Original Medicare Prior Authorizations Starting 2026 - YouTube

Medicare Launches Technology-Driven Prior Authorization Pilot: What Prostate Cancer Patients Need to Know

IPCSG Newsletter - Special Report

Understanding the WISeR Model and Its Potential Impact on Cancer Care

Key Takeaways

• Starting January 1, 2026, Medicare will test prior authorization for 17 specific outpatient services in six states through the Wasteful and Inappropriate Service Reduction (WISeR) Model
• The six-year pilot program runs through December 31, 2031, and uses artificial intelligence and machine learning alongside human clinical review
• The affected states are New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington
• The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed
• Important for prostate cancer patients: Telemedicine and telehealth services are NOT subject to prior authorization under WISeR and remain fully accessible

Background: A Historic Shift for Traditional Medicare

For decades, Original Medicare has operated with minimal prior authorization requirements, distinguishing it from Medicare Advantage plans that extensively use pre-approvals. This freedom has been one of the key distinguishing features between traditional Medicare and Medicare Advantage plans, making the upcoming changes particularly noteworthy for millions of beneficiaries.

CMS Administrator Dr. Mehmet Oz stated, "CMS is committed to crushing fraud, waste and abuse, and the WISeR Model will help root out waste in Original Medicare". The initiative aims to address what Medicare estimates as 25 percent of total health care spending in the United States being wasteful medical care spending that could be reduced without adversely affecting quality of care.

The Technology Behind WISeR

Unlike traditional prior authorization processes, the WISeR Model leverages cutting-edge technology. Technology companies participating in the model will help streamline the review of medical necessity for select items and services earlier in the claims process to reduce inappropriate utilization, lower spending in Original Medicare.

CMS conducted market research from various Medicare Advantage organizations that had experience with enhanced technology-enabled prior authorization processes. The research indicated significant reductions in the decision time to prior authorization determination, particularly for affirmed prior authorization requests. Some MA plans reported decision time to prior authorization approval being almost instantaneous for services with very clear clinical coverage criteria.

Importantly, all recommendations for non-payment will be determined by appropriately licensed clinicians who will apply standardized, transparent and evidence-based procedures.

Services Subject to Prior Authorization

The WISeR Model will initially target 17 categories of ambulatory services. Based on the Federal Register notice, the confirmed services include:

Confirmed Services from Federal Register:

• Electrical Nerve Stimulators (NCD 160.7)
• Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
• Phrenic Nerve Stimulator (NCD 160.19)
• Deep Brain Stimulation for Essential Tremor and Parkinson's Disease (NCD 160.24)
• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)
• Skin and Tissue Substitutes (various LCDs) - only applicable to MAC jurisdictions and states that have an active LCD in place

Additional Services Expected to Be Included: Based on industry reports, the full list of 17 services is expected to include procedures such as spinal stimulators, epidural injections, joint surgeries, and various outpatient diagnostic and therapeutic procedures that have been identified as vulnerable to fraud, waste, and abuse.

Implications for Cancer Care

While oncology-specific services are not prominently featured in the initial WISeR list, prostate cancer patients should be aware of several important considerations:

Current Oncology Models: Medicare currently operates the Enhancing Oncology Model (EOM), which focuses on beneficiaries receiving systemic chemotherapy for seven cancer types: breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer. This voluntary program provides enhanced services and care coordination for cancer patients.

ASCO's Position: The American Society of Clinical Oncology (ASCO) is monitoring the rollout of the model and whether CMS chooses to expand the services subject to prior authorization in Medicare FFS. ASCO has established position statements on both prior authorization and the use of artificial intelligence in prior authorization decisions.

Future Expansion Potential: If the pilot program demonstrates effective fraud reduction without significant patient care disruption, CMS may expand prior authorization requirements to additional services and states.

Telemedicine: A Protected Service for Prostate Cancer Patients

Good News for ADT and Active Surveillance Patients: Telemedicine and telehealth services are NOT included in the WISeR Model's prior authorization requirements. The model specifically excludes services that would pose a substantial risk to patients if delayed, and routine telehealth visits fall outside the scope of the targeted services.

Why This Matters for Prostate Cancer Care:

For Patients on Androgen Deprivation Therapy (ADT): Men receiving ADT require regular monitoring for side effects including cardiovascular health, bone density, metabolic changes, and psychological wellbeing. Telemedicine provides a convenient way to maintain this crucial oversight without the burden of frequent office visits.

For Active Surveillance Patients: Men on active surveillance need regular PSA monitoring, digital rectal exams discussions, and symptom assessments. Telehealth visits can efficiently handle many of these check-ins, with in-person visits reserved for physical examinations.

Current Medicare Telehealth Coverage: Medicare covers a broad range of telehealth services including:

• Evaluation and management visits (common office visits)
• Mental health counseling
• Preventive health screenings
• Virtual check-ins and e-visits
• Audio-only telephone visits (extended through December 31, 2024)

Telemedicine Benefits During Cancer Care:

• Reduces exposure risk for immunocompromised patients
• Eliminates travel burden, especially important for patients experiencing ADT-related fatigue
• Allows for more frequent monitoring without increased patient burden
• Enables timely medication adjustments and symptom management
• Maintains continuity of care during treatment gaps

How the Process Works

The WISeR Model offers providers three pathways:

1. Direct Prior Authorization: The provider submits a prior authorization request directly to the WISeR participant for review and determination
2. MAC-Routed Authorization: The provider submits a prior authorization request to the MAC, which then routes it to the WISeR participant for review and determination
3. Post-Service Review: The provider furnishes an included service without requesting prior authorization, and the WISeR participant flags the resulting claim for prepayment medical review

Providers and suppliers may resubmit prior authorization requests an unlimited number of times following a non-affirmation decision.

"Gold Card" Exemptions

Providers and suppliers with demonstrated records of compliance may be exempt from the WISeR review process in the future. This exemption, or "gold card," would reduce administrative burden while allowing participants to focus their resources on providers and suppliers at higher risk of delivering unnecessary care.

Criticism and Concerns

The program has faced opposition from various stakeholders. Rep. Suzan DelBene (D-Wash.), whose state participates in the pilot program, expressed frustration: "It's baffling how in one breath the administration is trying to take a victory lap on insurers streamlining prior authorization in Medicare Advantage, and in the other instituting the same delay tactics in traditional Medicare".

A 2022 investigation of the use of prior authorization in MA by the Department of Health and Human Services' Office of Inspector General concluded that Medicare Advantage can create an incentive for plans to "deny the prior authorization of services for beneficiaries, and payments to providers, including some services and payment that would not have been denied in original Medicare".

However, the paper the agency cites estimates that only 11% of overall waste (i.e., less than 3% of health care spending) is from overuse. The remainder is attributed to administrative complexity, coordination failures, errors in care, excessive pricing, and, to some extent, fraud.

What Patients Should Do

For prostate cancer patients, especially those in the six pilot states, consider these steps:

Immediate Actions:

• Discuss with your oncologist whether any planned procedures might fall under the WISeR model
• Maintain detailed medical records to support any prior authorization requests
• Understand your appeal rights under Medicare's existing appeals process
• For ADT and Active Surveillance patients: Confirm that your telemedicine visits remain unaffected and continue routine monitoring schedules

Long-term Planning:

• Stay informed about potential expansion of the program
• Consider how this might affect treatment timing and care coordination
• Monitor communications from Medicare and your healthcare providers
• Maximize telemedicine benefits: Work with your healthcare team to identify which visits can be conducted via telehealth to reduce travel burden while maintaining quality care

The Broader Context: Fraud Prevention

The WISeR program emerges from documented cases of significant Medicare fraud. The Justice Department conducted a 2025 National Health Care Fraud Takedown with results released on June 30, 2025, including charges against more than 300 defendants who were accused of a range of health care fraud schemes.

Examples include $10.6 billion in fraudulent claims involving stolen identities for durable medical equipment, $900 million in fraudulent claims for unnecessary amniotic wound grafts, and over $2.5 billion in alleged fraud from telemedicine and pharmaceutical schemes.

Timeline and Next Steps

• January 1, 2026: WISeR Model implementation begins in six pilot states
• December 31, 2031: Current pilot program scheduled to end
• 2032: Potential expansion based on program evaluation results

The WISeR Model doesn't reduce your benefits—it simply adds an extra layer of review for certain services to ensure Medicare funds are being used wisely.

Conclusion

While the WISeR Model represents a significant shift in how Original Medicare operates, its initial focus on services with documented fraud and abuse issues suggests a targeted approach rather than broad restrictions on cancer care. However, prostate cancer patients in pilot states should remain vigilant and work closely with their healthcare providers to understand any potential impacts on their treatment plans.

The success or failure of this pilot program will likely shape the future of Medicare's approach to utilization management and could influence whether similar requirements are extended to oncology services in the future.

---

Sources

1. Centers for Medicare & Medicaid Services. "Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model." Federal Register, July 1, 2025. Available at: https://www.federalregister.gov/documents/2025/07/01/2025-12195/medicare-program-implementation-of-prior-authorization-for-select-services-for-the-wasteful-and
2. Centers for Medicare & Medicaid Services. "WISeR (Wasteful and Inappropriate Service Reduction) Model." CMS Innovation Center. Available at: https://www.cms.gov/priorities/innovation/innovation-models/wiser
3. American Association of Medical Colleges. "CMMI Releases New Prior Authorization Model for Medicare." AAMC Washington Highlights. Available at: https://www.aamc.org/advocacy-policy/washington-highlights/cmmi-releases-new-prior-authorization-model-medicare
4. Davis Wright Tremaine LLP. "CMS Launches WISeR Model to Curb Overuse of Medicare Services." July 2025. Available at: https://www.dwt.com/insights/2025/07/cms-launches-wiser-model-to-curb-medicare-overuse
5. Healthcare Finance News. "CMS launches prior authorization pilot for Original Medicare." Available at: https://www.healthcarefinancenews.com/news/cms-launches-prior-authorization-pilot-original-medicare
6. Kiplinger. "Prior Authorization Coming to Traditional Medicare Starting in 2026." Available at: https://www.kiplinger.com/retirement/medicare/prior-authorization-coming-to-traditional-medicare
7. STAT News. "Plans to test prior authorization in traditional Medicare are deeply troubling." July 25, 2025. Available at: https://www.statnews.com/2025/07/25/medicare-advantage-prior-authorization-cms-innovation-center-wiser-project/
8. GovHealth DistilInfo. "Medicare Prior Authorization Changes Starting 2026." July 8, 2025. Available at: https://govhealth.distilinfo.com/2025/07/08/medicare-prior-authorization/
9. McDonald Hopkins. "CMS to implement prior authorization model starting in 2026." Available at: https://www.mcdonaldhopkins.com/insights/news/cms-to-implement-prior-authorization-model-starting-in-2026
10. MedicareMall.com. "What Is the WISeR Model in Medicare? Understanding New Prior Authorization Rules in 2026." July 10, 2025. Available at: https://medicaremall.com/senior-living/2025/07/10/what-is-the-wiser-model-in-medicare-understanding-new-prior-authorization-rules-in-2026/
11. American Society of Clinical Oncology. "CMS Testing Technology-Enabled Prior Authorization and Pre-Payment Review to Reduce Medicare Fraud, Waste, Abuse." June 27, 2025. Available at: https://www.asco.org/news-initiatives/policy-news-analysis/cms-testing-wiser-model
12. Centers for Medicare & Medicaid Services. "Enhancing Oncology Model." Available at: https://www.cms.gov/priorities/innovation/innovation-models/enhancing-oncology-model
13. ZERO Prostate Cancer. "ZERO's Guide to Telemedicine." Available at: https://zerocancer.org/blog/zeros-guide-telemedicine
14. Centers for Medicare & Medicaid Services. "Medicare Telemedicine Health Care Provider Fact Sheet." Available at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
15. Centers for Medicare & Medicaid Services. "List of Telehealth Services." Available at: https://www.cms.gov/medicare/coverage/telehealth/list-services
16. National Consortium of Telehealth Resource Centers. "Audio-Only Telehealth Post-PHE -- Medicare, Medicaid, and Private Payers." March 5, 2025. Available at: https://telehealthresourcecenter.org/news/audio-only-telehealth-post-phe-medicare-medicaid-and-private-payers/
17. American Urological Association. "Advanced Prostate Cancer: AUA/SUO Guideline." Available at: https://www.auanet.org/guidelines-and-quality/guidelines/advanced-prostate-cancer

Original Medicare Prior Authorizations Starting 2026 - YouTube