27 Aug WILL YOU LOSE HEALTH CARE COVERAGE DUE TO PRIOR AUTHORIZATION REQUIREMENT FOR TRADITIONAL MEDICARE COMING TO TEXAS IN 2026
Texas is one of six states that will require pre-authorization for certain traditional fee-for Medicare services starting January 1, 2026.
Previously, pre-authorization was only required by those who have Medicare Advantage plans.
This will apply to 17 services that the Centers for Medicare and Medicaid Services (CMS) says “are vulnerable to fraud, waste, and abuse”. Other services will likely be added at a future date.
According to a CMS press release, it will “test ways to provide an improved and expedited prior authorization process relative to original Medicare’s existing process, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars”. A new process using enhanced technologies, including artificial intelligence (AI), will be used to expedite the prior authorization process for select items and services that the government believes is most likely to be subject to fraud, waste, and abuse, including (without limitation) electrical nerve stimulator implants, knee arthroscopy for knee osteoarthritis, and skin grafts and tissue substitutes.
Inpatient-only services, emergency services, and services that would pose a substantial risk to patients, if delayed, are not included.
Licensed clinicians with appropriate expertise will make the final decision on Medicare coverage, although AI is used to support the review process. The clinicians will work for various companies selected, which will receive payments based on their ability to reduce unnecessary or non-covered services. As a result, it is likely more claims will be denied.
Otherwise, traditional Medicare coverage is the same, and beneficiaries can still seek the care provider of their choice. It is just that providers will have the choice of a pre-authorization request for selected services or go through post-service pre-patient medical review.
The 17 services subject to prior authorization are as follows:
- Electric nerve stimulators;
- Sacral nerve stimulation for urinary incontinence;
- Phrenic nerve stimulator;
- Deep brain stimulation for essential tremor and Parkinson’s disease;
- Induced lesions of nerve tracts;
- Vagus nerve stimulation;
- Epidural steroid injections for pain management (excluding facet joint injections);
- Cervical fusion;
- Percutaneous vertebral augmentation (PVA) for vertebral compression fractures;
- Arthroscopic lavage and arthroscopic debridement for osteoarthritic knee;
- Incontinence control devices;
- Hypoglossal nerve stimulation for sleep apnea;
- Diagnosis and treatment of impotence;
- Percutaneous image-guided lumbar decompression for spinal stenosis;
- Skin and tissue substitutes;
- Application of bioengineered skin substitutes to lower extremity chronic non-healing wounds; and
- Wound application of cellular and/or tissue-based products, lower extremities.
The difference between traditional Medicare and Medicare Advantage plans is that Medicare Advantage use its own criteria for medical necessity and almost all must obtain prior authorization – especially for higher cost services.
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