What WISeR is and why it matters
WISeR stands for Wasteful and Inappropriate Service Reduction Model. It's run by the Center for Medicare and Medicaid Innovation (CMMI), CMS's testing arm for new payment and service delivery models.
A few facts that define the model:
- Duration: Six performance years, January 1, 2026, through December 31, 2031.
- States: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
- MAC jurisdictions: JL (New Jersey), J15 (Ohio), JH (Oklahoma and Texas), JF (Arizona and Washington).
- Eligible population: Original Medicare beneficiaries in the six pilot states who receive selected items and services from the WISeR Select list. Medicare Advantage and Railroad Medicare beneficiaries are excluded.
- Scope: Original Medicare fee-for-service only. Medicare Advantage is not affected.
- Technology partners: Six tech companies contracted by CMS, one per state, each paired with that state's MAC jurisdiction: Cohere Health (Texas), Genzeon Corporation (New Jersey), Humata Health (Oklahoma), Innovaccer (Ohio), Virtix Health (Washington), and Zyter (Arizona).
Traditional Medicare has historically required prior authorization on a narrow set of services (primarily certain DMEPOS items, select hospital outpatient department services, and repetitive non-emergent ambulance transport). WISeR is the first model to test AI-assisted prior authorization across multiple Part B service categories at scale.
The services covered under WISeR in 2026
WISeR targets services CMS has flagged as having higher risk of waste, fraud, or low-value utilization. Each service is tied to an existing National Coverage Determination (NCD) or Local Coverage Determination (LCD), per the WISeR operational guide:
| Category | Services |
|---|---|
| Wound care | Bioengineered skin substitutes and cellular/tissue-based products (CTPs) for lower extremity chronic non-healing wounds (in WISeR states with an active skin-substitute LCD) |
| Nerve stimulators | Electrical, sacral, phrenic, and vagus nerve stimulation |
| Hypoglossal nerve stimulation | Hypoglossal nerve stimulation for obstructive sleep apnea |
| Spinal procedures | Cervical fusion, percutaneous vertebral augmentation for compression fractures |
| Pain management | Epidural steroid injections (excluding facet joint injections), induced lesions of nerve tracts (trigeminal nerve) |
| Orthopedic | Arthroscopic lavage and debridement for the osteoarthritic knee |
| Other | Incontinence control devices, impotence treatments |
Two services are not subject to WISeR review as of mid-2026. Deep Brain Stimulation (DBS) was excluded at launch on January 1, 2026. Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (PILD) was included initially but was removed effective April 6, 2026 (CMS-5056-N2; 91 FR 17282).
CMS plans to reevaluate both for a future performance year.
How the WISeR prior authorization process works
Providers in pilot states have three options for any service on the WISeR list:
- Direct submission to the WISeR model participant (the tech company assigned to the MAC jurisdiction).
- Submission to the MAC, which routes the request to the model participant for review.
- Proceed without prior authorization, accepting that the claim will undergo automatic post-service, pre-payment medical review. This delays payment until documentation is reviewed after the service is delivered and leaves the practice unpaid if the claim is ultimately denied.
Approved requests receive a Unique Tracking Number (UTN) that ties the prior authorization decision to the eventual claim. An affirmation means the service likely meets coverage criteria and the claim will be paid once submitted. A non-affirmation means the prior authorization is denied, and any claim tied to that UTN will also be denied.
Decision timelines, per the CMS WISeR FAQ:
- 72 hours for standard requests
- 48 hours for expedited requests
Submissions can be made by fax, mail, esMD (Electronic Submission of Medical Documentation), or the electronic portals of WISeR participants and MACs. Existing Medicare appeal rights are unchanged.
Coverage and payment policies are also unchanged. WISeR enforces the existing NCDs and LCDs, just at a different point in the claims process.
How AI is being used in Medicare prior authorization
CMMI hasn't published the exact algorithms, but it has been clear on what the AI does and doesn't do in Medicare prior authorization under WISeR:
- What AI does: screens incoming prior authorization requests, matches submitted documentation against existing NCD and LCD criteria, and routes likely approvals for faster affirmation.
- What AI doesn't do: issue denials. A licensed clinician with relevant expertise must review and make any non-affirmation decision. AI alone cannot non-affirm a request.
- What model participants must staff: clinicians qualified to conduct medical reviews for the specific service categories in their MAC jurisdiction.
This design responds to documented concerns about AI in payer decisions. A 2024 Senate investigation found Humana's post-acute care prior authorization denial rate was more than 16 times higher than its overall rate during a period when Medicare Advantage insurers were rolling out AI-driven review tools.
WISeR's human-in-the-loop denial requirement is CMMI's structural answer. CMS will also audit model participants throughout the pilot, with financial penalties for excessive appeal rates, delayed responses, and poor provider experience scores.
Why providers are pushing back
WISeR has drawn meaningful pushback:
- The American Hospital Association (AHA) urged CMS to delay the launch by at least six months.
- The House Appropriations Committee approved an amendment to block WISeR funding, which didn't survive final budget negotiations.
- Congressional representatives from multiple WISeR states introduced legislation to repeal the model.
- The Medical Group Management Association (MGMA) raised concerns about the pay-for-denial incentive structure.
WISeR model participants are compensated based on a percentage of expenditures averted from "wasteful" services. Critics argue this creates a financial incentive to deny care.
CMMI's response is that participant payments are also adjusted based on quality measures, including provider experience surveys, appeal rates, and decision timeliness.
The full incentive structure is detailed in the WISeR Request for Applications. CMMI has also signaled a "gold carding" feature planned for mid-2026 that would exempt providers who meet a consistent affirmation threshold from further prior authorization or pre-payment review.
What providers in pilot states should do now
Practices in the six pilot states that perform any of the listed services have a few priorities:
- Audit existing documentation against the NCDs and LCDs for each service. WISeR enforces existing criteria, so documentation gaps that have gone unnoticed in retrospective review will now block prior authorization.
- Identify the WISeR participant for the MAC jurisdiction and confirm submission paths (fax, esMD, mail, or portal).
- Build a prior authorization tracking workflow that captures UTNs and ties them to claims.
- Train staff on the 72-hour and 48-hour decision windows so requests don't stall during clinical scheduling.
- Track denials and appeal rates internally. Aggregate denial patterns will inform whether documentation needs to be strengthened or whether appeals are worth pursuing case by case.
Specialty practices most affected are in pain management, orthopedics, wound care, neurology, ENT, and urology. For these practices, the administrative load of WISeR is concentrated rather than spread thin.
Practices in pilot states now run two prior auth tracks
The work WISeR demands (clinical documentation, judgment about which path to take, appeals where they're warranted) isn't the kind of work that automates well. The portal work that surrounds it is.
Practices in pilot states still file commercial and Medicare Advantage prior authorizations through dozens of separate payer portals, and that's the part Kaizen handles.
Kaizen logs into the portals, attaches supporting documentation, completes dynamic forms, and pulls status updates back into a single tracker, without a team member having to repeat the work across every payer.
Most ops teams we work with redeploy that recovered capacity to the documentation and clinical review work WISeR now demands.
Want to see what that looks like for your prior auth workflow? Book a call, and we'll show you how to get it running automatically in days.
Frequently asked questions
Which states does WISeR apply to?
WISeR applies to six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It covers Original Medicare beneficiaries in those states across four MAC jurisdictions (JL, J15, JH, JF).
Does WISeR apply to Medicare Advantage?
No, WISeR doesn't apply to Medicare Advantage. The pilot is limited to Original Medicare fee-for-service, though CMS is tightening Medicare Advantage prior authorization rules separately in 2026.
Can AI deny my Medicare claim under WISeR?
No, AI alone can't deny a claim under WISeR. AI and machine learning screen requests, but any non-affirmation requires review by a licensed clinician with relevant expertise.
What's the difference between WISeR prior authorization and pre-payment review?
The main difference between WISeR prior authorization and pre-payment review is timing: prior authorization happens before the service is delivered, while pre-payment review happens after delivery but before payment.
Will WISeR expand to other states or services?
Yes, WISeR can expand to additional services during the pilot under Section 1115A of the Social Security Act. Geographic expansion would require CMS to evaluate the pilot's outcomes, which it will assess across the six performance years through 2031.
