Medicare Prior Authorization Getting WISeR? Five Essential Questions

On June 27, 2025, the Centers for Medicare and Medicaid Services introduced the WISeR model. This has generated an incredible number of discussions and questions. Here are answers to five of them.

What is WISeR?

• It stands for Wasteful and Inappropriate Service Reduction, another creative acronym from CMS. An Innovation Center model will text a new process on “whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use.”
• The test will run for six years, from January 1, 2026, to December 31, 2031, in six states – Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
• The model is voluntary. If a provider does not submit a request, the claim will be subject to the usual pre-payment review.
• There are 17 items and services on the list that will require prior authorization. (Find the list on page 7 of the Federal Register notice.)
• WISeR will apply only to Original Medicare. (CMS published a separate final rule for Medicare Advantage prior authorization. However, that rule focuses on standardizing and streamlining processes and communication. It does not target a specific group of services.)

What are the goals?

CMS wants to reduce fraud, abuse, and waste, including low-value care. The selected service codes no doubt are connected to these concerns. Here are just two examples.

1. Medicare loses an estimated $60 billion each year to fraud. One item on the list, Skin and Tissue Substitutes, which includes bioengineered skin substitutes, accounted for $1.2 billion in fraudulent claims submitted by just one couple.
2. Low-value services are those that offer minimal benefit but increased patient costs. According to MedPac, two low-value services on the WISeR list (percutaneous vertebral augmentation and knee arthroscopy) cost Medicare at least $808 million in 2022.

Why is CMS adding prior authorization to Original Medicare?

Contrary to a couple posts, prior authorization in Original Medicare is not new. Initially not part of the Social Security Act, the law was changed. Prior authorization has applied to Original Medicare for years.

For a long time, it focused mostly on power mobility devices (very prone to fraud) and procedures that might be considered cosmetic. For example, is rhinoplasty (nose surgery) necessary because the person can’t breathe or selective because he doesn’t like his nose? In 2020 and 2024, CMS expanded the list. Just as with the WISeR model, the current list of codes subject to authorization includes some with questionable medical necessity or low-value.

Will this push Original Medicare closer to Medicare Advantage?

Some recent headlines reflect this concern.

“It’s going to be just like Medicare Advantage, delay and deny.”

“CMS and insurers signed a pledge to reduce prior authorization and now they’re doing this.”

There is no way to know for sure whether WISeR will turn Original Medicare into an Advantage clone. But that may not happen because there are some significant differences between this system and that of Medicare Advantage.

• Providers and patients will know when authorization is required.
  Check the Evidence of Coverage for a Medicare Advantage plan and there will be many instances of, “prior authorization may be required.” All the details are in the plan’s portal, behind a wall.
  The WISeR model identifies 17 services that will require authorization.
• Coverage criteria will likely be more clearly defined.
  There have been concerns that Medicare Advantage plans apply different requirements, resulting in coverage that is more restrictive than Original Medicare.
  The 17 services in the WISeR model connect with either an NCD (national coverage determination) or LCD (local coverage determination), which provide insight into what Medicare requires. Some of these determinations contain very specific coverage criteria, like the one for knee arthroscopy, but others are more general. Hopefully, as the project moves forwards, there will be more specifics so providers know exactly what is required.
• The operation will be standardized.
  When checking Advantage plans, I discovered different authorization forms, some very short, others much longer. I have also read that submitting the wrong form can result in a denial.
  The Innovation Center standardizes model features to reduce administrative burden. Coverage criteria, protocols, and documentation for the WISeR Model will be developed and apply to all providers (except if no active LCD in place).
• There will be no denials or appeals of the decision.
  If a Medicare Advantage plan denies the request (3.2 million denials in 2023), the five-step appeals process begins. This can take time and considerable effort, which may be why fewer than 12% are appealed.
  Under the WISeR model, the request will be affirmed (meets Medicare’s criteria) or non-affirmed (does not meet the criteria). A provider has unlimited opportunities to resubmit the request (not an appeal).

Are there any big concerns?

With any new project, there will be concerns. Besides the one about pushing Original Medicare toward Medicare Advantage, here are three that pop up quite regularly:

• Paying companies that review submissions a percentage of the Medicare savings for non-affirmed requests (averted expenditures)
• Contracting with third parties connected with Medicare Advantage, and
• Using AI technology.

There is no denying something needs to be done to control the fraud and waste in Medicare. CMS recognizes that it will take to come up with a system and guardrails to achieve the goals while reducing provider burden and avoiding beneficiary harm. CMS has six years to get this right.

There is another WISER model. It stands for Watch, Pay attention, Interpret, Engage and Reflect, and helps to control strong emotions. It may be a wise thing to apply this model as we work through the CMS’ attempt to become WISeR.