First study of Medicare's prior authorization pilot finds use of targeted services fell

What happened

Researchers from the University of Minnesota and Brown University published the first study of WISeR, a six-year federal pilot that began in January 2026 and requires prior authorization in traditional Medicare for a set of services officials consider prone to waste or fraud. Prior authorization means a clinician must get approval before a service will be covered. It is common in Medicare Advantage and private insurance but has been rare in traditional Medicare. The pilot runs in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, and the contractors doing the reviews are encouraged to use artificial intelligence.

Using a large electronic health record database, the study published in JAMA and announced on October 26 compared those six states with the rest of the country. Epidural steroid injections for back pain, the most common service in the pilot, fell 15%, and other targeted services fell about 20% in the first six months. The drop was largest right after launch: for steroid injections it went from about 21% in the first quarter to about 9% in the second. Services that were never added to the pilot did not decline.

The authors said they cannot yet tell whether the care that did not happen was unnecessary or needed.

What it means for families

For now this pilot affects only people with traditional Medicare in six states. But Medicare is studying whether to keep or expand it, so families everywhere may hear more about prior authorization in traditional Medicare. If a service needs approval, delays are possible, and it helps to know who is handling the request.

For example: if your father lives in Ohio and his doctor recommends a back injection, ask the office whether it needs approval and how long that usually takes.

New York is not one of the six WISeR states, so New Yorkers with traditional Medicare are not affected by this pilot. New Yorkers with questions about Medicare coverage can get free counseling from HIICAP through NY Connects at 1-800-342-9871.

What to do this week

• If a parent lives in a pilot state, ask the doctor's office whether a planned service needs approval.
• Keep copies of any approval or denial letters.
• Ask about appeal rights if a request is denied.
• Use your state's free Medicare counseling program for help.

Sources

• Medicare's prior-authorization pilot test led to an immediate drop in use of services, study finds (University of Minnesota School of Public Health)
• JAMA study (DOI 10.1001/jama.2026.21230) (JAMA)

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