Alert
Medicare WISeR Model Requires Prior Authorizations in Six States
Beginning January 1, 2026, Medicare providers and suppliers in six states will need to obtain payment authorization for a variety of items and services under the Wasteful and Inappropriate Service Reduction (WISeR) Model.
The WISeR Model tests the use of advanced technology, such as Artificial Intelligence (AI), to reduce the provision of medically unnecessary care for certain services susceptible to fraud, waste, and abuse (FWA).
It’s designed to provide Medicare beneficiaries with safe and appropriate care, safeguard taxpayer funds, ease the provider administrative burden, and expedite payment decisions.
The model will be in effect for six performance years, through December 31, 2031, and operate in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
What’s the WISeR Model Methodology?
WISeR targets a specific group of services that have historically been associated with higher risks of FWA, or may be of low value to Medicare beneficiaries. Examples include skin and tissue substitutes, electrical nerve stimulators, and epidural steroid injections for pain management.
This model, split into two three-year agreements, will be a collaboration between the Centers for Medicare and Medicaid Services (CMS) and technology companies (the model participants) to enhance and accelerate the prior authorization process for the selected services.
Participants’ payments will be a percentage of the observed cost savings, based on requests that were reviewed but did not lead to a paid claim. Participants’ compensation will be performance-adjusted based on metrics including process quality (timeliness and accuracy of coverage determinations), survey-based provider and beneficiary experience, and downstream clinical outcomes.
Participating companies must provide proper clinical expertise during pre-approval and medical review processes, as well as adhere to all applicable federal, CMS, and HIPAA privacy and security requirements.
What’s the Impact of WISeR on Medicare Providers and Suppliers?
WISeR will apply to all providers and suppliers serving Original Medicare beneficiaries in the selected geographic areas. Medicare coverage and payment policies will remain the same under the WISeR Model, with no changes to provider or supplier payments or appeal rights.
Providers and suppliers have three options for obtaining payment authorization under WISeR:
- Submit a prior authorization request directly to the model participant to benefit from the streamlined processes offered by the model participant.
- Submit the prior authorization request to the Medicare Administrative Contractor (MAC), as they currently do for services that require prior authorization in Original Medicare. The MAC will forward the request to the model participant for determination.
- Post-service, pre-payment medical review: If providers don’t submit a prior authorization request for a WISeR-included service, the claim will undergo medical review to verify that the service meets Medicare coverage, coding, and payment criteria before payment for that claim is made.
For prior authorization requests, WISeR participants will issue a determination within three days of receiving the request, and expedited requests will be completed within two days. For post-service, pre-payment medical review, WISeR providers and suppliers will have 45 days to respond to the WISeR participant’s request for their clinical documentation, then the WISeR participant will issue a determination within three days.
The WISeR participant will send a copy of the authorization notification to both the requester and the Medicare beneficiary.
If denied, WISeR providers or suppliers may resubmit the authorization request and may include additional information to support the resubmission. Additionally, they may request peer-to-peer clinical review. There’s no limit to the number of times a particular authorization request can be resubmitted.
Once a prior authorization request is approved, the request is valid for 120 calendar days starting from the date it was approved. For example, a request affirmed on January 5, 2026, will be valid for dates of service through May 4, 2026.
Providers and suppliers with demonstrated records of compliance may be exempt from the WISeR review process in the future via a gold card exemption program.
Additional details can be found in the WISeR Model Provider and Supplier Operational Guide.
What Services are Included in the WISeR Model?
WISeR doesn’t include hospital inpatient services, given the importance of timely care. WISeR sites of service include: Hospital Outpatient Department (TOB 13X), Ambulatory Surgery Center (POS 24), home (POS 12), and office (POS 11).
The following services have been selected for payment authorization review under WISeR. A complete list of the associated HCPCS/CPT codes can be found in Appendix A of the Operational Guide.
- Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)
- Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
- Induced Lesions of Nerve Tracts (NCD 160.1)
- Vagus Nerve Stimulation (NCD 160.18)
- Phrenic Nerve Stimulators (NCD 160.19)
- Electrical Nerve Stimulators (NCD 160.7)
- Incontinence Control Devices (NCD 230.10)
- Sacral Nerve Stimulators for Urinary Incontinence (NCD 230.18)
- Diagnosis and Treatment of Impotence (NCD 230.4)
- Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (L34106, L38201, L35130)
- Epidural Steroid Injections for Pain Management (L39015, L39240, L36920)
- Cervical Fusion (L39741, L39758, L39793)
- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38307, L38310, L38385)
- Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041) and Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690)
- Deep Brain Stimulation (NCD 160.24) – proposed, but implementation has been delayed, to be re-evaluated for a future performance year.
Next Steps
While the WISeR Model will launch in the six selected states beginning January 1, 2026, MACs and WISeR participants will not start accepting prior authorization requests from providers and suppliers until January 5, 2026. WISeR will apply to services provided on or after January 15, 2026, allowing ample lead time to process requests and schedule approved services.
Providers located in the selected states should review the list of services and alert their billing department staff to the updated billing procedures required under WISeR. Providers may wish to evaluate the potential financial impact and may consider increasing documentation for medical necessity.
We’re Here to Help
To learn more about how the WISeR Model may affect your organization, contact your firm professional.