On January 1, 2026, CMS will launch the Wasteful and Inappropriate Services Reduction (WISeR) Model, a six-year demonstration designed to test technology-enhanced prior authorization in Medicare fee-for-service (FFS).

This program introduces new Medicare prior authorization requirements in six pilot states and applies to 17 services across multiple specialties. According to AAPC, WISeR represents a turning point in how Medicare approaches utilization management and compliance. (Source: AAPC)

States Impacted by WISeR

Medicare prior authorization will first apply in these six states:

• Texas
• Oklahoma
• New Jersey
• Ohio
• Arizona
• Washington

Practices in these states should prepare immediately, as lessons from this pilot could influence a nationwide rollout after 2031.

How WISeR Works

CMS says the WISeR model will require the same clinical documentation already needed for Medicare FFS payments, but submitted earlier, before services are rendered.

Services Requiring Prior Authorization

The model applies to the following 17 services with affiliated NCDs or LCDs:

• Electrical, sacral, phrenic, deep brain, and vagus nerve stimulators
• Induced lesions of nerve tracts
• Epidural steroid injections (excluding facet joint)
• Cervical fusion, percutaneous vertebral augmentation, arthroscopic knee lavage/debridement
• Hypoglossal nerve stimulation for obstructive sleep apnea
• Incontinence control devices, diagnosis and treatment of impotence
• Percutaneous image-guided lumbar decompression
• Bioengineered skin substitutes and cellular/tissue-based products (CTPs) for chronic non-healing wounds

See CMS’s full NCD/LCD list in the official WISeR notice.

Unique Tracking Number (UTN) Requirement

• A provisional affirmation = service likely meets coverage → claim paid once submitted with a Unique Tracking Number (UTN).
• A non-affirmative decision = prior auth denied → claim tied to that UTN will also be denied.
• Denied claims can be appealed under existing Medicare processes.
• No prior auth submitted? → claim subject to prepayment medical review by the model participant.

Specialties Affected and How

The services selected by CMS fall into some of the busiest specialty practices:

• Pain Management: epidural steroid injections, nerve stimulators, decompression procedures
• Orthopedics & Spine: cervical fusions, vertebral augmentation, arthroscopic knee surgery
• Cardiology / Sleep Medicine: hypoglossal nerve stimulation, implantable devices
• Neurology: deep brain stimulation, vagus and phrenic nerve stimulators
• Urology: incontinence devices, impotence treatments
• Gastroenterology: advanced endoscopic procedures
• Ophthalmology: cataract and vision-related implants
• Vascular Surgery: endovascular stents and interventions
• Dermatology / Wound Care: application of skin/tissue substitutes
• Radiology / Imaging: imaging tied to covered procedures

For these specialties, Medicare prior authorization will now determine whether services can be delivered and paid for.

Download our guide to see how these services impact your specialty and revenue risk → WISeR Specialty Impact Guide

Why Prior Authorization Matters for Physician Practices

The introduction of Medicare prior authorization represents:

• New Administrative Burden: staff must manage submissions, tracking, and appeals.
• Revenue Risk : claims without prior authorization or UTNs will be denied.
• Workflow Shifts: practices must align clinical documentation earlier in the process.

Denial Prevention and Compliance

Denials are one of the most expensive challenges in healthcare revenue cycle management. According to AAPC, over 90% of denials are preventable with correct coding, documentation, and authorization.

How Patient Care Is Affected

While CMS argues that prior authorization reduces waste without harming access, providers disagree. The AMA reports that 93% of physicians say prior authorization delays patient care, and 42% say it delays care often.

For practices, this means:

• Longer wait times for patients needing imaging, surgery, or device implantation
• Lower satisfaction scores when delays frustrate patients
• Risk of patient leakage to hospital systems that appear to move faster

Practice Support That Protects Every Specialty

At Peregrine Healthcare, we know prior authorization is more than a paperwork exercise, it’s about protecting revenue and patient trust. Through our Practice Support Center, we help practices:

✔ Submit, track, and follow up on Medicare prior authorizations
✔ Reduce denials with AAPC-certified coding oversight
✔ Manage UTN requirements and appeals
✔ Keep patient care on schedule by minimizing approval delays
✔ Streamline your entire revenue cycle management (RCM) workflow

Key Takeaways: Medicare WISeR Model

• Effective Date: January 1, 2026
• Pilot States: Texas, Oklahoma, New Jersey, Ohio, Arizona, Washington
• Services Affected: 17 high-risk outpatient services across 10 specialties
• New Requirement: Prior authorization + Unique Tracking Number (UTN) on claims
• AAPC Guidance: Over 90% of denials are preventable with proper coding and authorization oversight
• Peregrine Solution: Practice Support Center + 100% AAPC-Certified Coders

Get Support from Peregrine’s Practice Support Center

Don’t let Medicare’s WISeR model put your practice at risk. Our Practice Support Center helps you adapt to prior authorization requirements with expert guidance, denial prevention strategies, and compliance oversight from 100% AAPC-Certified Coders.

 877-463-1110

 Visit our Practice Support Center to learn more.