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Washington state has more than 1.5 million Medicare enrollees, just over half of whom are enrolled in traditional Medicare (51%). Until now, people with traditional Medicare have not been required to get prior authorization for most services. That means they can see specialists, visit hospitals, and receive out-of-state care without asking for permission first.

The federal agency that runs Medicare, the Centers for Medicare and Medicaid Services, has hired private companies in each pilot state — Washington, Arizona, Ohio, Oklahoma, New Jersey, and Texas — who will use AI tools to determine whether traditional Medicare patients qualify for certain procedures.

The list includes nerve stimulation to treat various ailments, steroid injections for pain management, cervical fusion, arthroscopic knee surgery, diagnosis and treatment of impotence, and certain skin and tissue substitutes.

AI companies will be paid a portion of the savings from claims they deny or, as the Wasteful and Inappropriate Service Reduction plan puts it, “compensated based on a share of averted expenditures.”

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Beginning January 1, 2026, the prior authorization process under this model will be implemented in the selected states on the following items and services with affiliated NCDs or LCDs:

Electrical Nerve Stimulators (NCD 160.7)

Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)

Phrenic Nerve Stimulator (NCD 160.19)

Deep Brain Stimulation for Essential Tremor and Parkinson's Disease (NCD 160.24)

Vagus Nerve Stimulation (NCD 160.18)

Induced Lesions of Nerve Tracts (NCD 160.1)

Epidural Steroid Injections for Pain Management excluding facet joint injections (L39015, L33906, L39036, L39240, L39242, L36920, L38994, L39054)

Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L33569, L34106, L34228, L38201, L34976, L35130, L38737, L38213)

Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)

Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)

Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38276, L38307, L38398, L38387, L38310, L38312, L38385, L38528)

Incontinence Control Devices (NCD 230.10)

Diagnosis and Treatment of Impotence (NCD 230.4)

Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)

Skin and Tissue Substitutes (LCDs below)—only applicable to MAC jurisdictions and states that have an active LCD in place

++ Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041)

++ Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690)