Medicare Will Require Prior Approval for Certain Procedures

[Harry Dresden]

They never have but they also have never required a pre authorization for an MRI or CT scan which this test in the 6 states will do.

i never knew you can set up an MRI without a doctor ordering one?...

 

[Lisa558]

Medicare is normally for people over 65. If you have lived that long in the wrong gender, you don't need it! If you are disabled, what does it matter?

The whole thing should never be covered by any insurance as it is elective.

And taxpayers sure shouldn’t be paying for it for convicts! What was the name of that Army guy who was imprisoned for a crime and got a fully paid-for trans operation?

 

[irosie91]

Sounds lucrative!

OMG

 

[debbiedowner]

i never knew you can set up an MRI without a doctor ordering one?...

Well, you can if you pay cash. But if a doctor orders one and a form, code and a reason will be sent to Medicare and their AI program will determine if it's going to be approved or denied. Then appeals start while the person may be dying. It should work like it does with a doctor and an insurance company.

 

[initforme]

And taxpayers sure shouldn’t be paying for it for convicts! What was the name of that Army guy who was imprisoned for a crime and got a fully paid-for trans operation?

Those cases are few and far between. While i dont agree with transition using it as a case is simpleton. If one is told they need a test, it should be covered. Case closed. Anything less is sticking it to average paycheck to paycheck workers, aka real americans.

 

[debbiedowner]

Medicare is normally for people over 65. If you have lived that long in the wrong gender, you don't need it! If you are disabled, what does it matter?

The whole thing should never be covered by any insurance as it is elective.

I know that and I agree if one lives to be 65 and then decides to transition it is possible Medicare would pay for it but that individual and doctor will have to jump through many hoops. I do think it's if they have lived 40 or 50 years why change after 65 as the surgery alone could kill them.
Yes, I know it's elective but that doesn't stop an insurance company from approving it.

More than likely the coverages for that will be terminated in 2026.

New Rule Proposes Changes to ACA Coverage of Gender-Affirming Care, Potentially Increasing Costs for Consumers | KFF

This brief examines a proposed rule that seeks to change how ACA plans would cover gender affirming care services. If finalized the rule could lead insurers to drop coverage or shift costs to individuals and states, making access to gender affirming care more difficult.

www.kff.org

 

[Greenbeard]

OMG

 

[skews13]

Medicare is launching a pilot program using AI to determine whether patients are covered under some procedures in a manner similar to private insurers, that has been heavily criticized. Thoughts USMB?​

​

Medicare Will Require Prior Approval for Certain Procedures​

A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.

https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.html?unlocked_article_code=1.hk8.L_ZA.095JZYck6sPh&smid=url-share

The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives.

The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.

The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections.

The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence.

Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays.

Mr. Sutton said the government experiment would examine practices that were particularly expensive or potentially harmful to patients. “This is what prior authorization should be,” he said.

​

The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused, he said.

But while experts agree that wasteful spending exists, they worry that the pilot program may pave the way for traditional Medicare to adopt some of the most unpopular practices of private insurers.

Illegal. Medicare Part A is automatic. Once you turn 65 years of age, it is absolutely required to cover 80% of the cost of any hospital stay. If you choose Part B, and pay the premium, it is absolutely required to cover Dr, and specialist treatment.

It would require Congress to act to change it.

Good luck to anyone in Congress, which would be Republicans that try to change it. When Democrats win back Congress, they should immediately end Medicare advantage, and pass a public option to the Affordable Care Act. It would be the fastest way to set back Republicans for at least a decade.

 

[Harry Dresden]

Illegal. Medicare Part A is automatic. Once you turn 65 years of age, it is absolutely required to cover 80% of the cost of any hospital stay. If you choose Part B, and pay the premium, it is absolutely required to cover Dr, and specialist treatment.

It would require Congress to act to change it.

Good luck to anyone in Congress, which would be Republicans that try to change it. When Democrats win back Congress, they should immediately end Medicare advantage, and pass a public option to the Affordable Care Act. It would be the fastest way to set back Republicans for at least a decade.

it is not absolutely required to cover everything,,,

 

[Lisa558]

Illegal. Medicare Part A is automatic. Once you turn 65 years of age, it is absolutely required to cover 80% of the cost of any hospital stay. If you choose Part B, and pay the premium, it is absolutely required to cover Dr, and specialist treatment.

It would require Congress to act to change it.

Good luck to anyone in Congress, which would be Republicans that try to change it. When Democrats win back Congress, they should immediately end Medicare advantage, and pass a public option to the Affordable Care Act. It would be the fastest way to set back Republicans for at least a decade.

And that’s the problem. If a doctor tells his elderly patients that they need to come back every 8 weeks just to “make sure things remain stable,” and thus gets Medicare to fork over a fortune so he can inflate his income, AND considering Medicare is insolvent, that needs to change.

 

[debbiedowner]

Illegal. Medicare Part A is automatic. Once you turn 65 years of age, it is absolutely required to cover 80% of the cost of any hospital stay. If you choose Part B, and pay the premium, it is absolutely required to cover Dr, and specialist treatment.

It would require Congress to act to change it.

Good luck to anyone in Congress, which would be Republicans that try to change it. When Democrats win back Congress, they should immediately end Medicare advantage, and pass a public option to the Affordable Care Act. It would be the fastest way to set back Republicans for at least a decade.

Wrong about part A covering 80% of a hospital stay.

2025 Medicare Parts A & B Premiums and Deductibles | CMS

On November 8, 2024, the Centers for Medicare & Medicaid Services (CMS) released the 2025 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2025 Medicare Part D income-related monthly adjustment amounts. Medicare Part B Premium and...

www.cms.gov

 

[debbiedowner]

Wrong about part A covering 80% of a hospital stay.

2025 Medicare Parts A & B Premiums and Deductibles | CMS

On November 8, 2024, the Centers for Medicare & Medicaid Services (CMS) released the 2025 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2025 Medicare Part D income-related monthly adjustment amounts. Medicare Part B Premium and...

www.cms.gov

A little add on to the premiums. Part B is expected to rise to $206.50 in 2026. The largest increase since 2022.

 

[Dekster]

Medicare is launching a pilot program using AI to determine whether patients are covered under some procedures in a manner similar to private insurers, that has been heavily criticized. Thoughts USMB?​

​

Medicare Will Require Prior Approval for Certain Procedures​

A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.

https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.html?unlocked_article_code=1.hk8.L_ZA.095JZYck6sPh&smid=url-share

The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives.

The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.

The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections.

The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence.

Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays.

Mr. Sutton said the government experiment would examine practices that were particularly expensive or potentially harmful to patients. “This is what prior authorization should be,” he said.

​

The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused, he said.

But while experts agree that wasteful spending exists, they worry that the pilot program may pave the way for traditional Medicare to adopt some of the most unpopular practices of private insurers.

I think the bigger problem is how private insurance pays people to churn out denials or approvals in the matter of seconds. Maybe this is a better system or will lead to one.

 

[justoffal]

Medicare is launching a pilot program using AI to determine whether patients are covered under some procedures in a manner similar to private insurers, that has been heavily criticized. Thoughts USMB?​

​

Medicare Will Require Prior Approval for Certain Procedures​

A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.

https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.html?unlocked_article_code=1.hk8.L_ZA.095JZYck6sPh&smid=url-share

The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives.

The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.

The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections.

The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence.

Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays.

Mr. Sutton said the government experiment would examine practices that were particularly expensive or potentially harmful to patients. “This is what prior authorization should be,” he said.

​

The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused, he said.

But while experts agree that wasteful spending exists, they worry that the pilot program may pave the way for traditional Medicare to adopt some of the most unpopular practices of private insurers.

This is absolutely necessary

 

[initforme]

This is absolutely necessary

Depends if they are going to continuously expand the list, that would be immoral.

 

[WorldWatcher]

This is absolutely necessary

So death panels are cool now?

Even better, an AI death panel.

WW

 

[justoffal]

So death panels are cool now?

Even better, an AI death panel.

WW

Fraud panels

 

[Captain Caveman]

Medicare is launching a pilot program using AI to determine whether patients are covered under some procedures in a manner similar to private insurers, that has been heavily criticized. Thoughts USMB?​

​

Medicare Will Require Prior Approval for Certain Procedures​

A pilot program in six states will use a tactic employed by private insurers that has been heavily criticized for delaying and denying medical care.

https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.html?unlocked_article_code=1.hk8.L_ZA.095JZYck6sPh&smid=url-share

The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives.

The federal government plans to hire private companies to use artificial intelligence to determine whether patients would be covered for some procedures, like certain spine surgeries or steroid injections. Similar algorithms used by insurers have been the subject of several high-profile lawsuits, which have asserted that the technology allowed the companies to swiftly deny large batches of claims and cut patients off from care in rehabilitation facilities.

The A.I. companies selected to oversee the program would have a strong financial incentive to deny claims. Medicare plans to pay them a share of the savings generated from rejections.

The government said the A.I. screening tool would focus narrowly on about a dozen procedures, which it has determined to be costly and of little to no benefit to patients. Those procedures include devices for incontinence control, cervical fusion, certain steroid injections for pain management, select nerve stimulators and the diagnosis and treatment of impotence.

Abe Sutton, the director of the Center for Medicare and Medicaid Innovation, said that the government would not review emergency services or hospital stays.

Mr. Sutton said the government experiment would examine practices that were particularly expensive or potentially harmful to patients. “This is what prior authorization should be,” he said.

​

The government may add or subtract to the list of treatments it has slated for review depending on what treatments it finds are being overused, he said.

But while experts agree that wasteful spending exists, they worry that the pilot program may pave the way for traditional Medicare to adopt some of the most unpopular practices of private insurers.

We don't that problem in the UK. Seems to be an obstacle in the, alleged, Land of the Free.

 

[justoffal]

We don't that problem in the UK. Seems to be an obstacle in the, alleged, Land of the Free.

The so-called Free people are actually more slave like now than the slaves they kept 125 years ago.