WISeR Model Implementation Information for Impacted WSMA Members
What is the WISeR model?
The Wasteful and Inappropriate Service Reduction model is a CMS Innovation Center pilot program that introduces prior authorization and pre-payment medical review supported by vendor artificial intelligence technology for a limited set of services delivered to original Medicare (fee-for-service) beneficiaries.
According to the Centers for Medicare and Medicaid Services, the model is designed to reduce services identified by the agency as having high risk of waste, inappropriate use, or patient harm, while preserving access to medically necessary care. WISeR does not change Medicare coverage rules or benefits; it adds an additional review step before payment for selected services.
Washington is one of six states participating in the WISeR model.
- Model period: Jan. 1, 2026–Dec. 31, 2031.
- Prior authorization requests accepted: Beginning Jan. 5, 2026.
- Services subject to WISeR review: Dates of service on or after Jan. 15, 2026.
The WSMA has created this resource for the convenience of impacted members, working directly from the following CMS, Medicare administrative contractor, and vendor documents:
These documents and guidance are subject to change as implementation continues. The WSMA will keep you apprised of any major changes to the program.
Who is affected in Washington?
WISeR applies to the following settings:
- Offices, hospital outpatient departments, ambulatory surgery centers, and home settings furnishing WISeR-selected Medicare Part B services to original Medicare beneficiaries in Washington.
WISeR does not apply to the following programs and services:
- Veterans Affairs.
- Indian Health Services.
- Medicare Advantage.
- Medicare Advantage sub-category IME-only claims.
- Emergency services. Claims for emergency department services when the claim is submitted with an ET modifier or 045x revenue code. (This does not exclude these claims from regular medical review.)
- Inpatient-only services.
- Part A/B rebilling.
- Services where delay would pose a serious risk to patient health.
Washington WISeR Vendor and MAC:
Virtix conducts prior authorization and pre-payment medical reviews for WISeR services in Washington, while Noridian remains responsible for claims processing and payment.
Impacted services
CMS has identified a defined list of services subject to WISeR review. These services are detailed in the CMS WISeR Provider and Supplier Operational Guide.
Services currently included under the WISeR model in Washington include, but are not limited to:
- Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9).
- Induced Lesions of Nerve Tracts (NCD 160.1).
- Vagus Nerve Stimulation (NCD 160.18).
- Phrenic Nerve Stimulators (NCD 160.19).
- Electrical Nerve Stimulators (NCD 160.7).
- Incontinence Control Devices (NCD 230.10).
- Sacral Nerve Stimulators for Urinary Incontinence (NCD 230.18).
- Diagnosis and Treatment of Impotence (NCD 230.4).
- Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (L34228, L38201, L35130).
- Epidural Steroid Injections for Pain Management (L39015, L39240, L36920).
- Cervical Fusion (L39741, L39758, L39793).
- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38307, L38310, L38385).
- Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041) and Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690).
- Deep Brain Stimulation (NCD 160.24) – Implementation delayed and will not occur on Jan. 1, 2026; to be re-evaluated for implementation in a future performance year.
- Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13) - Implementation delayed and will not occur on Jan. 1, 2026; to be re-evaluated for implementation in a future performance year.
WISeR applies existing Medicare coverage criteria; it does not establish new medical necessity standards. CMS may update the list over time as coverage policies evolve.
Specialties most likely to be impacted
Physicians and practices most likely to encounter WISeR prior authorization or review include:
- Anesthesia (pain codes)
- Emergency medicine
- Interventional radiology (vertebroplasty)
- Neurology
- Neurosurgery
- Orthopedic surgery, including sports medicine (arthroscopy) and spine surgery
- Otolaryngology
- Pain medicine and physical medicine & rehabilitation (pain codes)
- Sleep medicine
- Urology
- Vascular surgery
- Wound care
Exemptions
CMS has indicated it may implement automatic exemptions (“gold carding”) for physicians and practitioners demonstrating consistent compliance; operational details have not yet been released.
How prior authorization works in Washington
Under WISeR, prior authorization is optional but strongly encouraged by CMS for affected services.
Two possible pathways:
- Option 1: Submit a prior authorization request
Submitting prior authorization to Virtix before the service is furnished helps avoid claim delays and pre-payment medical review.
Submit a prior authorization request to Noridian. The MAC will forward the request to Virtix within 1 calendar day, or as soon as practicable. The WISeR form needed for this process can be found on the Medical Review Forms page.
Or
- Option 2: Pre-payment review (do not submit prior authorization)
If prior authorization is not submitted, the claim may be paused by Noridian and routed to Virtix for pre-payment medical review.
How to submit a prior authorization request via Virtix Health
Physicians or designated staff may submit prior authorization requests to Virtix Health using one of the methods below.
- Virtix WISeR portal. Visit Virtix portal and registration for more information.
- Fax and other Virtix-approved submission methods are also accepted, though not processed as quickly as portal submissions.
Review timelines:
- Standard review: Determination issued within three calendar days.
- Expedited review: Determination issued within two calendar days when a delay could seriously jeopardize patient health.
- If affirmed, Virtix issues a Unique Tracking Number (UTN).
After an affirmation:
- The UTN must be included on the Medicare claim submitted to Noridian.
- Claims submitted with a UTN are not subject to pre-payment medical review.
If prior authorization is not submitted:
- The claim may be paused by Noridian.
- An additional documentation request will be issued.
- Clinical documentation must be submitted for pre-payment review.
- Payment pending review outcome.
If a request is not affirmed:
Non-affirmations will require the review of a human clinician and cannot be performed solely by technology.
For a “non-affirmed” prior authorization request—meaning that a future service was found not to meet Medicare coverage, coding or payment requirements—physicians have “unlimited opportunities to resubmit a request”. Peer-to-peer review may also be requested.
Claim submission to Noridian
- Claims with affirmed prior authorization must include the UTN.
- Claims without prior authorization will undergo pre-payment review.
- Associated services are subject to denial if the primary WISeR service does not meet coverage criteria.
Prepayment review
Pre-payment claim review may occur when:
- A claim is submitted for a WISeR-applicable service.
- The service has already been delivered.
This review validates documentation before payment is issued and helps prevent future audits, recoupments, and appeals.
When your claim enters pre-payment claim review, you will receive an additional documentation request.
An additional documentation request will be sent to the physician, who will have 45 days to return before the medical review may commence. A determination will be issued within three days of receiving all necessary documentation.
WSMA advocacy
The WSMA has communicated numerous significant concerns about the WISeR model to Washington state's congressional delegation, CMS Regional Office X, and other federal policymakers. In addition, the WSMA led a coalition of impacted state medical associations in a joint letter to CMS Administrator Dr. Mehmet Oz outlining shared concerns, including:
- Increased administrative burden on physician practices.
- New barriers to timely, appropriate care for traditional Medicare patients.
- A vendor incentive structure that could encourage excessive denials driven more by profit motives than by fair, clinically grounded decision-making.
The WSMA emphasized that introducing AI-enabled utilization management into traditional Medicare represents a fundamental shift with far-reaching implications, and that CMS has not adequately demonstrated patient protections, transparency, or accountability safeguards.
Despite sustained advocacy efforts from the WSMA and other medical associations at the federal level, CMS has not indicated an intention to abandon or delay implementation of the WISeR Model. As a result, WSMA's focus will now expand to supporting impacted physician groups as they prepare for and navigate the program.
Let us know your experience
Physician experience under WISeR will be critical to informing ongoing congressional oversight and future CMS decision-making. We strongly encourage physician groups subject to WISeR to share their experiences, including administrative challenges, access issues, and any observed impacts on patient care-positive or negative. The WSMA is uniquely positioned to serve as a conduit between Washington physicians, members of Congress, Virtix, Noridian, and CMS.
Report access issues, delays, or operational problems to WSMA Director of Policy Jeb Shepard at jeb@wsma.org.