For years, Original Medicare almost never made your doctor ask anyone’s permission. If your doctor said you needed a procedure, you generally got it. That’s one of the best things it had going for it.
In six states, that changed this year. And now we have the first hard numbers on what happened next.
Starting in January, Medicare began requiring advance approval for a short list of procedures in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Outside contractors handle the reviews. Most are tech companies, and Medicare encourages them to use artificial intelligence.
Right away, Original Medicare patients in those states started getting noticeably less of that care. What nobody can tell you yet is whether they needed it.
Here’s what the research found, why it matters even if you live somewhere else, and what to do if a procedure you’re counting on is on the list.
What happened when doctors had to ask first
Researchers at the University of Minnesota and Brown University recently published the first study of the program, known as WISeR, in the journal JAMA. They tapped Epic Cosmos, a health-records database with more than 300 million patient records, and compared the six states with the rest of the country.
Here’s what they found, according to the University of Minnesota’s summary of the study:
- Epidural steroid injections for back pain, the most common service on the list, fell 15% relative to what was happening in the rest of the country.
- The other services on the list fell about 20%.
- Procedures that Medicare originally planned to include, but never did, showed no real drop.
That last finding is the clincher. If something else were driving the drop, those procedures likely would have fallen too. They didn’t. The researchers say that points to the approval requirement itself.
The effect was biggest right out of the gate. For back injections, the gap was roughly 21% in January through March, then shrank to roughly 9% in April through June. For the rest of the list, it barely moved: 21%, then 18%.
Was that care wasteful? Nobody knows
Medicare says the program targets services that are prone to fraud and waste. Maybe some of that missing care was exactly that.
But the researchers are upfront about what they can’t say. Lead author Hannah Neprash, an associate professor at the University of Minnesota School of Public Health, said they still can’t tell “whether the care not received was wasteful or necessary.”
Here’s what bothers me. Make anything harder to get, and people will get less of it. That’s not proof the care was unnecessary. It’s proof the hurdle works.
And the official in charge has acknowledged that most doctors aren’t the problem. Abe Sutton, director of the Center for Medicare and Medicaid Innovation, said in a statement to KFF Health News that “the percentage of providers committing waste, fraud, and abuse is small.”
Meanwhile, patients pay in time and aggravation. KFF Health News reported on a 65-year-old Oklahoma cattle rancher who’d been getting a back injection every three months for years. After he was suddenly told he needed approval, he logged 10 hours of driving to get one.
The same report cited figures from Sen. Maria Cantwell’s office showing that nearly 100 patients in the University of Washington’s health system alone were left waiting for back injections earlier this year because of program delays.
Quick thought — most financial “gurus” got rich selling advice, not following it. I’d rather show you what actually works, because I’ve lived it. Sign up for the free Money Talks Newsletter for money advice from someone who takes his own. 10 seconds, no spam.
Why it matters if you don’t live in those 6 states
WISeR is set to run through 2031, and Medicare can add services to the list along the way. Neprash says the agency is now weighing whether to continue the program or expand it.
In a June statement to KFF Health News, Sutton said no changes to the list were being considered, though the agency keeps evaluating whether any are warranted.
For now, the list covers procedures like these, according to Medicare’s guide for doctors:
- Epidural steroid injections for pain
- Knee arthroscopy for arthritis
- Kyphoplasty and similar procedures for spinal compression fractures
- One type of neck fusion surgery
- Implanted nerve stimulators for chronic pain, sleep apnea, seizures and bladder control
- Skin substitutes for chronic leg and foot wounds (not in Arizona or Washington)
Now here’s the twist, and it matters during open enrollment, which runs through Dec. 7. If these new hoops make you think about switching to Medicare Advantage, think again.
WISeR doesn’t apply to Medicare Advantage plans. They don’t need it. They already require approval, and far more of it.
According to KFF, 99% of Advantage members are in plans that require approval for some services. Medicare Advantage insurers handled nearly 53 million approval requests in 2024. Original Medicare handled just over 625,000 in fiscal 2024.
Before you switch, read which private Medicare plans denied specialized care at the highest rates.
And if you leave Original Medicare, getting back in with good supplemental coverage isn’t guaranteed. Read “Leaving Medicare Advantage This Fall? Medigap Can Turn You Down” before you make a move.
If you live in one of the 6 states, do this
The approval request is your doctor’s job, not yours. But you’re the one who has to live with the result, so stay on top of it.
- Ask before you schedule. If your procedure is on the list, ask the office whether the approval request has gone in. The contractor typically answers within three calendar days, or two if a delay could seriously harm your health.
- Watch your mail. You’re supposed to get a copy of every decision. An approval is good for 120 days, so get the procedure on the calendar.
- Don’t accept the first “no.” A rejected request can’t be appealed on its own. But your doctor can resubmit it as many times as needed with more records, and can ask to talk the case through with one of the contractor’s clinicians. Push the office to do it.
- Read before you sign. If your doctor goes ahead after a rejection, expect to be handed an Advance Beneficiary Notice — a form saying you may have to pay if Medicare won’t. Once Medicare actually denies the claim, your normal appeal rights kick in.
That last point matters more than most people realize. In Medicare Advantage, only 11.5% of denied approval requests were appealed in 2024, and 80.7% of those appeals were overturned in full or in part, KFF found. Different program, same lesson: Many denials don’t hold up when somebody pushes back.
If you’re wondering why the companies doing these reviews might lean toward “no,” we laid out how they get paid in “Medicare Is Letting AI Say No — and the Companies Doing It Get Paid for Denials.”
The bottom line
If you’re in Original Medicare, its best feature is still mostly intact. Outside six states, your doctor rarely has to ask permission.
But this study shows how fast that changes once permission is required. Some care dropped by about 20% compared with other states, and the researchers who studied it can’t yet tell you whether anyone was better off for it.
Keep an eye on what Medicare does with WISeR next. And whatever you decide before Dec. 7, don’t let a headline about red tape push you into a plan with more of it.
Add a Comment