Major Developments on Medicare Prior Approval - August 28, 2025

WASHINGTON, D.C. (August 28, 2025) - Two significant reports published today underscore the growing role of prior authorization in traditional Medicare, a process once confined almost entirely to Medicare Advantage plans.

JAMA Analysis Highlights Early Impact of WISeR Model

The Journal of the American Medical Association released an in-depth commentary today examining the first data emerging from CMS’s Wasteful and Inappropriate Service Reduction (WISeR) Model. The article, “Expanding Prior Authorization in Traditional Medicare-The WISeR Model,” outlines how the pilot-launched in six states on January 1, 2026-has subjected roughly 0.4 percent of Part B spending to prior authorization reviews, with initial denial rates between 26 percent and 32 percent and average review times of 4-6 days. The authors warn that although the program aims to curb fraud and low-value care, it may introduce delays in clinically necessary services and exacerbate clinician administrative burden.

Financial Outlook: Next Year’s Prior Approval Requirements

In a separate article published online today, Investopedia included the new prior authorization requirements for Original Medicare in its “10 Big Medicare Changes in 2026” roundup. The report notes that starting January 1, 2026, providers in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington must secure Medicare approval before performing 17 designated services-ranging from skin and tissue substitutes to knee arthroscopy-while emergency and inpatient care remain exempt. The piece emphasizes that this represents an unprecedented expansion of utilization management into traditional fee-for-service Medicare and could reshape patient access and provider workflows in the coming year.

Outlook and Stakeholder Response

• CMS officials maintain that licensed clinicians, not algorithms, will make final coverage decisions, even as contractors employ AI-powered tools to expedite reviews.
• Provider groups and some lawmakers have voiced concerns that financial incentives for denying approvals could lead to underuse of beneficial treatments.
• CMS will monitor pilot outcomes through 2031 before deciding whether to scale the model nationwide.

As traditional Medicare adapts elements long characteristic of Medicare Advantage, all eyes are on the WISeR pilot’s performance metrics and its broader implications for patient care, administrative burden, and federal spending.