Does Medicare require prior authorization?

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Does Medicare require prior authorization?

Medicare Advantage plans often require prior authorization. But these coverage reviews are rare for original Medicare. That distinction changes in 2026. Many older adults choose original Medicare (Part A and Part B) to avoid prior authorization. This step, which can delay and deny care, is common with private Medicare Advantage plans.

Starting Jan. 1, 2026, a six-year pilot program in six states will use prior authorization to review certain services and supplies for original Medicare enrollees. This means that recommended care by a healthcare professional could be denied if you receive care in the targeted states. GoodRx, a platform for medication savings, shares what this could mean for those who rely on Medicare.

Key takeaways:

• Original Medicare enrollees rarely face prior authorizations. They are far more common for people who have Medicare Advantage plans.
• In January 2026, a six-year pilot program of coverage reviews will begin for original Medicare enrollees. Prior authorization will be required for certain Medicare Part B services and items received in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The Part B services and items subject to these coverage denials have been deemed potentially wasteful and prone to fraud by the federal government.
• This pilot program does not apply to Medicare Part D prescription plans. Most of them already use prior authorization and step therapy. They also likely have quantity limits on some medications.

Does Medicare require prior authorization?

Prior authorization is preapproval of a service or medication by your health insurance plan.

For years, Medicare Advantage and commercial insurance plans have routinely required prior authorization for a broad range of healthcare. But original Medicare has had few prior authorization requirements. In 2026, original Medicare will require prior authorization for certain services and items in six states.

Medicare Part D prescription plans provide stand-alone drug coverage. They can also be part of a Medicare Advantage plan. Part D plans can require prior authorization as well as step therapy. They may also impose quantity limits on covered medications.

Prior authorization is also used to review whether durable medical equipment (DME), prosthetics, orthotics, and other supplies are necessary.

Does original Medicare require prior authorization?

Not usually. In most cases, you don’t need advance approval for a service or supply covered by original Medicare. That changes in 2026 for people who receive care in six states.

A six-year pilot program will test prior authorization for certain Part B items and services. The reviews will be powered by artificial intelligence and machine learning.

These services and items may be subject to prior authorization:

• Arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee
• Cervical fusion
• Deep brain stimulation for essential tremor and Parkinson’s disease
• Diagnosis and treatment of impotence
• Electrical nerve stimulators
• Epidural steroid injections for pain management, excluding facet joint injections
• Hypoglossal nerve stimulation for obstructive sleep apnea
• Incontinence control devices
• Induced lesions of nerve tracts
• Percutaneous image-guided lumbar decompression for spinal stenosis
• Percutaneous vertebral augmentation for vertebral compression fracture
• Phrenic nerve stimulator
• Sacral nerve stimulation for urinary incontinence
• Skin and tissue substitutes, such as bioengineered skin substitutes, to lower-extremity chronic nonhealing wounds and wound application of cellular- and tissue-based products for the lower extremities
• Vagus nerve stimulation

Prior authorization will not apply to inpatient services, emergency care, or care that would pose a substantial health risk if delayed.

A healthcare professional can submit a prior authorization request before services are rendered. Or they can have a prepayment medical review after services have been provided (though they risk not being paid). Companies hired to manage the program will be paid based on how much money they save the government. This is directly linked to how many claims for services are denied.

Which states will be affected by the new original Medicare prior authorization pilot program in 2026?

The program will be deployed for care provided in six states:

• Arizona
• New Jersey
• Ohio
• Oklahoma
• Texas
• Washington

Do Medicare Advantage plans require prior authorization?

Virtually every enrollee in a Medicare Advantage plan — 99% — is subject to prior authorization. Most often, it is for higher-cost services such as:

• Chemotherapy
• DME
• Inpatient hospital stays
• Skilled nursing facility stays

By November 2023, there were about 67 million people with Medicare. They were about equally split between original Medicare and Medicare Advantage plans. That year, Medicare Advantage plans made nearly 50 million prior authorization decisions — on average, about two per enrollee. That’s compared with about 400,000 prior authorization reviews for original Medicare enrollees in the same year.

About 6.4% of the Medicare Advantage prior authorizations were denied in 2023. Yet most prior authorizations that were appealed — roughly 82% — were partially or fully overturned.

How does prior authorization work?

Prior authorization means a healthcare professional must consult with your health plan about whether your care is medically necessary. Depending on your health plan’s view of the care, your benefits can be approved or denied. The process of making a coverage decision can delay or prevent the care you need.

The pilot program has been criticized as an experiment that will complicate, deny, and delay needed care, while giving tech contractors performing the reviews financial incentives to deny claims. Critics say prior authorization, in general, prioritizes insurance company profits over patient care.

For years, lawmakers and patient advocates have expressed concern about Medicare Advantage prior authorization reviews. A 2022 federal analysis concluded that Medicare Advantage enrollees have been prevented from accessing medically necessary care and have faced denials at higher rates for certain services. These include rehab after hospital stays for strokes and falls. An American Medical Association survey of physicians found that doctors view prior authorization as a wasteful burden that disrupts care and increases healthcare costs.

Can you appeal a prior authorization denial?

If your Medicare or Medicare Advantage plan denies coverage for a service or an item, you can appeal. So can a healthcare professional or a supplier. This includes services that are not part of the pilot program. The appeals process differs depending on whether your coverage or payment denial comes from original Medicare or a Medicare Advantage plan.

How do you know if your medication requires prior authorization?

Your prescription plan’s summary of benefits and coverage can provide information about the medications that are likely to require prior authorization. When a medication requires prior authorization, a pharmacy typically notifies your prescriber to provide more information. You can also learn about a prior authorization from a pharmacy, but it’s typically when your fill is delayed or denied.

The bottom line

For the most part, original Medicare enrollees have been able to avoid prior authorization. This ends for some in 2026. Starting Jan. 1, a six-year pilot program in six states will allow prior authorization reviews of certain services and items for original Medicare enrollees. According to the federal government, the test is intended to identify and prevent waste and fraud. Prior authorization contractors will use clinicians as well as technology to review claims and help the government avoid paying for items and services that have been flagged as potentially unnecessary treatment. You can appeal Medicare coverage denials. This includes those from a prior authorization review under the pilot program.

This story was produced by GoodRx and reviewed and distributed by Stacker.