Medicare Prior Approval in 2026: Key Changes and Processes

Summary: Medicare prior approval (also called Medicare prior authorization) verifies medical necessity before coverage. It’s common in Medicare Advantage and Part D, less so in Original Medicare. Providers usually handle requests. In 2026, the WISeR pilot added further prior approval requirements for certain services under Original Medicare in select states, aiming to reduce unnecessary care.

Overview of Medicare prior approval

Medicare prior approval, also known as Medicare prior authorization or Medicare pre-authorization, is a requirement to verify that a service, test, medication, or equipment is medically necessary before it is covered. For example, if your doctor recommends an MRI for back pain, Medicare may require documentation justifying the necessity before covering it. Without prior approval, the claim may be rejected even if deemed essential by your physician.

Prior authorization requirements exist because certain services have a history of being high-cost, frequently overused, or at higher risk of billing problems. Being informed about when prior approval is needed and how to prepare can help you navigate the process smoothly.

Does Medicare require prior authorization?

 
Original Medicare (Parts A and B) requires prior authorization only in limited circumstances for:

• Certain hospital outpatient procedures
• Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Medicare Part C (Medicare Advantage) and Medicare Part D prescription drug plans commonly require prior authorization. Medicare Part C often requires it for medical equipment, specialist visits, and non-emergency procedures, while Part D often requires it for certain medications.¹

The Medicare prior approval process

Your health care provider initiates the Medicare pre-authorization process for medical services, while your prescriber or pharmacy initiates it for prescription drugs. Doctors identify prior authorization requirements through insurance eligibility checks, alerts in electronic health record (EHR) systems, and plan coverage rules, while pharmacists review your plan’s drug list, also known as a formulary, to determine whether a prescribed medication requires prior approval.³ Standard decisions for medical services can take up to seven calendar days, while urgent requests require decisions within 72 hours for Medicare Advantage ⁴ and within two business days for Original Medicare.⁵

If your prior authorization request is denied, next steps depend on your Medicare coverage.⁶ If your Medicare Advantage plan denies coverage, you or your provider can file an appeal with your insurer.⁷ Under Original Medicare, prior authorization denials cannot be appealed, but providers may resubmit the request with complete documentation showing the care meets Medicare coverage requirements.

What procedures does Medicare require prior authorization for?

Although prior authorization is uncommon under Original Medicare, several specific procedures and DMEPOS items do require approval before Medicare will cover them. For certain surgeries and treatments, Medicare requires prior authorization when they are billed as hospital outpatient services (not inpatient or office‑based care). The services and DMEPOS items that typically require prior authorization include:⁴

• Eyelid surgery (blepharoplasty)
• Medical botulinum toxin injections (such as Botox)
• Removal of excess abdominal skin (panniculectomy)
• Nose surgery (rhinoplasty)
• Vein ablation
• Cervical fusion with disc removal
• Implanted spinal neurostimulators
• Facet joint injections for back or neck pain

Impact on access to patient care

Some critics say Medicare’s prior authorization process may slow down care because doctors must obtain approval before certain treatments, procedures, or medications are covered. They argue that these requirements add administrative steps that delay clinical decisions, even when a physician believes care is medically necessary or time sensitive.¹

Delays can be especially challenging for older adults and people managing chronic conditions, as prolonged waiting periods may raise the risk of worsening symptoms, increased discomfort, or more complications.

To help minimize delays and stay informed, patients and caregivers can take a few practical steps to navigate the prior authorization process more effectively:

• Ask your doctor right away if prior authorization is required and when a decision is expected.
• Keep key medical records and prescriptions organized and easy to share.
• Check directly with Medicare or your health insurance carrier to track approval status or appeal delays.
• Enlist a caregiver or patient advocate to help monitor paperwork and follow up when needed.

The 2026 Medicare Pilot Program: WISeR

On January 1, 2026, Medicare launched a test program called Wasteful and Inappropriate Service Reduction (WISeR) to ensure people receive care that is truly medically necessary and evidence-based while decreasing costs.⁸ The WISeR test program is planned to run for six years, ending December 31, 2031.

If you have Original Medicare and live in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, some additional services may require approval before Medicare will cover them. These services include, but are not limited to:

• skin and tissue substitutes
• implantation of electrical nerve stimulators

Inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed are excluded from the model.

How WISeR may affect patients

Here’s what to expect if you need a service or DMEPOS equipment that requires prior authorization before it is covered by Medicare:

• Your doctor may need to request approval from Medicare before proceeding with certain procedures or providing certain medical equipment.
• You could be asked to wait for a decision before receiving care.
• If approved, your care can move forward as planned and would be covered by Medicare.
• If the service is not considered medically necessary, it may not be covered and you may need to explore other options with your provider for covered care or expect to pay the full cost of the service out-of-pocket.⁸

Learn More about Your Medicare coverage options

Understanding Medicare’s prior authorization requirements can help you avoid delays and choose coverage that best fits your needs. To take the next step in determining your Medicare coverage, learn how to plan for unexpected costs in Medicare.

Frequently asked questions

Q1. Does Original Medicare require prior approval?

Generally, no. Most routine services do not require prior approval under Parts A and B, but prior authorization is required in limited situations for certain hospital outpatient procedures and some DMEPOS items.

Q2. What happens if I don’t get prior approval?

Your Medicare claim may be denied, making you responsible for the cost. Original Medicare only requires prior authorization for a limited set of services and medical equipment. Medicare Advantage plans typically require prior authorization for a broader number of services. To avoid unexpected costs, always confirm that prior authorization has been completed before receiving care.

Q3. How do I know if a medication needs prior authorization?

Check your Medicare Part D plan’s drug formulary and consult your prescriber or pharmacy to determine if prior authorization is needed.

Q4. Can I speed up an urgent Medicare prior approval?

If delaying care could seriously jeopardize your health, Medicare Advantage plans allow your provider to request an expedited (urgent) review, which must be completed within 72 hours. Original Medicare also offers expedited reviews for urgent requests, typically providing a decision within two business days.

Q5. What if my prior approval is denied?

Your options after a Medicare prior authorization denial depend on the part of Medicare that denied your claim.

You cannot appeal prior authorization denials from Original Medicare because these decisions aren’t treated as formal coverage determinations that come with appeal rights. However, your provider may resubmit the request with additional documentation to show the care meets Medicare coverage requirements.

Medicare Advantage (Part C) prior authorization denials can be appealed. Unlike Original Medicare, Medicare Advantage prior authorization rulings are considered pre-service initial determinations, which gives you formal appeal rights under Medicare rules.

Sources

¹ MedicareAdvocacy.org. Web page: Medicare Prior Authorization. Retrieved Jan. 23, 2026, from www.medicareadvocacy.org/prior-authorization

² Centers for Medicare & Medicaid Services (CMS). Web page: Durable Medical Equipment (DME) Coverage. Retrieved Jan. 23, 2026, from www.medicare.gov/coverage/durable-medical-equipment-dme-coverage

³ Medicare.gov. Web page: Drug plan rules. Retrieved Feb. 12, 2026, from www.medicare.gov/health-drug-plans/part-d/what-drug-plans-cover/plan-rules

⁴ Centers for Medicare & Medicaid Services (CMS). Web page: Prior Authorization for Certain Hospital Outpatient Department (OPD) Services. Retrieved Jan. 26, 2026, from www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services

⁵ Centers for Medicare & Medicaid Services (CMS). Press release: CMS finalizes rule to expand access to health information and improve prior authorization process. Retrieved Feb. 11, 2026, from www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process

⁶ Center for Medicare Advocacy. Web page: Medicare prior authorization. Retrieved Jan. 29, 2026, from www.medicareadvocacy.org/medicare-prior-authorization/

⁷ Medicare.gov. Web page: Appeals in Medicare health plans. Retrieved Mar. 18, 2026, from www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans

⁸ Centers for Medicare & Medicaid Services (CMS). Web page: Wasteful and Inappropriate Service Reduction (WISeR) Model. Retrieved Jan. 23, 2026, from www.cms.gov/priorities/innovation/innovation-models/wiser

Item #648547