Medicare · Coverage
The WISeR Model: prior authorization in Original Medicare
Last reviewed October 12, 20268 min readBy the Goodsurance editorial team Reviewed by the Goodsurance editorial team
The WISeR Model is a test run by Medicare. It adds prior authorization to Original Medicare for a short list of services in six states. Here is what it covers, who it affects, how the approval works, and what you can do if the answer is no.
WISeR at a glance
If you only read one part of this page, read this.
WISeR at a glance
It is a CMS test of prior authorization in Original Medicare
It runs from January 1, 2026 to December 31, 2031.
It covers six states
Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
It covers a short list of services
Things like skin substitutes for leg and foot wounds, some nerve implants, and knee arthroscopy.
Your provider does the paperwork, not you
You get a copy of the decision.
Medicare Advantage members are not affected
Your benefits and coverage rules do not change.
What is the WISeR Model?
WISeR stands for Wasteful and Inappropriate Service Reduction. It is a test run by the CMS Innovation Center. CMS is the federal agency that runs Medicare.
Prior authorization means getting approval before you get care. Original Medicare has rarely used it. Medicare Advantage plans use it a lot. WISeR tests it in Original Medicare for a small set of services.
CMS picked services it says are often used when they are not needed, or that have a history of fraud. Private companies review the requests. They use computer tools, including artificial intelligence, to help. But a licensed clinician must review every "no" before it is sent.
CMS says WISeR does not change what Medicare covers. The coverage rules are the same ones Medicare already uses. What changes is that someone checks the rules before payment.
When and where WISeR applies
Dates. The model started January 1, 2026. Reviewers began taking requests on January 5, 2026, for care on or after January 15, 2026. It runs through December 31, 2031.
States. WISeR applies in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. What counts is the state where you get the care. Each state has one company that reviews requests, shown below.
Congress has debated ending the model. As of October 2026, it is still running. See our news story on the July 2026 Senate vote.
| State | Company that reviews requests | Medicare contractor (MAC) |
|---|---|---|
| Arizona | Zyter Inc. | Noridian (JF) |
| New Jersey | Genzeon Corporation | Novitas (JL) |
| Ohio | Innovaccer Inc. | CGS (J15) |
| Oklahoma | Humata Health, Inc. | Novitas (JH) |
| Texas | Cohere Health, Inc. | Novitas (JH) |
| Washington | Virtix Health LLC | Noridian (JF) |
The rule follows the state where you get the service. Source: CMS WISeR model page, updated September 30, 2026.
Which services need approval
CMS gives three examples on its WISeR page. They are skin and tissue substitutes, nerve stimulator implants, and knee arthroscopy for arthritis. The full list is in the CMS operational guide. As of Version 7.0 (July 24, 2026), it has 13 groups of services. They are listed below in plain words.
CMS can add or remove services while the model runs. It already delayed one back procedure (a type of lower back decompression) and dropped some billing codes. Your provider will know if your exact service is on the list.
What needs approval under WISeR
On the WISeR list
- Skin substitutes for long-lasting leg and foot wounds
- Knee arthroscopy for knee arthritis
- Epidural steroid shots for pain
- Neck fusion surgery (cervical fusion)
- Spine fracture repair with bone cement (vertebroplasty, kyphoplasty)
- Some nerve implants: spinal cord, vagus, phrenic, and sacral nerve
- Hypoglossal nerve implants for sleep apnea
- Nerve treatments for face pain (trigeminal nerve)
- Devices and surgery for bladder control
- Penile implants for impotence
Not part of WISeR
- Emergency care
- Inpatient-only hospital services
- Care that would put you at serious risk if delayed
- Anyone in a Medicare Advantage plan
- Railroad Medicare members
- Every other service Original Medicare covers
Plain-language groups from the CMS operational guide, Version 7.0 (July 24, 2026). CMS can change the list. Your provider checks the exact billing codes.
Wound care and skin substitutes
Skin substitutes are sheets of lab-made or donated tissue. They are placed on a wound to help it heal. Under WISeR, they need approval when used for long-lasting wounds on the legs or feet. The guide names diabetic foot ulcers and venous leg ulcers.
Arizona and Washington are different for now. CMS says skin substitutes are not currently reviewed under WISeR in those two states. That is because the local coverage rule there was withdrawn.
A separate change applies everywhere. In 2026, Medicare also changed how it pays for skin substitutes across the whole country. That payment change is not part of WISeR. WISeR approval only applies in the six states.
For more on what researchers found about these services, see our news story on KFF's look at the WISeR Model.
Who WISeR applies to, and who it does not
It applies to you if you have Original Medicare and you get a listed service from a provider in one of the six states.
It does not apply to you if:
- You have a Medicare Advantage plan. CMS says WISeR will have no impact on you. Your plan has its own approval rules.
- You get Medicare through the Railroad Retirement Board.
- Your care is billed through the VA or the Indian Health Service.
- You need emergency care.
Some providers can also be excused. Starting in July 2026, a provider whose requests are almost always approved can earn an exemption. Then their patients skip the WISeR review.
Not sure which kind of Medicare you have? See Original Medicare or Medicare Advantage.
How prior authorization works under WISeR
Your provider, not you, deals with WISeR. They pick one of two paths.
Path 1: ask first. Your provider sends a prior authorization request before your care. They can send it to the state reviewer or to their usual Medicare contractor (the MAC). The MAC passes it on, usually within 1 day. The request includes your records showing why you need the care.
Path 2: skip the request. Your provider gives the care and sends the claim. Then the claim is held for a "prepayment review." The reviewer asks the provider for your records before Medicare pays or denies it.
Either way, Medicare uses its usual coverage rules to decide. You get a copy of a prior authorization decision in the mail.
- Your provider sends a request before your care
- A decision usually comes in 3 calendar days
- You get a copy of the decision
- You know before the service if Medicare is likely to pay
- Your provider gives the care and sends the claim
- The reviewer asks the provider for your records
- The answer comes after you already had the care
- If the claim is denied, you can appeal
How a WISeR request moves
A licensed clinician must review every "no" before it goes out. Source: CMS WISeR operational guide, Sections 4.1 to 4.4.
How long a WISeR decision takes
- Standard request: usually within 3 calendar days after the reviewer gets it.
- Expedited (rush) request: within 2 days. This is for cases where waiting could seriously harm your life, health, or ability to recover. If the reviewer does not agree it is urgent, it moves to the standard track.
- A request sent again: the same 3 days, or 2 days if expedited.
- Prepayment review (Path 2): the provider has 45 days to send records. The reviewer then decides within 3 days of getting them.
An approval lasts 120 days. If the care does not happen within 120 days, your provider must ask again.
Mail is slow, so CMS asks providers to use fax or online portals when they can.
If the answer is no: resubmitting and appeals
A "no" on a prior authorization request is called a non-affirmation. It explains what was missing or did not meet the rules.
Your provider can send it again. There is no limit on how many times. When they do, they can ask to talk with the reviewing clinician. This is called a peer-to-peer review.
The "no" itself cannot be appealed. That is because it is not a decision on a bill yet. But your provider can still give the care and send the claim. If Medicare then denies the claim, the normal Medicare appeal rights apply to you and your provider.
Before care after a "no," your provider should give you a form called an Advance Beneficiary Notice (ABN). It says Medicare may not pay. If you sign it and get the care, you may have to pay if Medicare denies the claim.
To appeal a denied claim, look at your Medicare Summary Notice. It lists the denied service and the date you must appeal by. Follow its steps, or send the Redetermination Request Form to your Medicare contractor. Add a note from your doctor if you can.
What to do if your care needs WISeR approval
You do not have to file anything to start. These steps help you stay on top of it.
What to do if your provider says you need WISeR approval
Check that WISeR applies to you
You have Original Medicare, and you get the care in one of the six states.
Ask which path your provider will use
Asking first means you know the answer before your care.
Watch your mail for a copy of the decision
Keep it with your medical papers.
If the answer is no, ask what was missing
Your provider can fix the request and send it again. There is no limit.
Read any "ABN" form before you sign it
If you sign it and Medicare does not pay, you may have to pay.
If Medicare denies a claim, you can appeal
Follow the steps on your Medicare Summary Notice.
Where to get help
Call 1-800-MEDICARE (1-800-633-4227) with questions about a claim or an appeal. TTY users can call 1-877-486-2048.
Your State Health Insurance Assistance Program (SHIP) gives unbiased Medicare help at no cost. Find yours at shiphelp.org.
CMS posts WISeR updates on its WISeR model page, including the full list of services and the operational guide.
Want to know more about how Original Medicare pays for outpatient care? See Medicare Part B and Original Medicare.
Common questions about Medicare
Quick answers, fast .
Tap any question to expand. Each links to a fuller standalone answer.
What is the WISeR Model in Medicare?
WISeR is a CMS test that adds prior authorization to Original Medicare for a short list of services. It runs in six states from January 1, 2026 to December 31, 2031. Private companies review the requests, and a licensed clinician must review every denial.
In which states is the CMS WISeR Model being used?
Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. What counts is the state where you get the care.
How do I get prior authorization under the WISeR Model?
You do not file it. Your provider sends the request to the state reviewer or to their Medicare contractor, with records that show why you need the care. Or your provider can skip the request, and the claim gets a review before Medicare pays.
What is the turnaround time for a WISeR decision?
A standard request is usually decided within 3 calendar days. An expedited request, for cases where waiting could seriously harm you, is decided within 2 days. An approval lasts 120 days.
What services need prior authorization under WISeR?
As of July 2026, there are 13 groups. Some are skin substitutes for leg and foot wounds, knee arthroscopy, and epidural steroid shots. Others are neck fusion, spine fracture repair, and some nerve implants. Bladder control devices and penile implants are on it too. CMS can change the list.
What changed for wound care in 2026?
Two separate things. In the WISeR states, skin substitutes for long-lasting leg and foot wounds now need approval or a review before payment. For now, that is not the case in Arizona and Washington. Also, Medicare changed how it pays for skin substitutes across the whole country in 2026.
Does WISeR affect Medicare Advantage plans?
No. CMS says WISeR does not apply to people with Medicare Advantage and will have no impact on them. Medicare Advantage plans have their own prior authorization rules.
Does WISeR change what Medicare covers?
No. CMS says coverage and payment rules stay the same. WISeR checks whether a service meets the rules Medicare already uses, before Medicare pays.
Can I appeal a WISeR denial?
A "no" on a prior authorization request cannot be appealed, but your provider can send it again as many times as needed. If your provider gives the care and Medicare denies the claim, you can appeal using your Medicare Summary Notice.
Will I have to pay if WISeR says no?
Not automatically. If your provider still plans to give the care, they should first give you an Advance Beneficiary Notice. If you sign it and Medicare denies the claim, you may have to pay.
Does WISeR use artificial intelligence to deny care?
The reviewers use computer tools, including AI, to help sort requests. CMS requires a licensed clinician to review every denial before it is sent.
Is emergency care part of WISeR?
No. Emergency services, inpatient-only services, and care that would put you at serious risk if delayed are left out of WISeR.
References
- CMS Innovation Center: WISeR (Wasteful and Inappropriate Service Reduction) ModelModel dates, the six states and reviewers, beneficiary protections, and the Medicare Advantage statement. Updated September 30, 2026.
- CMS: WISeR Provider and Supplier Operational Guide, Version 7.0The full service list, decision time frames, the 120-day approval window, resubmissions, ABNs, exclusions, and appeals. July 24, 2026.
- CMS: WISeR Model Frequently Asked QuestionsWho submits, review times, clinician review, and key dates.
- CMS: WISeR Model fact sheetWhat WISeR is, its goals, examples of services, and what does not change.
- CMS: WISeR provider fact sheetThe two paths for providers and suppliers.
- Federal Register: Implementation of Prior Authorization for Select Services for the WISeR Model (CMS-5056-N)The notice that announced the model. 90 FR 28749, July 1, 2025.
- Medicare.gov: Appeals in Original MedicareHow to file an appeal using your Medicare Summary Notice.
- CMS: Advance Beneficiary Notice of Noncoverage (ABN), Original MedicareWhen providers give an ABN and how it can make you responsible for the bill.
- SHIP: State Health Insurance Assistance ProgramsUnbiased Medicare counseling at no cost, in every state.
- KFF: Examining the Potential Impact of Medicare's New WISeR ModelAnalysis of the WISeR services and the separate 2026 skin substitute payment change. February 2026.