Medicare WISeR Prior Authorization: A Practical Guide for Independent Practices

What WISeR is

WISeR stands for the Wasteful and Inappropriate Service Reduction Model. It is a test run by CMS that adds prior authorization and pre-payment medical review to a short list of procedures for patients with Original Medicare. CMS contracts technology companies, called WISeR Participants, to review the requests in each state. Your regular Medicare Administrative Contractor (MAC) still pays the claims.

Two points matter for your staff. WISeR does not change Medicare’s coverage rules: reviewers apply the same National and Local Coverage Determinations (NCDs and LCDs) your claims already follow. And it keeps every Medicare appeal right for denied claims (Operational Guide, Section 1).

Does WISeR affect your practice?

CMS boils it down to two questions (Operational Guide, Quick Reference):

• Do you practice in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington?
• Do you deliver at least one of the 13 WISeR services below to patients with Original Medicare?

If both answers are yes, you are in the model. Patients with Medicare Advantage and Railroad Medicare are not affected. WISeR applies to requests submitted from January 5, 2026, for services on or after January 15, 2026, and runs through December 31, 2031 (Section 1.4).

The 13 services that need WISeR review

These are the services listed in Appendix A of the guide, as of July 24, 2026. Each one follows the Medicare coverage rule shown.

Two services are on the list but delayed: deep brain stimulation and percutaneous image-guided lumbar decompression. CMS says it will reconsider both in a future model year (Section 6.2). For services that follow an LCD, your MAC’s Local Coverage Article lists the supporting diagnosis codes. For vagus nerve stimulation, sacral nerve stimulation and skin substitutes, Appendix B of the guide limits WISeR review to specific diagnosis codes.

Your two routes: ask first, or be reviewed before payment

For each WISeR service you choose one of two paths (Sections 3 and 7.2):

• Prior authorization. Send a request before the service, either to your state’s WISeR Participant or to your MAC, which forwards it within about a day. Each request covers one WISeR service.
• Pre-payment medical review. Skip the request and submit the claim. The MAC holds the claim and the WISeR Participant asks for the medical record. You have 45 days to answer. If you do not answer, the claim is denied.

For most practices, asking first is the safer path. The answer comes before the patient is treated, and an approved claim gets some protection from later audits (Section 7.1.1).

What every request must include

Table 1 of the guide lists the data every request needs. Missing items cause delays or a dismissal:

• Patient: name, Medicare number (MBI), date of birth and address, exactly as on the Medicare card.
• Physician and facility: names, NPIs, PTAN and addresses.
• Requester: name, phone, email and fax.
• The service: procedure codes, diagnosis codes, place of service, and units to be performed within 120 days of the decision.
• The request type: initial or resubmission, and whether it should be expedited, with the reason.
• The clinical documentation that service requires (Section 6.2).

How fast decisions come back

Put the unique tracking number (UTN) on the claim whether the decision was yes or no. For an expedited approval, hold the claim until the UTN arrives (Section 4.2.2).

The four kinds of decision

• Provisional affirmation: the request meets Medicare’s rules.
• Non-affirmation: a preliminary finding that a claim would likely not meet the rules. The reviewer must list every missing or noncompliant item and explain how to resubmit, and a human clinician must review it before it is sent (Section 4.1.2).
• Provisional partial affirmation: since April 1, 2026, some services on the request were approved and some were not (Section 4.1.3).
• Dismissal: the request was incomplete, invalid, outside WISeR, or a duplicate. It was never reviewed. Fix the error and send it again with all of the original documentation. If the dismissed request was an initial request, mark the new one as initial too (Section 4.1.4).

After a non-affirmation: resubmit, don’t appeal

This is where practices lose the most time. A non-affirmation is not a claim decision, so it cannot be appealed. Instead, you can resubmit as many times as you need, as long as the claim has not yet been submitted and denied, with the missing documentation, and ask for a peer-to-peer review with the resubmission. A resubmission must match the patient’s first name, last name and date of birth exactly, and carry the UTN from the first decision (Sections 3.2 and 4.4).

Appeal rights begin only once a claim is denied, for example a claim submitted with a non-affirmation on file or one denied after pre-payment review. Then the normal Medicare appeals process applies (Sections 7.1.2 and 10).

Because the reviewer must list every missing item, a non-affirmation is a checklist in disguise. Work it line by line and the resubmission usually writes itself.

How your doctors earn an exemption

Since July 2026, doctors can earn their way out of WISeR review (Section 5):

• It is earned per doctor, by individual NPI, not by practice or facility.
• The bar: at least 10 prior authorization requests in an assessment period, and an approval rate at or above a minimum threshold. Each WISeR Participant publishes its own added criteria.
• The reward: exemption from WISeR review for all WISeR services, across all sites of care, for at least a year.
• Keeping it: exemptions are reviewed with up to 10 record requests a year, and a doctor who loses status is told at least 60 days before the next quarter.

In other words, every request your practice sends counts toward or against each doctor’s exemption. Sending complete requests the first time is how you get there.

Where to send requests, by state

Where MedMojo™ fits

WISeR Participants work for Medicare. MedMojo™ works for your practice. We check each request against the documentation that service requires before you send it, keep every request, decision, UTN and resubmission in one place, and turn a non-affirmation into a list of what to fix. Fewer non-affirmations means faster care for your patients, and a faster path to exemption for your doctors.