CMS Prior Authorization Demonstration and Protecting Patient Access

APMA has submitted comments to the Centers for Medicare & Medicaid Services (CMS) in response to a new prior authorization demonstration that will apply to certain services performed in ambulatory surgical centers (ASCs) across 10 states beginning December 15, 2025.

While APMA recognizes CMS's intent is to curb fraud, waste, and abuse, we are deeply concerned about the potential unintended consequences for patients and providers. APMA's comment letter to CMS voices the concerns of podiatric physicians, and it provides recommendations to CMS.

APMA highlighted risks to patient access and increased provider burden including:

• Barriers to Care: Prior authorization requirements often lead to delays in necessary medical treatment. For patients with venous leg ulcers and other acute or chronic foot and ankle conditions, delays can worsen outcomes, reduce mobility, and increase risk of complications.

• Provider Burden: Podiatric physicians already dedicate significant time and resources to ensuring compliance with Medicare and other payer requirements. Adding another layer of prior authorization creates additional administrative work which pulls focus away from patient care.

• Duplicative Oversight: APMA emphasized that CMS already has numerous mechanisms in place to address fraud, waste, and abuse. These safeguards are designed to protect the integrity of the Medicare program without restricting access to medically necessary services.

APMA provided CMS with the following recommendations to protect beneficiary access to medically necessary care and mitigate any associated administrative burden:

• Remove vein ablation from the demonstration because it is often medically necessary for treating venous leg ulcers and is not just for cosmetic purposes.

• Ensure timely review of prior authorization requests by adhering to CMS's finalized rule timeframes to prevent harmful delays in care.

• Adopt a "gold carding" policy to exempt compliant providers from prior authorization requirements. This would reduce administrative burden while safeguarding Medicare funds.

• Incorporate appropriate clinical expertise in review models. This ensures podiatrists are involved in developing and applying medical necessity criteria for vein ablation related to venous leg ulcers.

Read all advocacy comment letters at https://www.apma.org/commentletters. Contact the APMA Advocacy Department with any questions, concerns, or feedback.

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