Dealing with WISeR. What's your next move?

[drusso]

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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. 😂

 

[Agast]

2-3 day turnaround for our epidurals so far

 

[BobBarker]

I haven’t submitted any yet since we got an email that wiser was delayed until January 15th?

 

[Agast]

These are cases I’m doing next week

 

[Crybaby]

Getting a handful of denials.
I work in a clinic full of surgeons, who like to order injections with poor documentation and hire PAs with even poorer documentation. Will be a great few months!
This template has worked for me thus far
HPI: In summary, I recommend repeat epidural steroid injection. Justification as follows: Greater than 60% relief for 3 month minimum with accompanying improvement in ADLs and household chores. With average pre VAS being > 7 and average post VAS being <3. Improved mobility, walking, balance, and transfers. Previous failure to respond to 6-8 weeks of formal physical therapy, favorite exercises and stretches curated by PT is continued. Imaging shows nerve impingement and correlates with the experienced debilitating symptoms.

 

[Agast]

I’m 100% approved but I tried to submit for a permanent spinal cord stimulator and it came back “no prior authorization needed”

So now I’m confused about the electrical stimulators portion

 

[BobBarker]

The only scs code going through wiser is 63555 which is for a paddle placement.

 

[giddyup]

I created a dot phrase by taking things word for word from Wiser guidelines (thought it would be better to be very literal since they are using ai) and I asked my prior auth person this week and she has had zero issues. I did have a stimulator Rep come to my office and state they anticipate that about 40% of permanent paddle SCS will be denied now. will be an issue in my group because currently all of our perms are placed by the neurosurgeon owners via paddle lead so either they’re going to have to learn how to do perc or I’m going to have to do the ones that are denied. Will monitor

 

[mille125]

We have sent about 25 patients thru Cohere (TEXAS)as part of WISER. Most have been approved within 5-10 minutes. 2 have been denied. One was because some records weren't received. The other is truly puzzling. Large 2 cm (yes 2 cm) herniation obliterating left L5 with corresponding symptoms. Not denied but sent to 72 hour review. Really bizarre.

Other than that, it has been a non-factor so far. I am sure it will morph and metastasize to other states and other conditions though.

 

[mille125]

I created a dot phrase by taking things word for word from Wiser guidelines (thought it would be better to be very literal since they are using ai) and I asked my prior auth person this week and she has had zero issues. I did have a stimulator Rep come to my office and state they anticipate that about 40% of permanent paddle SCS will be denied now. will be an issue in my group because currently all of our perms are placed by the neurosurgeon owners via paddle lead so either they’re going to have to learn how to do perc or I’m going to have to do the ones that are denied. Will monitor

I agree with above. I read the 76 page document and I quite verbatim as well.

Paddle leads will get denied for sure as you have mentioned.

 

[mille125]

The only scs code going through wiser is 63555 which is for a paddle placement.

Correct....paddle is only SCS affected

 

[mille125]

I’m 100% approved but I tried to submit for a permanent spinal cord stimulator and it came back “no prior authorization needed”

So now I’m confused about the electrical stimulators portion

no prior auth needed for perc leads...only paddles

 

[mille125]

2-3 day turnaround for our epidurals so far

I am seeing instant to 10 minutes on intralaminars but 48-72 hours on transforaminals.

 

[Agast]

no prior auth needed for perc leads...only paddles

Well that will certainly cut down on a significant source of pain management fraud waste and abuse
/s

 

[mdo1738]

Anybody having problems with this yet? I had a first time LESI get denied today because “it has not been 3 months yet for repeat lumbar injection”, with our AI overlords considering the CESI I did 2 months ago as apparently a low back injection. Resubmitted with an angry addendum and will hopefully be approved the 2nd go round, it is just insane to have to write out “cervical and lumbar are actually different areas of the body”.

 

[mille125]

Anybody having problems with this yet? I had a first time LESI get denied today because “it has not been 3 months yet for repeat lumbar injection”, with our AI overlords considering the CESI I did 2 months ago as apparently a low back injection. Resubmitted with an angry addendum and will hopefully be approved the 2nd go round, it is just insane to have to write out “cervical and lumbar are actually different areas of the body”.

Wiser recs allow you to do a repeat in a few weeks but you have to go to another area or use another technique.

Haven't had any denials yet but some are taking 3-5 days to approve.

 

[mdo1738]

Wiser recs allow you to do a repeat in a few weeks but you have to go to another area or use another technique.

Haven't had any denials yet but some are taking 3-5 days to approve.

Wasn’t a repeat. I did cervical ESI in November. Requesting lumbar ESI now. But I “did a low back injection in November and it hasn’t been 3 months so can’t repeat”. It’s just stupid.

 

[mille125]

Wasn’t a repeat. I did cervical ESI in November. Requesting lumbar ESI now. But I “did a low back injection in November and it hasn’t been 3 months so can’t repeat”. It’s just stupid.

That is

 

[Ducttape]

Anybody having problems with this yet? I had a first time LESI get denied today because “it has not been 3 months yet for repeat lumbar injection”, with our AI overlords considering the CESI I did 2 months ago as apparently a low back injection. Resubmitted with an angry addendum and will hopefully be approved the 2nd go round, it is just insane to have to write out “cervical and lumbar are actually different areas of the body”.

for some insurances (medicaid advantage) so far, < 3 month is a hard no for same level, but no pushback against other areas.

with regards to repeat injection, i am now submitting on exactly 90 days post procedure to get next approved, so patients are technically getting it 3 months + 3 weeks afterwards.

 

[Agast]

Wasn’t a repeat. I did cervical ESI in November. Requesting lumbar ESI now. But I “did a low back injection in November and it hasn’t been 3 months so can’t repeat”. It’s just stupid.

Did you submit it yourself? Any chance a staff input the wrong CPT and ICD 10 codes?

 

[mdo1738]

Did you submit it yourself? Any chance a staff input the wrong CPT and ICD 10 codes?

I did not, hospital staff did. I reviewed the denial letter though, correct CPT code was used and they included my clinic note with correct documentation. Everything was submitted correctly.