Four days after health insurers pledged to reduce prior authorization, CMS announced it was adding some. On Friday, June 27, 2025, the CMS Innovation Center published the Wasteful and Inappropriate Service Reduction model, WISeR, a six-year test that will apply prior authorization to a defined list of services in traditional fee-for-service Medicare. It starts January 1, 2026 and runs through December 31, 2031 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
Traditional Medicare has had almost no prior authorization for physician services until now. The exceptions have been narrow: certain hospital outpatient department services since 2020, some durable medical equipment, repetitive scheduled ambulance transport. WISeR is different in kind. It puts technology companies with experience running prior authorization for Medicare Advantage plans between the ordering physician and the Medicare payment, and it pays them a share of what they prevent Medicare from spending.
Key takeaways
- WISeR applies prior authorization to a defined list of traditional Medicare Part B services in six states from January 1, 2026, for six years.
- The list is built around services with a history of improper payment or low-value use: skin and tissue substitutes, electrical nerve stimulator implants, knee arthroscopy for knee osteoarthritis, certain epidural steroid injections, cervical fusion, hypoglossal nerve stimulation and others.
- Providers can request authorization before the service or skip it and accept pre-payment medical review after. We think most affected practices should request it.
- The coverage standard does not change. Reviewers apply existing national and local coverage determinations, so the documentation that passes an LCD today passes WISeR.
- Reviewers are paid a share of averted spending, adjusted for performance including provider experience. Watch the appeal overturn rates.
What the model covers
CMS selected services it describes as vulnerable to fraud, waste, abuse or inappropriate use, with low-value evidence or a history of improper payment. The published list includes skin and tissue substitutes, implantation of electrical nerve stimulators, knee arthroscopy for knee osteoarthritis, and several other items that CMS listed in the announcement, including certain epidural steroid injections for pain management, cervical fusion, hypoglossal nerve stimulation for obstructive sleep apnea, incontinence control devices and treatments for erectile dysfunction. The model excludes inpatient-only services, emergency services and any service where a delay would pose a substantial risk to the patient.
Skin substitutes are the item with the largest dollar exposure. Medicare spending on them has risen sharply in recent years, and wound care practices, podiatrists and some primary care offices in the six states should expect this to be the category that draws the most scrutiny.
How the review works
| Element | What CMS has said |
|---|---|
| Who reviews | Model participants: companies with experience in prior authorization technology, including artificial intelligence and machine learning, selected by CMS and assigned to a state |
| Provider choice | Providers in the six states may submit a prior authorization request before the service, or skip it and have the claim go through pre-payment medical review after the service |
| Who decides denials | CMS says every recommendation of non-payment is made by a licensed clinician, not by the software alone |
| How participants are paid | A percentage of the Medicare spending averted on the selected services, adjusted for performance measures including provider experience |
| Exemptions | CMS describes a gold-carding approach under which providers with strong compliance records may be exempted from prior authorization for some services |
| Coverage standard | Existing Medicare coverage rules: national and local coverage determinations, and the reasonable and necessary standard. The model does not create new coverage criteria |
Who this affects
Practices in the six states that order or perform the listed services: pain management, orthopedics, neurosurgery, spine, wound care, podiatry, urology, sleep medicine and some primary care. Practices outside those states are not affected in 2026, though the Innovation Center's stated intent is to test whether the approach reduces spending and could be expanded. Medicare Advantage patients are not affected by WISeR, because their plans already run prior authorization under their own rules.
Ambulatory surgery centers and hospital outpatient departments where these procedures are performed will feel it too, because the facility claim and the professional claim rise and fall together. If the procedure is not authorized, both are at risk.
What changes in the workflow
For an affected practice, the decision in the autumn is whether to request authorization before each listed service or accept pre-payment review afterwards. We think most practices should request authorization. Pre-payment review means the service has been performed, the costs incurred and the claim held while a reviewer reads the chart, with no opportunity to fix a documentation gap before the fact. Prior authorization moves the same review to before the service, when a missing conservative therapy note or imaging report can still be supplied.
The documentation itself does not change. The coverage rules are the existing LCDs and NCDs, and the practices that struggle under WISeR will be the ones whose notes do not already meet them. For skin substitutes, that means documented wound measurements over time, failed standard care for the required period and the product's coverage status under the applicable LCD. For knee arthroscopy, it means the specific indications the coverage policy accepts and documentation of why the osteoarthritis diagnosis does not exclude the procedure. For injections and stimulators, it means the trial, the failed alternatives and the functional assessments the policy expects.
A worked example of the two paths
A pain management practice in Texas performs about 60 Medicare fee-for-service epidural steroid injections a month, roughly $250 in professional payment each, in an office setting. Under the prior authorization path, the practice submits each request with the imaging report, the conservative therapy notes and the pain and function scores the LCD asks for, and schedules the injection after the decision. A request that is not affirmed comes back before the patient is on the table, and the practice either supplies what was missing or does not perform the service. Under the pre-payment review path, the practice performs all 60, submits 60 claims, and each one is held while a reviewer reads the chart; every non-affirmed claim is a service already delivered for which the practice is now unpaid and appealing. If the practice's charts fail the LCD 15% of the time, that is 9 injections a month, about $2,250 in professional payment plus the drug and supply cost, at risk after the fact rather than before it. The prior authorization path costs staff time up front. The pre-payment path costs the same staff time later, plus the money.
Our view
We think the timing is awkward and the design is worth watching closely. Paying reviewers a share of denied spending is an incentive structure that physician groups have criticized in Medicare Advantage for years, and CMS has said it will adjust payments for provider experience to counter it. Whether that works will show up in the appeal overturn rates, and CMS should publish them. In the meantime the practical advice is unglamorous: know whether you are in a model state, know which of your services are on the list, and get the documentation right before January.
There is a fairness point worth making too. A wound care practice whose charts already meet the LCD has nothing to fear from the review itself and a good deal to gain from a gold card. The practices that will be hurt are the ones whose documentation has been thin for years and whose claims were paid because nobody looked. That is uncomfortable, but it is also the point of the model, and a documentation audit in the autumn is cheaper than learning it from non-affirmations in January.
Revelrex tracks prior authorization requirements by payer and service as part of denial management and reviews documentation against coverage policies in the RCM audit. Practices in the six model states with skin substitute, spine or pain management volume should consider a documentation review before the autumn.
Questions we hear
Is this the same as Medicare Advantage prior authorization?
Mechanically similar, legally different. MA plans set their own criteria within Medicare coverage rules and are paid capitation regardless of what they approve. WISeR reviewers apply Medicare's own coverage rules and are paid based on what they deny or deter, which is why the provider experience adjustment matters.
Can a patient in a model state get the service somewhere else?
The model applies to services furnished in the six states. A patient who travels to a neighboring state for the procedure would not be subject to WISeR review for that service, but that is not a reasonable basis for practice planning and it does not change the coverage rules the service has to meet anyway.
What happens if a prior authorization is denied?
CMS has said standard Medicare appeal rights apply to the resulting claim denial, and a provider can resubmit a prior authorization request with additional documentation. Details on the request and appeal mechanics are expected in the operational guidance later this year.
What to do this month
- Confirm whether your practice locations are in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington. The model applies by the state where the service is furnished.
- Pull your 2024 and 2025 Medicare fee-for-service volume for the listed service categories. If it is zero, you can stop here. If it is meaningful, name an owner for WISeR readiness.
- Read the current LCD for each affected service in your MAC jurisdiction and audit ten recent charts against it. Fix the documentation template where the charts fall short.
- Watch for CMS to publish the participant assigned to your state, the request process and the code list. CMS has said more operational detail will follow over the summer and autumn.
- Decide the prior authorization versus pre-payment review question for each service and write it into the scheduling workflow.
- Add a WISeR authorization field to the same authorization record you use for commercial and MA plans, so the tracking is in one place.
