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WISeR (Wasteful and Inappropriate Service Reduction) is a CMS Innovation Center model that adds prior authorization to selected services in Original Medicare. It runs from January 1, 2026, through December 31, 2031, in six states: Oklahoma, Washington, New Jersey, Ohio, Texas, and Arizona. Technology-enabled vendors review requests, and licensed clinicians make any non-affirmation decision. Providers can submit a prior authorization request or skip it, in which case the claim faces prepayment medical review. The initial service list targets procedures and devices, not clinical lab tests, but labs still feel the effects through referring-provider workflows, documentation demands, and the chance that CMS expands the list later.
Key Takeaways
Prior authorization has always been a Medicare Advantage headache. Original Medicare mostly stayed out of it. WISeR changes that, at least in six states.
If your lab runs outreach in Texas, New Jersey, Oklahoma or any of the other WISeR states, you probably have questions. Does it hit lab codes? Will ordering physicians slow down? What should your team watch? Here’s a clear, no-hype walkthrough.
| Feature | Details |
|---|---|
| Full name | Wasteful and Inappropriate Service Reduction Model |
| Run by | CMS Innovation Center |
| Model period | January 1, 2026 – December 31, 2031 |
| States | Oklahoma, Washington, New Jersey, Ohio, Texas, Arizona |
| Who it covers | Original (fee-for-service) Medicare beneficiaries |
| Who it doesn’t cover | Medicare Advantage enrollees |
| Reviewers | Tech-enabled vendors, with clinicians making non-affirmation decisions |
| Excluded services | Emergency services, inpatient-only services, and services where delay would put the patient at serious risk |
| State | MAC | Jurisdiction | MolDX applies to molecular tests? |
|---|---|---|---|
| Oklahoma | Novitas Solutions | JH | No |
| Texas | Novitas Solutions | JH | No |
| New Jersey | Novitas Solutions | JL | No |
| Ohio | CGS Administrators | J15 | Yes |
| Arizona | Noridian Healthcare Solutions | JF | Yes |
| Washington | Noridian Healthcare Solutions | JF | Yes |
Molecular labs in Ohio, Arizona, and Washington already work inside MolDX technical assessments and Z-code registration. That isn’t WISeR, but it shows how much pre-payment scrutiny molecular testing already faces in those states.
| Category | Examples on the initial list |
|---|---|
| Wound care | Skin and tissue substitutes |
| Neurostimulation | Electrical nerve stimulator implants, deep brain stimulation, vagus nerve stimulation, hypoglossal nerve stimulation for obstructive sleep apnea |
| Spine | Cervical fusion, epidural steroid injections, percutaneous vertebral augmentation |
| Orthopedics | Knee arthroscopy for knee osteoarthritis |
| Other | Incontinence control devices |
Providers have a real choice. They can request prior authorization before the service, which gives them certainty about coverage up front. Or they can skip it, perform the service, and accept that the claim will go through prepayment medical review, with records requested before payment. Most practices will find the first path smoother, because a records request after the fact ties up cash and staff time.
CMS has also said providers with consistently high affirmation rates may earn reduced review, similar to “gold carding.” Check CMS guidance for the current criteria.
Even though lab tests aren’t on the list, WISeR changes the environment around your claims. Expect four things:
| Area | What changes for ordering and rendering providers |
|---|---|
| Scheduling | Build prior auth time into procedure scheduling for listed services |
| Documentation | Records must support coverage criteria before the service, not after |
| Staffing | Front office and clinical teams take on submission and follow-up work |
| Cash flow | Skipping prior auth means prepayment review and slower payment |
| Patient communication | Patients need to know why a procedure is pending and what happens next |
| Task | Referring provider | Lab |
|---|---|---|
| Prior auth for WISeR-listed procedures | Owns it | Not involved |
| Diagnosis codes on lab orders | Supplies them | Checks them before billing |
| Medical necessity for lab tests | Documents it in the chart | Matches it to LCD/NCD rules |
| Eligibility and coordination of benefits | Verifies at visit | Re-verifies before claim |
| Tracking WISeR list updates | Watches for procedure changes | Watches for any lab code additions |