For as long as most of us have worked in billing, the one reliable thing about traditional Medicare was that you did not ask permission first. You met the coverage criteria, you documented, you billed, and if a contractor disagreed you found out afterward. On June 27, 2025, CMS announced a model that changes that for a defined set of services in six states, beginning January 1, 2026.
The model is called WISeR, for Wasteful and Inappropriate Service Reduction. It runs for six performance years, through December 31, 2031, in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. If your practice or your referral partners perform the targeted services in those states, the second half of 2025 is your preparation window. This article explains the mechanics as CMS has published them and what we think a practice should do between now and January.
Key takeaways
- WISeR brings prior authorization to a defined list of traditional Medicare services in six states from January 1, 2026 through 2031. Medicare Advantage is not involved; it already has its own rules.
- Technology companies, not MACs or plans, will run the reviews. Applications closed on July 25 and CMS has not yet named the participants; expect one per state, announced later this year.
- Providers get two paths: request authorization first, or accept pre-payment medical review of the claim. For scheduled procedures we would request authorization every time.
- Coverage decisions follow existing NCDs and LCDs, so most denials will be documentation failures against criteria that are already public. Build the templates now.
- Exposure is concentrated: wound care, pain management, spine, orthopedics and urology. Primary care feels it indirectly through referrals.
What WISeR is
WISeR is a CMS Innovation Center model that contracts with technology companies to run prior authorization reviews for selected items and services in traditional (fee-for-service) Medicare. It does not apply to Medicare Advantage, which has always had its own prior authorization rules. CMS published a request for applications alongside the June 27 announcement and applications from vendors closed on Friday, July 25. CMS has said it will select participants, each assigned to one of the six states, and announce them later this year. Until then, nobody knows which company will be reading their documentation, which is one more reason to build against the coverage rules rather than against a reviewer.
The participants will be paid a share of the spending that CMS determines was averted through the reviews, adjusted for performance measures on provider experience, review accuracy and turnaround. We will say plainly that we think paying reviewers a percentage of what they deny is the wrong incentive, and it is the part of the model most likely to draw challenge. CMS says the performance measures are designed to counteract it. Practices in the six states will find out whether that is true.
Which services
CMS describes the targets as items and services with a documented history of fraud, waste or abuse, or of low value to patients. The three named in the announcement are skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis. The request for applications goes further and lists the service families the model will cover, including epidural steroid injections for pain (facet joint injections excluded), cervical fusion, percutaneous vertebral augmentation for compression fractures, incontinence control devices, diagnosis and treatment of impotence, percutaneous image-guided lumbar decompression for spinal stenosis, and the stimulator family in detail: vagus, phrenic, hypoglossal, sacral and deep brain stimulation. CMS says it may add or remove items during the model. Emergency services, inpatient-only services and anything where a delay would pose a substantial risk to the patient are excluded.
Read that list against your own claims rather than against the headline. A pain practice that has never applied a skin substitute may assume WISeR is a wound care problem and then find that its epidural injection volume is squarely in scope. The specific HCPCS and CPT codes are in the appendix to the request for applications, and CMS has said an operational guide with the final code list will follow before January.
The overlap with the CY 2026 Physician Fee Schedule proposed rule is not a coincidence. Skin substitutes account for a spending increase from roughly more than $250 million in 2019 to more than $10 billion in 2024, and CMS is attacking that from two directions at once: payment reform in the fee schedule and utilization review in WISeR.
How a request will work
Providers in the six states will have two paths for a targeted service. The first is to submit a prior authorization request, either directly to the WISeR participant for their region or through their Medicare Administrative Contractor, which forwards it. The second is to skip the request and accept pre-payment medical review of the claim, which means the claim is held while a reviewer examines documentation before payment. CMS has also said that providers with strong compliance records may eventually be exempted from the requirement through a gold-carding program, though the affirmation threshold and the timing have not been published.
Medical necessity decisions are supposed to follow existing Medicare coverage rules, national and local coverage determinations included, and CMS states that a licensed clinician with relevant expertise will review any request the technology does not approve, that a non-affirmed request can be resubmitted with more documentation, and that peer-to-peer discussion will be available. Those sentences are the ones to hold them to. Turnaround expectations have not been published either; the Medicare Advantage standard of 72 hours for expedited and seven days for standard requests is the obvious benchmark, and we would be surprised if the model is allowed to be slower.
What this means for a practice in the six states
| Practice type | Exposure | First action |
|---|---|---|
| Wound care, podiatry, vascular | Skin substitute applications (CPT 15271 to 15278 and the Q-code products) | Pull 2024 to 2025 volume by product and site; read the LCD for your MAC |
| Pain management, neurosurgery, urology | Nerve stimulator implants (for example CPT 64590, 64581) | Audit documentation on the last 20 cases against coverage criteria |
| Orthopedics, sports medicine | Knee arthroscopy in osteoarthritis (CPT 29880, 29881 and related) | Review indication documentation; confirm imaging and conservative treatment are recorded |
| Pain management, physiatry, anesthesiology | Epidural steroid injections (for example CPT 62321, 62323, 64483) | Check that the LCD frequency limits and the imaging guidance requirement are met on recent cases |
| Spine surgery, interventional radiology | Cervical fusion; vertebral augmentation (CPT 22551, 22612 and related; 22510 to 22515) | Audit conservative care documentation and fracture imaging against the LCD |
| Urology, urogynecology, ENT, sleep medicine | Incontinence control devices, impotence treatment, sacral and hypoglossal nerve stimulation | Confirm the trial-phase and failed-therapy documentation the coverage articles require |
| Primary care | Indirect: referrals to the above | Warn patients that Medicare may now require authorization for certain procedures |
Mistakes we expect to see
The first is treating WISeR like Medicare Advantage authorization and calling the wrong entity. Requests go to the WISeR participant or through the MAC, not to a plan. The second is assuming the practice is exempt because it is small or because it has never had a Medicare audit. The exemption pathway is a future possibility, not a current rule. The third is scheduling January procedures in December without checking whether the service is on the list. A knee arthroscopy booked for January 6 needs its request in before the holidays.
Questions we hear
Our patients are in Texas but the practice is across the border. Does WISeR apply?
The model is defined by the provider's location and MAC jurisdiction, not the patient's address. If you are enrolled in a participating state, it applies. If you are not, it does not, even for patients who live in a participating state.
Will Medicare Advantage plans copy the list?
Most already require authorization for these services. If anything, WISeR narrows the gap between traditional Medicare and MA rather than widening it.
Can we appeal a WISeR denial?
A denied prior authorization can be resubmitted with additional documentation, and a denied claim follows the standard Medicare appeals process. Our denial management team expects to be writing a lot of first-level appeals against LCD criteria in the first quarter of 2026, and the practices that will win them are the ones building the documentation templates now.
What to do this month
- Quantify. Run a report of traditional Medicare claims for the targeted codes over the last 18 months, by rendering provider and place of service. If the number is zero, you are done with WISeR for now.
- Read the coverage rules. Print the relevant LCD and its billing and coding article from your MAC. Most denials under any prior authorization program are documentation failures against criteria that were already public.
- Build a documentation template. For each targeted service, a checklist of the elements the LCD requires: diagnosis, failed conservative therapy with dates, measurements, imaging findings, and the physician's statement of necessity. Put it in the EHR as a note template, not a paper form.
- Decide your path. Prior authorization before the service or pre-payment review after. For scheduled procedures, we would choose prior authorization every time; a hold on a $4,000 claim costs more than a form.
- Assign an owner. Whoever handles commercial prior authorization should own WISeR requests too. The skills are identical, and the volume in most practices will be small.
- Watch for the participant announcement and the operational guide. CMS has said submission details, portal access and turnaround expectations will be published before January. Sign up for your MAC's listserv if nobody at the practice is on it.
