gains.
Operational Framework and Safeguards
The model includes several important protections for beneficiaries:
- Emergency services remain exempt from prior authorization
- Inpatient-only procedures that would pose substantial patient risk if delayed are excluded
- Existing Medicare coverage and payment rules remain unchanged
- Providers can choose between prior authorization or post-service/pre-payment medical review
CMS Administrator Dr. Mehmet Oz stated, “CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare.” The program runs from January 1, 2026, through December 31, 2031, providing a five-year testing period.
Complete List of 17 Affected Services
The following services will require prior authorization under the WISeR Model:
Neurological and Pain Management Services
- Electrical nerve stimulators
- Sacral nerve stimulation for urinary incontinence
- Phrenic nerve stimulator
- Deep brain stimulation for essential tremor and Parkinson’s disease
- Vagus nerve stimulation
- Induced lesions of nerve tracts
- Epidural steroid injections for pain management (excluding facet joint injections)
Surgical and Orthopedic Procedures
- Percutaneous vertebral augmentation (PVA) for vertebral compression fracture
- Cervical fusion
- Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee
- Percutaneous image-guided lumbar decompression for spinal stenosis
Specialized Treatment Services
- Hypoglossal nerve stimulation for obstructive sleep apnea
- Incontinence control devices
- Diagnosis and treatment of impotence
Wound Care and Tissue Services
- Skin and Tissue Substitutes
- Application of bioengineered skin substitutes to lower extremity chronic non-healing wounds
- Wound Application of cellular and/or tissue based products (CTPs), lower extremities
Political Response and Criticism
Bipartisan Concerns Emerge
Criticism has emerged from both sides of the political spectrum, reflecting concerns about the potential impact on patient care and access to services.
Rep. Suzan DelBene (D-Wash.), whose state participates in the pilot program, expressed frustration: “It’s baffling how in one breath the administration is trying to take a victory lap on insurers streamlining prior authorization in Medicare Advantage, and in the other instituting the same delay tactics in traditional Medicare.”
Conservative Skepticism
From the conservative perspective, Michael Baker, director of healthcare policy at the American Action Forum, questioned the administration’s approach to prior authorization reform. Baker warned that “adding a duplicative third party to the already established Medicare Administrative Contractor network, particularly one that may be using untested artificial intelligence, machine learning, or algorithmic decision logic, may only increase the overall administrative burden and delay beneficiary care.”
Current Prior Authorization Landscape
Traditional Medicare vs. Medicare Advantage
The contrast between traditional Medicare and Medicare Advantage authorization requirements remains stark. Traditional Medicare currently requires prior authorization for only a limited set of services, including certain outpatient hospital services, non-emergency ambulance transport, and durable medical equipment. In 2023, fewer than 400,000 prior authorization reviews were submitted for traditional Medicare beneficiaries.
Medicare Advantage operates under a dramatically different model. According to the Kaiser Family Foundation (KFF), 99% of Medicare Advantage enrollees must obtain prior authorization for some services, typically higher-cost procedures such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy treatments.
What This Means for Beneficiaries
Preparing for the Changes
Medicare beneficiaries in the six pilot states should prepare for potential changes in their healthcare experience starting January 1, 2026. While emergency care and truly urgent procedures remain protected, routine services on the authorization list may require additional planning and lead time.
Providers and suppliers will need to adapt their workflows to accommodate either prior authorization requests or post-service medical reviews. This transition period may initially create some delays as healthcare systems adjust to the new requirements.
Long-term Implications
The success or failure of the WISeR Model will likely influence future Medicare policy decisions. If the pilot program demonstrates effective fraud reduction without significant patient care disruption, CMS may expand prior authorization requirements to additional services and states. Conversely, significant operational challenges or patient access issues could lead to program modifications or discontinuation.
The integration of AI and machine learning technologies in Medicare administration represents a significant technological advancement that could reshape how government healthcare programs operate in the digital age.
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