New Medicare Pilot Program: What You Need to Know About Prior Authorization in 2026
For the first time, this rule will apply to people with traditional Medicare, not just those with Medicare Advantage.
The program will take place in six states:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington
The goal, according to the Centers for Medicare & Medicaid Services (CMS), is to help reduce fraud, waste, and unnecessary spending. Medicare is a big part of the federal budget, so the government is looking for ways to better manage costs.
What makes this pilot different is that private companies and artificial intelligence (AI) will be used to review requests for procedures. Although licensed medical professionals will make the final decisions, initial reviews will be done using automated systems.
Criticism and Concerns
Some people are worried the new system could make doctors less involved in care or cause delays for patients who need treatment quickly. A similar program was tried about ten years ago and, while it saved money, it also led to confusion, paperwork, and treatment delays, so it was canceled.
Supporters of the new plan believe that AI can make the process faster and easier, but some lawmakers and patient groups are concerned it could make healthcare harder for seniors, especially those with complex needs.
Which Procedures Need Prior Authorization?
The pilot program will include a wide range of procedures, mainly for chronic conditions affecting older adults. Here are the treatments that will require approval starting in 2026:
- Electrical nerve stimulators
- Sacral nerve stimulation for urinary incontinence
- Phrenic nerve stimulator
- Deep brain stimulation for tremors and Parkinson's disease
- Vagus nerve stimulation
- Induced lesions of nerve tracts
- Epidural steroid injections for pain (not including facet joint injections)
- Percutaneous vertebral augmentation for fractured vertebrae
- Cervical fusion
- Arthroscopic cleaning of the knee for arthritis
- Hypoglossal nerve stimulation for sleep apnea
- Incontinence control devices
- Diagnosis and treatment for impotence
- Image-guided lumbar decompression for spinal stenosis
- Skin and tissue substitutes (only in some states with special coverage rules)
If you are a Medicare patient in any of the pilot states, you may need to get prior authorization for these procedures starting in 2026. The aim is to save money and improve care, but be aware that there may be new steps and possible delays to getting certain treatments.
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