Implementation of the Wasteful and Inappropriate Service Reduction (WISeR) Model, which tests using enhanced technologies including AI to reduce clinically unsupported care in Original Medicare while preserving access to appropriate services begins January 1st.
Effective Date and Duration
The WISeR model begins January 1, 2026, and continues for 6 years through December 31, 2031. Prior authorization requests will be accepted starting January 5, 2026, for dates of service on or after January 15, 2026.
Geographic Scope
The model will operate in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, with each state paired with one of six technology company model participants.
Model Structure
Technology companies with expertise in prior authorization and AI will process prior authorization requests and issue decisions. Medicare Administrative Contractors (MACs) covering selected jurisdictions (J15, JF, JH, and JL) will interface with WISeR participants to implement data flows supporting the process.
Services Subject to Prior Authorization
The model includes specific services known to be vulnerable to fraud, waste and abuse, including:
- Electrical Nerve Stimulators.
- Sacral Nerve Stimulation for Urinary Incontinence.
- Phrenic Nerve Stimulator.
- Vagus Nerve Stimulation.
- Induced Lesions of Nerve Tracts.
- Epidural Steroid Injections for Pain Management.
- Percutaneous Vertebral Augmentation.
- Cervical Fusion.
- Arthroscopic Lavage and Debridement for Osteoarthritic Knee.
- Other procedures including skin substitutes.
Provider Options
Providers in selected states have three options:
- Submit prior authorization requests directly to the model participant.
- Submit requests to their MAC, which will forward to the model participant.
- Submit claims without prior authorization, which will be suspended and forwarded for pre-payment medical review.
Determination Timeframes
For prior authorization requests, WISeR participants will issue determinations within 3 days (2 days for expedited requests). For pre-payment medical review, providers have 45 days to submit documentation, and determinations will be issued within 3 days of receipt of all documentation.
Beneficiary Eligibility
The model includes Medicare beneficiaries who:
- Are eligible for Part A and enrolled in Part B.
- Are aged 18 years or older.
- Are not enrolled in Medicare Advantage.
- Are not covered under United Mine Worker Health and Retirement Funds.
- Indian Health Service claims are excluded.
MAC Responsibilities
MACs will:
- Coordinate with model participants to implement processes and establish secure communication channels.
- Identify claims requiring prior authorization.
- Suspend and forward claims missing prior authorization.
- Process claims based on model participant determinations.
- Deny claims with non-affirmative decisions.
- Establish Joint Operating Agreements with WISeR participants.
Appeals and Resubmissions
Standard Medicare appeals processes apply. Providers may resubmit prior authorization requests with additional information if they receive a non-affirmation decision, with no limit on resubmissions. Peer-to-peer clinical review is available for resubmissions.
