guide
The Medicare prior authorization list, by program and plan
Medicare has two kinds of prior authorization list. Original Medicare needs approval only for the services on a few national CMS lists, plus the WISeR Model’s services in six states. Each Medicare Advantage plan keeps its own, longer list and revises it on its own schedule, so the list to check depends on the patient’s plan.
CMS indexes its programs on one page, Prior Authorization and Pre-Claim Review Initiatives (updated September 15, 2025). It lists hospital outpatient department services, repetitive scheduled non-emergent ambulance transport, certain durable medical equipment and the Review Choice Demonstrations for home health and inpatient rehabilitation facility services.
At a glance
- Original Medicare’s outpatient list covers eight service types, from blepharoplasty to facet joint interventions.
- CMS decides outpatient and DMEPOS requests in 7 calendar days, or 2 business days if expedited.
- Repeat scheduled ambulance trips need approval nationwide, with no expedited review.
- 99% of Medicare Advantage enrollees are in plans that require prior authorization for some services.
- Aetna updates its precertification list each year, usually in January and July.
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Original Medicare’s national prior authorization lists
Three CMS programs require prior authorization across the country. The contractor reviewing the request answers within these limits:
| Program | What needs approval | Decision time |
|---|---|---|
| Hospital outpatient department services | Blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, vein ablation, implanted spinal neurostimulators, cervical fusion with disc removal, facet joint interventions | 7 calendar days, or 2 business days if expedited |
| DMEPOS Required Prior Authorization List | Lower limb prosthetics, orthoses, pneumatic compression devices, power mobility devices, pressure reducing support surfaces | 7 calendar days, or 2 business days if expedited |
| Repetitive, scheduled non-emergent ambulance transport | Repeat ambulance trips scheduled in advance | 7 calendar days, with no expedited review |
The outpatient list grew in three steps: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation on July 1, 2020, implanted spinal neurostimulators and cervical fusion with disc removal on July 1, 2021, and facet joint interventions on July 1, 2023. The decision limits come from 42 CFR 419.82, and CMS may exempt a provider that shows it follows Medicare’s coverage, coding and payment rules.
The DMEPOS list is drawn from a longer Master List of items that may need prior authorization, under 42 CFR 414.234. CMS last updated the required list on July 29, 2026, so check each code’s effective date before delivery. Ambulance prior authorization reached every state between December 1, 2021 and August 1, 2022, and since January 9, 2025 CMS has dropped the expedited option.
WISeR services in six states
The WISeR Model adds prior authorization to Original Medicare for 13 services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, and runs from January 1, 2026 to December 31, 2031. It sits beside the three national programs. Silna’s guide to the Medicare prior authorization pilot lists the services and how to submit them.
Where Medicare Advantage plans publish their lists
99% of Medicare Advantage enrollees are in plans that require prior authorization for some services, and insurers made 52.8 million determinations in 2024, denying 4.1 million (7.7%), according to KFF (January 28, 2026). Only 11.5% of denials were appealed, and 80.7% of appeals were overturned in full or in part.
Each plan publishes its own list:
| Plan | Where the list lives | What to know |
|---|---|---|
| Humana | Medicare and D-SNP Prior Authorization and Notification List | In effect from July 1, 2026 and revised October 1, 2026. It applies in full to HMO, HMO-POS and PPO plans, private fee-for-service plans need notification only, and drugs are on a separate list. |
| Aetna | Participating provider precertification list | One list for Aetna’s Medicare and commercial plans, updated each year, usually in January and July. |
| Wellcare (Centene) | 2026 Medicare Advantage Provider Manual | Availity Essentials is the preferred portal, and Evolent reviews imaging, physical medicine, pain management and musculoskeletal care in select states. |
After the request is sent, federal deadlines apply. Since January 1, 2026, CMS-0057-F has required Medicare Advantage plans to decide standard requests within 7 calendar days and urgent ones within 72 hours, according to the CMS fact sheet (January 17, 2024).
Checking a code before you schedule
- Confirm the patient’s program. Original Medicare and each Medicare Advantage plan use different lists. Silna’s Medicare prior authorization guide shows how to tell them apart.
- Look up the exact code. Match the CPT or HCPCS code, since a list can name a service category and still exclude some of its codes.
- Check the list’s effective date. Use the version in force on the date of service, because plans revise their lists during the year.
- Find the reviewer. Many Medicare Advantage plans send some services to a review vendor, which decides where the request goes.
How Silna checks Medicare codes and submits requests
Silna checks each patient’s coverage and whether the plan requires prior authorization for the scheduled codes. It flags the supporting documents a request needs, checks them against the payor’s medical necessity criteria, and submits the full package to the payor or its review vendor. It then follows the request to a decision and tracks re-authorization cycles, so an approval doesn’t lapse in the middle of treatment.
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Key terms
- Original Medicare
- Medicare Part A and Part B, also called traditional or fee-for-service Medicare, paid by CMS through its contractors, which uses CMS’s national prior authorization programs.
- Medicare Advantage
- A private plan that provides Medicare benefits and sets its own prior authorization list within CMS rules.
- DMEPOS
- Durable medical equipment, prosthetics, orthotics and supplies.
- Master List
- CMS’s list of DMEPOS items that may be subject to prior authorization, from which the required list is chosen.
- Pre-claim review
- A CMS review similar to prior authorization that takes place after services begin and before the final claim is submitted.
Frequently Asked Questions
Is there one Medicare prior authorization list?
No. Original Medicare uses CMS’s national programs and, in six states, the WISeR Model. Each Medicare Advantage plan publishes its own list.
What is on a Medicare precert list?
It depends on the plan. Humana’s and Aetna’s Medicare Advantage lists name the services and codes that need approval, and Humana keeps drugs on a separate list.
How often do the lists change?
Aetna updates its list each year, usually in January and July. CMS last updated the DMEPOS required list on July 29, 2026.
How long does a Medicare prior authorization take?
CMS decides outpatient and DMEPOS requests within 7 calendar days, or 2 business days if expedited. Medicare Advantage plans have 7 calendar days, or 72 hours for urgent requests.
This article is general educational information and does not give medical, legal or insurance advice. CMS and each plan change their lists, so check the current version before you rely on it.
About the author
Jeffrey Morelli
Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).
Last updated: October 30, 2026.