Medicare Shake-Up: 4 Things to Know About Prior Authorization Changes for 2026

For decades, Original Medicare (sometimes called traditional Medicare) has been known for its simplicity.

Beneficiaries rarely needed prior authorization before receiving care, unlike those enrolled in Medicare Advantage plans. That is about to change.

Starting Jan. 1, 2026, the federal government’s Centers for Medicare and Medicaid Services (CMS) will introduce a new pilot prior-authorization program in select states. Here’s what you should know about how it could affect you.

1. The changes start in six states

The new prior-authorization requirements will be piloted in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.

If you live in one of these states and are enrolled in Original Medicare, some procedures that used to be straightforward will soon require advance approval.

CMS describes the program as a test model that will run through 2031, but its scope and duration mean the changes are significant. Beneficiaries in these states will be the first to feel the impact, and the results could influence whether the model is expanded nationwide in the future.

2. Seventeen services will be affected

CMS has identified 17 services it says are especially vulnerable to fraud, waste or abuse. Beginning in 2026, these will require prior authorization under the new model:

1. Electrical nerve stimulators
2. Sacral nerve stimulation for urinary incontinence
3. Phrenic nerve stimulator
4. Deep brain stimulation for essential tremor and Parkinson’s disease
5. Vagus nerve stimulation
6. Induced lesions of nerve tracts
7. Epidural steroid injections for pain management (excluding facet joint injections)
8. Percutaneous vertebral augmentation (PVA) for vertebral compression fracture
9. Cervical fusion
10. Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee
11. Hypoglossal nerve stimulation for obstructive sleep apnea
12. Incontinence control devices
13. Diagnosis and treatment of impotence
14. Percutaneous image-guided lumbar decompression for spinal stenosis
15. Skin and tissue substitutes
16. Application of bioengineered skin substitutes to lower extremity chronic non-healing wounds
17. Wound application of cellular and tissue-based products (CTPs) to lower extremities

For beneficiaries, this means that treatments once scheduled directly through a provider may now require extra paperwork and approval before moving forward.

3. The program will run through 2031

CMS plans to run the program through Dec. 31, 2031, under what it calls the Wasteful and Inappropriate Service Reduction (WISeR) Model. This gives the agency six years to evaluate whether stricter controls on certain services reduce costs and prevent fraud.

If successful, the program could become a permanent feature of Original Medicare or expand to additional states and services.

4. Technology will support reviews but not replace clinicians

CMS plans to use advanced tools such as artificial intelligence and machine learning to streamline the process of reviewing prior-authorization requests for the 17 affected services. These technologies are designed to speed up requests and cut down on unnecessary paperwork.

However, CMS emphasizes that licensed clinicians will make the final decisions. A request can only be denied if it does not meet Medicare’s coverage requirements, and human reviewers, not algorithms, will make that judgment.

Preventive care remains essential, especially as access rules evolve. Life Line Screening reveals hidden risks so you can act early. Book a screening today and have peace of mind.

How to prepare for the new rules

Prior authorization has long been a frustration for patients in Medicare Advantage plans, and critics warn that expanding it to Original Medicare could lead to increased delays. Beneficiaries in the six pilot states should prepare for this change.

Here are some practical steps to consider:

• Check if you might need a service on the list. For example, if you are being treated for chronic pain, spinal conditions or sleep apnea, ask your provider whether upcoming procedures are affected.
• Schedule elective procedures early. If you are already considering one of the affected treatments, completing it before Jan. 1, 2026, could help you avoid issues.
• Talk with your doctor about documentation. Prior authorization often hinges on detailed medical records. Having paperwork ready may shorten approval times.
• Strengthen your financial backup. Even with Medicare coverage, unexpected out-of-pocket expenses can pop up. Earn as much as possible on your emergency savings. SoFi Checking is offering up to 4.50% APY and a bonus of up to $300 with direct deposit. (May change without notice.)
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Medicare’s goal is to protect taxpayer dollars and reduce fraud, but for patients, the reality is more paperwork, potential wait times and even denial of service. Planning ahead now can help ensure that you get the care you need without unnecessary disruption.