The CMS WISeR Model 2026 requires prior authorization or pre-payment medical review for 13 select Medicare services in 6 states, effective January 15, 2026, running through December 31, 2031.
The model is an indication of a larger change in the way Medicare is addressing payment integrity. Rather than conducting post-payment audits, CMS is shifting the reviews further up the revenue cycle, which has a direct effect on the way providers file and record claims.
For practices, this implies stricter documentation requirements and possible delays unless workflows are modified beforehand. Billing teams, coders, and providers will be required to work in close coordination with each other to facilitate services to comply with the requirements of medical necessity prior to submissions.
What Is the CMS WISeR Model 2026?
The CMS WISeR Model 2026 is a Medicare pilot program run by the Center for Medicare and Medicaid Innovation (CMMI).
WISeR: Wasteful and Inappropriate Service Reduction
The goal is simple: reduce unnecessary or inappropriate care paid for by Original Medicare. Before services are paid, CMS will review claims that have a history of fraud, waste, or abuse using AI and machine learning tools.
This model does not change what Medicare covers. It introduces an additional review phase over the prevailing coverage regulations. This will have an impact on how you bill in 2026, in case you practice in one of the 6 WISeR states and you do any of the 13 covered services.
Which Providers Does WISeR Affect?
WISeR is applicable to the original Medicare suppliers and providers in 6 states:
- Arizona
- New Jersey
- Ohio
- Oklahoma
- Texas
- Washington.
If you answer yes to both questions below, WISeR applies to you:
- Do you practice in one of these 6 states?
- Do you perform any WISeR Select Items and Services for original Medicare patients?
WISeR is not applicable to Medicare Advantage, Railroad Medicare, Veterans Affairs, or Indian Health Services claims. The only one that is in scope is original Medicare (fee-for-service).
Each state is assigned one private WISeR Participant, a company using AI-powered review, and one Medicare Administrative Contractor (MAC).
| State | WISeR Participant | MAC |
| Texas | Cohere Health, Inc. | JH / Novitas Solutions |
| New Jersey | Genzeon Corporation | JL / Novitas Solutions |
| Oklahoma | Humata Health, Inc. | JH / Novitas Solutions |
| Ohio | Innovaccer Inc. | J15 / CGS Administrators |
| Washington | Virtix Health LLC | JF / Noridian |
| Arizona | Zyter Inc. | JF / Noridian |
Which 13 Services Require Prior Authorization?
WISeR covers 13 service categories. These were selected because they are typically elective, have existing Medicare coverage criteria, and show patterns of fraud or waste.
Two services, deep brain stimulation and percutaneous image-guided lumbar decompression, were originally included but are delayed indefinitely. They are not currently subject to review.
The 13 active service categories are:
- Arthroscopic Lavage and Debridement for Osteoarthritic Knee (CPT 29877)
- Induced Lesions of Nerve Tracts: neurolytic trigeminal nerve destruction (CPT 64605, 64610)
- Vagus Nerve Stimulation: initial implantation only, for refractory seizures or treatment-resistant depression
- Phrenic Nerve Stimulators: for respiratory paralysis and central sleep apnea
- Spinal Cord Stimulators: permanent implantation only (excludes CPT 63650, already in the CMS OPD program)
- Incontinence Control Devices: mechanical/hydraulic devices for stress urinary incontinence
- Sacral Nerve Stimulators: permanent implantation only, for urge incontinence or urinary retention
- Penile Prosthesis: insertion only (CPT 54400, 54401, 54405)
- Percutaneous Vertebral Augmentation: for vertebral compression fractures
- Epidural Steroid Injections: CPT 62323 only, for covered LCD indications
- Cervical Fusion: WISeR focuses on CPT 22554 (CPT 22551 and 22552 are in the existing OPD program)
- Hypoglossal Nerve Stimulation: for obstructive sleep apnea; updated March 12, 2026, to include new HCPCS codes
- Bioengineered Skin Substitutes and CTPs: for lower extremity non-healing wounds (not applicable in Arizona and Washington, where the MAC’s LCD has been withdrawn)
Your Two Options Under WISeR
When you plan to deliver a WISeR service, you have 2 options: request prior authorization before the service or perform the service and face mandatory prepayment review afterward.
Option 1: Submit a Prior Authorization Request
Send your request to either the WISeR Participant in your state or your MAC. There should be no delays in electronic submission. You can also fax or mail.
- Standard decision: Within 3 calendar days of receiving your request
- Expedited decision: Within 2 calendar days, when delay would seriously harm the patient
Once it is confirmed, the prior authorization is good for 120 days from the date of the decision. After that, you need a new request.
You will receive a Unique Tracking Number (UTN) with the decision. The UTN must appear on every related claim you submit, whether the decision was affirmed or not.
Option 2: Skip Prior Authorization
If you skip prior authorization, the MAC will hold your claim and route it to the WISeR participant for prepayment medical review. The WISeR Participant sends you an Additional Documentation Request (ADR).
You have 45 calendar days to respond with the supporting medical records. If you do not respond, your claim is denied. If you do respond, the WISeR participant issues a decision to the MAC within 3 days of receiving complete documentation.
What Happens After a Decision?
There are 4 possible outcomes from a prior authorization request:
- Provisional Affirmation: Your service meets Medicare coverage criteria. The claim is likely to be paid if all coding and billing requirements are also met.
- Non-Affirmation: Coverage criteria are not met. A clinician with specialty expertise must review every non-affirmation before it is issued. You can still perform the service, but the claim will be denied. You keep all Medicare appeal rights.
- Provisional Partial Affirmation: Available from April 1, 2026. On a multi-service request, some services are affirmed and others are not. Each is handled by its respective process.
- Dismissal: Your request had missing or invalid information (e.g., incorrect MBI, wrong state submission). It was not reviewed for medical necessity. Correct the issue and resubmit.
There is no limit on resubmissions. You can resubmit a non-affirmed request as many times as needed. Each resubmission allows you to add new documentation and request peer-to-peer clinical review with a relevant specialist.
The Exemption Program: A Path Out of Prior Authorization
From June 2026, providers who consistently comply with the rules can get an exemption and not have to go through the prior authorization process at all.
To qualify, you must:
- Submit at least 10 prior authorization requests across WISeR services during an assessment period
- Meet a minimum affirmation rate (the exact threshold will be published by WISeR Participants in Spring 2026)
Exemption is granted quarterly and maintained for at least one year. WISeR Participants will reevaluate exempt providers annually using no more than 10 ADRs per year. If you lose exemption status, you receive at least 60 days’ notice before the change takes effect.
This is the most sustainable long-term strategy for high-volume practices. Providers who build airtight documentation workflows from day one will qualify faster.
What Providers Must Do Now
The documentation requirements under WISeR are not new; they are based on existing NCDs and LCDs. But the review is now happening before payment, not after. That changes everything about how your front-end processes need to work.
Before the next WISeR service is scheduled, confirm your team has:
- Identified all WISeR-covered CPT and HCPCS codes in your charge master
- Built a documentation checklist aligned with the applicable NCD or LCD for each service
- Trained billing staff on UTN placement requirements for claim submission
- Established an internal workflow for responding to ADRs within the 45-day window
Practices that treat WISeR as a documentation problem, rather than a billing problem, will adapt fastest.
Is Your Practice Ready for WISeR?
Practices that prepare their documentation workflows now will avoid denials, protect cash flow, and position themselves for the Exemption Program starting in June 2026.
At Kansas Medical Billing, we help physicians and providers in WISeR-affected states build prior authorization documentation systems that align with CMS requirements from the first request. If your practice delivers any of the 13 WISeR services, the time to prepare is now, not after the first denial arrives.
Don’t let a documentation gap turn into a denied claim.
Kansas Medical Billing provides physician-focused prior authorization support and revenue cycle management built around CMS compliance standards.
Get a free WISeR readiness review for your practice.
Contact Kansas Medical Billing Services today.
Frequently Asked Questions
- Does WISeR apply to Medicare Advantage patients?
No. WISeR applies only to Original Medicare (Fee-for-Service) beneficiaries. Medicare Advantage plans have their own prior authorization requirements.
- Can I still perform a WISeR service after a non-affirmation?
Yes. A non-affirmation is not a final payment denial. You can perform the service and submit the claim, but the MAC will deny it. All standard Medicare appeal rights remain available.
- Is there a limit on how many times I can resubmit a prior authorization request?
No. Resubmissions are unlimited. Each one can include updated documentation and a peer-to-peer clinical review request.
- Do trial procedures require prior authorization?
No. For spinal cord stimulators, sacral nerve stimulators, and hypoglossal nerve stimulators, WISeR prior authorization covers the permanent implantation only. Documentation for the permanent procedure should include evidence of a successful trial.
- What if I don’t respond to an ADR within 45 days?
The WISeR Participant notifies the MAC, and the MAC denies the claim automatically. Treat the 45-day window as a hard deadline with no exceptions.
