Skip to main content
Ethos - Now You Know For Sure

Top 5 Utilization Review Trends in 2026

Explore 5 utilization review trends in 2026, including AI, rising medical costs, new treatments, targeted review, and updated guidelines.

By Caroline Caranante | Oct 8, 2026 | 3 min. read

Top 5 Utilization Review Trends in 2026

What you will find below:

    1. AI Is Changing Utilization Review, but Human Oversight Still Matters
    1. Rising Medical Severity Is Making Treatment Review More Important
    1. More Complex Injectable Treatments Are Making Reviews Harder
    1. Utilization Review Is Becoming More Targeted
    1. Treatment Guidelines Are Changing Faster
  • What These Trends Mean for Claims Professionals

Utilization review still comes down to one question: Is this treatment reasonable and necessary?

That question is getting harder to answer in 2026. Medical costs are rising. New treatments are entering claims. Review rules are changing. AI is also becoming part of the review process.

1. AI Is Changing Utilization Review, but Human Oversight Still Matters

AI can make utilization review faster, but qualified clinicians still need to make the final decision.

CMS launched the WISeR Model on January 1, 2026. The model uses AI and human clinical review to evaluate certain Medicare services in six states. A licensed clinician must make any recommendation not to pay for a service.

States are taking similar steps. Seven states passed laws in 2026 that address AI in coverage and reimbursement decisions. Some of those laws limit the use of AI in denial decisions.

The rules for workers’ compensation are still developing, but the broader trend is clear. AI can help review cases, but a qualified clinician must remain accountable for the decision.

2. Rising Medical Severity Is Making Treatment Review More Important

Higher medical costs make it more important to determine whether treatment is appropriate for the claim.

NCCI found that medical claim severity rose 4% in 2025. NCCI’s medical price index rose about 1.8% as of March 2026. [SOURCE NEEDED]

WCRI found a similar increase in claim costs. Total claim costs rose an average of 6% per year from 2022 to 2025 across 18 states. Higher medical prices and high-cost claims drove much of that growth. [SOURCE NEEDED]

The reasons for rising costs vary by state and claim, which makes claim-level review important.

3. More Complex Injectable Treatments Are Making Reviews Harder

Newer injectable treatments can be harder to review because established treatment guidance may not exist.

A January 2026 WCRI study found that 39% of workers’ compensation claims with more than seven days of lost time involved an injectable therapy.

Self-administered injectables are also becoming more common. These include migraine biologics and GLP-1 drugs. They accounted for 15% of injectable payments in 2024, up from 7% in 2018.

Cost is only part of the challenge. Some newer treatments have limited guidance around treatment goals, duration, and when treatment should stop.

That creates more uncertainty during utilization review. Reviewers need current evidence and guidelines to determine whether newer therapies are appropriate.

4. Utilization Review Is Becoming More Targeted

Utilization review is shifting toward the care that needs the most scrutiny. Routine, guideline-supported treatment may not need the same level of review.

California offers a good example of this shift. New UR regulations took effect in April 2026. The rules formalized exemptions from prospective review for certain types of treatment during the first 30 days after an injury.

The change reflects a simple idea. If most early treatment requests are already approved, reviewing every request may add time without changing the outcome.

Research from California’s Division of Workers’ Compensation supports that point. More than 90% of early treatment requests were approved both before and after the exemption. After the change, injured workers were also 13% more likely to receive guideline-recommended physical therapy within 30 days. The average wait for a first visit fell from 13.4 days to 11.9 days.

The goal is not to eliminate utilization review. It is to use it where it adds the most value. Routine care can move forward faster, while more complex or questionable treatment can receive closer review.

5. Treatment Guidelines Are Changing Faster

Current guidelines are becoming more important because the standards used for review can change throughout the year.

For example, California updated its MTUS guidelines in January and April 2026. It also updated its drug list in April.

These updates matter because guidelines often provide the standard for medical necessity decisions.

California’s 2025 Independent Medical Review data shows the importance of MTUS. It remained the primary resource for medical necessity decisions. The overturn rate for treatment denials also fell from 12.7% in 2024 to 10.2% in 2025.

A current guideline can support a stronger review, and an outdated guideline can weaken one.

These trends show that utilization review is becoming more focused.

AI can help identify cases that need attention. Review changes can move routine care through faster. New treatments can create more complex cases.

These changes make current guidelines more important. They also make qualified clinical review and clear documentation even more important.

It’s essential for claims professionals to know the current standards. They need to understand the treatment being reviewed. They also must be able to explain the reasoning behind a decision.

Strong utilization review can help move appropriate care forward and give claims professionals a clear basis for questioning treatment that is not supported.

As utilization review continues to evolve, having the right clinical expertise and current guidelines matters. Connect with our experts for utilization review support that helps ensure treatment decisions are informed, timely, and defensible.

Sources:

Related Articles

Dive deeper into the world of risk management and investigative insights with our curated selection of related articles.