Medicare 2026 Pilot: Which Medical Procedures Will Need Prior Authorization?
- Author: Wilbert Raynor
- Posted: 2025-09-01
In January 2026, traditional Medicare beneficiaries in six states will experience a major change: certain medical procedures will require prior authorization before they can be approved.
The pilot program, launching in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, marks the first time traditional Medicare (not just Medicare Advantage) applies these rules.
What’s New in the 2026 Medicare Pilot?
The Centers for Medicare & Medicaid Services (CMS) is introducing a new system that uses artificial intelligence (AI) tools and private contractors to review requests.
Licensed clinicians will make final decisions, but AI will play a central role in screening.
The stated goal is to reduce fraud, overuse, and unnecessary spending, but critics fear that the shift could delay essential care and sideline physician expertise.
Patient advocacy groups also warn that seniors with complex health needs could face longer wait times and more red tape.
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Procedures Requiring Prior Authorization in 2026
CMS has confirmed that the pilot will target procedures across multiple specialties, including pain management, neurology, orthopedics, and urology. The full list includes:
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Electrical Nerve Stimulators
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Sacral Nerve Stimulation for Urinary Incontinence
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Phrenic Nerve Stimulator
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Deep Brain Stimulation for Parkinson’s Disease and Essential Tremor
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Vagus Nerve Stimulation
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Induced Lesions of Nerve Tracts
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Epidural Steroid Injections (excluding facet joint injections)
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Percutaneous Vertebral Augmentation (PVA) for Compression Fractures
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Cervical Fusion
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Arthroscopic Lavage and Debridement for Osteoarthritis of the Knee
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Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
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Incontinence Control Devices
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Diagnosis and Treatment of Impotence
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Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
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Skin and Tissue Substitutes (only in states with Local Coverage Determinations)
Lessons from the Past
A similar Medicare demonstration a decade ago saved $1.1 to $1.9 billion in five years, according to the Government Accountability Office (GAO), but it was eventually scrapped due to confusion, paperwork overload, and treatment delays.
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