CMS adding prior auth for epidurals in certain states

[myrandom2003]

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In other bad news....
I just got an alert that CMS will require prior authorization for epidurals

"They include epidural steroid injections for pain management, cervical spinal fusion, percutaneous image-guided lumbar decompression for spinal stenosis and percutaneous vertebral augmentation for vertebral compression fracture."

"WISeR will run from Jan. 1, 2026, through Dec, 31, 2031, and the model will begin with providers in Arizona, Washington, New Jersey, Texas and Oklahoma. It doesn’t alter Medicare coverage or payment rules, and doesn’t affect Medicare Advantage plans."

CMS to add prior authorization for spine procedures in traditional Medicare - Becker’s Spine Review

Some fee-for-service spine procedures in traditional Medicare will have prior authorizations added, according to CMS’ new Wasteful and Inappropriate Service Reduction model. CMS is partnering with AI and machine learning companies to test ways to implement an expedited prior authorization...

www.beckersspine.com

https://www.cms.gov/files/document/wiser-model-rfa.pdf (scroll to page 20)

 

[Ducttape]

ironically, it was put under the "Wasteful and Inappropriate Service Reduction" model

as if prior auth wasnt wasteful...

https://www.cms.gov/files/document/wiser-fact-sheet.pdf

(just the fact sheet, myrandom2003 already posted the full link)

 

[myrandom2003]

I thought RFKjr was supposed to work on getting rid of prior auths

 

[Ducttape]

 

[Ducttape]

so SCS, kypho, MILD are included in this list.

so get all your Medicare cases out of the way before Jan 2026.



yep elections have consequences.

 

[lobelsteve]

so SCS, kypho, MILD are included in this list.

so get all your Medicare cases out of the way before Jan 2026.



yep elections have consequences.

Except all of these modalities are overutilized and incorrectly chosen.
I am fully for PA and determination for these services.

46 y/o today sent from PCP.. ETOH withdrawal seizure d/o led to Fxs of T/L spine. Kypho by IR. Still hurts.

Internal referral bypassed my staff. Fortunately a no show. But no way should have had those kyphos.

 

[bedrock]

In other bad news....
I just got an alert that CMS will require prior authorization for epidurals

"They include epidural steroid injections for pain management, cervical spinal fusion, percutaneous image-guided lumbar decompression for spinal stenosis and percutaneous vertebral augmentation for vertebral compression fracture."

"WISeR will run from Jan. 1, 2026, through Dec, 31, 2031, and the model will begin with providers in Arizona, Washington, New Jersey, Texas and Oklahoma. It doesn’t alter Medicare coverage or payment rules, and doesn’t affect Medicare Advantage plans."

CMS to add prior authorization for spine procedures in traditional Medicare - Becker’s Spine Review

Some fee-for-service spine procedures in traditional Medicare will have prior authorizations added, according to CMS’ new Wasteful and Inappropriate Service Reduction model. CMS is partnering with AI and machine learning companies to test ways to implement an expedited prior authorization...

www.beckersspine.com

https://www.cms.gov/files/document/wiser-model-rfa.pdf (scroll to page 20)

Thanks. One thing it doesn’t state clearly is if other states will be included later that year or if they intend to test this for a full year just in those states?

 

[Laryngospasm]

I’m all for prior auths for any spine surgery for sure. So many mistakes there. Agree ESis are overused.. mostly in the pills for pokes model that so many love. If I see another decompression for a tiny inconsequential bulge I may lose it.

 

[SSdoc33]

i dont care if they are overutilized. they are not overutilized by me and now i will have extra paperwork. no bueno

 

[Ducttape]

Except all of these modalities are overutilized and incorrectly chosen.
I am fully for PA and determination for these services.

46 y/o today sent from PCP.. ETOH withdrawal seizure d/o led to Fxs of T/L spine. Kypho by IR. Still hurts.

Internal referral bypassed my staff. Fortunately a no show. But no way should have had those kyphos.

i assume you get auth for the kyphos on the LOL who had a nontraumatic VCF. i get auth for all of my procedures, so no change for this practice. but it can delay care, annoys patients, who sometimes blame the doctor.


this extra step to prior auth is for insurance to limit your procedures.

 

[Multimodal]

I imagine that mbb/rfa isnt too far off too if they're going to start PA for ESI. My prediction, in 5 years, we'll all have an AI assistant in the office to help process these damn PA's. I think we should all move to using the LCD criteria as part of a template in our notes.

 

[BoardingDoc]

I think we should all move to using the LCD criteria as part of a template in our notes.

I already do. I wrote a macro for ESI, SIJ injection (one for dx one for tx), MBB and RFA. All of them explicitly address each item in the Medicare LCD for the procedure.

E.g.
Will plan on diagnostic MBB of {{BILATERAL|LEFT|RIGHT}} {{L1-2, L2-3|L2-3, L3-4|L3-4, L4-5|L4-5, L5-S1}} at next visit with ultimate plan for RFA of the same levels.

•Justification for interventional procedure:•
1. Patient has moderate to severe pain {{6/10|7/10|8/10|9/10|10/10}} which interferes with ADLs
2. Pain has been present for >3 months and has failed to respond to conservative measures including {{OTC analgesics|physical therapy|acupuncture}}
3. Patient has no untreated radicular symptoms
4. No alternative pain generator suspected beyond facetogenic pain at this time.

 

[Laryngospasm]

I imagine that mbb/rfa isnt too far off too if they're going to start PA for ESI. My prediction, in 5 years, we'll all have an AI assistant in the office to help process these damn PA's. I think we should all move to using the LCD criteria as part of a template in our notes.

They already do for HOPD.

 

[PinchandBurn]

Isn't this good? If we get prior auths then Medicare cant clawback...its a pain in the butt...but I think it helps us

 

[jsaul]

This is not good news in any way which way

 

[SgtThunderfistMD]

Isn't this good? If we get prior auths then Medicare cant clawback...its a pain in the butt...but I think it helps us

Medicare can still claw back.
Pre-authorization is an agreement that (if you follow all the rules) they will pay for a procedure.
They can still go back and look at your epidurals in 5 years and say you didn't do X Y Z obscure stupid thing and take back the money
So now they are screwing us on the front end, still with a chance to screw us later on

 

[mdo1738]

Isn't this good? If we get prior auths then Medicare cant clawback...its a pain in the butt...but I think it helps us

They can always clawback

 

[lobelsteve]

i assume you get auth for the kyphos on the LOL who had a nontraumatic VCF. i get auth for all of my procedures, so no change for this practice. but it can delay care, annoys patients, who sometimes blame the doctor.


this extra step to prior auth is for insurance to limit your procedures.

Maybe. Not my part of the job. Someone else does it. I just eval and treat.
I get paid either way.

 

[Taus]

As my OR that I go to once a month is in an HOPD… I have had to deal with Medicare prior auth for Rfa and Scs. Granted that was before I was able to move almost all those to the office. Still some of patients occasionally want the OR due to its closer proximity to their home or they “need” IV sedation.

You better have your templates spot on with their LCD/NCD. If you are missing one little thing or they overlook something…. response time and getting that rectified quickly is a huge pita. I have learned the hard way, but they are dead serious for Rfa wanting not only the 80% reduction AND pain score on the NRS but also an ODI or other standardized scale for both pain and function before RFA and before repeat RFA.

Based on what I see in my local community… are Rfa, ESI, mild, scs grossly overutilized in the Medicare population… Yep. The routine series of three did not die until Medicare forced it with the new change to Q3 months. And thats why we can’t have nice things…

Get your templates ready for every procedure, not just Kypho on Medicare.

 

[Linktones]

This seems like a voluntary program. They are going to try and incentivize you to participate but likely just a sneaky way to reduce or block payments in the future.


1. Model SummaryThis Request for Applications (RFA) invites interested parties to apply to participate in theWasteful and Inappropriate Service Reduction (WISeR) Model, a new Center for Medicare andMedicaid Innovation (Innovation Center) model from the Centers for Medicare & MedicaidServices (CMS). Wasteful medical care spending accounts for an estimated 25% of totalhealthcare spending with a substantial portion being attributable to fraud, waste (including lowvalue services), and abuse (FWA).1,2 The WISeR Model will test an innovative approach toaddressing this issue by implementing a six-year model, in two three-year agreement periods.Under the WISeR model, CMS seeks qualified technology partners as model participants toimplement and streamline the prior authorization process for select items and services that maybe fraudulent, and wasteful, or of low-value to beneficiaries in Original Medicare.

8. Payment DesignPayment DesignPayments to WISeR model participants will be based on the demonstrated reductions inspending for medically unnecessary or non-covered services, as defined by the OriginalMedicare LCD or NCD. For each of the selected items and services, a participant will receive apercentage of the reduction in expenditures, or savings, that can be directly attributed to theprior authorization review process in their applicable region. These savings will be calculatedfrom requests that did not result in a paid claim (i.e., non-affirmations not followed by anaffirmed resubmission or a successfully appealed claim denial), multiplied by the average claimlevel payments for historical regional claims submitted with the applicable item(s)/service(s)during the prior 12 months (adjusted for performance year pricing). The use of total claimpayments in the savings calculation (as opposed to claim-line payments for the eligibleCPT®/HCPCS codes) is intended to accurately depict the total revenue impact, includingsecondary or add-on services that are regularly billed and reimbursed along with the primaryprocedure or service codes.Initially, model participants will receive model payments for non-affirmations that were notsubsequently resubmitted and affirmed during the initial 120-day window. A model participantwill only be paid for one non-affirmation involving the same beneficiary, item/service, andprovider/supplier within a period of 120 calendar days. For instance, if a provider/supplierresubmitted a request twice within 120 days of an initial non-affirmation and neitherresubmission was affirmed, the model participant would receive a single payment for the seriesof non-affirmations, not three separate payments. Payments for non-affirmations will be heldfor up to one year if the associated request is resubmitted, to ensure that the initial nonaffirmation was upheld in the subsequent determination(s). In the event that aprovider/supplier performs and bills for a non-affirmed item or service and successfully appealsthe denial of the associated claim, the model payment associated with that record will beclawed back from the participant once the claim payment is processed.As detailed above, model payments will be based on a percentage of the observed cost savingsthat can be directly attributed to prevention of medically unnecessary or non-covered items orservices. Additionally, payments will be subject to an annual quality adjustment based on anaggregated score of the participant’s performance across each of the defined quality metrics. Aspoor-quality performance will result in downward adjustment of model payments, thisadjustment will be critical in enforcing the defined quality metrics and minimizing any adverseincentives related to WISeR participation.Finally, given that WISeR participants will make determinations based on the same coveragecriteria that are currently available and used by the MACs to assess medical necessity andPage 24 of 35coverage, it is likely that a portion of the savings attributed to WISeR participants wouldotherwise have been captured by the MACs during prepayment reviews or post-payment audits.To account for this counterfactual, the Innovation Center will utilize historical claims data (preimplementation) by item/service and region to determine the baseline medical necessity denialrate. This baseline rate will then be applied as a discount to the total savings attributed to eachrecord. For example, if three percent of claims for a selected item or service were historicallydenied by the MACs for medical necessity reasons, the cost sa

 

[myrandom2003]

We already do get PA on HOPD SCS, MBB/RFA. They give us a "provisional affirmation". they can still clawback if they audit and don't like something.
Sometimes we dont get paid despite PA because the hospital forgets to submit the superbill with the prior auth code and it gets denied right off the bat. Then its a whole who is responsible issue to fix it with the hospital so I can get my pro fee.

 

[clubdeac]

We already do get PA on HOPD SCS, MBB/RFA. They give us a "provisional affirmation". they can still clawback if they audit and don't like something.
Sometimes we dont get paid despite PA because the hospital forgets to submit the superbill with the prior auth code and it gets denied right off the bat. Then its a whole who is responsible issue to fix it with the hospital so I can get my pro fee.

My hospital now makes me document in the procedure note everything they’ve done to qualify for mbbs. It’s so stupid. I tried to explain to them that that’s not what a procedure note is for

 

[giddyup]

I imagine that mbb/rfa isnt too far off too if they're going to start PA for ESI. My prediction, in 5 years, we'll all have an AI assistant in the office to help process these damn PA's. I think we should all move to using the LCD criteria as part of a template in our notes.

I do this, very effective