Medicare prior authorization for procedures

Plan year 2026. The pilot facts on this page are the 2026 position, read from CMS on August 12, 2026. What changed for 2026: the WISeR Model began on January 1, 2026 in six states. The nationwide hospital outpatient department process did not change. It has run since July 1, 2020, with two more service categories added in 2021 and one more in 2023.

Your doctor schedules a procedure in a hospital outpatient department. For a short list of services, a request for approval has to go in before it is delivered.

What is worth knowing is which of Medicare's two prior authorization programs your procedure falls under. Only one of them is new, and only one has states.

What is prior authorization for procedures?

It is a review that happens before the service rather than after it. CMS established a nationwide prior authorization process for certain hospital outpatient department services, in force since July 1, 2020. Original Medicare now runs two such programs, not one, and only one of them has states.

Original Medicare now runs two such programs, not one, and only one of them has states.

Start with the nationwide one, because it is the one that applies wherever you live. CMS created it through the Calendar Year 2020 Outpatient Prospective Payment System and Ambulatory Surgical Center Final Rule, under a section of the Social Security Act that lets the Secretary establish methods to control unnecessary increases in the volume of hospital outpatient department services. CMS shortens hospital outpatient department to OPD.

CMS states what it expects the process to do, and the third part of that sentence is the one providers care about. It says the process will ensure that Medicare beneficiaries continue to receive medically necessary care, while protecting the Medicare Trust Fund from improper payments, and at the same time keeping the medical necessity documentation requirements unchanged for providers.

The second program is newer and much narrower. CMS describes the Wasteful and Inappropriate Service Reduction Model, which it calls WISeR, as a model that uses enhanced technologies such as artificial intelligence and machine learning, along with human clinical review, to ensure timely and appropriate Medicare payment for select items and services. CMS calls it a voluntary model.

WISeR runs for six performance years, from January 1, 2026 to December 31, 2031, in six states.

One boundary before going further, stated once and then dropped. This page is about procedures under Part B. Prior authorization inside a Medicare drug plan is a different subject with different rules, and it has its own page in this publication.

Which services need it?

The nationwide program names eight service categories, added in three waves. Five from July 1, 2020: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. Two from July 1, 2021. One from July 1, 2023. The six state pilot covers a different, separate set.

The two later waves are short. Implanted spinal neurostimulators and cervical fusion with disc removal joined for services provided on or after July 1, 2021. Facet joint interventions joined for services provided on or after July 1, 2023.

Those eight are the categories CMS names for the nationwide process.

The program	Where and when it applies	The trap
Nationwide hospital outpatient department process	Everywhere, since July 1, 2020	Thinking prior authorization in Original Medicare started in 2026
The WISeR Model	Six states, January 1, 2026 to December 31, 2031	Thinking it applies to Medicare Advantage

The pilot's list is built differently. CMS gives three examples rather than a closed list: skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis.

It also publishes the three tests a service had to pass to be selected. It may pose concerns related to patient safety if delivered inappropriately. It has existing publicly available coverage criteria. And it may involve prior reports of fraud, waste and abuse.

What the pilot leaves out is stated plainly and it is worth holding on to. The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.

Who requests it?

Your provider, not you, and the published answer is about the six state pilot. CMS states that providers and suppliers there choose between submitting a prior authorization request for a selected service and going through a review of the claim after the service instead.

The choice is real and CMS spells out both halves of it. Providers and suppliers for people with Original Medicare in selected regions may submit a prior authorization request for the model's selected items and services, or they may go through a post-service and pre-payment review.

Those who choose the prior authorization route have two ways in. They may submit the request directly to the model participant, or through their Medicare Administrative Contractor, which CMS shortens to MAC, and which then forwards the request to the model participant.

Those who do not submit are not simply paid. CMS states that if providers or suppliers opt not to submit a request for an included service, their claim is subject to medical review to ensure the delivered service met Medicare coverage, coding and payment criteria prior to payment.

So the review happens either way under the pilot. What the provider chooses is when it happens, before the service or after the claim.

CMS also describes an exemption, and it writes it in the future tense. Providers and suppliers with demonstrated records of compliance may be exempt from the WISeR review process in the future.

CMS calls that exemption a gold card. It says the exemption would reduce administrative burden while letting participants focus their resources on providers and suppliers at higher risk of delivering unnecessary care. Both hedges are CMS's own: may be, and in the future.

The nationwide process is where the sourcing stops, and this page says so rather than filling the gap. CMS's page for it does not state who submits a request. This publication read that page on August 12, 2026 and found no filer named on it, and that absence is our finding rather than CMS's statement.

What CMS does say about the nationwide process points the same way without naming anyone. It states that the process keeps the medical necessity documentation requirements unchanged for providers, so the paperwork it describes sits with providers rather than with you.

How long does a Part B prior authorization take?

Seven calendar days for a standard decision, on requests submitted on or after January 1, 2025. CMS changed that timeframe from 10 business days. Expedited requests stay at 2 business days. Both figures belong to the nationwide hospital outpatient department program, not to the pilot.

The change is worth reading twice, because it shortened the wait and changed units at the same time. The old rule was 10 business days. The new rule is 7 calendar days. Those are different units, so the two numbers cannot be compared directly.

CMS dated the change to requests submitted on or after January 1, 2025, and left the expedited timeframe alone at 2 business days.

CMS publishes no decision deadline for the six state pilot. Its model page states no number of days, and neither do the three sections this publication expanded on it.

That absence is this publication's own finding, checked on August 12, 2026. This page does not fill it with the nationwide figure, because the two programs are separate and their published rules are separate.

What if it is denied?

CMS calls the answer non-affirmative rather than denied. Under the six state pilot, every recommendation for non-payment is made by an appropriately licensed clinician applying standardized, transparent and evidence-based procedures. Appeals are a separate subject and this publication carries them elsewhere.

Read that safeguard next to what CMS says the technology does, and note that the two sentences say different things. The model uses artificial intelligence and machine learning along with human clinical review. The recommendation not to pay is determined by a licensed clinician. CMS states one as a method and the other as a requirement, and this page states each at its own strength.

CMS's clearest illustration of what non-affirmative means is a change it made to the nationwide list. It removed two billing codes, 64492 and 64495, from the codes requiring prior authorization, and it published the reasoning.

Under the revised coverage determinations for facet joint interventions, three-level and four-level procedures are not medically necessary and non-covered. The decision on such a request would therefore always be non-affirmative, so submitting it would be unnecessary.

That is the useful thing to take from it. A non-affirmative answer is a statement about whether the service meets Medicare's coverage and payment rules, not a statement about the surgeon.

CMS also draws a boundary around what the pilot decision does not do. WISeR does not change Medicare coverage or payment policy. Payment to providers and suppliers for covered items and services does not change under the model.

Where an unfavourable decision goes next, what the appeal levels are and what the deadlines are, are carried by the Appeals section of this publication rather than by this page.

Which states are in the pilot?

Six, and CMS publishes them rather than leaving them to be reconstructed. New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. WISeR runs there for six performance years, from January 1, 2026 to December 31, 2031, and it does not apply to people with Medicare Advantage.

CMS states the exclusion in its own words: WISeR does not apply to people with Medicare Advantage and will have no impact on them. This pilot sits on the Original Medicare side of that line.

The participants are not states or contractors. CMS describes them as companies with expertise providing recommendations on medical necessity of coverage for payers, using enhanced technology like AI.

It attaches a requirement to them in the same breath. They are required to have clinicians with the expertise to conduct medical reviews to validate determinations.

Each selected participant covers a jurisdiction or region. This page does not name which company sits in which state, because each of those six states has its own page planned here.

Now the part CMS publishes about how the reviewers are paid. Call it the Published Percentage.

In the section that names the participants, CMS also states how they are paid. Model participants receive a percentage of the expenditures associated with averted wasteful, inappropriate care as a result of their reviews.

CMS adds one more line about that percentage. It is adjusted based on the participant's performance on measures related to the process, including provider experience.

Three facts sit together there, and all three are the government's. The reviewers must have clinicians. Any recommendation not to pay is made by a licensed clinician. And the reviewers are paid a share of what their reviews avert, on a percentage that moves with provider experience scores.

Noticing that CMS published the payment mechanism at all, and setting it beside the two safeguards it published in the same place, is ours.

What is not ours to say, and is not said here. CMS does not call this a conflict. It does not publish the percentage. It does not state that the arrangement has changed any decision. No source read for this page states any of those things, so this page states the three published facts and stops.

CMS frames the model as a first of its kind. It says WISeR is the first Innovation Center model in which technology innovators are the only model participants, and the first that incentivizes the use of cutting-edge tools to ensure that payment complies with Medicare documentation, coverage, payment and coding rules.

Alongside all of it, CMS states what does not move. Health care coverage for people with Medicare does not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice.

What this means for you

Prior authorization in Original Medicare is two programs, not one. Eight categories of hospital outpatient service have needed it nationwide since 2020. The six state pilot that started in 2026 is the newer part, it is voluntary for providers, and CMS states that it does not change what Medicare covers.

If you live in one of the six states and a selected service is being planned, the question to ask your provider is which route they are taking, because CMS gives them a choice between a decision before the service and a review after the claim.

If you live anywhere else, the nationwide list is the one that reaches you, and it is eight categories long. What happens after an unfavourable decision, and how Medicare appeals work, are carried by the Appeals section.

FAQ

Is prior authorization in Original Medicare new in 2026?

No. The nationwide part has been in force since July 1, 2020. CMS established a prior authorization process for certain hospital outpatient department services through its Calendar Year 2020 payment rule, and the first five categories applied to services provided on or after July 1, 2020: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation.

Two more joined for services provided on or after July 1, 2021, implanted spinal neurostimulators and cervical fusion with disc removal. Facet joint interventions joined for services provided on or after July 1, 2023.

What is new in 2026 is a separate six state pilot, the WISeR Model, which CMS runs from January 1, 2026 to December 31, 2031. The two are different programs with different lists, and the older one is the one that applies in every state.

What does non-affirmative mean?

It is CMS's term for a prior authorization request that does not get approved, and CMS's clearest example of it is a change it made to its own list. It removed billing codes 64492 and 64495 from the codes requiring prior authorization, and published the reason.

Under the revised coverage determinations for facet joint interventions, three-level and four-level procedures are not medically necessary and non-covered, so the decision on such a request would always be non-affirmative and submitting it would be unnecessary. That shows what the answer is about.

Under the six state pilot, CMS states that every recommendation for non-payment is determined by an appropriately licensed clinician applying standardized, transparent and evidence-based procedures to the review.

Does the WISeR pilot change what Medicare covers or pays?

CMS says no, in four separate sentences on the model page. WISeR does not change Medicare coverage or payment policy. Health care coverage for people with Medicare does not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice.

Payment to providers and suppliers for covered items and services does not change under the model. And WISeR does not apply to people with Medicare Advantage and will have no impact on them.

What the model changes is when and how a coverage decision gets reviewed for a selected set of items and services, in six states, for six performance years. The coverage rules being applied are the ones that already existed, which is why CMS required the selected services to have publicly available coverage criteria.

What happens if my provider does not submit a request?

The claim still gets reviewed, just later. CMS states that if providers or suppliers opt not to submit a request for an included service, their claim is subject to medical review to ensure the delivered service met Medicare coverage, coding and payment criteria prior to payment.

That is why CMS describes the model as voluntary and describes the provider's decision as a choice. Providers and suppliers in the selected regions may submit a prior authorization request for the model's selected items and services, or go through a post-service and pre-payment review instead.

Either route ends in a review of whether the service met Medicare's rules. The difference is timing. One happens before the service is delivered and the other happens before the claim is paid.

What is a gold card?

It is an exemption CMS describes for the future rather than one it has granted. CMS states that providers and suppliers with demonstrated records of compliance may be exempt from the WISeR review process in the future, and calls that exemption a gold card.

Its stated purpose is to reduce administrative burden while allowing model participants to focus their resources on providers and suppliers at higher risk of delivering unnecessary care.

Two hedges in CMS's own sentence are worth keeping rather than smoothing away: may be exempt, and in the future. CMS's sentence names no criteria, no date and no process, so what a demonstrated record of compliance amounts to is not something this page can state.