Susan Park
Most people with Traditional Medicare have never had to ask permission before getting a test or procedure. You show your red-white-and-blue Medicare card, your doctor orders the service, and the claim gets paid. That’s how it has always worked. But as of January 1, 2026, that assumption is no longer true for about 1.5 million beneficiaries living in six specific states, and six months into this experiment, a lot of people still don’t know it applies to them.
The program is called WISeR, which stands for Wasteful and Inappropriate Service Reduction. It’s the first time in Medicare’s 60-year history that the federal Centers for Medicare & Medicaid Services, or CMS, has required prior authorization inside Traditional Medicare (also called Original Medicare or Part A and Part B). If you live in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, and your doctor wants to order one of 17 specific Part B procedures, the provider now has to get pre-approval before delivering that care. Miss that step and you could be on the hook for the bill yourself.
What surprised me when I went deep on this is how little awareness there is even among people directly affected. According to reporting from TIME in May 2026, beneficiaries and advocates are raising real concerns about confusion and care delays. The pilot runs all the way through December 31, 2031, after which CMS will decide whether to roll it out nationwide. That’s not a small test. That’s six full years of real patients experiencing a fundamentally different Medicare than the one they enrolled in.
- WISeR is the first prior authorization program inside Traditional Medicare, active since January 1, 2026.
- Six states are affected: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
- Seventeen specific Part B procedures require pre-approval before care is delivered.
- Medigap supplement plan holders (Plan G, Plan N, etc.) in those states are also subject to the rules.
- The pilot runs through December 31, 2031; CMS will then decide whether to expand it nationwide.
Which 17 Procedures Are We Talking About?
CMS hasn’t published the full list in one easy consumer-facing document, which is itself part of the problem. But the procedures covered tend to cluster around services that have historically shown patterns of overuse or outright fraud. Think certain imaging services, some types of durable medical equipment (that’s things like wheelchairs or home oxygen), and specific surgical procedures. Resource Medicare’s November 2025 analysis of the WISeR rule noted that these 17 services were specifically selected because they appear frequently in fraud investigations and wasteful billing patterns.
Here’s a simplified look at the categories and what the authorization requirement means in practice:
| Service Category | Example Procedures | Prior Auth Required? |
|---|---|---|
| Advanced imaging | Certain MRI and CT scans | Yes, in WISeR pilot states |
| Durable medical equipment | Specific home health devices | Yes, in WISeR pilot states |
| Certain surgical services | Procedures flagged for overuse patterns | Yes, in WISeR pilot states |
| Routine office visits | Standard evaluation and management | No |
| Standard lab work | Blood panels, urinalysis | No |
| Most Part A services | Hospital inpatient stays | No |
I’ll be honest: the lack of a plain-English, complete list of the exact 17 procedures from CMS is a real gap. Your best move right now is to ask your doctor’s office to check before any non-routine procedure whether it requires prior authorization under WISeR. They should be checking anyway, but the system is new enough that not every practice has solid processes in place yet.
How the Review Process Actually Works
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Here’s where it gets genuinely interesting. CMS isn’t using human reviewers alone to flag claims. According to analysis from Katten’s QuickReads in November 2025, prior authorization contractors are using a combination of clinicians and AI-driven technology to review requests before care is delivered. The AI flags claims that look potentially wasteful or fraudulent, and then human clinicians make the final call.
That’s a pretty significant shift in how Medicare oversight works. For proponents, it’s a smarter, faster way to catch fraud before money goes out the door rather than chasing it afterward. For critics, the concern is real: an AI flagging a legitimate medical need as suspicious, a review that takes days, and a patient who needed that procedure last week. TIME’s reporting in May 2026 captures both sides of this debate without sugarcoating it, and I think that tension is worth sitting with.
CMS is also exploring a compliance-based exemption process in 2026. The idea is that high-performing providers who consistently show proper documentation could eventually be exempt from the pre-approval requirement. That would be a meaningful relief valve for experienced physicians with clean track records. But as of July 2026, that process is still described as “being explored,” meaning it’s not yet operational for most practices.
What This Means If You Have a Medigap Plan
One thing that catches people off guard: this isn’t just a Traditional Medicare problem. If you have a Medigap supplemental insurance plan, say Plan G or Plan N, and you live in one of the six pilot states, you are also affected. Medigap plans wrap around Original Medicare. They don’t replace it. So if Traditional Medicare requires prior authorization for a procedure and that authorization is denied or skipped, your Medigap plan won’t save you, because the underlying Medicare coverage didn’t approve the service in the first place.
This matters a lot because many people choose Medigap specifically to reduce paperwork and out-of-pocket surprises. The WISeR program introduces a new layer of complexity that Medigap was never designed to handle.
What You Should Actually Do Right Now
If you live in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington and you’re on Traditional Medicare, here are the practical realities to keep in mind.
Before any non-routine procedure, ask your doctor’s office: “Is this one of the 17 WISeR procedures? Has prior authorization been requested?” Don’t assume they’ve already built this into their workflow. Some practices are on top of it; some are not.
If you get a prior authorization denial, you have the right to appeal. Medicare’s appeals process hasn’t changed. You can request a redetermination, and if that fails, there are multiple additional levels of appeal. GoodRx’s overview of Medicare prior authorization notes that understanding your appeal rights is one of the most important protections available to beneficiaries in any prior authorization situation.
And if you’re not sure whether WISeR applies to a specific service your doctor is recommending, call 1-800-MEDICARE (that’s 1-800-633-4227) or visit Medicare.gov. The WISeR model is new enough that even some providers are still catching up.
The research on whether prior authorization programs actually improve care quality or simply create delays is genuinely mixed. Some studies show real savings; others document patients who gave up on getting care altogether after hitting bureaucratic walls. This pilot will generate six years of data, and the decisions CMS makes in 2031 will affect every Medicare beneficiary in the country. That gives everyone, not just people in the six states, a reason to pay attention to how this unfolds. Talking to a licensed Medicare counselor or your State Health Insurance Assistance Program (SHIP) counselor, who provides free unbiased help, is a smart step if you’re uncertain how WISeR affects your specific situation.
Sources
- Resource Medicare , Prior Approval Required for These 17 Services (published November 4, 2025)
- TIME , Medicare’s New Prior Approval Pilot: What You Need to Know (published May 11, 2026)
- GoodRx , Does Medicare Require Prior Authorization? (published September 26, 2025)
- Katten / QuickReads , Medicare Launches Prior Authorization Pilot for Six States (published November 18, 2025)
- ElderLawAnswers , 6 States to Pilot Prior Authorizations for Original Medicare (published September 11, 2025)
Photo: Kampus Production via Pexels
This article is for informational purposes only. Medicare rules change annually. Always verify current plan details at Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227). This site does not sell insurance or recommend specific plans.
Recommended Resources
Disclosure: As an Amazon Associate, we earn a small commission from qualifying purchases at no extra cost to you. We only recommend products that genuinely support the topics covered in this article.
- Medicare For Dummies (~$22), The definitive consumer guide to Medicare, enrollment windows, Part A/B/C/D, and supplement plans.
- Get What’s Yours for Medicare (~$17), Maximize your Medicare benefits and minimize out-of-pocket costs. Covers Part D drug coverage gaps and Medigap in depth.
