What is WISeR, and who does it apply to?
WISeR stands for Wasteful and Inappropriate Service Reduction. CMS says the pilot uses technology, including artificial intelligence, along with clinician review to check certain Original Medicare services before payment. Traditional Medicare had almost never required prior authorization before 2026.
| Question | What CMS says |
|---|---|
| When and where | Six performance years from January 1, 2026 to December 31, 2031 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. |
| Who it covers | People in Original Medicare in those states. CMS says it does not apply to people in Medicare Advantage. |
| Does coverage change | CMS says WISeR does not change Medicare coverage or payment policy, and that people keep the freedom to seek care from their Original Medicare provider or supplier of choice. |
| Who decides | Companies that use enhanced technology review requests. CMS says all recommendations for non payment are determined by appropriately licensed clinicians. |
| What is excluded | Inpatient only services, emergency services and services that would pose a substantial risk to patients if delayed. |
Which 13 services need approval?
The CMS provider guide, version 7.0 dated July 24, 2026, lists 13 services. CMS chose services that may pose patient safety concerns if delivered inappropriately, have public coverage criteria and may involve prior reports of fraud, waste and abuse.
| Service in the guide | In plain words |
|---|---|
| Arthroscopic lavage and debridement for the osteoarthritic knee | Knee arthroscopy for knee arthritis |
| Induced lesions of nerve tracts | Procedures that create lesions in nerve pathways |
| Vagus nerve stimulation | A device that stimulates the vagus nerve |
| Phrenic nerve stimulator | A device that stimulates the nerve that controls the diaphragm |
| Electrical nerve stimulators | Implanted electrical nerve stimulators |
| Incontinence control devices | Devices used to control incontinence |
| Sacral nerve stimulation for urinary incontinence | Nerve stimulation for bladder control |
| Diagnosis and treatment of impotence | Evaluation and treatment for erectile dysfunction |
| Percutaneous vertebral augmentation for vertebral compression fracture | Procedures such as kyphoplasty for spinal fractures |
| Epidural steroid injections for pain management | Back and neck pain injections |
| Cervical fusion | Surgery that joins bones in the neck |
| Hypoglossal nerve stimulation for obstructive sleep apnea | An implant that treats sleep apnea |
| Bioengineered skin substitutes and cellular and tissue based products for lower extremity chronic non healing wounds | Skin substitute products for chronic leg and foot wounds |
The list has changed since launch. The guide's version history shows CMS delayed implementation of percutaneous image guided lumbar decompression for lumbar spinal stenosis in December 2025, and the guide is now on version 7.0. Ask your doctor's office whether your service is currently on the list.
Which company reviews requests in each state?
CMS selected one participating company for each state. We are licensed in Arizona, Ohio, Oklahoma and Texas, and we are not licensed in New Jersey or Washington.
| State | Participant CMS lists |
|---|---|
| Arizona | Zyter Inc. |
| New Jersey | Genzeon Corporation |
| Ohio | Innovaccer Inc. |
| Oklahoma | Humata Health, Inc. |
| Texas | Cohere Health, Inc. |
| Washington | Virtix Health LLC |
CMS says participants receive a percentage of the expenditures associated with averted wasteful or inappropriate care, adjusted for their performance on measures that include provider experience. Its FAQ adds that participants are paid once per beneficiary and are not paid, or have payments recouped, when a non affirmation is followed by a successful claims appeal.
How long does a decision take, and what if my request is not approved?
CMS says participants will typically issue a determination within three days. Your doctor's office usually submits the request, but you can ask about its status.
| Step | What CMS says |
|---|---|
| Standard decision | Typically within three days of receiving the initial or resubmitted request. Requests sent directly to the participant or by mail may take longer. |
| Expedited decision | If delays could seriously jeopardize life or health and the participant confirms it, a decision within two days. CMS expects expedited requests to be rare. |
| If the service is not affirmed | The physician must notify you with an Advance Beneficiary Notice of Non-Coverage before furnishing the service. Providers can resubmit with no limit, and peer to peer review is allowed as part of a resubmission. |
| If a claim is denied | A non affirmed decision does not prevent the provider from delivering the service and submitting a claim. A claim denial is an initial payment determination that can be appealed through the existing appeals process, and CMS says all appeal rights are preserved for providers and people with Medicare. |
What do supporters and critics of WISeR say?
Each statement below belongs to the person or group that made it. We do not take a side.
| Who | What they say |
|---|---|
| CMS | It says Medicare spent up to $5.8 billion in 2022 on unnecessary or inappropriate services with little to no clinical benefit, citing the Medicare Payment Advisory Commission. It also says the model aims to apply commercial payer prior authorization processes that may be faster, easier and more accurate. |
| CMS Administrator Mehmet Oz and the CMS innovation center director, quoted by KFF Health News | Dr. Oz said in December that the purpose is not to deny care but to make sure you get the care you need. The innovation center's director said in a statement that the model aims to reduce inappropriate care without delaying appropriate care. |
| The HHS inspector general, cited by KFF Health News | The inspector general warned, in a report KFF Health News cites, that Medicare spending on skin substitutes had surged nearly 700 percent over two years, raising major concerns about fraud, waste and abuse. |
| Humata Health's chief executive, quoted by KFF Health News | He said the system gives an immediate yes in 88 percent of cases in which clinical data supports an approval. |
| Doctors and their staff, as reported by KFF Health News | Patients, doctors and other health care professionals said the rollout created confusion, errors, long waits and stress. A Phoenix area pain doctor said that as of May he had not been paid by Medicare for nine epidurals. A Zyter executive acknowledged in April a large backlog in payments stretching to January, and CMS's innovation center director said the backlogs were being resolved. |
| Senators Patty Murray and Ron Wyden, both Democrats | In an October 9 press release, Murray called the model essentially a cut to Medicare and said it cannot expand. She also said the participants are financially incentivized to deny requests, and that in July she and Wyden forced a vote on a Congressional Review Act resolution to overturn WISeR and Republicans blocked it. |
| KFF polling | A KFF poll in January found 69 percent of insured adults consider prior authorization a burden for care. |
What does the first research show?
A study in JAMA, reported by the University of Minnesota School of Public Health on October 26, 2026, found use of the targeted services fell after launch, then the drop shrank. The authors say they cannot yet tell whether the care not received was wasteful or necessary.
- First quarter of 2026
- Second quarter of 2026
- Epidural steroid injectionsFirst quarter of 2026: 21%Second quarter of 2026: 9%
- Other targeted servicesFirst quarter of 2026: 21%Second quarter of 2026: 18%
Source: University of Minnesota School of Public Health and Brown University study in JAMA, reported October 26, 2026
Over the whole first six months, the researchers report epidural steroid injections, the highest volume service in the model, declined 15 percent and other targeted services declined about 20 percent. Services that were first slated for WISeR but never put in place showed no significant decline. The data came from Epic Cosmos, a dataset covering more than 300 million patient records, and the study compared the two years before launch with the first six months after.
The lead author, Hannah Neprash, said the effect was immediate and that the key unanswered question is whether the care not received was wasteful or necessary. The authors say the weakening over time may reflect the time it took to work out a new workflow, clinicians learning the requirements or both.
What should I do if I live in a WISeR state?
Plan ahead for any nonemergency procedure on the list. Nothing in CMS's description of the model changes what Medicare covers, but the approval step can add time.
- Ask your doctor's office whether your planned service is one of the 13 and whether they have submitted the request. Ask what the decision was and when it came.
- Allow extra time when you schedule. CMS says decisions typically take three days, and mailed requests take longer.
- If you receive an Advance Beneficiary Notice of Non-Coverage, read it, ask the office what your choices are and remember that appeal rights remain.
- If you are choosing a Medicare plan now, open enrollment runs October 15 to December 7, 2026. Medicare Advantage plans are not part of WISeR, but the University of Minnesota researchers note that Medicare Advantage and commercial insurers widely use prior authorization, so ask each plan which services need approval.
How can an agent help with Medicare in a WISeR state?
An agent can compare the Medicare plans we offer using your doctors, your prescriptions and the services you expect to need, and explain how Original Medicare and Medicare Advantage handle approvals. Have your Medicare card and a list of your doctors and drugs ready.
Health Insurance Solutions agents are licensed in 22 states and help by phone and online. Marketplace plans cost the same with or without an agent, so the comparison does not add to your premium.
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