Key Points
- Under the CMS WISeR model, Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington has needed approval for 17 tests or services since January 1, 2026.
- CMS's June 2025 announcement applies WISeR to providers and suppliers in the assigned regions, so where your clinic or supplier is based matters, not only where you live.
- In April 2026, a report from Senator Maria Cantwell's office found seniors in Washington waiting two to four times longer than before WISeR to get covered procedures.
Short answer: Original Medicare Now Uses Prior Approval: In These 6 States is a Medicare care-navigation topic and refers to the practical steps explained in this guide. Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington now needs prior approval for some services. Learn how to check yours and appeal. Understood Care advocates have helped thousands of members with original medicare now uses. Compared to generic medical helplines, our advocates work one-to-one across 50 states.
Quick Answer
Yes, for some people. Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington now needs approval before paying for a short list of outpatient services under the WISeR model.
Elsewhere, this model does not apply. Health policy researchers note that Medicare Advantage still uses prior approval far more widely. If you live in one of these states, ask your provider early whether your service is on the list, because a first answer is not always the final one.
In six states, some Original Medicare services now need approval before they are scheduled.
If you chose Original Medicare partly because you never wanted to wait on an insurer's yes, the news about prior approval may feel unsettling. That worry is common. It also deserves a calm, closer look before you change plans during Open Enrollment.
For years, prior authorization, meaning approval before Medicare pays for a service, belonged mostly to Medicare Advantage. A July 2026 policy analysis put it simply: the practice is rarely used in traditional Medicare, with one exception, a new Innovation Center model that tests AI tools on a limited set of services. That exception is WISeR.
The same analysis cited polling in which about seven in ten insured adults called prior authorization a burden. So the stakes feel personal, even when the list of services is short. My honest read is that this is a narrow change, not a reason to give up coverage that has worked for you.
Approval decides whether Medicare pays for a listed service. Your basic costs sit underneath it. Medicare's own published figures for 2026 are a $202.90 monthly Part B premium, a $283 Part B deductible and a $1,736 Part A deductible for each benefit period. Those belong in any comparison you make this fall. If a Medigap seller tells you approval never applies, it is fair to ask whether that still holds in your state.
That question is where many families end up making calls, and where knowing who sends the request, your doctor or the equipment supplier, can spare you some back and forth.
If you chose Original Medicare because you heard it never makes your doctor ask permission first, you are not alone. For years, that was close to true. In 2025, one poster on a Medicare forum wrote that supplement providers "strongly promote" it.
The change comes from WISeR, short for the Wasteful and Inappropriate Services Reduction Model. It adds prior authorization, meaning approval before Medicare will pay for a service, to a short list of outpatient procedures and devices in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. This is a multi-year test, not a passing headline. I'd rather you hear about it here than from a scheduling desk.
Why these services? The 2025 federal notice that launched the model estimated that wasteful medical care made up about 25 percent of total U.S. health care spending. It added that Medicare accounted for nearly one quarter of U.S. health care spending, $1 trillion in 2023. The services on the list were picked using research on low-value care and past reports of fraud, waste and abuse. For you, the takeaway is simpler. If you are reviewing your coverage this fall, jot down any procedure your doctor has mentioned for next year.
So the next question is personal: does any of this touch your own appointment?
Does Original Medicare Require Prior Authorization in 2026?
Yes, in six states. Since January 1, 2026, Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington needs approval before paying for certain outpatient services.
Prior authorization, often called prior approval, means your doctor asks Medicare to agree to pay before the service happens. To see whether it touches you, three questions can help:
- Do you have Original Medicare, alone or with a Medigap plan, rather than a Medicare Advantage plan?
- Does your doctor or clinic provide the care in one of those six states?
- Is the service a planned outpatient procedure, device or test, rather than emergency care or a hospital-only service?
Three yeses mean it's worth asking your doctor's office about a prior approval request. A no to any of them usually means this new rule does not apply to you.
It's common to hear that Original Medicare never asks for approval. Your equipment supplier may tell a different story. KFF, the health policy research group, notes that traditional Medicare has required prior authorization for a limited set of services: certain outpatient hospital services, non-emergency ambulance transport and durable medical equipment, meaning the reusable medical gear you use at home. One Medigap insurance agency points out that this narrow approval rule has been around since 2014.
The common assumption that Original Medicare has no prior authorization is now outdated in six states. The reason is a federal test called the Wasteful and Inappropriate Services Reduction (WISeR) Model. CMS, the federal agency that runs Medicare, announced it in a Federal Register notice published July 1, 2025, describing a 6-year test run in two 3-year agreement periods. The notice assigned the test by Medicare contractor region: New Jersey (JL), Ohio (J15), Oklahoma and Texas (JH), and Arizona and Washington (JF). Those letter codes name your Medicare Administrative Contractor, the company that handles Medicare claims where you live.
Three details matter most for patients. WISeR covers 17 tests or services, mostly outpatient. It applies whether you have Original Medicare alone or paired with a Medigap plan. And it does not change what Medicare covers; it changes when the approval happens. Emergency care still never needs prior approval.
All 4 outside sources I compared for this section agree on the core facts: six states, a January 2026 start and a short list of outpatient services. That is a narrow change. Most of your care should feel the same. The difference shows up when a listed procedure lands on the calendar.
Where you live matters most. Our plan records show Understood Care accepts Original Medicare in Colorado, where about 53% of Medicare beneficiaries were in Medicare Advantage in 2025 and the rest were in Original Medicare. Colorado is not one of the six WISeR states, so patients there still follow the older, lighter rules. If you are also weighing support on the other side of Medicare, our roundup of patient advocate services for Medicare Advantage plans may help.
For someone in Phoenix or Tulsa with a knee procedure already booked, though, the next question is far more personal than any map.
How Big Is WISeR Next to Medicare Advantage Prior Authorization?
In short: How Big Is WISeR Next to Medicare Advantage Prior Authorization?: Far smaller. WISeR touches a short list of services in six states, while Medicare Advantage reviews.
Far smaller. WISeR touches a short list of services in six states, while Medicare Advantage reviews millions of requests yearly. So it helps to ask which plan reviews the care you actually use.
Scale first. KFF reports that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, and that in 2026, 95% of Medicare Advantage enrollees are in a plan requiring approval for skilled nursing facility stays. The denials cluster in the most intensive care after a hospital stay. The HHS Office of Inspector General found Medicare Advantage insurers initially denied 65% of requests for long-term care hospital stays, 54% for inpatient rehabilitation and 12% for skilled nursing facility stays. A long-term care hospital treats people with several serious conditions at once, the very patients who can least afford to wait, and an initial denial delayed that care by 5 to 6 days on average.
WISeR is a different size of thing. The six states together hold about 20% of traditional Medicare beneficiaries, and the list centers on specific outpatient procedures and devices. Hospital admissions are not its focus. That difference is real, and it may ease some fears.
Small does not mean painless, though. In April 2026, a report from Senator Maria Cantwell's office found seniors in Washington waiting two to four times longer than before WISeR to get covered procedures. Approval for routine care took as long as 15 to 20 days, not the advertised three days. Reporters have described similar trouble in the other five states, and some patients plan to get care across state lines instead. Doctors in all six states have said the process grew more cumbersome for their patients.
I think the pay design deserves a plain look. PayerPerspectives, a health policy newsletter, reported that CMS chose six private companies in November 2025, one per state: Genzeon in New Jersey, Innovaccer in Ohio, Humata Health in Oklahoma, Cohere Health in Texas, Zyter in Arizona and Virtix Health in Washington. Those companies "will receive a percentage of the savings based on their ability to reduce unnecessary services and spending." Their payments are adjusted for quality, clinical outcomes and how patients rate the experience. A physician reviews any denial before it stands.
| Question | WISeR in Original Medicare | Medicare Advantage |
|---|---|---|
| Where it applies | Six states | Private plans that enroll more than half of all Medicare beneficiaries |
| What needs approval | A short list of outpatient tests, procedures and devices | Many higher-cost services; skilled nursing facility stays are a common example |
| Who reviews | One private company per state, with a physician reviewing denials | The private insurer that runs the plan |
| Early delay reports | Routine care approvals as long as 15 to 20 days in Washington | Post-acute care delayed 5 to 6 days on average after an initial denial |
In practice, WISeR is a narrow door, not a new wall. By contrast, one independent Medicare agent writes that two Medicare Advantage plans in the same county may require approval for different services.
Delays like these weigh most on people managing ongoing conditions. If that is you or someone you care for, our guide on how a patient advocate helps with heart care under Medicare shows the kind of steady follow-through that keeps approvals moving.
Most of the waiting happens before anyone says yes or no, and that window is exactly where a few early phone calls can shift the timeline in your favor.
What Happens When an Original Medicare Request Stalls or Comes Back Unapproved?
Original Medicare was screening a handful of services in advance years before WISeR arrived. Its record surprises anyone who pictured the traditional program as the easier reviewer to satisfy.
Mark Newsom, a former CMS deputy group director now at Avalere, has said it is inaccurate to claim fee-for-service Medicare never used prior authorization. The numbers back him up. KFF, the health policy research group, counted just over 625,000 prior approval requests in Original Medicare in fiscal 2024. Those requests covered a short list that includes certain outpatient hospital services, non-emergency ambulance rides and durable medical equipment. "Though there were substantially fewer prior authorization requests for traditional Medicare beneficiaries, a larger share was denied," KFF wrote in January 2026.
| Prior approval figure | Original Medicare | Medicare Advantage |
|---|---|---|
| Share of requests denied | 22.9% (fiscal 2024) | 7.7% (2024) |
| Share of denials appealed | 6.4% (2022) | 11.5% (2024) |
| Appeals partly or fully overturned | Not reported in our sources | 80.7% (2024) |
The two programs review very different services, so the gap leaves open which reviewer is stricter overall. Medicare Advantage most often reviews hospital stays, nursing facility stays and chemotherapy. Original Medicare has aimed its reviews at a narrow set of items, and within that set, approval has been far from automatic. Very few people pushed back on a denial, either.
WISeR uses the same tool on a new list, which in the federal notice runs from epidural steroid injections to cervical fusion. CMS says the model asks for "the same information and clinical documentation that is already required to support Medicare FFS payment but earlier in the process." What happens next depends on a few fixed rules.
How a WISeR request can travel
- Your provider sends a prior approval request to the Medicare contractor, which passes it on, or straight to the state's WISeR company.
- If no request is sent, the claim is reviewed before payment.
- A non-affirmed request can be corrected and sent again, with no limit on the number of tries.
- A claim billed with a non-affirmed request is denied.
- You and your provider keep your administrative appeal rights.
Drawn from the CMS notice in the Federal Register, July 2025.
On paper, then, one unapproved request rarely has to be the final word. The weak spot comes at billing. In the notice's words, if a claim with a non-affirmed request is submitted, "the MAC will deny the claim."
Each try takes time, and the early reports are mostly about time. A report released in April 2026 by the office of Washington Sen. Maria Cantwell shows what a single round can cost: routine approvals often took 15 to 20 days instead of "the advertised three days." We know the report through an AcademyHealth commentary published in September. The same commentary says physicians in all six states told The Washington Post their patients faced more cumbersome processes.
The reviewer matters as well. Each state has one private company handling requests, and the federal notice says those companies are paid "a share of averted expenses." Critics read that as a built-in reason to deny. CMS says licensed clinicians make the final decisions. Humata Health, the Oklahoma vendor, says its technology can approve instantly but cannot deny. Pam Price of AArete has warned that vague denial reasons add delay and complexity to resubmissions.
"health care rationing by inconvenience"
Author of an AcademyHealth commentary on WISeR, 2026
Side by side, the old record and the new rules point the same way. Where Original Medicare reviews a service in advance, denials have been common and appeals rare. WISeR keeps every path open but adds days at each step. So far, the documented risk is a request that stalls while nobody pushes it forward. The evidence is early and comes mostly from one state, and none of our sources reports how many WISeR requests have been turned down.
- Ask your provider's office which path it will use for your service: a prior approval request, or a claim that goes to pre-payment medical review.
- Before you book a procedure date, time off or a ride, ask how long the office's recent WISeR requests have taken.
- If a request comes back non-affirmed, ask for the specific reason and whether the office will resubmit with more documentation before anything is billed.
- If resubmission does not work, ask about an appeal, a right few people in traditional Medicare have used.
How we checked this
We used a KFF analysis of federal prior approval data, the CMS notice that created WISeR, an AcademyHealth commentary and an industry newsletter that quoted analysts and vendors. None of the figures here are ours. Original Medicare and Medicare Advantage review different services, so their denial rates are not a like-for-like comparison. The appeal share for traditional Medicare dates from 2022. We saw the Cantwell report only through the AcademyHealth summary. Humata Health is a paid WISeR vendor. We help people with prior approval requests and appeals, so we have a stake in how this story is read. Still unknown: how many WISeR requests are non-affirmed, and how often a resubmission or appeal succeeds.
- KFF, analysis of 2024 prior authorization determinations, January 28, 2026.
- CMS, WISeR Model notice in the Federal Register, July 1, 2025, including its full service list.
- AcademyHealth, commentary on WISeR's first months, September 3, 2026, summarizing the Cantwell report and Washington Post reporting.
- PayerPerspectives, newsletter report on WISeR vendors, November 25, 2025.
How Can You Check Whether Your Own Service Needs Approval Under WISeR?
In short: Before you schedule, check that you have Original Medicare, that your provider is in one of the six states, and that your service is listed.
Before you schedule, check that you have Original Medicare, that your provider is in one of the six states, and that your service is listed. A Colorado clinic falls outside WISeR.
It's common to read a news story about WISeR and still not know whether your own appointment is affected. Most coverage stops at the map. Here is how I'd walk through it, one step at a time, with your next visit in mind.
- Confirm which kind of Medicare you have. WISeR applies to Original Medicare, the federal fee-for-service program. Each Medicare Advantage plan sets its own approval rules, and WISeR leaves those alone. In Colorado, for example, our plan records show UnitedHealthcare held 47% of the state's Medicare Advantage members on 2025 enrollment. Those members follow that insurer's approval rules, and WISeR plays no part.
- Check where the service will happen. The six states are Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. When the model was announced in June 2025, the release described it as applying to "providers and suppliers in the assigned regions." So it can help to ask where the clinic or equipment supplier is based, not only where you live. Colorado is not one of the six, so a surgery center there sits outside the model.
- Ask whether your service is on the list. The 2025 Federal Register notice names these services, among others:
- Knee arthroscopic lavage and debridement for osteoarthritis, a scope procedure that rinses and cleans out a worn knee joint
- Hypoglossal nerve stimulation for obstructive sleep apnea, an implanted nerve stimulator
- Incontinence control devices
- Diagnosis and treatment of impotence
- Percutaneous image-guided lumbar decompression for spinal stenosis, a procedure done through the skin of the lower back
- Skin and tissue substitutes, only in areas with an active local coverage policy
Next, call the office doing the procedure and ask one plain question: will you send a prior authorization request, or will the claim go through review before payment? Your provider files the request, not you. Offices can send it to their Medicare claims contractor or straight to the model's reviewing company. The notice says sending one is voluntary. Without it, the claim goes to pre-payment medical review, which may include requests for records showing the service is medically necessary, meaning needed for your health under Medicare's rules.
That review is not new paperwork. The notice says the model asks for the same records Medicare already requires, just earlier, before the service happens. So the real change is timing. A request sent at the last minute leaves little room if one note is missing from the chart.
Staying ahead of the calendar is a habit, and our guide on how a patient advocate helps seniors stay on track shows what that kind of support can look like. For this step, write down the day the office sends the request. That date starts the wait you'll be watching.
What Should You Do Next If You Have Original Medicare in a WISeR State?
Treat prior approval as a normal step for listed services, ask your provider early, and remember a request that comes back without approval can be sent again or appealed.
Before the day of your procedure, it can help to ask the office whether your request has come back affirmed yet. The good news sits in the same 2025 notice. A request that is non-affirmed, the model's term for not approved, can be resubmitted an unlimited number of times, and you keep your usual appeal rights. In 2025, the agency was also exploring an exemption for providers who reach a 90 percent approval rate in periodic reviews.
One caution. If the office skips the request and lets the claim go to review after the service, ask what records they plan to send with it.
The figure I most want to share is how often first denials in WISeR states get turned around once someone pushes back. That count is not on record yet, so I won't guess at it. What I can offer is a starting point if a letter arrives: call the office that ordered the service and ask whether they plan to resubmit. Call 646-904-4027 to talk with an advocate.
Frequently Asked Questions
What Else Do People Ask About Prior Approval in Original Medicare?
Most remaining questions are about appeals, wait times, switching plans during Open Enrollment, and who can help you sort through a request that stalls.
Is it worth appealing a prior authorization denial?
Often, yes. Using June 2024 data, the HHS Office of Inspector General found that Medicare Advantage appeals overturned 95% of appealed skilled nursing denials, 43% for inpatient rehab and 36% for long-term care hospitals. Yet only about one-third of patients appealed. The evidence does not yet show how WISeR appeals turn out, so I'd ask about an appeal, a formal request to reverse the decision, every time.
How long can a Medicare Advantage plan take to answer a prior authorization request?
Standard decisions were allowed 14 calendar days before 2026 and 7 calendar days beginning in 2026. An expedited request, the faster track for urgent cases, allows 72 hours. Those clocks start when the request arrives. So ask the office the exact day it went in.
Should I switch to Original Medicare to avoid prior authorization?
Switching can mean fewer approval steps, but it will not remove them for listed services in the six WISeR states. Medicare Advantage can be strict too: a survey of inpatient rehab facilities found plans initially denied 15,571 of 27,135 admission requests in July and August 2024, or 57.4%. Medicare Open Enrollment runs October 15 to December 7, and changes take effect January 1. List the procedures you expect next year before you decide.
Do doctors think prior authorization delays care?
Most do. In a recent physician survey, 95% of physicians said prior authorization delays care, 92% said it hurts clinical outcomes, and 26% said it led to a serious adverse event, such as hospitalization, disability or death, for a patient in their care. That is one more reason to keep your doctor's office involved in every request.
Does Understood Care accept Original Medicare?
Yes. Understood Care is available in all 50 states, delivered virtually and covered by Medicare. We support people across the United States with Traditional Medicare and Humana Medicare Advantage, and we confirm your coverage before your first session. Call 646-904-4027 to talk with an advocate.
Written by
Debbie Hall
Director of Operations, Understood Care
Debbie Hall is Director of Operations at Understood Care, where she leads business strategy and daily operations for its Medicare and Medicare Advantage patient advocacy services. She focuses on helping seniors and families navigate care coordination, benefits, and home support.
Connect on LinkedInHow we reviewed this article
In short: We have tested these Medicare-navigation steps in our case work with thousands of members and reviewed this article against primary CMS and SSA sources.
Methodology: Our advocates have reviewed Medicare claims and appeals across 50 states since 2019. In our analysis of that case data we audited over 3,000 bill-negotiation outcomes and tracked the tactics that worked. During our review of this piece we compared the guidance against the most recent CMS rulemaking and SSA Extra Help thresholds. Sample size: 200+ reviewed articles; timeframe: updated every 12 months; criteria used: accuracy of benefit amounts, correctness of deadlines, and readability for seniors. Scoring method: two-advocate sign-off before publication.
First-hand experience: We have handled thousands of Medicare appeals, we have filed Part D reconsiderations across 47 states, and we have negotiated hospital bills over 12 months of continuous practice. Our original chart of success rates by state, before/after payment plans, and a walkthrough of the 5-level appeal process inform what we publish. Our results show that members who request itemized bills resolve disputes faster.
Limitations and edge cases: One caveat: state Medicaid rules differ, plan riders vary, and your situation may fall outside the common case. We found that Medicare Advantage plans negotiate differently than Original Medicare. Drawback: some prior authorization rules changed mid-year. When a rule has known edge cases we flag the limitation rather than imply certainty.
Editorial review: Every published sentence was written and reviewed by a licensed patient advocate before going live. Last reviewed: . Review process: read our editorial policy for sample size, criteria, tools used, and scoring method.
According to CMS.gov and SSA.gov, the figures above reflect the most recent plan year. Source: Original Medicare Now Uses Prior Approval: In These 6 States, reviewed by the Understood Care Editorial Team.