Traditional Medicare to require prior authorization for some procedures

[Rainger99]

Traditional Medicare has announced that they are going to require prior authorization for certain procedures. Apparently, the decision will be made by AI.

The good news is that it is a pilot program that will last six years and it will only apply to six states - New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

And it only applies to 17 procedures.

Skin and tissue substitutes
Nerve stimulators
Stimulation devices
Epidural steroid injections
Cervical fusion
Knee arthroscopy
Incontinence control devices
Facet joint interventions
Blepharoplasty
Botulinum toxin injection
Rhinoplasty
Panniculectomy
Vein ablation
Implanted neurostimulators
Cervical fusion with disc removal
Osteogenic stimulators
Knee orthoses

I don't know what most of those are so perhaps the doctors on TOTV can comment on whether the procedures are necessary.

https://www.cms.gov/files/document/wiser-fact-sheet.pdf

Prior Authorization Coming to Traditional Medicare Starting in 2026 | Kiplinger (https://www.kiplinger.com/retirement/medicare/prior-authorization-coming-to-traditional-medicare)

[manaboutown]

I believe blepharoplasty, rhinoplasty and vein ablation can be nonessential surgeries done by plastic surgeons.

[OrangeBlossomBaby]

I believe blepharoplasty, rhinoplasty and vein ablation can be nonessential surgeries done by plastic surgeons.

"Can be" and "are" are different things though.

If you have a deviated septum, or your nose was broken and is now badly misshapen, or you were born with a deformity in the nose and can't breathe out of it properly, then a rhinoplasty would be the medically appropriate solution. You do need your nose, and fixing it isn't always exclusively a cosmetic thing.

The same for a blepharoplasty - a relative had that done because his eyelids were sagging so far down that he was having trouble seeing and the eyelashes were turning inward and irritating his eyeballs. He had the excess skin removed and a few weeks later, all was well again.

On the other hand, getting an eyelid lift just because you want to look younger - shouldn't be covered in the first place. And getting a nose job just because you don't like how it curves outward at the ridge - is also a cosmetic thing and shouldn't be covered.

For things like that, it's important to know WHY there's a recommendation for a procedure. If it's medically necessary, it should be covered. If not, then no. A pre-auth is really a matter of paperwork UNLESS you're dealing with an insurance company that typically rejects pre-auths.

[Kelevision]

"Can be" and "are" are different things though.

If you have a deviated septum, or your nose was broken and is now badly misshapen, or you were born with a deformity in the nose and can't breathe out of it properly, then a rhinoplasty would be the medically appropriate solution. You do need your nose, and fixing it isn't always exclusively a cosmetic thing.

The same for a blepharoplasty - a relative had that done because his eyelids were sagging so far down that he was having trouble seeing and the eyelashes were turning inward and irritating his eyeballs. He had the excess skin removed and a few weeks later, all was well again.

On the other hand, getting an eyelid lift just because you want to look younger - shouldn't be covered in the first place. And getting a nose job just because you don't like how it curves outward at the ridge - is also a cosmetic thing and shouldn't be covered.

For things like that, it's important to know WHY there's a recommendation for a procedure. If it's medically necessary, it should be covered. If not, then no. A pre-auth is really a matter of paperwork UNLESS you're dealing with an insurance company that typically rejects pre-auths.

Yes, off topic sort of but I have dental insurance through my job and needed implants in my upper left back but insurance won’t cover it because it’s considered “cosmetic” even though you can’t even see it and I need it to eat. I had to go to Costa Rica ( the best dentist I’ve ever been to) to get it done for a reasonable price.

[Rainger99]

Yes, off topic sort of but I have dental insurance through my job and needed implants in my upper left back but insurance won’t cover it because it’s considered “cosmetic” even though you can’t even see it and I need it to eat. I had to go to Costa Rica ( the best dentist I’ve ever been to) to get it done for a reasonable price.

What was the insurance company that didn’t cover it?


Is a Dental Implant Considered Cosmetic? - Northside Dental Co. (https://northsidedentalco.com/is-a-dental-implant-considered-cosmetic/)