Medicare is launching a new pilot program called WISeR (short for Wasteful and Inappropriate Service Reduction) that will introduce enhanced prior authorization—or in some cases prepayment review—for certain medical services under Original Medicare (Parts A and B). This development is significant because Original Medicare traditionally has required fewer pre-authorizations than Medicare Advantage plans. The WISeR model will operate in six states, including Texas, and may reshape how providers, hospitals, and patients approach medical decision-making in those regions. Below is a detailed, up-to-date look at WISeR: what it is, how it works, what safeguards exist, and what it means for access to care.
What Is the WISeR Model?
The WISeR model is a pilot program designed by the Centers for Medicare & Medicaid Services (CMS) to more actively manage services considered at higher risk of overuse, waste, or misuse. In other words, instead of simply paying claims and doing audits afterward, WISeR will require that certain services undergo review before payment or possible retrospective (“prepayment”) scrutiny. The model will test whether this form of utilization management can reduce unnecessary care while preserving patient access and quality. Centers for Medicare & Medicaid Services+2Federal Register+2
WISeR is scheduled to run for six years beginning January 1, 2026, through December 31, 2031. Centers for Medicare & Medicaid Services+2Federal Register+2
Where the Model Will Be Tested
WISeR will be implemented in six U.S. states: Texas, Arizona, Washington, New Jersey, Ohio, and Oklahoma. Centers for Medicare & Medicaid Services+2Newsweek+2
In Texas, the model falls under the Medicare Administrative Contractor (MAC) jurisdiction JH (which includes Texas and Oklahoma). Providers in that region who deliver services covered by WISeR must engage with the new review protocols. Society of Interventional Radiology+2AASM+2
The choice of these states appears to relate in part to existing coverage patterns, existing contractor coverage policies, and stakeholder readiness. Newsweek+2Centers for Medicare & Medicaid Services+2
Which Services Are Covered by WISeR Pre-Approval?
WISeR focuses on a targeted set of services that CMS considers particularly vulnerable to overuse or that historically trigger disputes about medical necessity. Some of the services included are:
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Electrical nerve stimulation implants
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Epidural steroid injections for pain management (excluding facet injections)
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Cervical spinal fusion
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Arthroscopic lavage/debridement for osteoarthritic knees
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Skin and tissue substitutes (for chronic wounds)
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Certain incontinence devices
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Lumbar decompression techniques
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Phrenic nerve stimulators
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Deep brain stimulation
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Hypoglossal nerve stimulators for sleep apnea Centers for Medicare & Medicaid Services+3Davis Wright Tremaine+3Federal Register+3
Importantly, WISeR does not apply to emergency services, inpatient-only services, or procedures where delaying care poses a substantial safety risk. Davis Wright Tremaine+2Centers for Medicare & Medicaid Services+2
Because WISeR covers only selected services, beneficiaries will still receive most of the same covered services under Medicare as before, but some providers may need to navigate additional steps for those specific items. Centers for Medicare & Medicaid Services+2Society of Interventional Radiology+2
How the WISeR Review Process Works
Under WISeR, providers and suppliers in the pilot areas have two options for delivering the targeted services:
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Pre-service prior authorization: Providers submit a request ahead of delivering the service to a WISeR model participant (or via the MAC who forwards to the participant). If the request is affirmed, the provider proceeds with the service.
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Post-service, prepayment review: If the provider does not request prior authorization, the claim may be flagged for review before Medicare pays it. In that case, the provider may face scrutiny and possibly delayed reimbursement if the service is judged non-affirmed. Society of Interventional Radiology+3Davis Wright Tremaine+3Health Industry Washington Watch+3
Requests that are non-affirmed can be resubmitted, and providers may attempt peer-to-peer or additional clinical review. Appeals remain available under existing Medicare processes. Centers for Medicare & Medicaid Services+3Davis Wright Tremaine+3Federal Register+3
Importantly, WISeR participants cannot simply rely on AI alone: any denial or decision must be reviewed by a licensed clinician to ensure it adheres to coverage criteria and evidence-based standards. Centers for Medicare & Medicaid Services+2Federal Register+2
CMS will audit the performance of WISeR participants and may apply negative adjustments, or even termination, if accuracy, timeliness, or fairness standards aren’t met. Centers for Medicare & Medicaid Services+1
Why CMS Is Doing This: Goals, Risks, and Oversight
Goals
CMS aims to reduce Medicare spending on services that deliver limited or no clinical benefit, improve consistency and transparency in medical necessity determinations, and reduce downstream complications from overuse. Part of the WISeR model’s objective is to test whether combining technology with clinician review can improve efficiency and reduce waste. Federal Register+3Centers for Medicare & Medicaid Services+3Centers for Medicare & Medicaid Services+3
CMS anticipates that limiting wasteful services could yield billions in savings over the pilot period. (Some estimates suggest addressing as much as $5.8 billion in Medicare waste in 2022 alone.) TIME+2Health Industry Washington Watch+2
Risks and Criticisms
Some worry that introducing stricter pre-authorization in Original Medicare could delay needed care, especially for patients with chronic or complex conditions. Critics argue that using AI-driven systems might replicate the coverage-denial patterns seen in some private insurers and Medicare Advantage, with marginalization of clinical discretion. TIME+2Federal Register+2
Because WISeR contractors will be partially paid based on savings, critics say there could be incentives to deny more services. To counterbalance this, CMS has built in performance measures, appeals rights, and auditing. Centers for Medicare & Medicaid Services+3Davis Wright Tremaine+3Health Industry Washington Watch+3
Another concern is administrative burden on providers—especially smaller clinics or practices that may struggle with additional paperwork or appeal processes. Some providers may need to adapt workflows or invest in technology to comply. Health Industry Washington Watch+2Davis Wright Tremaine+2
Safeguards and Guardrails
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Decisions not to affirm a prior authorization must be reviewed by a qualified clinician. Centers for Medicare & Medicaid Services+1
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WISeR will not change Medicare’s coverage or payment rules. A denial under WISeR does not mean the service is not covered by Medicare—it simply failed the prior authorization or review criteria. Society of Interventional Radiology+2Centers for Medicare & Medicaid Services+2
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CMS is considering “gold carding” for providers with strong prior approval track records, exempting them from future WISeR reviews in some cases. Davis Wright Tremaine+1
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Providers retain the right to appeal denied claims through existing channels. Centers for Medicare & Medicaid Services+2Federal Register+2
What Texas (and Patients in Texas) Can Expect
Because Texas is one of the pilot states, patients and providers in the state will begin seeing these changes in Original Medicare starting January 1, 2026. The Dallas-Fort Worth area and other regions of Texas will be subject to the program under the state’s MAC region. Medicare 4 USA+2Centers for Medicare & Medicaid Services+2
For Texas Medicare beneficiaries, this means that for certain surgical or device-based services or interventional treatments, your provider may need to submit a prior authorization request or risk having the claim reviewed after service. This could lead to procedural delays or negotiation over evidence. Medicare 4 USA+2AASM+2
Texas providers serving Medicare fee-for-service patients must prepare by developing workflows to submit documentation, track authorizations, and manage appeals. Some may seek exemptions via “gold card” status if their approval performance is consistently high. Davis Wright Tremaine+2AASM+2
Patients should ask their providers whether a requested service is on the WISeR list and whether a prior authorization is necessary. It’s also wise to discuss contingency plans if a claim is non-affirmed or delayed.
What You Can Do Now
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If you are a Medicare beneficiary in Texas, ask your doctor whether proposed services are subject to WISeR review.
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Request early authorization submissions where possible rather than risking post-service denial.
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If you receive a denial under WISeR, appeal promptly using your Medicare rights.
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Providers should begin training clinical and billing staff on WISeR processes, documentation standards, and timelines.
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Monitor CMS and your MAC’s updates, as the rules and service lists may evolve over time.
Bottom Line
The WISeR model introduces a new layer of oversight in Original Medicare in six states, including Texas, by applying prior authorization and enhanced review to selected services thought to be overused. While the model aims to curb waste and ensure clinical appropriateness, it also introduces real risks of care delays, administrative burden, and conflicts between algorithm-driven review and individualized patient care. The balance will depend heavily on how CMS, providers, and WISeR participants implement processes, safeguard access, and hold denials accountable to clinical standards. For those in Texas, the change is not distant—2026 will mark the start of this experiment.
