Traditional Medicare Put 15 Procedures Under New Review in Six States. The List Can Grow.

A 71-year-old retiree in Phoenix schedules an epidural steroid injection for chronic back pain. Three days later, her doctor’s office calls with an unfamiliar complication. Before putting the procedure on the calendar, it wants a private reviewer to confirm that Medicare’s coverage rules are met. She has spent more than five years on Original Medicare without hearing the phrase prior authorization. Her Medicare card has not changed. The route to care has.

The Wasteful and Inappropriate Service Reduction (WISeR) Model began in January 2026 as a six-year test across half-a-dozen states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. It applies only to Original Medicare, not Medicare Advantage, and only to selected outpatient procedures. Original Medicare has used prior authorization in smaller programs before. WISeR carries that idea into a broader collection of elective services, with private companies and technology helping to review whether the care meets Medicare’s existing coverage rules.

Fifteen Categories Now Face an Extra Review

The Centers for Medicare & Medicaid Services (CMS) originally announced 17 service categories. In April 2026, it delayed two of them, deep brain stimulation and percutaneous image-guided lumbar decompression, because the review process was not ready. That leaves 15 active categories, although the exact mix can vary by state because some wound-care services depend on local Medicare coverage policies.

The current list includes epidural steroid injections, cervical fusion, spinal-cord and other nerve stimulators, vertebral augmentation, certain knee procedures, incontinence devices, erectile-dysfunction treatments, and some skin and tissue substitutes used in lower-extremity wound care. CMS chose services it believes are vulnerable to overuse or improper billing. Emergency care and inpatient-only procedures are excluded, as are services for which a delay could pose a substantial health risk.

Providers Can Choose Between Two Routes

The headline version of WISeR sounds like mandatory prior authorization. The actual system gives the provider two paths. One is to send the records before treatment and request a prior-authorization decision. The private reviewer generally has three business days to respond, or two business days for an expedited case. Requests routed through a Medicare Administrative Contractor may take longer.

The other is to perform the procedure without advance approval. The claim then receives a post-service, prepayment review before Medicare releases payment. That second route avoids waiting before care, but it shifts the uncertainty until afterward. The procedure is finished, the claim is pending, and nobody yet knows who will be paid.

The Financial Incentive Deserves Attention

The companies conducting WISeR reviews receive a portion of the Medicare spending associated with care they identify as wasteful or inconsistent with coverage rules. Their compensation is also adjusted for measures such as accuracy, timeliness, and provider experience. Technology, including artificial intelligence, can help organize records and flag cases. It does not get the final word. A licensed clinician reviews any recommendation that Medicare not pay.

Still, the incentive points in a clear direction: savings come from stopping payment for care judged unnecessary or unsupported. That makes the safeguards more than administrative fine print. They are the balance against a system that rewards lower spending.

A Negative Decision Is Not the End

If a request is not affirmed, the provider can submit it again with additional documentation. There is no set limit on resubmissions, and the office can request a peer-to-peer discussion with a reviewing clinician. A non-affirmed prior-authorization request cannot yet be formally appealed because Medicare has not denied an actual claim. Appeal rights begin after the procedure is performed, the claim is submitted, and payment is denied.

That leaves the patient with an important document to recognize. If the provider wants to proceed despite expecting Medicare not to pay, Medicare’s rules call for an Advance Beneficiary Notice of Noncoverage (ABN). Signing it can shift the financial responsibility to the patient. It should not be treated as one more clipboard form at check-in.

Before the Procedure Reaches the Calendar

Anyone in a WISeR state with one of these procedures approaching should pin down the review path early:

• Ask the provider whether the exact billing code appears on the current WISeR list and whether the office is seeking advance approval or accepting prepayment review afterward.
• If the first request is not affirmed, ask what documentation was missing and whether the office will resubmit or arrange a peer-to-peer review.
• Read any ABN carefully. Ask for the estimated price, the reason Medicare may not pay, and whether another covered treatment is available before agreeing to take responsibility for the bill.
• Keep the determination letter, medical records, and Medicare Summary Notice. If Medicare ultimately denies the claim, those documents become the foundation of an appeal.

CMS has left room to add more services during the pilot. It has not announced that more states will join. The Medicare card still says Original Medicare. In six states, however, certain scheduled procedures now make an extra stop at a private reviewer’s desk. The safest time to discover that detour is before the appointment is booked, not when the bill arrives.

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