WISeR Prior Authorization 2026: What Pain Management Practices in 6 States Must Know

Quick Answer: WISeR is a CMS Innovation Center model that adds prior authorization to 14 categories of services in Original Medicare in six states (New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington) from January 1, 2026 to December 31, 2031. Technology companies review the requests with AI support, and licensed clinicians make every non-affirmation. Five of the 14 categories are core pain management procedures, including epidural steroid injections and nerve ablation.

Here is something most pain practices did not expect to hear in 2026: traditional Medicare now has prior authorization, and an AI-assisted reviewer is reading your notes before you get paid.

That is WISeR prior authorization, the biggest change to how Original Medicare reviews outpatient procedures in years. If you bill epidural steroid injections, radiofrequency ablation, kyphoplasty or nerve stimulators for Medicare patients in Texas, Arizona, Ohio, Oklahoma, New Jersey or Washington, every one of those claims now runs through it. Congress tried to stop the WISeR model this summer, and the Senate voted the repeal down. So the question is no longer whether your practice deals with it, but how well.

This guide explains what the model covers, how the prior authorization process works step by step, what happens when a request is not affirmed, and what your billing team should change now. Every rule below comes from the official CMS WISeR model page, the CMS WISeR provider fact sheet and the CMS WISeR FAQ.

What Is the Medicare WISeR Model?

WISeR stands for the Wasteful and Inappropriate Service Reduction Model. CMS launched it to test whether technology, including artificial intelligence and machine learning, can speed up prior authorization for a set of services that CMS considers vulnerable to fraud, waste and abuse in Original Medicare.

The key facts at a glance:

• Who it applies to: all providers and suppliers in the selected states who serve Original Medicare (fee-for-service) patients.
• Who it does not apply to: Medicare Advantage patients. CMS states that WISeR does not apply to people with Medicare Advantage.
• Where: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
• When: six performance years, January 1, 2026 through December 31, 2031. Prior authorization requests opened on January 5, 2026, for services furnished on or after January 15, 2026.
• Settings: hospital outpatient departments, ambulatory surgery centers, the office and the home. Inpatient-only services, emergency services and services that would put the patient at substantial risk if delayed are excluded.
• Payment rates: unchanged. CMS says WISeR enforces existing Medicare coverage and payment criteria and does not change provider payments or appeal rights.

Who Reviews WISeR Prior Authorization Requests?

Each state is assigned one technology company, called a model participant, which processes prior authorization requests and pre-payment reviews alongside the state’s Medicare Administrative Contractor (MAC):

This is why WISeR is often called Medicare’s AI prior authorization pilot. The participants use AI-assisted tools to process requests, but CMS requires that licensed clinicians employed by the participant review every request that is not affirmed. One detail matters for how practices should read this model: participants are paid a share of the Medicare spending that is averted, adjusted for timeliness, accuracy and provider experience, rather than a flat fee per review.

The WISeR Prior Authorization List: 14 Services in 2026

For the first performance year, CMS lists 14 service categories, each tied to an existing National or Local Coverage Determination (NCD or LCD). WISeR does not create new coverage rules. It enforces the ones already in those NCDs and LCDs.

The exact CPT and HCPCS codes and the documentation requirements for each category are published in the WISeR Provider and Supplier Operational Guide. CMS notes that codes may change and that WISeR codes do not overlap with existing Medicare prior authorization programs, so services already covered by the hospital outpatient prior authorization program or the DMEPOS prior authorization program stay in those programs.

Why WISeR Hits Pain Management Practices Hardest

Five of the 14 categories are procedures that interventional pain practices perform every week: epidural steroid injections, nerve ablation (induced lesions of nerve tracts), kyphoplasty and vertebroplasty, minimally invasive lumbar decompression, and spinal cord and peripheral nerve stimulators. For a practice in a WISeR state with a large traditional Medicare population, a meaningful share of procedural revenue now depends on getting prior authorization right.

These services were already documentation-heavy. The LCDs behind them spell out conservative care requirements, imaging findings, prior response to treatment and frequency limits. Under WISeR, a reviewer checks all of that before the procedure instead of during a post-payment audit months later. If your notes do not show it, the request is not affirmed. Our guide to pain management billing compliance mistakes covers the documentation gaps reviewers flag most often.

How the WISeR Prior Authorization Process Works

1. Decide with the patient and check the requirements. Confirm the service is on the WISeR list for your state and review the LCD or NCD documentation requirements before scheduling.
2. Submit the request with documentation. Send it directly to your state’s WISeR participant through its portal, or through your MAC, which routes it to the participant. CMS notes that requests routed through the MAC or sent by mail may take longer.
3. Wait for the decision. CMS says a standard decision is typically made within 3 days of receiving the request, and an expedited decision within 2 days when the participant confirms that a delay could seriously jeopardize the patient’s life or health.
4. Receive a Unique Tracking Number (UTN). Affirmed requests get an affirmative UTN. Non-affirmed requests get a non-affirmative UTN with a detailed rationale.
5. Put the UTN on the claim. CMS says every claim that went through prior authorization, affirmed or not, should carry its UTN. A missing UTN is one of the easiest denials to avoid.

What Happens If You Skip Prior Authorization?

WISeR does not force a prior authorization request. You can choose to furnish the service without one. If you do, the MAC flags the claim for pre-payment medical review, the WISeR participant requests and reviews your documentation, and the MAC pays or denies based on that review. For dates of service on or after January 15, 2026, every claim for a WISeR service without prior authorization goes through this review.

In practice, skipping prior authorization does not avoid the review. It moves it to after the procedure, when you have already spent the time and supplies and the patient has already been treated.

What to Do When a WISeR Request Is Not Affirmed

A non-affirmation is not the end of the road. CMS describes several paths:

• Resubmit. CMS describes unlimited resubmissions for non-affirmed requests. Read the detailed rationale, fix the documentation gap it names and send the request again.
• Request a peer-to-peer review. Peer-to-peer is available as part of a resubmission, under the same standard or expedited timeframes. For complex cases this is often the fastest route, because your physician can explain clinical context that a note does not capture.
• Furnish the service anyway, with an ABN. A non-affirmation does not prevent you from performing the service. If you go ahead, CMS says the physician must notify the patient with an Advance Beneficiary Notice (ABN) before furnishing it, and the MAC will deny the claim because the request was non-affirmed.
• Appeal the claim denial. The MAC’s denial is an initial payment determination, so the standard Medicare appeals process applies. Providers, suppliers and patients keep their existing appeal rights.

If denials are already piling up, our denial management services team works WISeR non-affirmations the same way we work any payer denial: by root cause, not by blind resubmission.

Why WISeR Is Drawing Criticism

WISeR has not been quiet. In September 2026, the patient advocacy group Medicare Rights Center published records it says show the model causing inappropriate denials of care. Critics have also focused on the payment design, since participants earn a share of averted spending.

CMS’s position is that WISeR only enforces existing coverage rules, that clinicians make every non-affirmation, and that participant payments are adjusted for accuracy and provider experience. Whichever side you agree with, the operational lesson is the same: documentation that clearly meets the LCD is the only reliable way to get WISeR services paid.

Is WISeR Being Repealed?

Not right now. On May 12, 2026, the Government Accountability Office concluded that WISeR counts as a rule, which opened the door for Congress to try to overturn it under the Congressional Review Act. Senate Democrats introduced a resolution of disapproval, S.J.Res.198. On July 16, 2026, the Senate rejected the motion to take it up by a 46 to 50 vote.

There is a second front. On June 9, 2026, the House Appropriations Committee voted unanimously to add language to the fiscal year 2027 Labor-HHS spending bill that would block funding for WISeR. That language only takes effect if it survives the full House, the Senate and the final bill signed into law. As of October 2026, the government is running on a short-term continuing resolution through mid-December, so the full-year bill, and the defund language with it, has not been enacted.

The bottom line for practices: WISeR is live today. Keep submitting requests and documenting to the LCD, and watch the final FY2027 spending bill for whether the defund language makes it through.

Is There a WISeR Gold Card Exemption?

CMS has said it plans a gold card or exemption program in 2026 for providers who consistently meet the affirmation threshold. Exempt providers would generally skip additional prior authorization and pre-payment review for the selected services for a set period before being re-evaluated. CMS has not published the threshold, so the practical path to an exemption is simple: build a track record of clean, affirmed requests starting now.

A WISeR Checklist for Pain Management Billing Teams

• Flag every Original Medicare patient scheduled for a WISeR service in your state at the time of scheduling, not at check-in.
• Build a documentation checklist per service from its LCD or NCD: conservative care tried, imaging, prior response, frequency limits.
• Submit through the participant portal when possible to avoid MAC routing delays.
• Track every request, its UTN and its decision date in one place.
• Add a claim edit that stops any WISeR claim without a UTN from going out.
• Use the non-affirmation rationale to fix templates, so the same gap does not repeat.
• Get a signed ABN before furnishing any service whose request was non-affirmed.
• Keep Medicare Advantage patients on their plan’s own prior authorization rules, since WISeR does not apply to them.

For the broader process, see our complete guide to prior authorization in medical billing.

Frequently Asked Questions

What is WISeR prior authorization?

WISeR prior authorization is a CMS Innovation Center model that requires prior authorization, or pre-payment review, for 14 categories of services in Original Medicare in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. It runs from January 1, 2026 to December 31, 2031, and technology companies process the requests with clinician review.

Which states are in the WISeR model?

Six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Each state has one assigned technology company that processes WISeR prior authorization requests with the state’s Medicare Administrative Contractor.

Is the WISeR model being repealed?

Not so far. A Congressional Review Act resolution to overturn WISeR, S.J.Res.198, failed in the Senate on July 16, 2026, when the motion to proceed was rejected 46 to 50. Separately, the House Appropriations Committee voted on June 9, 2026 to block WISeR funding in the FY2027 Labor-HHS bill, but that bill has not been enacted. For now the model remains in effect and is scheduled to run through December 31, 2031.

Does WISeR apply to Medicare Advantage?

No. CMS states that WISeR applies only to Original Medicare (fee-for-service) patients. Medicare Advantage plans continue to use their own prior authorization rules.

Does WISeR cover DME?

WISeR is not a DME program. It focuses on procedures furnished in hospital outpatient departments, ambulatory surgery centers, offices and the home. CMS states that WISeR codes do not overlap with existing Medicare prior authorization programs, so items in the DMEPOS prior authorization program stay in that program.

How long does a WISeR prior authorization decision take?

CMS says a standard decision is typically made within 3 days of receiving the request, and an expedited decision within 2 days when a delay could seriously jeopardize the patient’s life or health. Requests routed through the MAC or by mail may take longer.

Can I still perform a service if WISeR does not affirm it?

Yes. A non-affirmation does not prevent you from furnishing the service, but the physician must give the patient an Advance Beneficiary Notice first, and the MAC will deny the claim. You can resubmit the request, request a peer-to-peer review, or appeal the claim denial through the standard Medicare appeals process.

Does WISeR change Medicare payment rates?

No. CMS says WISeR enforces existing Medicare coverage and payment criteria and does not change provider payments or appeal rights. What changes is when and how documentation is reviewed.

Get WISeR Requests Right the First Time

WISeR rewards practices that treat prior authorization as part of the revenue cycle, not an afterthought at the front desk. If your practice is in one of the six WISeR states and Medicare procedures make up a real share of your revenue, a billing partner that tracks every request, UTN and rationale can protect that revenue. See how our pain management medical billing services handle prior authorization from scheduling to payment.

Written by

Ajay Pillai CEO & Founder, Aayur Solutions LLC

Ajay Pillai is the CEO of Aayur Solutions LLC, a U.S.-based medical billing and revenue cycle management company serving DME/HME providers, dental practices, pain management clinics, and specialty care organizations. With 17+ years of hands-on RCM experience, he has led billing operations, denial management workflows, and prior authorization programs for healthcare providers across the United States. Ajay holds credentials from the Indian Institute of Management and Case Western Reserve University, and is based in Sheridan, Wyoming. He holds a management qualification from IIM Calcutta and a certificate from Case Western Reserve University's health management programme.

Connect on LinkedIn