Medicare beneficiaries aged 65 and older traditionally have the option to select between the classic Medicare program and Medicare Advantage plans. One of the key advantages of traditional Medicare has been its limited use of prior authorizations, simplifying patient access to necessary medical services by eliminating additional insurer approval steps.
However, this established pattern is shifting with the launch of a new pilot program that introduces prior authorization requirements for certain medical interventions. The initiative, set to take effect in six states, represents a fundamental change to how traditional Medicare manages care authorization.
The affected states include New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Together, these regions account for approximately 6.4 million Americans enrolled in traditional Medicare. Participants in these areas will now be subject to the pilot program, which leverages artificial intelligence technology to evaluate requests for payment coverage of select medical services.
Named the Wasteful and Inappropriate Service Reduction (WISeR) model, this pilot changes the operational landscape by imposing pre-approval procedures similar to those common in Medicare Advantage, a private sector alternative known for more rigorous authorization protocols.
The WISeR pilot requires prior authorization for 17 distinct types of procedures and treatments under traditional Medicare. These include a range of interventions, from specialized surgeries and nerve stimulation devices to skin substitute applications and pain management injections. Specifically, the mandated pre-authorizations concern:
- Arthroscopic lavage and debridement for osteoarthritis in the knees
- Application of bioengineered skin substitutes to chronic lower limb wounds
- Cervical fusion surgeries
- Deep brain stimulation for essential tremor and Parkinson's disease treatment
- Electrical nerve stimulators
- Epidural steroid injections, excluding facet joint injections, for pain management
- Hypoglossal nerve stimulation targeting obstructive sleep apnea
- Incontinence control devices
- Diagnosis and treatment for impotence
- Percutaneous vertebral augmentation
- Image-guided lumbar decompression procedures for spinal stenosis
- Phrenic nerve stimulators
- Sacral nerve stimulation aimed at urinary incontinence relief
- Skin and tissue substitutes
- Surgeries inducing lesions in nerve tracts
- Vagus nerve stimulation
- Application of cellular or tissue-based products to lower limb wounds
The introduction of these new pre-authorization rules has prompted concern among healthcare advocates and lawmakers. Critics argue that requiring prior approval can generate significant delays and administrative burdens for both patients and healthcare providers. For instance, several Democratic senators opposed the expansion of prior authorization within traditional Medicare. Washington Senator Patty Murray expressed apprehensions that the program would force seniors into prolonged waiting periods and complex paperwork hurdles to receive medical care deemed necessary by their doctors.
Despite opposition, the pilot is beginning in January, and Medicare beneficiaries within the affected states must now navigate this changed approval landscape. If approvals are not granted, retirees may need to consider alternative funding methods to cover these healthcare expenses, such as drawing from their personal retirement savings.