Medicare Is Putting Certain Procedures Under a New Review System. Is Your Practice Ready?

For practices performing certain procedures for Original Medicare patients, a new payment checkpoint is already in place.

The Centers for Medicare & Medicaid Services’ Wasteful and Inappropriate Service Reduction Model — WISeR — began January 1, 2026, in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The six-year model covers selected services and gives providers and suppliers a choice: submit a prior authorization request before the service, or allow the resulting claim to go through pre-payment medical review.

CMS says WISeR doesn’t change Medicare’s underlying coverage or payment rules. What it changes is how certain services are reviewed before Medicare pays for them, and that distinction matters for practices. A procedure that has historically moved from the physician’s order straight to the claim now may have another checkpoint in between. For some practices, the issue will be getting an authorization affirmed before the procedure; for others, it’ll be having the medical record withstand pre-payment review after the service has already been performed. Either way, the documentation supporting the service has become part of the payment workflow.

WISeR Is More Than a New Authorization Requirement

It would be easy to treat WISeR as another prior authorization program, but the mechanics are different enough that practices shouldn’t.

For WISeR-selected services, providers can submit a prior authorization request directly to the WISeR model participant or through their Medicare Administrative Contractor. If they don’t, the claim is subject to pre-payment medical review to determine whether the service met applicable Medicare coverage, coding, and payment requirements.

So there’s no simple “skip authorization and bill normally” option for an included service — the practice is choosing between review before the procedure and review before payment. For requests submitted through a WISeR participant’s electronic portal, the participant’s turnaround requirement is 72 hours for applicable dates of service beginning January 15, 2026. Requests submitted through a MAC can take longer, since the MAC has to forward the request to the WISeR participant and return the determination.

CMS also allows expedited review when a delay could seriously jeopardize the beneficiary’s life or health, though because WISeR focuses on non-emergent services, CMS expects expedited requests to be uncommon. For a practice scheduling procedures weeks in advance, that makes the workflow decision fairly practical: if the procedure is in scope, the review pathway should be settled before the patient is on the table.

Which Procedures Are in Scope?

WISeR isn’t a blanket review of Medicare procedures. CMS has selected specific items and services, including:

Epidural steroid injections for pain management
Electrical nerve stimulators
Sacral nerve stimulation for urinary incontinence
Percutaneous vertebral augmentation for vertebral compression fractures
Cervical fusion
Arthroscopic lavage and debridement for osteoarthritic knees
Hypoglossal nerve stimulation for obstructive sleep apnea
Incontinence-control devices
Diagnosis and treatment of impotence
Certain skin and tissue substitute applications and wound-related services
Other selected services identified in the WISeR Provider and Supplier Operational Guide

The list is more complicated than the procedure names suggest. CMS distinguishes between primary codes and associated codes. Primary codes in the WISeR guide are subject to the model’s prior authorization and pre-payment review requirements; associated codes aren’t independently subject to WISeR review, and are instead handled in connection with the relevant primary service.

So a practice shouldn’t determine WISeR applicability from the procedure name alone. The CPT/HCPCS code, the applicable diagnosis, and the specific Medicare coverage requirements all matter, particularly for practices that perform multiple variations of a procedure or bill services across different clinical indications.

One Procedure on the List Isn’t Currently Being Reviewed

There’s another detail worth catching before a practice changes its workflow. CMS has delayed implementation of percutaneous image-guided lumbar decompression (PILD) for spinal stenosis under WISeR. Although PILD appears in the model’s service materials, CMS says it isn’t currently subject to WISeR prior authorization or pre-payment review, and will be reconsidered for implementation in a future performance year. It’s a reminder that a procedure appearing on a general WISeR list doesn’t necessarily mean the review requirement is active for that service today, which is why using the current CMS guide matters.

Who Should Be Watching This?

The most obvious exposure is for practices performing WISeR-selected procedures in the six participating states. That touches parts of several specialties:

Pain management. Epidural steroid injections are among the selected services, putting particular emphasis on documenting the clinical indication and the Medicare coverage criteria supporting the injection.
Spine and orthopedics. Cervical fusion and vertebral augmentation are within the current WISeR service universe.
Interventional radiology. Several of the selected services involve image-guided or procedure-based care, making code-level and documentation-level review especially relevant.
ASCs and other suppliers. WISeR isn’t limited to a traditional physician-office workflow — the model applies to providers and suppliers furnishing selected services to people with Original Medicare in participating regions.

There’s also an important boundary: WISeR doesn’t apply to Medicare Advantage. It’s a model operating in Original Medicare only.

The Documentation Problem May Come Before the Coding Problem

WISeR doesn’t create a new set of Medicare medical-necessity standards. CMS says the model relies on existing Medicare requirements, including statutes, regulations, National Coverage Determinations, Local Coverage Determinations, and other applicable coverage policies. That doesn’t make documentation less important, though — if anything it makes it more visible.

For a selected service, the practice should be able to connect the billed procedure to the clinical record without gaps, which can include the relevant history and physical findings, imaging or laboratory results, prior treatment history, the medical-necessity rationale, and the current treatment plan, depending on the service. CMS specifically recommends submitting organized, complete supporting clinical information with prior authorization requests.

A useful pre-submission review should ask:

Does the record document the indication for the procedure?
Are the applicable Medicare coverage criteria met and clearly supported?
Is the relevant conservative treatment history documented when required?
Do imaging or other diagnostic findings support the service?
Does the procedure note match the service that was ordered and ultimately billed?
Are the CPT/HCPCS codes and modifiers supported by the documentation?
If a WISeR authorization is required or elected, has the request been submitted through the correct pathway?

This is where billing, coding, and clinical documentation stop being separate processes. The medical record itself becomes part of the revenue cycle.

A Non-Affirmation Isn’t the End of the Process

Another point practices should build into the workflow is what happens when a request isn’t affirmed. CMS says every non-affirmation must be reviewed by a human clinician with relevant clinical expertise — technology alone can’t make the non-affirmation decision. Providers can also use the resubmission process and request peer-to-peer review before a final determination, and appeals rights remain available for denied claims. For a practice, a WISeR non-affirmation shouldn’t just disappear into a generic denial queue.

The reason matters. Was the documentation incomplete? Was a specific coverage criterion missing? Was the wrong code submitted? Was additional clinical information needed? Did the service fail to meet the applicable Medicare policy? Those answers can determine whether the next request runs into the same problem.

WISeR Can Also Turn Review Results Into a Practice Metric

The model has another feature worth attention: Gold Card, or exemption, status. CMS has established an exemption process for providers and suppliers that demonstrate a consistent record of meeting Medicare coverage criteria. Providers that achieve the required affirmation threshold can become exempt from additional WISeR review for selected services for a defined period.

The current process is already operating. The American College of Radiology reports that providers must submit at least 10 WISeR prior authorization requests during the assessment period and meet the required affirmation threshold. Providers are evaluated quarterly, and those who receive exemption status maintain it for one year from the effective date. ACR reported in July that providers with an average affirmation rate of 80% or higher should have received notification from their designated WISeR participant. That gives practices a reason to look beyond individual claims and consider tracking, if WISeR-selected procedures are a meaningful part of their Medicare volume:

number of prior authorization requests;
affirmation rate;
non-affirmation rate;
reasons for non-affirmation;
resubmissions;
peer-to-peer reviews;
appeals;
pre-payment review outcomes;
results by physician;
results by procedure or code.

A high non-affirmation rate may point to a documentation or workflow problem that’s otherwise hard to see. A consistently high affirmation rate, on the other hand, may help the practice qualify for reduced review burden — which makes WISeR performance more than an administrative statistic.

What Practices Should Check Now

For a practice in one of the six WISeR states, the first step isn’t creating another generic authorization checklist. It’s identifying exactly where WISeR intersects with the practice’s own services.

Start with the code, not the procedure name
Compare the CPT/HCPCS codes the practice actually bills with the current WISeR Provider and Supplier Operational Guide. CMS updates the guide and related code and documentation information during the model.
Confirm the patient’s Medicare type
WISeR applies to Original Medicare, not Medicare Advantage. The patient’s coverage should be confirmed before staff assume the model applies.
Establish the review pathway before the procedure
If a selected service is being performed, determine whether the practice is submitting prior authorization or allowing the claim to undergo pre-payment review. That should be an intentional workflow decision, not something discovered after the claim is held.
Review the record before submission
For procedures with significant medical-necessity requirements, make sure the supporting information is in the chart before the request is submitted. Retrospectively searching for missing documentation after a non-affirmation is considerably harder.
Track WISeR separately from ordinary Medicare denials
A WISeR non-affirmation or pre-payment review result should have its own category in the practice’s denial and authorization reporting. Without that separation, management may see “Medicare denials” increasing without knowing whether WISeR is responsible or what’s causing the problem.
Monitor affirmation performance
If the practice performs enough WISeR-selected services, monitor the affirmation rate and the practice’s Gold Card eligibility. The exemption process is designed to reduce review burden for providers that demonstrate consistent compliance with Medicare coverage criteria.

What WISeR Means for the Revenue Cycle

CMS designed WISeR to reduce wasteful and inappropriate services in Original Medicare while applying existing Medicare coverage rules. The model doesn’t change payment rates or Medicare coverage policy.

For affected practices, though, the operational change is significant. A selected procedure may now have an additional checkpoint before Medicare pays for it, addressed either before the service through prior authorization or after it through pre-payment review.

The difference is timing, and timing matters. A documentation problem identified before a procedure can be corrected before the patient is treated. The same problem discovered during pre-payment review becomes a payment issue, a follow-up task, and potentially a delay in revenue. For practices performing WISeR-selected services in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington, this is no longer a future policy change to watch.

WISeR is already part of the Medicare claims workflow. The practical response is straightforward: know which codes are in scope, understand the review pathway, make sure the clinical record supports the service, and track what happens to your own requests.

Because once WISeR data starts accumulating, the most useful question may not be whether Medicare is reviewing your procedures — it may be why some of them are getting through and others aren’t.

Sources

Centers for Medicare & Medicaid Services, WISeR Model
Centers for Medicare & Medicaid Services, WISeR Model Frequently Asked Questions
Centers for Medicare & Medicaid Services, WISeR Provider and Supplier Operational Guide, Version 4.0
Centers for Medicare & Medicaid Services, CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare
American College of Radiology, Check Your WISeR Gold Card Exemption Status Today, July 9, 2026
American College of Radiology, CMMI Updates WISeR Model Provider, Supplier Operational Guide