CMS Launches WISeR Model to Curb Overuse of Medicare Services

The Centers for Medicare and Medicaid Services (CMS) is looking to reduce the volume of "low value" services furnished to Original Medicare beneficiaries through the recently announced Wasteful and Inappropriate Service Reduction (WISeR) Model.

WISeR participants will be health technology companies that use advanced tools—such as artificial intelligence—to assess the medical necessity of services on behalf of payers. These organizations must also employ qualified clinicians to perform medical reviews and validate their coverage determinations. Model participants will earn a share of the savings generated by reducing wasteful or inappropriate care through their review activities. The exact percentage will be adjusted based on their performance on key process measures, including metrics reflecting provider experience.

WISeR will require prior authorization for 17 kinds of services that CMS believes are either commonly overused or historically have had a higher risk of waste, fraud, and abuse.

WISeR is a pilot program that will be implemented in six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington) for a period of six years, starting January 1, 2026, and ending December 31, 2031.

Services Targeted for Prior Authorization

The services eligible for prior authorization under WISeR include:

• Electrical Nerve Stimulators
• Sacral Nerve Stimulation for Urinary Incontinence
• Phrenic Nerve Stimulator
• Deep Brain Stimulation for Essential Tremor and Parkinson's Disease
• Vagus Nerve Stimulation
• Induced Lesions of Nerve Tracts
• Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
• Epidural Steroid Injections for Pain Management, Excluding Facet Joint Injections
• Percutaneous Vertebral Augmentation for Vertebral Compression Fracture
• Cervical Fusion
• Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee
• Incontinence Control Devices
• Diagnosis and Treatment of Impotence
• Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
• Skin and Tissue Substitutes
• Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
• Wound Application of Cellular and/or Tissue-Based Products, Lower Extremities

Providers and suppliers of the above-listed services for Original Medicare beneficiaries will have the choice of submitting a pre-service, prior authorization request through the WISeR model or going through post-service, prepayment review.

Services Have Existing Clinical Validation

Although CMS considers the above services suspect, it should be noted that they all fall under national coverage determinations (NCDs) or local coverage determinations (LCDs), including some that are subject to coverage with evidence development requirements. Rigorous evidence reviews and established standards of care are required before CMS grants an NCD or the Medicare Administrative Contractors (MACs) grant an LCD. These services have also passed the U.S. Food and Drug Administration's "safety and effectiveness" thresholds.

CMS Guardrails to Protect Access to Care

CMS has added some guardrails in an attempt to ensure WISeR doesn't impede access to care:

• None of the services subject to prior authorization are "inpatient-only, emergency services, or services that would pose a substantial risk to patients if substantially delayed."
• Any recommendations for Medicare to not pay a provider for services have to be reviewed by an appropriately licensed clinician using "standardized, transparent, and evidence-based procedures."
• And CMS is considering implementing a "gold card" program to exempt certain providers from prior authorizations if 90% of their requests get approved in a provisional period.

Technology-Driven Prior Authorization: Promise and Risk

WISeR will test technology-enabled prior authorization and prepayment review to ensure that selected services are medically necessary and clinically appropriate. To implement the new program, CMS is contracting with outside private organizations who will use artificial intelligence to drive the prior authorization process. This creates at least two problems.

First, the private agencies will be paid a "share of the averted expenditures" and thereby incentivized to deny more claims.

Second, the reliance on artificial intelligence to identify overused services could inappropriately increase the number of prior authorization requests if the AI tools are not properly vetted or well-implemented.

Given that Medicare Advantage plans have used AI to systematically deny claims for beneficiaries, there is an understandable reluctance to use AI for prior authorization in traditional Medicare.

How WISeR Will Operate in Practice

WISeR applies the prior authorization requirements to all Medicare-enrolled providers in the six pilot states. While the program is billed as "voluntary," claims for included services submitted without prior authorization will instead undergo prepayment medical review. In practice, provider participation will play out in one of three ways:

• The provider submits a prior authorization request directly to the WISeR participant for review and determination.
• The provider submits a prior authorization request to the MAC, which then routes it to the WISeR participant for review and determination.
• The provider furnishes an included service without requesting prior authorization, and the WISeR participant flags the resulting claim for prepayment medical review.

Providers and suppliers may resubmit prior authorization requests an unlimited number of times following a non-affirmation decision. They may also request a peer-to-peer clinical review during resubmission to address the reason for non-affirmation and discuss alternative clinical options. If a claim is submitted and denied after a non-affirmation decision, it will be subject to the standard Medicare claims appeals process.

Ultimately the success of WISeR will depend on the quality of the AI tools used, the integrity of the outside contractors and the efficacy of the CMS guardrails.

A New Direction for Traditional Medicare Oversight

Beyond its immediate operational details, WISeR represents a significant policy shift in how CMS approaches utilization management within traditional Medicare. Historically, prior authorization has been used more sparingly in fee-for-service Medicare due to concerns about administrative burden and care delays. By integrating technology-enabled prior authorization, WISeR could establish a precedent for more centralized and proactive cost containment strategies. However, this also raises questions about whether AI-based models are sufficiently nuanced to account for patient-specific clinical variation and whether they can be meaningfully overseen by human reviewers in high-volume settings.

What to Watch For

Stakeholders—including providers, patient advocates, and health technology companies participating in the model—will need to monitor implementation closely. Providers in the pilot states may face steep learning curves and new administrative complexity, particularly in navigating resubmissions and appeals. Patient access advocates are also likely to scrutinize WISeR for signs of delayed or denied medically necessary care, especially for vulnerable populations with chronic or complex conditions.