REMINDER WISeR Model - Medicare Prior Authorization Now Active in Your State
- HC Intellect
- Mar 4
- 3 min read
Date: March 5, 2026
To: Providers, Billing & Compliance Teams
From: Compliance & Coding Department
Subject: REMINDER: WISeR Model — Medicare Prior Authorization Now Active in Your State
Bottom Line
As of January 15, 2026, Medicare's WISeR (Wasteful and Inappropriate Service Reduction) model is active in your state. This is a six-year pilot program running through December 31, 2031, that requires prior authorization for select outpatient procedures before they are performed — or subjects claims to pre-payment medical review. It applies only to Traditional Medicare (Original Medicare) patients, not Medicare Advantage. For interventional pain practices, the most directly impacted services are epidural steroid injections, spinal cord stimulators, percutaneous vertebral augmentation, and cervical fusion.
Who This Affects
WISeR applies to Traditional Medicare beneficiaries who permanently reside in one of the following six states. Your state determines which DME MAC and WISeR participant handles your requests.
State | MAC Jurisdiction | DME MAC Contractor | WISeR Participant Portal |
Arizona | Jurisdiction D (JF) | Noridian Healthcare Solutions | Noridian or WISeR participant portal |
New Jersey | Jurisdiction A (JL) | Noridian Healthcare Solutions | Noridian or WISeR participant portal |
Ohio | Jurisdiction B (J15) | CGS Administrators | CGS or WISeR participant portal |
Oklahoma | Jurisdiction C (JH) | CGS Administrators | CGS or WISeR participant portal |
Texas | Jurisdiction C (JH) | CGS Administrators | CGS or WISeR participant portal |
Washington | Jurisdiction D (JF) | Noridian Healthcare Solutions | Noridian or WISeR participant portal |
How It Works
For each service on the WISeR list, practices have two options:
Submit a prior authorization request before performing the service. An affirmed PA is valid for 120 calendar days. Standard review turnaround is 72 hours; expedited review (48 hours) is available when delay would jeopardize the patient's health.
kip the PA and submit the claim — but the claim will be subject to pre-payment medical review, which delays payment and increases denial risk. CMS is planning a "gold card" exemption by mid-2026 for providers with consistently high approval rates, which would reduce or eliminate the PA requirement for those providers going forward.
WISeR Covered Services — Full List
All 13 service categories are listed below. Gold rows indicate services with high relevance to interventional pain practices.
Service / Procedure | Key CPT/HCPCS Codes | Relevance | |
Epidural Steroid Injections for Pain Management | 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327 | ★ High | |
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture | 22510, 22511, 22512, 22513, 22514, 22515 | ★ High | |
Cervical Fusion | 22554 (anterior interbody) | ★ High | |
Electrical Nerve Stimulators (Spinal Cord Stimulators) | 63650, 63655, 63663, 63664, 63685, 63688, 95970, 95971, 95972 | ★ High | |
Induced Lesions of Nerve Tract (Neurolytic Destruction — Trigeminal) | 61790, 61791 | Low | |
Arthroscopic Lavage/Debridement for Osteoarthritic Knee | 29877 | Low | |
Vagus Nerve Stimulation (VNS) | 61885, 61886, 64568, 64569, 64570, 95976, 95977 | Low | |
Phrenic Nerve Stimulator | 64570, 0424T, 0425T, 0426T, 0427T | Low | |
Sacral Nerve Stimulation for Urinary Incontinence | 64561, 64581, 64585, 64590, 64595 | Low | |
Incontinence Control Devices | 53860, 0729T | Low | |
Diagnosis and Treatment of Impotence | 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416 | Low | |
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | 64582, 64583, 64584, 95970, 95976, 95977 | Low | |
Application of Bioengineered Skin Substitutes / Wound CTPs (Lower Extremity) | 15271–15278, Q4XXX skin substitute codes | Low |
What This Means for Your Practice
• Epidural steroid injections (ESIs) are among the highest-volume services affected. CPT codes 62320 62327 all require PA under WISeR. Practices performing ESIs without a PA on file face pre-payment review on every claim.
• Spinal cord stimulator implants and revisions fall under the Electrical Nerve Stimulators category. Trial and permanent implant codes (63650, 63655, 63685) are included.
• Vertebral augmentation (kyphoplasty/vertebroplasty) is included under PVA for vertebral compression fracture.
• Cervical fusion at C2 and above (CPT 22554) is included. Note that CPT 22585 was removed from the WISeR list as of December 23, 2025.
• Payment and coverage policies have not changed. WISeR reviews compliance with existing Medicare coverage criteria — it does not create new coverage rules or reduce reimbursement for appropriately documented, medically necessary services.
— End of Memo —
HC Intellect is a Milwaukee-based healthcare revenue cycle management (RCM) and technology firm with a deep specialization in interventional pain management and related surgical specialties. The company partners closely with pain practices and ASCs to optimize coding, billing, and collections across the full revenue cycle, with particular expertise in complex procedure coding, E&M optimization, and payer-specific reimbursement challenges unique to interventional pain. By combining experienced RCM teams with proprietary analytics and AI-driven tools, HC Intellect helps pain practices reduce denials, accelerate cash flow, and sustainably improve financial performance.
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