Most Medicare beneficiaries have experienced little interference when their doctors prescribe a treatment. Original Medicare is designed to cover anything “medically necessary,” and prior authorizations have historically been rare. Private Medicare Advantage plans, by contrast, frequently require prior authorization for services; insurers insist on pre‑approvals to control costs, which can delay or deny care. This disparity has been a source of frustration for seniors accustomed to making medical decisions with their doctors.
Beginning in January 2026, however, Original Medicare will test a prior authorization model of its own—but with a very different objective. The Wasteful and Inappropriate Service Reduction (WISeR) pilot aims to reduce fraud and waste rather than ration medically necessary care. It targets 17 categories of high‑fraud procedures, including electrical nerve stimulators, sacral nerve stimulation, deep brain stimulation, epidural steroid injections, cervical fusion, arthroscopic debridement, and the application of bio‑engineered skin substitutes. In recent years, criminals have used stolen identities to bill Medicare for unnecessary or nonexistent treatments. Examples include transnational crime rings billing for prosthetic limbs that patients never receive and telemedicine schemes pushing opioid prescriptions.
Under WISeR, participating providers in six states—Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington—must seek prior authorization for the designated procedures. The program is voluntary, meaning providers can opt out, and patients may avoid the requirement by switching to a doctor who does not participate. A combination of artificial intelligence and human reviewers will determine whether claims are appropriate. Importantly, the program runs only through 2031 and is designed to focus on reducing fraud; it explicitly does not change medically necessary coverage requirements.
The pilot underscores Medicare’s commitment to combating fraud while distinguishing itself from Medicare Advantage’s broad prior authorization protocols. WISeR aims to save taxpayers money without imposing barriers on legitimate care. Beneficiaries should understand that the program is localized, temporary and targeted at specific procedures with high fraud rates. It does not represent a shift toward widespread pre‑authorization in Original Medicare. Instead, it reflects the agency’s responsibility to protect the integrity of the program while balancing the need for timely and necessary medical services.
For more details on the WISeR pilot and how it differs from prior authorizations in Medicare Advantage plans, read the full article: Does Medicare Require Prior Authorizations?.
