Medicare Part B – Preauthorization? Yes.

In 2026, Medicare Part B will implement new prior authorization requirements for certain services in a pilot program called the Wasteful and Inappropriate Services Reduction (WISeR) Model. This model will initially apply to providers in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

The services that will require prior authorization under the WISeR Model include:

·         Deep brain stimulation for Parkinson's disease and essential tremor

·         Epidural steroid injections for pain management (excluding facet joint injections)

·         Cervical fusion

·         Skin and tissue substitutes (application of bioengineered skin substitutes to lower extremity chronic non-healing wounds, and application of cellular and/or tissue-based products (CTPs) to lower extremities)

·         Knee arthroscopy for osteoarthritis (arthroscopic lavage and arthroscopic debridement)

·         Electrical nerve stimulators and stimulation (including phrenic nerve stimulator, vagus nerve stimulation, and hypoglossal nerve stimulation for obstructive sleep apnea)

·         Induced lesions of nerve tracts

·         Percutaneous vertebral augmentation (PVA) for vertebral compression fracture

·         Incontinence control devices

·         Diagnosis and treatment of impotence

·         Percutaneous image-guided lumbar decompression for spinal stenosis

These services were selected based on evidence of potential fraud, waste, and abuse, patient safety concerns, availability of National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), and cost-saving opportunities.

It's important to note that this is a model, and providers in these states will have a choice to either submit a prior authorization request or undergo a post-service prepayment medical review for these specific items and services. Services that are inpatient-only, emergency services, or those that would pose a substantial risk to patients if substantially delayed by a prior authorization are excluded from this model.

Additionally, while not specific to Part B services directly, the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires impacted payers (including Medicare Advantage plans, Medicaid, and CHIP) to shorten prior authorization decision timeframes by January 2026. For standard requests, decisions must be made within 7 calendar days (down from 14), and for expedited requests, decisions must be made within 72 hours (unchanged).