WISeR — prior authorization arrives in traditional Medicare

Where it applies, and who runs it

WISeR covers six states across four Medicare Administrative Contractor jurisdictions: New Jersey (JL), Ohio (J15), Oklahoma and Texas (JH), and Arizona and Washington (JF). CMS selected them for service volume, geographic spread, and existing local coverage determinations on the services in scope.

The reviews themselves are run by third-party technology companies CMS calls Model Participants — Cohere Health, Innovaccer and Genzeon among them. Decisions are made with AI- and ML-assisted review, with human clinician review required for every non-affirmation. No request is denied by a model alone.

WISeR is a demonstration, not a permanent rule. CMS has been explicit that it is a precursor to broader policy, and the six-year model period is long enough that treating it as temporary is not a strategy.

The 13 service categories, and the part most coverage gets wrong

WISeR is a spine-and-pain model. It is not an orthopedic model, and the difference matters when a center is estimating its own exposure.

These are the 13 active categories for the 2026 performance year.

Total joint replacement is not in WISeR.Neither is arthroscopic repair. The only pure orthopedic category is knee arthroscopy limited to lavage and debridement, the procedure governed by national coverage determination 150.9. A center that reads “Medicare prior authorization for orthopedics” and starts modelling its total-joint volume is preparing for something that is not happening.

The categories that carry real ASC volume are the pain and spine ones — epidural steroid injections above all, then radiofrequency ablation and the nerve-tract lesion family, spinal cord stimulators, and kyphoplasty and vertebroplasty. Two more are worth naming because they sit outside what people expect from a spine model: sacral nerve stimulation, which lands on urology and urogynecology, and hypoglossal nerve stimulation for obstructive sleep apnea, which lands on ENT and sleep surgery. A sinus-and-sleep practice in Texas is inside WISeR and frequently does not know it.

Deep brain stimulation and percutaneous image-guided lumbar decompression were proposed for the model but are not active for the 2026 performance year.

How a request actually moves

Participation is voluntary on paper. In practice it is not. A provider may skip the prior authorization, but doing so routes the claim into pre-payment medical review, which delays cash and requires the same documentation the authorization would have required. The choice is when to assemble the evidence, not whether.

Decisions are due within 72 hours for standard requests and 48 hours for expedited ones. An affirmed request produces a Unique Tracking Number, valid for 120 days from the date of the decision. The UTN must appear on the claim. An affirmation that never reaches the claim is an affirmation the center does not get paid for.

Non-affirmation is not the end of the line. Resubmission with additional documentation is unlimited, peer-to-peer review is available, and the standard Medicare appeals ladder — redetermination, reconsideration, administrative law judge — remains intact after a claim denial.

Gold carding is live, and it is the number nobody has

This is the part of WISeR with the most upside and the least attention.

A provider who reaches a 90% affirmation rate across the assessment period, on a minimum of ten requests, and who is in good standing and not on a Medicare exclusion list, is exempted from prior authorization going forward. The exemption lasts one year from the date it is obtained and is re-evaluated quarterly. There is no application. The Model Participant evaluates quarterly and notifies qualifying providers by email and through its portal.

Ninety percent is a ceiling CMS fixed, not a floor. A Model Participant may set a lower bar; none may set a higher one.

The program went live on July 6, 2026, in Washington, administered by Virtix Health, and in Texas, administered by Cohere Health. Per the Texas Medical Association, a gold-carded Texas physician is exempt across all WISeR Select services, not category by category — a materially better deal than the per-category reading that circulated early. Providers in the other four states should confirm status with their own Model Participant rather than assume the Texas terms apply.

Here is the operational problem. Affirmation is reported per case. The MAC tells you about the request in front of you and nothing else. Almost no surgery center can state its rolled-up affirmation rate by service category — and that rolled-up number is the only one that decides the exemption. A center sitting at 85% and unaware of it is leaving a year-long exemption on the table and will not find out until the quarter closes.

What WISeR does not do

WISeR changes process, not coverage. National and local coverage determinations are unchanged; a procedure that was covered before the model is covered under it. It does not touch Medicare Advantage, Medicaid, or commercial plans — only fee-for-service Medicare in the six states. It does not apply to inpatient services, to emergency services, to any service where delay would harm the patient, or to Railroad Medicare beneficiaries.

The repeal question is settled

Coverage of WISeR through the first half of 2026 carried a running asterisk about whether the model would survive. It did, and the date is worth knowing precisely.

The Government Accountability Office ruled on May 12, 2026 that WISeR is a “rule” under the Congressional Review Act. Senators Wyden, Cantwell, Blumenthal and Gillibrand introduced S.J.Res.198, a resolution of disapproval, on May 20, 2026. On July 16, 2026 the Senate rejected the motion to proceed, 46 to 50, with four members not voting. The resolution never reached a vote on the merits, and there is no live repeal vehicle.

Source: Senate Roll Call Vote 119-2-00199.

Planning around a repeal that is not coming is its own kind of cost.

WISeR is not the only CMS program, and they are not interchangeable

Three separate CMS prior authorization programs are running at once, and they are routinely collapsed into one another.

The Outpatient Department demonstrationapplies to hospital outpatient departments only — not to ASCs — and has since 2020. The ASC Prior Authorization Demonstration is ASC-specific, operates in ten states including Texas, and covers five cosmetic categories: blepharoplasty, botulinum toxin injection, panniculectomy, rhinoplasty, and vein ablation. WISeR is the third and is the one that reaches spine, pain and the stimulator families.

An ortho-and-pain center in Texas is inside WISeR and inside the ASC Demonstration at the same time, for entirely different procedures. Getting this wrong changes which cases a center thinks need a gate.

Medicare Advantage plans run their own prior authorization programs, governed separately by the CMS-0057 final rule.

Do you know your affirmation rate by service category?

Most centers cannot answer that from their own systems — the MAC reports per case, and the number that decides a year-long exemption never gets totalled anywhere. It is one of several figures a center has earned and cannot see. We will show you where they live, on screen, in thirty minutes.

This content is for informational purposes only and does not constitute legal or regulatory advice. Consult your compliance counsel for authoritative guidance on your specific obligations.