Starting January 1, 2026, Medicare Original will require an additional step for 17 specific services. This is a federal government pilot program called the WISeR Model, which stands for Wasteful and Inappropriate Services Reduction. In order to eliminate waste and fraud in the healthcare system, your primary care physician will now be required to request authorization before performing certain specific services.
What does this “prior authorization” mean?
Prior authorization is a type of “coverage permission” that a doctor must obtain from Medicare before performing a service or procedure. Without this formal permission, Medicare coverage could be denied. In other words, the patient could be forced to pay 100% of the bill. The new model seeks to ensure that treatment is medically necessary according to clinical guidelines, reduce wasteful spending of Medicare funds, and combat widespread fraud in the medical system.
While this requirement was common in Medicare Advantage private plans and Part D (prescription drugs), the introduction of this requirement in Original Medicare for these 17 services is new. Previously, Original Medicare was based on physician trust and retrospective review. For most services, Medicare used a system called fee-for-service: the doctor performed the service, and then the bill was sent to Medicare for payment.
This put the healthcare provider in a vulnerable position: if Medicare determined—sometimes months later—that the service was unnecessary, it could retroactively deny payment. That is why the new WISeR model requires a mandatory pre-service review process.
From now on, the doctor must submit a large amount of clinical documentation before surgery, device implantation, or treatment in order to obtain provisional coverage. If this approval is denied, the patient and physician know in advance, so they can seek alternatives or initiate an appeal process before the expense is incurred. This process is being managed by private companies that use artificial intelligence—a rather controversial practice—to pre-screen and expedite applications. However, the final decision to deny payment is made by a licensed human being.
The WISeR Program
This WISeR model will not take effect nationwide all at once, but will apply only to Original Medicare beneficiaries living in six specific states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
This pilot program is scheduled to run from January 1, 2026, through 2031. This rule affects Medigap supplemental insurance plans (such as Plan G or Plan N); if Original Medicare denies basic coverage, your Medigap plan will not pay the remaining coinsurance or deductible.
The 17 medical services
These are the medical services that will require prior authorisation starting in 2026:
- Electrical Nerve Stimulators (NCD 160.7), used for chronic back pain.
- Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18).
- Phrenic Nerve Stimulator (NCD 160.19): Helps patients with diaphragmatic paralysis breathe.
- Deep Brain Stimulation for Essential Tremor and Parkinson’s (NCD 160.24): A surgical procedure involving the implantation of brain electrodes.
- Vagus Nerve Stimulation (NCD 160.18): A treatment for resistant epilepsy.
- Induced Nerve Pathway Lesions (NCD 160.1): Procedures that temporarily destroy—or interrupt—nerves to block pain signals.
- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (LCDs L38307, L38312, L38385). This is an implant that helps keep the airways open while sleeping.
- Epidural Steroid Injections for Pain Management (LCDs L39015, L39242, L36920): Common injections for back pain, Medicare prefers to ensure that other alternatives have been tried first.
- Percutaneous Vertebral Augmentation (PVA) for Compression Fractures (VCF) (LCDs L34106, L38201, L35130): A procedure to stabilize fractured vertebrae. Authorization is required due to overuse of this treatment in recent years.
- Cervical Fusion (LCDs L39741, L39762, L39793): High-risk surgeries to join two or more vertebrae in the neck.
- Arthroscopic Lavage and Arthroscopic Debridement for Knee Osteoarthritis (NCD 150.9). It is suspected that it has no proven benefits and is considered a “low value” medical surgery.
- Incontinence Control Devices (NCD 230.10): Certain medical equipment and supplies for incontinence control.
- Diagnosis and Treatment of Impotence (Erectile Dysfunction) (NCD 230.4)… No comments.
- Image-Guided Percutaneous Lumbar Decompression for Spinal Stenosis (NCD 150.13): Procedure to relieve pressure on the nerves in the spine.
- Skin and Tissue Substitutes (General Category): Expensive biological and artificial products used in the treatment of complex wounds.
- Application of Bioengineered Skin Substitutes to Chronic Lower Extremity Wounds (LCD L35041).
- Application of Cellular and/or Tissue-Based Products (CTPs) to Lower Extremity Wounds (LCD L36690).