For most of its history, Original Medicare did not require prior authorization for physician services. That changed on January 1, 2026, when the CMS Innovation Center launched the Wasteful and Inappropriate Service Reduction model, known as WISeR, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Requests could be submitted from January 5 and the requirement applied to services furnished on or after January 15. The model runs through December 31, 2031. It applies to Original Medicare only; Medicare Advantage plans have their own authorization rules and are not part of it.
We are now six months in. The practices we talk to in the model states fall into two groups. One group treats WISeR as another payer rule, built a workflow in January, and reports that most requests come back within a few business days. The other group learned about it from a suspended claim. This article is for the second group, and for practices in the other 44 states who want to know what is coming if CMS expands the model, which it has said it may.
Key takeaways
- WISeR covers 13 categories of outpatient services in six states. Skin substitutes are most of the dollars; spine, knee and nerve stimulator procedures are most of the surgical volume.
- Decisions come back in about three business days (two when expedited). A provisional affirmation is valid for 120 days and carries a unique tracking number that must be on the claim.
- Skipping the request is allowed, but the claim then goes to pre-payment review with a 45-day records window. Practices that default to this route build no record for gold carding.
- Providers with an affirmation rate of 90 percent or better may be exempted from the process. Clean packets now are the path to that exemption.
What the model covers
WISeR targets a specific set of outpatient services that CMS considers vulnerable to fraud, waste or low-value use. The 13 categories: skin and tissue substitutes (CPT 15271 to 15278); epidural steroid injections for pain management (62321, 62323, 64479 to 64484); percutaneous vertebral augmentation (22510 to 22515); cervical fusion (22554); knee arthroscopy and related procedures for osteoarthritis (29877, 29880, 29881, 64447); spinal cord stimulator implantation (63655); sacral nerve stimulation (64561, 64581); phrenic nerve stimulators (33276, 33277); vagus nerve stimulation (64568); hypoglossal nerve stimulation (64582, 42975); induced lesions of nerve tracts (64605, 64610); incontinence control devices (53440, 53445, 53451, 53452, 57288); and impotence treatment including penile prostheses (54400, 54401, 54405). Deep brain stimulation was on the original list and has been delayed. CMS has said the model excludes inpatient-only services, emergency services and situations where a delay would pose a substantial risk to the patient.
The dollars are concentrated. KFF's February 10, 2026 analysis put 2024 national spending on WISeR services at $12.3 billion, about 5.3 percent of Part B, with skin substitutes making up 83 percent of that, about $10.3 billion. The average price of a skin substitute service rose roughly 820 percent between 2019 and 2024, from about $2,300 to about $21,200. About 1.1 million beneficiaries used a WISeR service nationally in 2024, and roughly 207,500 of them live in the six model states. If you treat wounds in one of those states, you are the reason the model exists, whether or not your own billing was ever the problem.
How the process works
| Step | Detail |
|---|---|
| Submission | Electronic submission to the state's review participant or through the Medicare Administrative Contractor. Novitas handles New Jersey, Oklahoma and Texas; CGS handles Ohio; Noridian handles Arizona and Washington. The vendors are Cohere Health (Texas), Genzeon (New Jersey), Humata Health (Oklahoma), Innovaccer (Ohio), Virtix Health (Washington) and Zyter (Arizona). |
| Decision | Within about three business days for a standard request; about two when expedited. Peer-to-peer discussion is available on a non-affirmation. |
| Affirmation | A provisional affirmation is valid for 120 calendar days from the decision and carries a unique tracking number (UTN) that must appear on the claim. |
| Non-affirmation | Unlimited resubmissions are allowed with additional documentation addressing the reviewer's stated reason. |
| Alternative | Furnish the service without prior authorization; the claim is suspended for pre-payment medical review, records are requested with a 45-day window to respond, and a decision follows within about three days of complete records. |
| Exemption | Providers with a provisional affirmation rate of 90 percent or higher over a review period may be exempted from submitting requests. |
What the practices doing well have in common
They decided who owns the UTN. The single most common cause of a paid service becoming an unpaid one is a valid affirmation whose tracking number never made it onto the CMS-1500 or the facility claim. In practices where the surgeon operates at an ASC or hospital, both the professional and the facility claim need the number. The practices with clean results assigned one person to write the UTN into the encounter before the date of service and made it a required field in the charge template.
They watch the 120-day clock. A spine case affirmed in February and rescheduled to July needs a new request. Scheduling systems do not know this. A weekly report of affirmed cases with service dates approaching day 100 catches it. For wound care, where a skin substitute course may run several applications over weeks, the practices doing well request the full planned course and track the expiry against the last planned application, not the first.
They front-load documentation. The reviewers apply Medicare coverage criteria, which for these services usually means a documented trial of conservative therapy, imaging that supports the diagnosis, and a treatment plan. For skin substitutes that means wound measurements over time, duration, failed standard care and the specific product with its coverage status. Practices that attach the same well-organized packet every time get faster decisions than practices that attach the whole chart. A one-page cover sheet that maps each coverage criterion to a page in the packet is the single most effective habit we have seen.
They log turnaround. Patient advocacy groups have published early reports of delayed care under the model, and practices that can show their own submission and decision dates are in a much stronger position with patients and with CMS when something goes wrong.
A worked example
A two-physician pain practice in Oklahoma performs about 40 epidural steroid injections a month on Original Medicare patients. In January it submitted every request the day the procedure was scheduled, attached the full chart, and saw a median decision time of four business days with a 78 percent affirmation rate; most non-affirmations cited missing documentation of conservative therapy. In March it switched to a standard packet: the note documenting six weeks of physical therapy or medication trial, the imaging report, the pain scores, and the plan. The median dropped to two business days and the affirmation rate rose to 94 percent. The clinical practice did not change. The packet did. That practice is now above the exemption threshold, and if CMS opens the process on the terms it has described, it will qualify.
What this means outside the six states
Three things. First, the coverage criteria WISeR reviewers apply are the same national and local coverage rules that MACs use everywhere. If your skin substitute or spine documentation would not pass a WISeR review, it may not pass a post-payment audit in your state either. Second, CMS has structured the model to expand if it shows savings, and the vendors are paid a share of the expenditures associated with averted care, which is a strong incentive to show savings. Third, the WISeR services list is a useful audit target this summer: pull your own 2025 volume of these codes, review twenty charts against the coverage criteria, and fix what you find.
What we think
We think prior authorization in Original Medicare was probably inevitable given the skin substitute spending curve, and we think the vendor compensation structure deserves the scrutiny it has received. Both things can be true. The practical question for a practice is not whether the model is well designed but whether your claims get paid, and that comes down to documentation and the tracking number. Complaining about the model does not get a claim paid. A cover sheet does.
Questions we hear
Does WISeR apply to our Medicare Advantage patients in Texas?
No. WISeR is Original Medicare fee-for-service only. Your MA plans have their own authorization lists, which may or may not include the same codes, and their own deadlines under CMS-0057-F.
We are in Ohio and were never told. Are our January claims lost?
Claims for WISeR services without a UTN are suspended for pre-payment review, not denied outright. Respond to the documentation request within the 45-day window with the complete record. If the record supports coverage, the claim can be paid. If you missed the window, contact CGS; the options depend on the specifics and on how long ago the request went out.
Can you help with the packets?
Our denial management team builds coverage-criteria templates for the WISeR service categories and runs the UTN and 120-day tracking for practices in the model states. An RCM audit is the fastest way to find out whether your current documentation would hold up.
What to do this month
- Pull your 2026 volume of WISeR codes by month and calculate your affirmation rate. If you cannot calculate it, that is the first problem.
- Name the UTN owner and make the field required in the charge template for every WISeR code.
- Build the weekly report of affirmed cases approaching day 100.
- Write the one-page cover sheet for your highest-volume category and use it on every request from August 1.
- If you are outside the six states, audit twenty charts for your highest-volume WISeR code against the applicable coverage determination.
