Traditional Medicare has never required much prior authorization for physician services. That changed on January 1, 2026 for practices in six states, when the Wasteful and Inappropriate Service Reduction model, known as WISeR, began its first performance year. The model is run by the CMS Innovation Center and it is unusual in that the only formal participants are technology companies, not providers. Those companies review prior authorization requests for a defined list of services, using automated tools alongside licensed clinicians, and the Medicare Administrative Contractor pays or does not pay accordingly. CMS announced the model on June 27, 2025 and published the implementing notice in the Federal Register on July 1, 2025.
The states are Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. The model is scheduled to run for six performance years, through December 31, 2031. If you practice in one of those states and perform any of the covered services, you have been living with it for three months. If you practice elsewhere, this is a preview of a tool CMS is clearly interested in expanding.
Key takeaways
- WISeR applies to traditional Medicare fee-for-service claims only, in six states, for a published list of services CMS considers low-value or at high risk of fraud and waste.
- You can request authorization before the service or accept pre-payment medical review after it. Nearly everyone who understands the second option chooses the first.
- A provisional affirmation comes with a tracking number that belongs on the claim. A hold rule in the practice management system prevents most cash flow problems.
- Providers with a 90 percent or better affirmation rate on at least ten requests can qualify for an exemption. Complete submissions the first time are the path.
What is covered
CMS chose services it considers high risk for fraud, waste or low-value use, and it excluded emergency services, inpatient-only procedures and anything where a delay would pose substantial risk to the patient. The list published with the model is longer than most summaries suggest:
| Service category | Who typically bills it | Documentation the reviewers ask for |
|---|---|---|
| Skin and tissue substitutes | Wound care, podiatry, dermatology, vascular | Wound measurements over time, failed conservative care, product selection rationale |
| Electrical nerve stimulator implants (including spinal cord, vagus, hypoglossal for sleep apnea, deep brain) | Pain management, neurosurgery, ENT, neurology | Diagnosis, failed alternatives, psychological evaluation where the coverage policy requires it |
| Knee arthroscopy for knee osteoarthritis | Orthopedics | Imaging, symptoms, conservative therapy tried |
| Cervical fusion and lumbar decompression for spinal stenosis | Spine surgery | Imaging correlation, neurologic findings, conservative care |
| Epidural steroid injections and destruction of nerve tissue | Pain management, physiatry | Pain scores, prior response, frequency limits |
| Vertebral augmentation for compression fractures | Interventional radiology, spine | Fracture age, pain, failed conservative care |
| Incontinence control devices and impotence treatment | Urology | Diagnosis, duration, prior treatments |
Skin substitutes are the largest by dollar volume, and it is no coincidence; Medicare spending on them grew enormously in the years before the model. Check the current list on the CMS Innovation Center page for WISeR rather than relying on a summary, including this one, because CMS has reserved the ability to adjust it.
How a request works
A practice in a model state performing a covered service has two paths:
- Request prior authorization before the service, either directly with the model participant assigned to your state or through your MAC, which forwards the request. If the reviewer issues a provisional affirmation, the claim is paid under normal rules. If it issues a non-affirmation, the service can still be performed, but the claim will be denied and the usual appeal rights apply. Requests can be resubmitted with additional documentation as many times as needed.
- Skip the request and have the claim reviewed before payment. This is pre-payment medical review: the participant asks for records after the claim is submitted, and payment waits for the review. Cash flow suffers, and a denial at this stage is a denial after the service has been rendered.
Nearly every practice we have talked to in the model states chose the first path once they understood the second. The model also includes a gold card provision: providers whose requests are consistently affirmed may be exempted from review for the covered services. CMS has described the threshold as a provisional affirmation rate of 90 percent or higher on at least ten requests during the review period, with exemptions lasting at least a year and re-evaluated quarterly. The participant maintains the exemption list and sends it to the MAC.
What practices are running into
| Issue | What we are seeing | What helps |
|---|---|---|
| Documentation requests | Requests for wound measurements, prior conservative therapy and product selection rationale for skin substitutes | A template that captures size, depth, duration and failed treatments at every visit |
| Turnaround | Most standard decisions returned within the stated timeframes; delays when records are incomplete | Submit the complete record the first time; a pend costs more days than it saves |
| Confusion about scope | Practices requesting authorization for services not on the list, or missing that a service is on it | A one-page crosswalk of covered HCPCS and CPT codes taped to the authorization desk |
| Medicare Advantage overlap | Staff assuming WISeR applies to MA patients | It does not; MA plans have their own rules |
| Denials citing coverage criteria | Denials referencing the local coverage determination for skin substitutes | Read the LCD; the denial usually names the exact criterion |
| Facility coordination | Hospital outpatient department and physician each assuming the other obtained the affirmation | Agree in writing who requests and who shares the tracking number |
The revenue cycle mechanics
Treat WISeR like any other prior authorization payer, with three differences. First, the affirmation is tied to a specific service and date range; a change in the plan of care means a new request. Second, denials flow through the standard Medicare appeals process (redetermination by the MAC within 120 days, then reconsideration by the Qualified Independent Contractor), not a plan-specific appeal. Third, the affirmation or non-affirmation decision comes with a unique tracking number that belongs on the claim; a claim without it for a covered service triggers the pre-payment review path whether you intended it or not.
Put the covered codes on a hold rule in your practice management system so that a claim for one of them in a model state cannot go out without the tracking number populated. That single edit prevents most of the cash flow problems we have seen.
A worked example from a wound care practice in one of the model states: in January it submitted eleven skin substitute requests, and four came back non-affirmed for missing wound measurements at the prior visit. All four were resubmitted with the measurements and affirmed within a week. The practice then changed its wound visit template so that length, width, depth and the date of the last measurement are required fields. February requests were affirmed on first submission. That first-submission record is what the exemption criteria measure, so the template change did double duty.
Why practices outside the six states should care
CMS built WISeR as a test of whether technology-assisted prior authorization reduces low-value spending without harming access. It is a six-year model, and the agency has already expanded prior authorization in traditional Medicare in other ways over the last several years for hospital outpatient departments and for certain DMEPOS. We think the direction is clear: the list of services and the number of states are more likely to grow than to shrink. Practices that perform the covered services anywhere should be documenting as though the request were coming.
There is also a quieter effect. The documentation the WISeR reviewers ask for is the documentation the coverage policies have always required. Practices outside the model states that perform skin substitute applications or spinal injections are subject to the same LCDs and to post-payment review by the same contractors. The model has simply moved the review to before the payment.
Questions we hear
Does WISeR apply to Medicare Advantage patients in the six states?
No. It applies to traditional Medicare fee-for-service claims only. MA plans continue to run their own prior authorization programs under their own rules, including the timeframes from CMS-0057-F.
Our request was denied. Can we bill the patient?
Only with a valid Advance Beneficiary Notice signed before the service that specifically identifies the service and the reason Medicare may not pay. A blanket ABN for every patient is not valid. Given how specific WISeR non-affirmations are, we recommend resubmitting first with the documentation the decision asks for.
How do we get gold carded?
Ask the model participant for your state how it measures the affirmation rate and when the next review period closes. Consistently complete requests that are affirmed on first submission are the path. It is one more reason to submit the whole record the first time. If authorization work is straining your team, denial management and authorization support is something we handle for practices in several specialties, and our live courses cover Medicare medical review and appeals in detail.
What to do this week
- Compare your charge master against the current WISeR service list and mark every covered HCPCS and CPT code.
- Add a claim hold rule for those codes in model states that requires the tracking number before submission.
- Pull every WISeR request since January 1 and calculate your first-submission affirmation rate; it is the number the exemption depends on.
- Update the visit template for your covered services so the documentation the reviewers ask for is captured every time.
- Confirm with each facility you operate in who requests the affirmation and how the tracking number reaches the other party's claim.
