Dealing with WISeR. What's your next move?

[drusso]

---

Members do not see this ad.

CMS is rolling out yet another “we swear this is about waste” experiment, the WISeR (Wasteful and Inappropriate Service Reduction) model, starting January 15, 2026, in six states: NJ, OH, OK, TX, AZ, and WA.

For 14 “high-abuse” procedures — including kyphoplasty/vertebroplasty, epidural steroid injections, various neurostim implants, cervical fusion, arthroscopy, and a grab bag of urology/sleep/wound services — Medicare will now require prior auth. No prior auth = automatic prepayment review. If the chart doesn’t meet the NCD/LCD medical necessity standard, both the procedural claim and the anesthesia claim get denied.

The kicker for anesthesia: you have zero control over whether the surgeon/pain doc actually meets medical necessity or even bothers to get prior authorization, but you still eat the denial if they don’t. Early 2026 is likely to be a bloodbath in those six states as surgeons plow ahead without knowing the rules, and anesthesia gets dragged down with them. On the chronic pain side, this mainly hits interlaminar/transforaminal ESIs, kypho/vert, and stim implants. CMS has a 27-item prior authorization data set and expects decisions within 3 days, which means practices will need procedure-specific prior authorization templates and tight workflows if they don’t want their cash flow wrecked.

So, for those of you doing anesthesia or interventional pain in these WISeR states: how are you going to handle this?

 

[FacetiousJoint]

easiest way is probably just copy the coverage guidelines from the document, run them thru an AI, and ask it to make you the template,

every note will be templated to follow whatever coverage crap they need.

it already is a pain in the ass to get neuromodulation covered at our place

 

[Agast]

The ASCs are required to also get prior auth, apparently using the same notes we provide, but to a separate portal. Somehow this doubling of work will reduce waste…. But if the doctor gets approval and the ASC doesn’t have it yet, the procedure won’t happen at the scheduled date.

ASCs got a delay to going live in February

 

[giddyup]

I’ll create a dot phrase. I’m in Ohio and will let y’all know how it goes.

 

[Ducttape]

something like this?



We are asking for authorization for a {type of epidural} epidural injection.

The patient has {smartlist with types of symptoms - radicular pain/back pain associated with impairment of ADLs and significant image abnormalities/low back pain with impairment of ADLs and severe spinal stenosis/neurogenic claudication/zoster}


The patient has symptoms and clinical findings appropriate for clinical diagnosis: pain >6, with radiating pain in a dermatomal distribution of ***

The patient has failed 4 weeks of non surgical and non injection care, including physician directed physical therapy and medication trials. Patient has done conservative self-management therapies over a 2 month period of time without significant clinically meaningful improvement. Has tried lifestyle modification of activities with no clinically meaningful benefit.

The pain is severe enough that it is impacting the patient's quality of life and has affected the patient's functionality.

{exemptions: pain unresponsive to medications/repeat injection of >50% improvement for at least 3 months duration/zoster/cannot tolerate surgery for other medical conditions}



Appropriate imaging were reviewed and are compatible with the clinical diagnosis.

Only 1 level will be performed during this session.

No more than 1 epidural have occurred in the past 3 months and no more than 4 epidurals have occurred in the past 12 months.



{Auth lesi 12 mo:28758}


There are no contraindications or major risk factors for the epidural injection.

Image guidance, fluoroscopy, and contrast medium if not allergic will be utilized for the procedure, and images will be saved and available for review.

No limitations exist for the procedure itself. No other procedures are to be done concurrently. Medications to be used are restricted to saline, local anesthetic agents, with steroids or contrast where indicated.

 

[Agast]

https://www.cms.gov/files/document/wiser-provider-supplier-guide.pdf

Page 18 starts the portion on what needs to be done and documented

 

[Ducttape]

thanks. i didnt look for this as my state is thus far not affected.

epidural is 6.2.11

the smartphrase from above does not include specifics from this document. on first glance, i dont see any significant additions, but ill have to go over it in greater detail.

(i should mention that the specific injection, laterality and level are documented later on in the note)

 

[mdo1738]

Did it actually get funding? Last I heard, the House had blocked funding to where it wasn’t going to go through this upcoming year. I had not been able to find any definitive updates since then.

Either way, it won’t be hard. I’ve got templates for every NCD/LCD. Just another bit of BS to add to the massive pre-existing pile we have to deal with.

 

[CleanUp]

Maybe it’s just me but the templates didn’t work as well as I anticipated. I’m crazy in love with templates and dot phrases, too. Maybe it’s just me but it happened more often than not where they asked the specific dates of PT or for the actual PT note.

 

[Ducttape]

i have not had that request with injections, but have that with MRI auth.

part of the mri smartphrase includes the date that i last saw the patient and when HEP directed by myself started, and that has obviated that aspect of the denials.

 

[clubdeac]

i have not had that request with injections, but have that with MRI auth.

part of the mri smartphrase includes the date that i last saw the patient and when HEP directed by myself started, and that has obviated that aspect of the denials.

I now get denials on MRIs after they complete an exercise program. They want to know specific exercises and how many days per week they were done. It’s becoming ridiculous

 

[Dr. Ice]

My precert department will get all the PT notes with dates and summaries before submitting for any procedure. For some reason we can get MRIs without any issue

 

[mdo1738]

Was anybody else on that video conference today? I had not realized until the CMS representatives were talking today that prior authorization is not going to be required, but rather that we have a case-by-case option of submitting for PA or just doing the procedure like always, with the change being that bypassing auth will result in prepayment review. So it will still be an option to do same day or expedited injection, just rolling the dice on payment if AI decides to deny medical necessity after the fact. As HOPD doc, I’m just going to proceed as usual with ESI and kypho.

 

[Agast]

I might just suck it up. It looks like Cohere is administering for Texas and I’m used to their portal for Humana, turnaround is pretty quick

I don’t want to risk not being paid

 

[BobBarker]

Who is administering for Oklahoma?

 

[mdo1738]

AI company called Humata

 

[mdo1738]

 

[1 Up]

I now get denials on MRIs after they complete an exercise program. They want to know specific exercises and how many days per week they were done. It’s becoming ridiculous

Is a class action even possible at this point?

 

[au bon pain]

Is a class action even possible at this point?

An additional option could be to keep a list of frivolous/improper denials and then file a complaint with HHS OIG against the contractor.
Probably wouldn’t hurt to let AARP know along the way.

 

[Multimodal]

AI company called Humata

I read that company name as a combination of the word "human" and the spanish word for kill, "matar". so Hu-mata (human-killer).

 

[BobBarker]

I read that company name as a combination of the word "human" and the spanish word for kill, "matar". so Hu-mata (human-killer).

It is even in the correct tense! 😂

 

[Agast]

I read that company name as a combination of the word "human" and the spanish word for kill, "matar". so Hu-mata (human-killer).

I thought it was Humana with glasses and a mustache

 

[BobBarker]

Yes, that is what I saw in my head as well. 😂