As a retired and otherwise healthy physician, I recently endured weeks of intense pain this summer due to a herniated disk, which developed out of the blue without an obvious cause. This pain was beyond anything I had previously experienced – I am generally quite stoic, but these episodes reduced me to tears in the middle of the night.

Disk herniation is a common spine condition that causes intense back pain and sciatica. The herniated (bulging) disk impinges on a spinal nerve causing inflammation that in turn increases pressure on the nerve leading to worse pain and inflammation in a vicious cycle. Epidural steroid injections are simple outpatient procedures that are performed in a few minutes without general anesthesia but must be done by a specialist using fluoroscopy (real- time X-ray imaging) to guide the injection to the site of the herniation. By delivering anti-inflammatory steroids to the exact site of the herniation, the epidural injection reduces the inflammation, thereby breaking the vicious cycle of pain and providing short term relief, often to a dramatic extent.

In the long term, the patient’s immune system can trim the bulging disc, leading to a full recovery, but it is difficult for that healing process to begin when a patient is struggling with the vicious cycle of painful inflammation worsened by daily activity or impaired sleep. Thus, epidural steroid injection is a straightforward and minimally invasive procedure that can play a critical role in management of a common form of back pain.

Pain specialists spend years learning when and how to use this important tool. Shockingly, “epidural steroid injection for pain management” is one of the 17 procedures that will soon require prior authorization for patients in Original (Traditional) Medicare in Washington State, thanks to a new program called WISeR(1) about to be instituted by Dr. Oz, the new Director of the Center for Medicare and Medicaid Services (CMMS).

My herniated disk prevented me from sleeping for more than 90 minutes at a time without severe pain for much of this past summer. Because my Washington State town lacks practitioners who offer epidural injection, I tried other approaches for pain relief, including nonsteroidal anti-inflammatory medications, oral steroids, and intra- muscular steroid injections. But after seven weeks of repeated setbacks and severe sleep deprivation, I searched outside our area for the procedure. Because I am on Original Medicare, I was able to choose the best physician for this purpose regardless of location or network affiliation. A highly regarded pain specialist an hour away was able to schedule the initial visit in two weeks and the procedure, which included a diagnostic and therapeutic component, a week later. Within days after the procedure, I was sleeping pain-free for the first time in 10 weeks, and a couple days later I resumed my previous level of exercise. A month out from the procedure, I continue to be pain-free and my spine appears to be well on its way to healing.

Under the new WISeR program, Washington State residents on Original Medicare will need prior authorization (PA) to obtain epidural steroid injections for pain management in the future, along with 16 other procedures - a list that could grow over time. Authorization will be decided by companies that use AI to make decisions and will gain profit through denying authorizations. This approach will be modeled on the current use of PA by Medicare Advantage (MA). MA, which is offered by for-profit insurers as an alternative to Original Medicare, has gained attention for the use of PA as a mechanism for enhancing corporate profits(2,3). “Data submitted by MA insurers show that 81.7% of prior authorization denials were overturned in 2023” upon appeal according to a recent article from Healthcare Uncovered(4). The success of most appeals shows that prior authorization denials are often medically inappropriate – in which case why is CMMS replicating MA programs already proven to be problematic(5) and imposing them on Original Medicare?

I cannot begin to imagine how much worse it would have made my life to endure weeks or even months of additional excruciating pain and sleep deprivation while awaiting prior authorization and perhaps even an appeal. Is this what our country has come to? Will seniors now be forced to endure pain and illness, while knowing that relief used to be easily available if their physician deemed it necessary? Important procedures will soon be out of reach because our government allows corporations to reap huge profits by denying necessary healthcare.

Citations:

1.    WISeR Model RFA. Center for Medicare and Medicaid Services. P. 20. https://www.cms.gov/files/document/wiser-model-rfa.pdf

2.    Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds. Reed Abelson, The New York Times, April 28, 2022. https://www.nytimes.com/2022/04/28/ health/medicare-advantage-plans- report.html

3.    Insurers Pledge to Ease Controversial Prior Approvals for Medical Care. Reed Abelson, The New York Times, June 20, 2025.

https://www.nytimes.com/2025/06/20/ health/health-insurance-prior-authori- zation.html

4.    CMS is Trying to Expand Prior Authorization in Traditional Medicare Even Though All Data Points Say That’s a Bad Idea. Rachel Madley, Healthcare Uncovered, July 7, 2025. https://healthcareuncovered.substack. com/p/cms-is-trying-to-expand-prior- authorization

5.    About the Current Prior Authorization System. AMA Website FixPrior- Auth.

https://fixpriorauth.org/issue