Understanding WISeR: New Prior Authorization Rules for Original Medicare in Six States

If you have Original Medicare and live in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington, a new program called WISeR may affect how certain medical services are approved starting in 2026. Here’s a clear, factual look at what the program does, what it doesn’t do, and what you should know if you’re a beneficiary in one of the affected states.

What Is WISeR?

WISeR stands for Wasteful and Inappropriate Service Reduction. It is a six-year pilot program launched by the Centers for Medicare & Medicaid Services (CMS) on January 1, 2026, and scheduled to run through December 31, 2031.¹

The program adds a prior authorization requirement — meaning advance approval — for 17 specific outpatient services delivered through Original Medicare in the pilot states. Until now, Original Medicare has generally not required prior authorization the way Medicare Advantage plans often do.¹

According to CMS, the goal is to reduce wasteful or low-value care, identify potential overutilization, and protect beneficiaries from unnecessary procedures. The program uses a combination of artificial intelligence tools and licensed clinical reviewers. CMS has stated that final decisions on whether a service meets coverage requirements are made by licensed clinicians, not by automated systems.²

Which Services Require Prior Authorization?

WISeR applies to a defined list of 17 outpatient services that CMS has identified as having existing coverage criteria, available evidence-based guidelines, and prior reports of fraud, waste, or abuse.¹ Examples include:

• Epidural steroid injections for pain management (excluding facet-joint injections)
• Skin and tissue substitutes used in wound care
• Electrical nerve stimulators
• Percutaneous vertebral augmentation

The full list of covered services and the relevant procedure codes is published in the WISeR Provider and Supplier Operational Guide on the CMS website.¹

Important to note: emergency services and hospital inpatient services are excluded from the program. Services where a delay would pose a substantial risk to a patient’s health are also excluded.²

How Does the Approval Process Work?

For services on the WISeR list, providers in the pilot states have three options:

• Submit a prior authorization request directly to a participating WISeR technology vendor
• Submit the request through their Medicare Administrative Contractor (MAC), who forwards it to the vendor
• Skip prior authorization, in which case the claim is subject to pre-payment medical review after the service is delivered

CMS has set a target turnaround of 72 hours for standard requests submitted through participant electronic portals, and 48 hours for expedited cases.³ If a request is initially denied, providers may resubmit it as many times as needed, request a peer-to-peer clinical review, or pursue the standard Medicare appeals process — appeal rights remain unchanged under WISeR.⁴

CMS has also indicated it plans to introduce a “gold carding” exemption in 2026 for providers who consistently demonstrate high approval rates, exempting them from future prior authorization on these services.³

What WISeR Does Not Change

This is an important point that often gets lost in the broader conversation. According to CMS:

• Medicare coverage rules and payment policies remain the same
• Beneficiaries keep their existing appeal rights
• You retain the freedom to see your Original Medicare provider of choice
• Final clinical decisions on prior authorization requests are made by licensed clinicians, not by AI

WISeR is a process change for how certain services get reviewed — not a change to what Medicare covers.²

What Are the Concerns Being Raised?

Several medical associations and provider groups have expressed concerns about the program’s rollout. The Medical Group Management Association raised early concerns about the pilot, and various provider organizations have noted potential challenges including added administrative burden, possible delays in scheduling for certain procedures, and the operational complexity of integrating new prior authorization workflows for traditional Medicare.⁵

CMS has stated it is committed to timeliness, accuracy, and transparency in the program, and that vendors who fail to meet performance standards will face corrective actions including potential payment penalties.³

As with any new program, real-world performance will become clearer as the pilot progresses through its first year.

What Should You Do If You Live in a Pilot State?

If you have Original Medicare and live in one of the six pilot states, the practical impact for most people is limited — WISeR only applies to 17 specific outpatient services, not to routine care, primary care visits, hospital admissions, or emergency services.

That said, a few sensible steps can help you prepare:

• Confirm whether a planned procedure is on the WISeR list. Your doctor’s office or your Medicare Administrative Contractor can tell you.
• Talk with your provider in advance about scheduling. If a service requires prior authorization, ask how that affects your timeline.
• Know your appeal rights. If a request is denied, your provider can resubmit, request peer-to-peer review, or pursue formal appeal. Your standard Medicare appeal rights have not changed.
• Use free counseling resources. Every state has a State Health Insurance Assistance Program (SHIP) offering free, unbiased Medicare guidance. You can find your state’s SHIP at shiphelp.org.