The Wasteful and Inappropriate Service Reduction initiative from CMS is set to take effect Jan. 1, 2026, introducing new prior authorization requirements for select services.
Here are seven things to know:
1. The WISeR model will launch as a pilot program in Arizona, Washington, New Jersey, Texas, Ohio and Oklahoma through Dec. 31, 2031. Providers in these states, including ASCs, will be required to follow the new prior authorization protocols.
2. CMS contractors will use a combination of artificial intelligence tools and clinical review to evaluate prior authorization requests, according to CMS. The process will align with existing Medicare coverage policies and patient safety standards.
3. The initial procedures subject to prior authorization include:
- Electrical nerve stimulator implants
- Epidural steroid injections for pain management (excluding facet joint injections)
- Percutaneous vertebral augmentation for vertebral compression fractures
- Percutaneous image-guided lumbar decompression for spinal stenosis
4. CMS released an operational guide for providers and suppliers on Oct. 10, outlining steps to adapt to the new process. The agency also confirmed that it is delaying inclusion of deep brain stimulation from the initial rollout, with plans to reassess at a later date.
5. CMS plans to pilot a “gold carding” feature by mid-2026, which would exempt clinicians with high prior authorization approval rates from future pre-authorization or pre-payment review requirements.
6. The WISeR model has drawn scrutiny from lawmakers, particularly House Democrats, who have voiced concerns about the use of AI in prior authorization. Some have introduced a congressional resolution opposing the model, citing potential risks to patient access and care delays.
7. The House Appropriations Committee advanced a 2026 spending bill with an amendment blocking funding for the pilot program.
