CMS WISeR Model Prior Authorization 2026: Complete Provider Guide for 6 States

What Is the CMS WISeR Model?

The Wasteful and Inappropriate Service Reduction (WISeR) model is a CMS Innovation Center payment model that runs from January 1, 2026 through December 31, 2031. It introduces prior authorization requirements for Traditional Medicare (Original Medicare Part B) in six states, targeting service categories identified as high-risk for overutilization and fraud.

WISeR is not a Medicare Advantage program. It applies to fee-for-service Medicare — the program covering approximately 35 million Americans who have not enrolled in a Medicare Advantage plan.

CMS uses AI and machine learning tools — alongside human clinical review — to make coverage determinations. The model does not change Medicare coverage policy; covered services remain covered. It adds an authorization step before (or immediately after) the service is delivered.

Which States Are Affected?

WISeR currently operates in six states. One technology vendor (called a "model participant") operates in each state and handles prior authorization review:

Providers in all other states are not affected by WISeR during the 2026 performance year.

Which Services Require Prior Authorization?

WISeR covers 13 service categories. Each has specific CPT codes that trigger the prior authorization or pre-payment review requirement. The table below lists each category and its primary CPT codes, sourced from the American Society of Anesthesiologists' WISeR CPT code reference (accessed March 2026).

Note: Deep brain stimulation implementation has been delayed by CMS and is not currently active. Always verify the current CPT code list directly from your MAC's WISeR resources or the CMS WISeR provider operational guide before submitting.

Provider Options: Prior Authorization vs. Post-Payment Review

Providers have a choice when furnishing WISeR-covered services to Traditional Medicare patients in the six affected states:

Option 1 — Prior Authorization (Recommended)

Submit a prior authorization request before rendering the service. If affirmed, the authorization is valid for 120 calendar days from the approval date. Payment for a compliant claim is not subject to further medical review for the approved service.

Option 2 — Post-Service Pre-Payment Review

Skip the prior authorization step and allow the claim to go through pre-payment medical review after the service is rendered. The MAC requests documentation; providers have 45 days to respond. A determination is issued within 3 days of a complete documentation submission.

Post-service review carries payment risk: if the claim is not affirmed, payment is withheld. For high-cost procedures like cervical fusion or vertebral augmentation, this risk is significant.

How to Submit a WISeR Prior Authorization Request

Prior authorization requests can be submitted through two pathways:

Direct to the Model Participant

Contact the model participant for your state (see table above) and submit the request directly. Each participant operates a portal or accepts submissions by fax or mail. Check your MAC's WISeR resource page for participant contact details and preferred submission method.

Through Your MAC

Submit the request to your Medicare Administrative Contractor. The MAC will forward it to the appropriate model participant for review. This pathway is useful if your practice already has established workflows with the MAC.

Documentation to Include

Strong prior authorization submissions include:

• Patient demographics and Medicare beneficiary ID
• Diagnosis codes (ICD-10) supporting medical necessity
• Procedure code(s) (CPT) being requested
• Clinical notes documenting the indication and relevant history
• Conservative treatment history (especially for spine and knee procedures)
• Ordering physician attestation and NPI
• Any relevant imaging reports, lab results, or specialist notes

Decision Timelines

If Your Prior Authorization Is Not Affirmed

A "non-affirmation" decision from the model participant means the request was not approved in its current form. Non-affirmation decisions are not directly appealable through the standard Medicare appeals process — but they are not final.

Providers have two options:

1. Resubmit with Additional Documentation

Unlimited resubmissions are permitted. Add clinical documentation that addresses the reviewer's concern — additional imaging, a specialist letter, documentation of failed conservative care, or updated clinical notes.

2. Request Peer-to-Peer Review

Contact the model participant to schedule a clinical review with a physician reviewer. Peer-to-peer calls are one of the most effective tools for overturning a non-affirmation. Prepare a concise clinical rationale before the call.

If You Performed the Service and the Claim Is Denied

If you skipped prior authorization and the post-service pre-payment review results in a claim denial, you retain full Medicare appeal rights under the standard five-level Medicare appeals process. See prior authorization denial appeals: complete guide and what happens if prior authorization is denied for the full appeals workflow.

What WISeR Does Not Change

CMS has been explicit about the model's scope:

• Medicare coverage does not change. All 13 service categories remain covered by Traditional Medicare when medically necessary.
• Patient cost-sharing does not change. Beneficiaries in WISeR states pay the same copays and deductibles.
• Patients can still choose their provider. WISeR does not restrict access to specific networks.
• Non-WISeR states are unaffected. Providers outside NJ, OH, OK, TX, AZ, and WA continue to bill without WISeR prior authorization requirements.

Preparing Your Practice for WISeR

Step 1: Confirm Affected Services

Review your billing history for the 13 CPT code categories above. Identify which services — and how many claims per month — are now subject to WISeR review in your state.

Step 2: Identify Your Model Participant and MAC

Know who your model participant is (see the state table above) and confirm contact information and submission preferences. Your MAC's website will have WISeR-specific resources and portal links.

Step 3: Build Documentation Templates

Create service-specific checklists aligned with WISeR's medical necessity criteria. For high-frequency services like epidural steroid injections, a standardized documentation template can dramatically reduce non-affirmation rates.

Step 4: Train Billing and Clinical Staff

Both clinical staff (documentation) and billing staff (prior auth submission, tracking, follow-up) need to understand the new workflow. Map out who submits the request, who tracks it, and who escalates non-affirmations.

Step 5: Track Affirmation Rates

Monitor your prior authorization affirmation rate by service category. A rate consistently above 90% puts you on the path to gold card status. Below 80% signals a documentation or clinical indication gap that needs investigation.

How Muni Appeals Helps With WISeR Compliance

The WISeR model adds a meaningful administrative layer to Traditional Medicare billing in six states. For practices performing high volumes of covered services, the prior authorization and documentation burden compounds quickly.

Muni Appeals helps practices:

• Generate service-specific prior authorization submissions aligned with WISeR medical necessity criteria
• Track prior authorization status, expiration dates, and resubmission deadlines in one place
• Standardize clinical documentation across billing and clinical teams
• Prepare peer-to-peer scripts when non-affirmations need escalation
• Build toward gold card affirmation rates through consistent documentation quality

Start Free With Muni Appeals

Frequently Asked Questions

Does WISeR apply to Medicare Advantage patients?

No. WISeR applies only to Traditional Medicare (Original Medicare Part B). Medicare Advantage plans have separate prior authorization requirements managed by each plan. If your patient has a Medicare Advantage plan, their prior authorization process is determined by that plan — not WISeR.

What if I'm in a WISeR state but don't perform any of the 13 service categories?

No action is required. WISeR only applies to providers who furnish one or more of the 13 covered service categories. If none of those CPT codes appear in your billing, the model does not affect your practice.

Can I still get paid if I perform a service without prior authorization?

Yes, but with risk. You can opt for post-service pre-payment review instead of prior authorization. If the review affirms the claim, you're paid. If not, payment is withheld — and you'll need to either appeal the denial or write off the service. Prior authorization eliminates this payment uncertainty.

How long is a WISeR prior authorization approval valid?

An affirmation is valid for 120 calendar days from the date of approval. If the service is not rendered within that window, you need a new prior authorization.

What is the gold card exemption and how do I qualify?

Providers who maintain a provisional affirmation rate of 90% or higher during a designated performance review period may be exempted from prior authorization requirements for WISeR services. Gold card status is earned through consistently strong documentation practices and high approval rates over time.

Is there a peer-to-peer review available for WISeR denials?

Yes. If a prior authorization request is not affirmed, you can request a peer-to-peer review with a physician reviewer at the model participant. This is your strongest tool for overturning a non-affirmation before resubmitting. Schedule the call promptly and prepare a concise clinical summary of why the service is medically necessary.

What does WISeR mean for practices in non-affected states?

Nothing changes for providers outside the six WISeR states. If CMS expands the model in future performance years, CMS will announce changes through official channels. Monitor CMS Innovation Center updates and your MAC's communications for any expansion announcements.

Where can I get current WISeR CPT codes and submission instructions?

The most current source is the CMS WISeR Provider and Supplier Operational Guide (version 4.0), available at cms.gov/priorities/innovation/innovation-models/wiser. Your MAC's WISeR resource page also contains state-specific submission portals and contact information for your model participant.

Ready to Streamline WISeR Prior Authorizations?

The WISeR model runs through 2031 — this is a long-term workflow change, not a temporary disruption. Practices that build strong prior authorization documentation and tracking processes now will reach gold card exemption faster and face fewer payment delays.

Get Started:

• Service-specific prior authorization documentation aligned with WISeR criteria
• Prior auth tracking with 120-day expiration alerts
• Peer-to-peer preparation support for non-affirmation follow-ups
• Consistent documentation quality toward gold card eligibility

Start Free With Muni Appeals

---

This guide reflects CMS WISeR model procedures and state assignments as of March 2026. CMS may update service categories, model participants, or state assignments during the six-year model period. Verify current requirements at cms.gov/priorities/innovation/innovation-models/wiser and with your Medicare Administrative Contractor.