Medicare Pilot 2026: Procedures That Will Need Prior Authorization

Beginning in January 2026, Medicare beneficiaries in six pilot states will face new requirements for certain medical treatments.

For the first time in traditional Medicare, patients will need to obtain prior authorization before undergoing selected procedures.

The program will launch in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington, with the goal of cutting costs and reducing unnecessary treatments.

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How the Pilot Will Work

The Centers for Medicare & Medicaid Services (CMS) plans to use a mix of artificial intelligence (AI) tools and private contractors to process prior authorization requests.

Although licensed clinicians will provide the final review, the initial screening will be automated.

Supporters argue that this will help curb waste and fraud in Medicare, which represents nearly a quarter of the federal budget.

However, critics, including patient advocates and lawmakers, warn that automation could delay access to critical care, especially for seniors with urgent health needs.
 

Medical Procedures Requiring Approval in 2026

The pilot covers treatments across several specialties, including orthopedics, neurology, urology, and pain management.

The list of affected procedures includes:

• Electrical Nerve Stimulators

• Sacral Nerve Stimulation for Urinary Incontinence

• Phrenic Nerve Stimulator

• Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease

• Vagus Nerve Stimulation

• Induced Lesions of Nerve Tracts

• Epidural Steroid Injections (excluding facet joint injections)

• Percutaneous Vertebral Augmentation for Compression Fractures

• Cervical Fusion

• Arthroscopic Lavage and Debridement for Osteoarthritic Knees

• Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

• Incontinence Control Devices

• Diagnosis and Treatment of Impotence

• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis

• Skin and Tissue Substitutes (limited to states with active Local Coverage Determinations)

Background and Concerns

This isn’t Medicare’s first attempt at prior authorization.

A similar program introduced a decade ago reportedly saved billions of dollars, but it was ultimately discontinued due to bureaucratic delays and heavy paperwork.

Now, with AI tools at the center of the process, officials believe the system can be faster and more efficient.

Still, opponents fear the risks of computer-driven decision-making outweigh the benefits.

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