The CMS WISeR Model: A Targeted Approach Toward Expanding Prior Authorizations

The Centers for Medicare & Medicaid Services (CMS) has announced the establishment of the Wasteful and Inappropriate Services Elimination and Reduction (WISeR) Model, a six-year initiative launching Jan. 1, 2026.

This so-described voluntary model (although in reading the guidelines, it becomes clear it is very much mandated for the six states) introduces a structured, technology-enabled approach to prior authorization and pre-payment review for selected Medicare Part B services deemed to be of low clinical value, overused, or associated with fraud, waste, and abuse.

The WISeR Model represents a significant evolution in the CMS oversight strategy. Historically, the use of prior authorization by Medicare has been limited to targeted service categories such as durable medical equipment (DME), non-emergency transportation, or certain outpatient procedures. WISeR is the first push to pair broad-scale, claims-based utilization analytics with Medicare Administrative Contractor (MAC)-directed pre-payment medical necessity review for professional and outpatient services.

As noted, WISeR will be implemented across six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. These states were selected based on Medicare volume, geographic diversity, and alignment within four existing MAC jurisdictions:

• JL (New Jersey);
• J15 (Ohio);
• JH (Oklahoma, Texas); and
• JF (Arizona, Washington).

Each participating state will serve as a testing ground for evaluating changes in service utilization, program integrity, and cost savings.

Providers in the six participating states will be required to either submit prior authorization requests for these services or accept a pre-payment review upon claim submission. Instead of the MACs, from the ruling, CMS will be using designated contractors, under MAC oversight, that will determine whether claims meet established medical necessity criteria. The ruling also mentioned the provision of this group to utilize artificial intelligence (AI)-enabled tools.

The specific procedures and devices that CMS has identified include the following:

• Electrical Nerve Stimulators (NCD 160.7);
• Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18);
• Phrenic Nerve Stimulator (NCD 160.19);
• Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease (NCD 160.24);
• Vagus Nerve Stimulation (NCD 160.18);
• Induced Lesions of Nerve Tracts (NCD 160.1);
• Epidural Steroid Injections for Pain Management excluding facet joint injections (L39015, L33906, L39036, L39240, L39242, L36920, L38994, L39054);
• Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L33569, L34106, L34228, L38201, L34976, L35130, L38737, L38213);
• Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788);
• Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9);
• Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38276, L38307, L38398, L38387, L38310, L38312, L38385, L38528);
• Incontinence Control Devices (NCD 230.10);
• Diagnosis and Treatment of Impotence (NCD 230.4);
• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13);
• Skin and Tissue Substitutes (LCDs below) – only applicable to MAC jurisdictions and states that have an active LCD in place;
• Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041); and
• Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690).

An interesting consideration in the ruling, mentioned as an exploration, is the CMS provider safeguard known as “provisional affirmation.” If a claim is not affirmed, providers would receive a detailed rationale and may resubmit or appeal the determination.

Additionally, organizations demonstrating an affirmation rate of more than 90 percent over time may qualify for a gold-carding exemption, temporarily removing them from the prior authorization requirement, similar to commercial plans.

Financially, CMS will compensate the third-party reviewers not on volume, but based on a share of the Medicare expenditures they help avert, ensuring alignment with the CMS goals of reducing low-value care and reducing waste.

While inpatient services are not directly subject to the model, the ripple effects on outpatient surgery, interventional procedures, and medical device utilization will require cross-functional coordination. Surgical locations will want to have a clear understanding of the required medical guidelines for procedural authorization and approval. Clear, evidence-based documentation will be critical for both prior authorization requests and appeals.

WISeR reflects the CMS continued movement toward proactive utilization management, with an invested approach towards leveraging technology and a commercial payer approach. While the model is currently limited to six states and select services, its structure suggests a potential framework for broader application.

Programming note: Listen live on Talk Ten Tuesday today at 10 am Eastern, when Tiffany Ferguson reports this story.