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Original Medicare now requires prior authorization in six states, and most people in them have never heard of it
People choose Original Medicare partly to avoid prior authorization. Since January 2026 a pilot called WISeR has applied it to a narrow list of services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
The short answer
The WISeR model applies prior authorization or prepayment review to a defined list of Original Medicare services in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. It began January 1, 2026 and is scheduled to run through 2031. It does not change what Medicare covers, it does not apply to Medicare Advantage, and it affects a narrow set of procedures rather than routine care.
- Six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
- Original Medicare only: The model does not apply to Medicare Advantage plans, which already use prior authorization.
- Narrow list: Targeted services include skin and tissue substitutes, electrical nerve stimulators, and epidural steroid injections for pain management.
- Timeline: Started January 1, 2026 and scheduled to run through December 31, 2031.
Applies to people with Original Medicare who live in one of the six pilot states and are scheduled for one of the targeted procedures. It does not affect routine office visits, hospital stays, lab work or imaging, and it does not apply to Medicare Advantage members.
What happened
On January 1, 2026, CMS started a pilot called the Wasteful and Inappropriate Service Reduction model, or WISeR. It applies prior authorization or prepayment review to a defined list of services under Original Medicare in six states.
It has been running for nine months. Most people living in those states have never heard of it, because nothing about their card, their premium or their eligibility changed.
| Question | Answer |
|---|---|
| Which states | Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington |
| Which coverage | Original Medicare only, not Medicare Advantage |
| Which services | A narrow published list, not routine care |
| How long | January 1, 2026 through December 31, 2031 |
| Who submits the request | Your provider or supplier, not you |
Why this is worth knowing
A great many people choose Original Medicare with a Medigap plan specifically to avoid prior authorization. It is one of the most common reasons given, and until recently it was straightforwardly true: Medicare Advantage plans use prior authorization, traditional Medicare largely did not.
In these six states, for this narrow list of procedures, that distinction has softened.
It is important not to overstate it. This is a pilot covering a short list of services, not a general requirement across Medicare. Office visits, hospital admissions, lab work and imaging are untouched. If you are on Original Medicare and you are not scheduled for one of the listed procedures, nothing about your care changes.
But if someone told you Original Medicare never involves prior authorization, that statement now needs a footnote in six states.
Which services are on the list
CMS selected procedures it describes as historically associated with fraud, waste and abuse, or as low value to beneficiaries. Published examples include:
- Skin and tissue substitutes
- Electrical nerve stimulators
- Epidural steroid injections for pain management
The pattern is spine, pain management and certain devices. If you are being scheduled for something in those areas and you live in one of the six states, it is a fair question to ask the office.
What actually happens
Your provider submits a prior authorization request through the Medicare Administrative Contractor, which routes it to a technology vendor contracted by CMS for review. Standard requests are expected to be processed within three days, urgent ones within two.
If a provider performs the service without requesting authorization first, the claim goes through prepayment medical review instead, with a request for clinical documentation.
An approved authorization is valid for 120 calendar days from the date of approval, which is worth knowing if your procedure gets rescheduled.
If a request is denied, the provider can resubmit with more documentation, and there is no cap on resubmissions. They can also ask for a peer-to-peer clinical review. Your own Medicare appeal rights are not changed by any of this.
The part that gets argued about
The review uses artificial intelligence and machine learning to support determinations, and the vendors performing it are paid a share of the savings from requests that were reviewed and did not result in a paid claim.
That payment structure is the source of most of the criticism. CMS has said the compensation is performance-adjusted on measures including timeliness and accuracy, and that clinical determinations rest with licensed professionals. Whether that is sufficient is a genuine policy dispute, and in March members of Congress asked House appropriators to include language prohibiting implementation of WISeR or any similar model in traditional Medicare. That concerns the fiscal 2027 appropriations process, so the pilot's future is unresolved.
CMS has also said it plans a gold carding exemption that would spare clinicians with consistent approval records from future review.
What to do if you live in one of the six states
Three practical steps
- If you are scheduled for a spine, pain management or device procedure, ask the office whether a prior authorization determination is pending and on what grounds.
- If your procedure gets rescheduled, check that the approval is still inside its 120-day window.
- If a request is denied, ask the office whether they plan to resubmit or request a peer-to-peer review. Both are available and neither costs you anything.
What this does not warrant is switching plans. A pilot affecting a short list of procedures is not a reason to leave Original Medicare, and the decision to move between Medicare Advantage and Medigap carries consequences that are much harder to reverse than a prior authorization request.
If you are choosing coverage this fall
The honest framing is this. Medicare Advantage plans use prior authorization routinely, across a broad range of services. WISeR applies it to a narrow list, in six states, under Original Medicare. Those are not equivalent, and anyone presenting them as equivalent is selling something.
If avoiding prior authorization is a priority for you, Original Medicare with a supplement is still the route with less of it. Just know that "none at all" is no longer precisely accurate in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
Open enrollment for 2027 coverage runs October 15 through December 7. If you are weighing your options, our guide to the Annual Enrollment Period covers what you can and cannot change, and our Medicare page is the place to start if you would rather talk it through with someone.
Questions people ask
Does this change what Medicare covers?
No. A service Medicare covers is still covered. The model adds a review step before payment for certain procedures. It does not give the reviewing vendors authority to rewrite coverage rules.
Does it apply to Medicare Advantage?
No. WISeR applies only to Original Medicare. Medicare Advantage plans have always used prior authorization, and this pilot exists partly to test the approach on the traditional side.
Which services are affected?
A defined list that CMS describes as prone to overuse or improper billing. Published examples include skin and tissue substitutes, electrical nerve stimulators, and epidural steroid injections for pain management. Your provider can tell you whether a specific procedure is on it.
Do I have to do anything?
No. The request is submitted by your provider or supplier, not by you. The useful step is asking the office whether a determination is pending before your procedure is scheduled.
What if the request is denied?
Your provider can resubmit with additional documentation, and there is no limit on resubmissions. They can also request a peer-to-peer clinical review. Your normal Medicare appeal rights are unaffected.
Is it permanent?
It is a pilot scheduled through 2031, and its future is a live legislative question. Members of Congress have asked appropriators to block funding for it, so the scope could change.
Sources
- CMS Innovation Center, Wasteful and Inappropriate Service Reduction (WISeR) Model, accessed September 19, 2026
- Medicare.gov, How Medicare works with prior authorization and coverage decisions, accessed September 19, 2026
Not sure whether this affects your coverage?
Tell us your state and which plan you have. A licensed advisor will tell you plainly whether the pilot touches you and what, if anything, it changes. One business day, no cost.
Ask about my coverageCall or text (773) 657-9140Smart Insurance Agents LLC is an independent, licensed insurance agency and is not connected with or endorsed by the U.S. government or the federal Medicare program. We do not offer every plan available in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program for information on all of your options. Content is for general information and is not a guarantee of coverage or rates; figures are subject to change by CMS and carriers.