- Joined
- Nov 21, 1998
- Messages
- 13,273
- Reaction score
- 7,911
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?
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?
