What the Pilot Does
If a spine injection or a similar outpatient procedure was delayed this year and nobody explained why, a federal pilot program that began in January may be the reason.
The WISeR model, short for Wasteful and Inappropriate Service Reduction, launched January 1 and runs through December 31, 2031. It applies prior authorization or prepayment review to a defined list of procedures in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
CMS contracts with third-party technology vendors that use artificial intelligence and machine learning, alongside human clinical review, to decide whether a requested service meets existing Medicare coverage rules. The agency announced the participating vendors in November 2025, and the requirement applied to services delivered on or after mid-January.
The model is described as voluntary, but in practice providers in those states have little room to opt out. Claims for listed services that are not submitted for prior authorization are automatically routed into prepayment review instead. The Congressional Research Service has described it as "one of the largest expansions of PA in the history of traditional Medicare."
Why This Is Not Medicare Advantage
The most common confusion about this program is the one that matters most, so it belongs up front.
Prior authorization is familiar to Medicare Advantage members, whose private plans have used it for years and have been criticized for delays and denials. WISeR is the opposite population. It applies to Original Medicare, the traditional fee-for-service program covering roughly 35 million people who did not enroll in an Advantage plan.
For many of those beneficiaries, prior authorization is a new experience. Someone who deliberately stayed in Original Medicare partly to avoid it may have encountered it this year without understanding what changed.
CMS has been explicit that the model does not alter what Medicare covers. Coverage and payment policies remain the same, covered services remain covered, and beneficiaries keep the freedom to choose their provider. What the model adds is an approval step before, or immediately after, the service is delivered.
CMMI Deputy Administrator Abe Sutton has said the incentive structure differs from private plans, and that contractors are not rewarded for denying claims but for getting "the determination right."
Which Services and Which States
The list is narrow, and knowing whether a procedure is on it is the first step in figuring out whether the pilot touched a specific patient.
Services confirmed as included involve pain management and spine and device procedures: epidural steroid injections for pain management, cervical fusion, lumbar decompression, vertebral augmentation, skin and tissue substitutes, and implanted electrical nerve stimulators. Published accounts differ on the total number of categories, and the authoritative list is in the CMS Provider and Supplier Operational Guide rather than in news coverage, so patients should ask rather than assume.
Geographically, the six states span four Medicare Administrative Contractor jurisdictions: New Jersey, Ohio, Oklahoma and Texas together, and Arizona and Washington together. CMS says it chose these states so each could be compared against non-model states within the same claims processing region, and to capture a range of practice environments.
A patient outside those six states was not affected by this program, whatever else may have delayed their care.
How to Find Out If a Determination Is Pending
Patients can get an answer, but they generally have to ask the practice rather than Medicare.
Call the office that scheduled the procedure and ask three things. Whether the procedure is on the WISeR service list. Whether a prior authorization request has been submitted and when. And whether a determination has been received, or whether the claim is instead going through prepayment review after the fact.
Timing gives a sense of what to expect. CMS has indicated determinations are expected within roughly 72 hours for standard requests and 48 hours for expedited ones. Where a request is affirmed, the authorization is generally valid for a set period, reported as 120 days, which matters if a procedure gets rescheduled.
Providers retain their existing administrative appeal rights, and a denial does not end the matter. Ask specifically whether the practice intends to appeal or resubmit with additional documentation, and ask for the reason given for any non-affirmation, because a documentation gap is fixable in a way a coverage exclusion is not.
Keep a written record of dates and names. If a delay is affecting symptoms, say so directly, since expedited handling exists for urgent situations.
What Has Not Changed, and What Congress Is Doing
Two things are worth keeping in proportion.
Nothing about Medicare eligibility or benefits changed, and the pilot does not give vendors authority to rewrite coverage rules. A service that Medicare covers is still covered. CMS has also said it plans a gold carding feature that would exempt clinicians with consistent approval records from future review, which, if implemented, would reduce friction for established practices.
At the same time, the program has drawn organized opposition. In March, members of Congress wrote to the House Appropriations subcommittee overseeing health spending asking for language prohibiting implementation of WISeR or any related model introducing prior authorization into traditional Medicare. That request concerns the fiscal 2027 appropriations bill, so the pilot's future is a live legislative question rather than a settled one.
Patients should not delay or decline recommended care while an authorization is pending without discussing it with their clinician. A pending determination is an administrative status, not a medical instruction, and for some conditions waiting has its own cost.
The confirmed facts are that WISeR has operated since January in six states, applying prior authorization to a defined list of Original Medicare procedures. Those most affected are Original Medicare beneficiaries in those states needing spine, pain or device procedures. The reasonable action is asking the practice whether a determination is pending and on what grounds. The central uncertainty is whether Congress restricts the model. The next expected development is the gold carding feature and the fiscal 2027 appropriations process.
Frequently Asked Questions
What is the WISeR model? A CMS Innovation Center pilot applying prior authorization or prepayment review to selected Original Medicare procedures in six states, running 2026 through 2031.
Which states are included? New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Patients elsewhere were not affected by this program.
Does it apply to Medicare Advantage? No. It applies to Original Medicare fee-for-service, which covers roughly 35 million people who are not in an Advantage plan.
Which procedures are covered? Confirmed examples include epidural steroid injections, cervical fusion, lumbar decompression, vertebral augmentation, skin substitutes and implanted nerve stimulators. Ask your practice for the current list.
Did Medicare coverage change? No. CMS says coverage and payment policies are unchanged. The model adds an approval step, not a new exclusion.
How long do decisions take? CMS has indicated roughly 72 hours for standard requests and 48 hours for expedited ones. Affirmed authorizations are reported as valid for 120 days.
What if my request was denied? Ask the practice for the stated reason, whether it plans to resubmit with more documentation, and whether it will appeal. Existing appeal rights remain.
