Prior Authorization for Select Services

[JasonV59]

Medicare Program; Implementation of
Prior Authorization for Select Services
for the Wasteful and Inappropriate
Services Reduction (WISeR) Model

Has anyone heard about this going into effect? Shouldn't we be concerned? It is going to impact 6 states to start with.

This is for standard Medicare.

New Jersey, Ohio, Oklahoma and Texas, Arizona and Washington.

It will mostly impact procedures that deal with pain mitigation.

[papawofboo]

I thought it was already in effect. We have had to have approval for many years, even before we got on MC. 

Wife's doctor send in for one, got turned down, he sent wife to another dr. who requested the same thing. Got approved. The way that was explained is that doctors in certain fields can get things approved while other can't. 

Always remember to save the letter with the approval until you get the eob. 

[JasonV59]

From what I understand pre-authorization is rare for traditional medicare, but common for advantage plans. For clarity I'm including a link to the detailed information. This was released in July 2025.

https://www.regulations.gov/document/CMS-2025-0241-0001

They are handing these claims to companies that will be paid for every claim they deny. They will be using AI for determination. The program is called WISeR (Wasteful and Inappropriate Service Reduction).

[TRL1111]

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@JasonV59 wrote:

They are handing these claims to companies that will be paid for every claim they deny. They will be using AI for determination. The program is called WISeR (Wasteful and Inappropriate Service Reduction).

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That's a pretty dense document.  Can you point to where it says companies will be paid for every claim they deny?  

[JasonV59]

I'm including a link to Chris Westfall's Medicare site. He explains all this. It's a great site and contains loads of information regarding Medicare. I originally submitted this post in hopes of getting AARP to investigate and fight any pre-authorization tactics by the Feds for traditional medicare.

https://www.youtube.com/watch?v=TmnEt-GAFgA

[GailL1]

Why would you rely on the advice of some Medicare insurance sales person when you need to be looking at what the program is actually going to be testing - which is - MEDICAL NECESSITY.

CMS spends tons of money keeping the Medicare Coverage Determinations updated with the most up to date scientific knowledge.  Every procedure is not medically necessary based on the condition and diagnosis of the beneficiary - in fact, sometimes it is actually harmful or the beneficiary is exposed to something that could produce harmful results.

All this does is review the patient records for facts that document the doctor’s treatment plan.  This is not new to Medicare - we are just adding a few more procedures to the list.

AI is the perfect answer to this since it can compare diagnosis and treatment to the approved method of handling such in the approval method - AI does not make the final decision, it just helps in the comparison.  

You have no idea how much we are spending each year on things that aren’t medically necessary.  

Take these:  

CMS.gov - Outpatient Department Services That Require Prior Authorization Beginning for service date... 

or

CMS.gov - Prior Authorization for Certain Hospital Outpatient Department (OPD) Services 

These are in affect EVERYWHERE - not just in those specific states that are being tested with added ones for a while. 

This does not mean that they are denied - it just means that the beneficiary’s file has to be documented with the medical need.

In some of these cases, it would be as simple as the provider sending in a pic of the patient.  

YES, we do need checks and balances if not, your Part B (SMI coverage) premiums will go much, much higher and not just because we are making headwinds on expensive treatments but because some doc can get away with doing things that not medically necessary because nobody is checking up on them.

From the 2025 Social Security Trustee Report -

The Supplementary Medical Insurance (SMI) Trust Fund is adequately financed into the indefinite future because, unlike the other trust funds, its main financing sources—enrolled beneficiary premiums and the associated federal contributions from the Treasury—are automatically adjusted each year to cover costs for the upcoming year. Although the financing is assured, the rapidly rising SMI costs [Part B] have been placing steadily increasing demands on beneficiaries and general taxpayers.

SSA.gov - 2025 Social Security [and Medicare] Trustee Report Summary 

Providers make money off of Medicare - Medicare pays for those approved treatments and services that are MEDICALLY NECESSARY - If they aren’t Medically Necessary, Medicare should NOT pay and the providers should not make money off of procedures and services that are not medically necessary.

What’s so hard about that rationale????

I also fail to see the objection.  

[papawofboo]

I think this proves what you are saying.

I was/am having problem with one of my eyes. The doctor had me apply for a grant that would pick up what the insurance didn't pay. I got approved, but MC wouldn't pay for the use of that drug until the doctor had tried using another drug.

Sometimes when they deny it's because they want you to take a certain path to recovery.

[GailL1]

@papawofboo 

That’s called “step therapy” - what this means is if there is a cheaper drug that does basically the same thing - you can be required to use it 1st to find out the result of this usage before you move to the higher priced medication.  

Medicare uses several different cost containment processes that are used to save money for the program - Prior Authorization and Step Therapy in medications are two such cost containment methods.    But cost containment methods don’t have anything to do with medical necessity.

Under this CMS plan, they look at procedures and services that could be legit medical necessities under some circumstances but not others.  

One example would be the surgery for drooping eyelids called blepharoplasty (for cosmetic reasons) or ptosis surgery (for functional reasons, like limited vision). Blepharoplasty involves removing excess skin, muscle, and fat to improve appearance. Ptosis surgery aims to correct the drooping muscle, often by shortening it or attaching it to a different muscle, to raise the eyelid. The best procedure depends on the cause and severity of the drooping.

Now in most cases, drooping eyelids don not cause any medical necessity to fix them - that would be cosmetic surgery for which Medicare has NO coverage.  

However if the condition is severe enough to cause vision to be impaired then that puts a new spin on the medical necessity requirement and the surgery would be approved.  

Another example would be the non-emergent medical transport - in most instances Medicare does not pay for non-emergency transport of a patient.  But there are certain situations where a doctor orders it and it is covered - maybe the patient is too obese to travel in a normal auto or has too many connecting life lines to go in a regular transport.  

Many of the current procedures under scrutiny do involve procedures for neuro-muscular-skeletal problems - the whole thing here is when the procedure is medically necessary based on the beneficiaries medical file - where the problem is and what has been tried up to now - these procedures often do not work because they are reliant on the exactness of the procedure in what nerves are involved.  The exact nerve is often very often difficult to pinpoint.  So yes, in this situation, a type of step therapy would be looked at to determine the medical necessity of the next step in the medical procedure.

Then you have the old steroids and pain killer injections - yes, they may work for a while and it is the determination of how many in what period of time would be in the determining factor because doing the same thing over and over and expecting different results is not a remedy for medical necessity - something else needs to be done.  But some docs just keep on giving them - and expecting different results and don’t get them.  

I have no idea why they pick certain states - they do seem to be geographically located around different areas of the country - but maybe there are some of these procedures that are done more often in those areas - I do not know why those specific states are picked - 

The CMS prior authorization review of certain procedures is based on the premise of ensuring that care is medically necessary and appropriate, while also controlling unnecessary increases in the volume of services and protecting the Medicare Trust Fund from improper payments.  This is accomplished by requiring documentation of medical necessity before a procedure is performed. 

CMS is also setting up a set procedure for both traditional Medicare and Medicare Advantage plans for prior approvals so that they can be done in as fast a process as possible without undue hardship on the beneficiary or the provider.  

The new prior authorization reviews for certain procedures are being done under the WISeR Model - Wasteful and Inappropriate Service Reduction Model.

This is a new demonstration project for Original Medicare. 

The Centers for Medicare & Medicaid Services (CMS) announced this payment model on June 29, 2025, to target fraud, waste, and abuse in Medicare fee-for-service. The model will test whether prior authorization can reduce inappropriate spending without harming patient care. 

The WISeR Model is a pilot project developed by the Center for Medicare and Medicaid Innovation (CMMI). The CMMI has long been around to find better ways of handing health care in Medicare and Medicaid. 

I have no objection to them doing this especially if it ends up saving the programs money - especially Medicare - Part B premiums to be specific.

[TRL1111]

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@papawofboo wrote:

I thought it was already in effect. We have had to have approval for many years, even before we got on MC. 

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Yeah, before you got on Medicare.  Preauthorizations are common in employer-sponsored plans and plans bought on the individual market, and in fact that's a selling point for Advantage plans--people are already used to dealing with preauthorizations (and networks).  (Note that they don't say "people like it"--just that they're familiar with it.)

And that's a selling point of Medicare--nobody getting in between you and your doctor when it comes to your care.  But that sort of freedom costs the system a lot of money, and a pathway for abuse by unscrupulous providers.

The preauthorizations being instituted are new for traditional Medicare, which has always required some preauthorizations, but far fewer than Advantage.  In 2023, Medicare received 400,000 requests for preauthorization, while Advantage plans received 50,000,000, even though Medicare and Advantage had about the same number of members.

[Winter2025VA]

Papaw @papawofboo , I agree and wondering IF I am missing something? Nicole!

➡️[*** PAPAW @papawofboo wrote:

I thought it was already in effect. We have had to have approval for many years, even before we got on MC. 

Wife's doctor send in for one, got turned down, he sent wife to another dr. who requested the same thing. Got approved. The way that was explained is that doctors in certain fields can get things approved while other can't. 

Always remember to save the letter with the approval until you get the eob. 

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[SereneSeagull]

Just read it’s AI driven.  Hold on to your hats, bumpy road ahead possibly.  Scheduled staring Jan 1, 2026 and supposedly runs for 6 years.