A pain management practice in Texas has three epidural steroid injections scheduled for the week of January 19. Until this month those visits needed a signed order and a diagnosis that matched the local coverage determination. Starting today, the practice can submit a prior authorization request to Medicare for them, and starting January 15, if it doesn't, the claim will be pulled for medical review before it pays.
That is the Wasteful and Inappropriate Service Reduction model, or WISeR, and it is the first time traditional Medicare has required prior authorization for physician services at any scale. It runs from January 1, 2026 through December 31, 2031 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. The MACs and the model's technology vendors began accepting requests today, January 5, and the requirement applies to services furnished on or after January 15, 2026.
Key takeaways
- WISeR applies only to traditional Medicare fee-for-service claims for a defined list of services, furnished in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington, with dates of service on or after January 15, 2026.
- You can skip the request, but the claim then goes to pre-payment medical review, which means an additional documentation request and a payment delay after the patient has already been treated.
- CMS expects the vendors to decide standard requests within three days and expedited requests within two, and a non-affirmed request can be resubmitted as many times as needed.
- Requests that read like the local coverage determination checklist get affirmed; requests that are a pasted progress note do not.
- Providers with an affirmation rate of 90 percent or better over a review period can be exempted from the request step, so the quality of the first few months of submissions matters beyond the individual claim.
Which services are on the list
CMS chose services it describes as vulnerable to fraud, waste and abuse. The list for the first performance year includes skin and tissue substitutes, implantation of electrical nerve stimulators, knee arthroscopy for knee osteoarthritis, epidural steroid injections for pain management, cervical fusion, incontinence control devices, and diagnosis and treatment of impotence. Two categories originally announced, deep brain stimulation and percutaneous image-guided lumbar decompression, have been deferred to a later year. CMS has said inpatient-only services, emergency services and services where a delay would pose a substantial risk to the patient are excluded.
The exact HCPCS and CPT codes are in the operational guide CMS published with the model. Pull the list, run it against your 2025 charge history, and you will know within an hour whether WISeR touches your practice. For most primary care offices it doesn't. For pain management, wound care, urology, orthopedics and spine surgery in the six states, it touches a meaningful share of revenue.
How the review works
Each state has one technology vendor: Cohere Health in Texas, Genzeon in New Jersey, Humata Health in Oklahoma, Innovaccer in Ohio, Virtix Health in Washington and Zyter in Arizona. The vendors use software, including AI tools, to check the request against Medicare coverage criteria. CMS has been specific that any recommendation to deny is made by a licensed clinician, not by the software alone, and that the vendors are paid a share of the spending their reviews avert. We think that payment structure deserves scrutiny, and we expect the appeal volume to tell us within a few months whether the reviews are fair.
You are not forced to request authorization. A practice can skip the request and bill the service, in which case the claim is subject to pre-payment medical review to confirm it meets coverage, coding and payment criteria. In practice that means the claim stops, the MAC sends an additional documentation request, and payment waits for a decision. For a practice with a thin cash position, skipping the request is the more expensive option.
A comparison of the two paths
| Step | Request prior authorization | Skip and bill |
|---|---|---|
| Before the visit | Submit clinical documentation to the MAC or vendor; receive an affirmed or non-affirmed decision | Nothing |
| At claim submission | Claim carries the unique tracking number from the decision | Claim is flagged for pre-payment review |
| After submission | Affirmed claims process normally; non-affirmed claims deny and can be appealed | Additional documentation request, then a pay or deny decision |
| Cash impact | Delay before the service, not after | Delay after the service, with the patient already treated |
Non-affirmed decisions are not final. You can resubmit with additional documentation, and a denied claim goes through the standard Medicare appeal process starting with redetermination. Keep the decision letter; the reason code on it tells you what the reviewer thought was missing.
Setting up the workflow in the practice
Treat WISeR like a new payer with its own rules rather than as a change to Medicare. The practices we have set up so far did five things.
- Loaded the WISeR code list into the scheduling system as a flag, so any appointment for a listed service in a listed state prompts the authorization step.
- Assigned one person to own WISeR submissions, with a tracking log of request date, decision date, tracking number and outcome.
- Built a documentation template for each service category that mirrors the coverage criteria: for epidural injections, the conservative treatment history and imaging; for skin substitutes, the wound measurements, duration and prior standard care.
- Decided in writing which services they will always request authorization for and which, if any, they will bill without one.
- Told the physicians that the order alone no longer moves the visit forward.
Documentation is where this will be won or lost. The vendors are applying Medicare's own coverage criteria, most of which live in local coverage determinations that have existed for years. A request that reads like the LCD checklist gets affirmed. A request that is a copy of the last progress note does not.
Turnaround, resubmission and the exemption
CMS has told the vendors it expects a decision within three days on a standard request and within two days on an expedited one. We would plan around those numbers rather than count on them; the first weeks of any new program are slow, and a request that arrives incomplete does not start the clock in any meaningful sense. Schedule listed services at least ten business days out through February and tighten the window once you have seen your own vendor's actual turnaround on twenty or thirty requests.
A non-affirmed decision is not the end. The model allows unlimited resubmissions, so the right response to a non-affirmation is to read the reason, add the missing element (usually the documented conservative treatment, the measurement, or the imaging finding the LCD names) and send it again before the scheduled date. Only if the service goes ahead without an affirmation does the claim deny, and then the normal Medicare appeal path applies, starting with redetermination within 120 days of the remit.
There is also an exit. CMS has said that providers and suppliers who reach a provisional affirmation rate of 90 percent or higher during a designated review period may be exempted from submitting requests, with their claims instead subject to a lighter post-payment sample. That is worth aiming for. It means the first several months are, in effect, an audition, and a practice that submits sloppy requests to see what sticks will stay in the process longer than one that submits complete packets from the start.
What we don't know yet
We don't know how the vendors will handle a request that is incomplete: whether it is rejected outright, pended with a request for more information, or non-affirmed. Assume the worst and submit complete packets. We don't know how consistently the six vendors will read the same LCD, and a practice with locations in two model states may get different answers to identical requests. And we don't know yet what the appeal data will show about the fairness of AI-assisted review with a vendor paid on averted spending. We will write about that once there is enough of it to say something.
Finally, watch for spillover. Medicare Advantage plans already require authorization for most of these services. If a practice builds a good WISeR documentation packet, the same packet works for the MA plans, and our denial management team has already seen that the practices with the tightest MA authorization process are the ones adapting fastest.
Questions we hear
We are in a WISeR state but our patient has a Medicare Advantage plan. Does WISeR apply?
No. WISeR applies to traditional Medicare fee-for-service claims. The MA plan's own authorization rules apply, and those have not changed because of the model.
Our physician practices in Ohio but the procedure is performed at an ASC in Pennsylvania. Which state counts?
The model is based on where the service is furnished, so the location of the procedure controls. Confirm with your MAC for edge cases, since the operational guide addresses several border scenarios and we don't want to guess for you.
Is there a modifier or a claim field for the tracking number?
The affirmed decision comes with a unique tracking number that goes on the claim. Your billing software vendor should have a field for it; if it doesn't, ask now rather than on January 15.
What to do this week
- Run the WISeR code list from the operational guide against your 2025 charge history and note which services, physicians and locations are affected.
- Load those codes as a scheduling flag for the six states so any listed appointment prompts the request step.
- Name the person who owns submissions and start the tracking log: request date, decision date, tracking number, outcome and reason for any non-affirmation.
- Build one documentation template per affected service category from the relevant LCD, and have the physicians review it before the first request goes out.
- Confirm your billing system has a field for the unique tracking number and that it maps to the claim.
- Schedule listed services at least ten business days out through February and revisit the lead time once you have your own turnaround data.
