Medicare To Require ‘Prior Authorization’ for Procedures in 2026

Starting January 1, 2026, Medicare will roll out a new requirement that could significantly change how millions of patients access care. Under the Wasteful and Inappropriate Service Reduction (WISeR) Model, certain medical procedures will require “prior authorization” before being approved. The program will launch as a six-year pilot across six states, sparking both hope for efficiency and concern over delayed patient care.

What Is Prior Authorization?

Prior authorization is a process where insurers require doctors to obtain approval before a patient undergoes certain treatments, tests, or prescriptions. While it’s common in private insurance, critics argue it creates barriers to timely care. Supporters say it prevents unnecessary or low-value medical services, ultimately lowering costs. With Medicare set to adopt it, millions of beneficiaries may soon face new administrative hurdles.

CMS and the WISeR Model

The Centers for Medicare & Medicaid Services (CMS) announced the WISeR Model in June 2025 as a way to target inefficiencies and reduce unnecessary spending. According to CMS, the model is designed to address “wasteful and inappropriate services” that not only drain the program financially but can also expose patients to unneeded risks.

Timeline and Pilot States

The pilot program begins on January 1, 2026, and is set to run for six years. Initially, it will launch in Arizona, New Jersey, Oklahoma, Ohio, Texas, and Washington. Within these states, CMS will work with selected companies to test how prior authorization impacts patient outcomes, costs, and provider workloads (Time).

Types of Procedures Affected

While CMS has not yet published the full list, prior authorization will likely target high-cost or frequently misused services. This could include advanced imaging like MRIs, elective orthopedic surgeries, and certain specialty drugs. These categories are often flagged for overuse, making them prime candidates for tighter oversight.

Concerns From Advocacy Groups

Patient advocates are worried the program could restrict access to necessary care. The Center for Medicare Advocacy warns that prior authorization often leads to delays, denials, and patient frustration, particularly for older adults who may already struggle with complex healthcare systems. They caution that efficiency should not come at the expense of timely treatment.

CMS’s Justification

CMS defends the move as a safeguard against waste. Officials point to studies showing that unnecessary procedures not only cost taxpayers billions but can also pose health risks, such as avoidable surgeries or redundant scans. By adding this layer of review, CMS argues, patients could be spared from interventions that may do more harm than good (CMS).

How Patients Could Be Impacted

For patients, the change may mean longer waits for approval before undergoing treatment. However, supporters argue it may also save them from risky, unnecessary procedures. Beneficiaries in the pilot states should be prepared for more communication with providers and insurers as the system rolls out.

Impact on Doctors and Hospitals

Doctors and hospitals may feel the pinch from increased administrative tasks. Prior authorization often requires paperwork, follow-up calls, and delays in scheduling, which can strain already overburdened staff. Hospitals warn that this could frustrate both providers and patients, though CMS hopes the program will encourage more careful medical decision-making.

Looking Ahead

The WISeR Model is expected to run until 2032, with CMS closely tracking its effectiveness. If it proves successful in reducing waste without significantly harming patient care, the program could expand nationwide. For now, beneficiaries and providers in the pilot states should prepare for a new era of oversight in Medicare.