Mostly no. Original Medicare (the traditional program, as opposed to Medicare Advantage) still does not require prior authorization for the overwhelming majority of care. What changed in 2026 is a limited six-year pilot called WISeR, running in six states, that adds an approval step for a short list of outpatient procedures that Medicare considers frequently overused. Your doctor's office handles the paperwork, a computer is not allowed to deny your care, your appeal rights are unchanged, and if you live outside the six states nothing is different at all. Here is the whole picture, calmly. (Full disclosure: Slothwise, the company behind this site, makes one of the apps in the Medicare App Library on Medicare.gov.)

What is the WISeR model?

WISeR stands for Wasteful and Inappropriate Service Reduction. It is a test program from the CMS Innovation Center that runs from January 1, 2026 through December 31, 2031. For a specific list of procedures, providers in the pilot states either request approval before performing the service or have the claim reviewed before payment. Technology companies hired by Medicare run the reviews using software plus human clinicians.

The stated goal is to stop spending taxpayer money on services that offer patients little benefit and, in some cases, can cause harm. Whether the pilot achieves that fairly is genuinely contested, which this article covers honestly further down. But the scope is narrow by design.

Which states and which procedures does WISeR affect?

Six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. If you live anywhere else, WISeR does not apply to your care in any way.

Within those states, it covers a short list of outpatient procedures. Examples include skin substitutes applied to slow-healing wounds, epidural steroid injections for back pain, arthroscopic knee surgery for osteoarthritis, certain implanted nerve stimulators, neck (cervical) spine fusion, and certain devices for incontinence. Emergency care, hospital-stay care, and anything whose delay would put a patient at substantial risk are all excluded.

The scale is small so far. Nationally, about 3 percent of people with Original Medicare used any service on the WISeR list in 2024, and the health policy group KFF expects the pilot's first-year impact to be modest. If you never need one of the listed procedures, you will likely never notice WISeR exists.

Can AI deny your Medicare care?

No, and this is the most misunderstood part of the program. WISeR's reviewers use artificial intelligence to help process requests, and the software is allowed to approve them. It is not allowed to deny them. Medicare's rule states that any recommendation against coverage must be made by an appropriately licensed human clinician, not a machine, and that denials "cannot be performed solely by technology."

So the accurate version of the scary headline is: a computer can say yes on its own, but only a licensed clinician can say no. Whether those human reviews are done well is a fair question, and the appeals process exists for exactly that reason.

What do you actually have to do?

Essentially nothing. Your doctor or supplier submits the request and the medical records that support it. You do not fill out forms, call anyone, or manage the process. You will receive a copy of the decision notice for your records, which is worth keeping with your Medicare paperwork. If you want a refresher on reading Medicare paperwork generally, our guide to reading your Medicare Summary Notice covers the notices you already get.

What happens if a service is denied?

Three protections apply. First, if the request is not approved, your doctor can fix the paperwork and resubmit; a non-approval is not a final judgment. Second, you cannot be surprise-billed: if a provider wants to perform a non-approved service anyway, they must give you an Advance Beneficiary Notice first, a form that tells you in writing, before the procedure, that you may have to pay. No form, no bill. Third, if a claim is denied, your normal Medicare appeal rights apply in full. Medicare states plainly that all appeal rights are preserved under WISeR, so if you read somewhere that the pilot has "no appeals," that is wrong. Appealing is free, and your State Health Insurance Assistance Program (SHIP) or 1-800-MEDICARE (1-800-633-4227) can help you through it.

Is prior authorization actually new for Original Medicare?

No. Original Medicare has required prior authorization for a small, targeted set of things for years: certain hospital outpatient procedures like eyelid surgery and vein ablation, power wheelchairs and certain prosthetics, and repetitive non-emergency ambulance rides. WISeR expands that existing idea to a new short list in six states. It does not introduce prior authorization to a program that never had it, and it does not change what Medicare covers.

How is this different from Medicare Advantage?

Enormously, and the contrast is the point. Prior authorization is routine in Medicare Advantage: plans processed about 52.8 million requests in 2024, and nearly every enrollee is subject to it for some services. Original Medicare handled roughly 628,000 prior-authorization reviews across the entire country that year, about two per hundred beneficiaries. WISeR narrows that gap slightly in six states for a short list of procedures. Critics worry it is the first step toward importing Medicare Advantage-style gatekeeping into the program people chose to avoid it; supporters say it targets only procedures with real evidence of overuse. Both of those things can be true at once, which is why the pilot's results matter.

How is the rollout actually going?

Honestly: it has been bumpy, and you deserve the unvarnished version. The start slipped two weeks, to January 15, 2026, because of technical problems. Doctors in some states reported that review portals did not work properly for weeks. A March 2026 Washington Post report found early approval rates in Texas around 62 percent before physician review, rising to 84 percent after, which is still below the roughly 92 percent typical in Medicare Advantage, and some patients experienced delayed care. Some physicians have reported repeated denials even with valid authorization numbers.

There is also a structural criticism worth knowing about: the companies running the reviews are paid a share of the money saved when care is not delivered, which hospital groups argue creates an incentive to deny. Medicare counters that reviewers are financially penalized for inappropriate denials, are not paid for denials that get overturned on appeal, and that the goal is getting determinations right rather than saying no. Members of Congress have tried to stop the pilot; the most recent attempt failed in a Senate vote on July 16, 2026, so WISeR continues in all six states as of mid-July 2026. Medicare has also begun exempting doctors with strong approval track records from the process entirely, a so-called gold-carding program that started rolling out in Washington state in July 2026.

The practical takeaway for a beneficiary: most of the day-to-day friction lands on doctors' offices, and the protections above (no surprise billing, human-only denials, full appeals) are the parts built for you. WISeR is one of several Medicare changes this year; our plain-English roundup of everything new in Medicare in 2026 has the rest.

Common questions

Is my state affected? Only if you live in New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington. The other 44 states are untouched.

Can AI deny my Medicare claim? No. Under WISeR's rules, software can approve a request but cannot deny one. Every denial requires a licensed human clinician, and every denied claim can be appealed.

Do I need prior authorization for an epidural steroid injection on Medicare? Only if you live in one of the six pilot states, and even then your doctor's office submits the request. You do not arrange anything yourself.

Will WISeR affect my Medigap coverage? Medigap plans do not add any prior authorization of their own. They pay their share after Original Medicare approves a claim, so the only effect you might notice is the same approval step your doctor already handles.

How long will the pilot last? It is scheduled to run through December 31, 2031. Congress or CMS could change or end it earlier; a Senate attempt to repeal it failed in July 2026.

How can Slothwise help?

Programs like WISeR add paperwork to a system that already generates plenty of it, and the notices rarely explain themselves. Slothwise brings your health information together in one place and explains your Medicare paperwork in plain English, so when a decision notice or a confusing denial arrives, you can simply ask what it means and what your options are. You can use it in the app or right from your text messages, and it is free to start, with no credit card.

Slothwise is one option, not the only one. For a denied claim or a confusing notice, 1-800-MEDICARE and your local State Health Insurance Assistance Program (SHIP) offer free help, and the appeal instructions printed on your Medicare notices work without any app at all.

The short version

• Original Medicare still has no general prior-authorization requirement. WISeR is a six-state pilot covering a short list of outpatient procedures through 2031.

• The six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Everywhere else, nothing changed.

• Software can approve a request but cannot deny one; denials require a licensed human clinician.

• Your doctor files everything. You cannot be billed for a denied service unless you signed an Advance Beneficiary Notice first, and your appeal rights are fully preserved.

• The rollout has been rocky for doctors' offices, a repeal attempt failed in the Senate in July 2026, and the pilot continues in all six states.

Slothwise is not affiliated with or endorsed by Medicare, the Centers for Medicare & Medicaid Services, or any government agency, and does not sell, endorse, or recommend any Medicare plan. This article is general information, not legal, financial, or medical advice. For questions about your specific coverage, contact 1-800-MEDICARE, your State Health Insurance Assistance Program (SHIP), or a qualified professional. Last updated: July 2026.