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WISeR Model and its Possible Effects on ASCs

The new Medicare prior authorization rule is set to begin in six states in 2026

BY ALEX TAIRA | DECEMBER 10, 2025

The Wasteful and Inappropriate Service Reduction (WISeR) Model, scheduled to run from January 1, 2026, to December 31, 2031, could affect facility payment and timing for ASCs.

The Centers for Medicare & Medicaid Services (CMS) announced the introduction of the WISeR Model on June 27, 2025. Administered by the Center for Medicare & Medicaid Innovation (CMMI), the model will incorporate technology companies using “enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML)” into services already subject to prior authorization or prepayment review. The model includes services performed at ASCs for fee-for-service Medicare in six states: Arizona, Ohio, Oklahoma, New Jersey, Texas and Washington.

Read the WISeR Model Provider and Supplier Operational Guide, which expands upon all of the logistical information described below.

WISeR Model Procedures

CMMI has stated that the WISeR Model is intended to address services that the agency has deemed low value due to “limited clinical evidence of effectiveness.” Each of the services included in the WISeR Model are already subject to either National Coverage Determination (NCD) or Local Coverage Determination (LCD). An NCD is a national payment policy issued by CMS that establishes specific criteria—generally related to medical necessity—that a provider must provide before receiving reimbursement for that service. An LCD is a similar payment policy but developed by a Medicare Administrative Contractor (MAC) rather than CMS, and thus is usually only active in the specific geographic region overseen by that MAC. Therefore, the WISeR Model is not establishing any new prior authorization or medical necessity criteria but rather modifying the review process for existing NCDs and LCDs via the use of technology.

As of November 2025, 14 procedures corresponding to 23 total coverage determinations are slated to be part of the model.

1. Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)
2. Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
3. Induced Lesions of Nerve Tracts (NCD 160.1)
4. Vagus Nerve Stimulation (NCD 160.18)
5. Phrenic Nerve Stimulator (NCD 160.19)
6. Electrical Nerve Stimulators (NCD 160.7)
7. Incontinence Control Devices (NCD 230.10)
8. Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
9. Diagnosis and Treatment of Impotence (NCD 230.4)
10. Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (L34106, L38201, L35130)
11. Epidural Steroid Injections for Pain Management (L39015, L39240, L36920)
12. Cervical Fusion (L39741, L39758, L39793)
13. Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38307, L38310, L38385)
14. Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041) and Wound Application of Cellular and/or Tissue Based Products (CTP), Lower Extremities (L36690)

All information and supporting evidence for coverage determinations can be found through CMS’ Medicare Coverage Database. The coverage determinations can relate to more than one CPT code; for example, Induced Lesions of the Nerve Tract (NCD 160.1) is associated with both CPT 64605 and CPT 64610.

WISeR Model Process

CMMI has consistently stated that the WISeR Model should not cause significant interruptions for providers and suppliers. Medicare providers in the model states have the following two options when providing services covered under the WISeR Model.

Option 1: Submit a prior authorization request for the WISeR item or service directly to the WISeR participant in their state or to their regularly assigned MAC.

Option 2: Provide the WISeR item or perform the WISeR service and submit a claim without prior authorization. Claims submitted without prior authorization will be subject to prepayment medical review. The WISeR participant will contact the WISeR provider or supplier to request the clinical documentation related to the claim.

The “model participant” as it relates to the WISeR Model refers to the technology companies and not providers such as ASCs. As shown above, providers in the model states are not technically required to submit anything to their state’s technology vendor. However, if a provider submits medical necessity documentation to the MAC that information will ultimately be forwarded to the WISeR Model technology company who will make a payment determination. If a provider submits a claim to a MAC without any documentation, that claim will be flagged for medical review and the technology company will contact the provider directly, after which the MAC will approve or deny payment based on the technology company’s determination.

Prior authorization requests must include certain data elements including basic demographic information—for the beneficiary, facility, provider and requester—as well as relevant diagnosis codes, units of service and clinical documentation. CMMI states that determinations will be issued within three days but can be expedited if certain qualifications are met.

Model Participants

In early November 2025, CMMI announced the six technology companies that would act as WISeR Model participants, along with the states and MAC jurisdictions each vendor would be responsible for.

Reaction to WISeR Model

The healthcare community and many politicians have pushed back on CMS’ implementation of the WISeR Model. On July 16, 2025, just days after the model announcement, the American Medical Association (AMA) sent a letter to CMMI Director Abe Sutton citing significant concerns with the model, including administrative burden, care disruption, vender oversight and data privacy. The AMA asked CMS and CMMI to consider delaying the model implementation date to allow more time for stakeholder engagement and assessment of operational impacts. Numerous other organizations, including the American Hospital Association (AHA), the Society for Interventional Radiology (SIR) and a coalition of 12 major specialty organizations have sent letters with similar concerns and requests. On September 18, a group of 18 Democratic senators signed a letter expressing alarm at the WISeR Model and asking for a pause in implementation. The senators cited CMMI’s decision to make the technology companies the model participants, which allowed the model to be voluntary and not subject to traditional notice and comment requirements even though all providers in selected states will be subject to the model. As of December 2025, CMMI has declined to engage with any of the opposition and the model is scheduled to begin on January 1, 2026, as planned.

Write Alex Taira at ataira@ascassociation.org with any questions.