WISeR (Wasteful and Inappropriate Service Reduction) Model

November 2025

Overview

CMS has the responsibility to protect the Medicare Trust Funds, and routinely analyzes data associated with all facets of the Medicare program. A 2020 analysis of claims submitted by providers and suppliers revealed a significant increase in the utilization volume of some covered outpatient department (OPD) services. Subsequently, CMS initiated a hospital outpatient department prior authorization program in CY 2020 to control unnecessary increases in the volume of the following five categories of services, including blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. Initiating a prior authorization process for certain OPD services would ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Funds from improper payments, and at the same time keeping the medical necessity documentation requirements unchanged for providers.

On June 27, 2025, the Center for Medicare and Medicaid Innovation (CMMI) introduced the Wasteful and Inappropriate Service Reduction (WISeR) Model to reduce clinically unsupported and low value services with limited clinical evidence of effectiveness. The WISeR Model will help reduce clinically unsupported care by working with companies experienced in using enhanced technologies to expedite and improve the review process for a pre-selected set of services that are vulnerable to fraud, waste, and abuse. Technology companies participating in the model will help streamline the review of medical necessities for select items and services earlier in the claims process to reduce inappropriate utilization, lower spending in Original Medicare, expedite decision making and ease provider administrative burden.

Key Points

What is WISeR:

• A CMS Innovation Center model to test AI-enabled prior authorization for 15 outpatient procedures prone to fraud, waste, and abuse.

Which states are included:

• Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington

How it works:

• Starting on January 1, 2026, select items and services covered under Original Medicare will be subject to prior authorization or pre-payment medical review under the WISeR model.
  • Providers and suppliers for people with Original Medicare in the selected regions will have the choice of submitting a prior authorization request for the model’s selected items and services or go through a post service/pre-payment medical review.
    • Those that choose the prior authorization route may either submit the prior authorization request
      • directly to the model participant or
      • to their Medicare Administrative Contractor (MAC) that will forward the request to the model participant
  • If prior authorization for an included service is not obtained the claim will be subject to medical review by the model participant to ensure the delivered service met with Medicare coverage, coding, and payment criteria prior to payment.

Guardrails:

Artificial Intelligence can only affirm a request. All non-affirmations will be reviewed and decided on by a board-certified medical doctor with a license to practice in at least one U.S. state and relevant specialty designation, ensuring that human medical judgement remains central to every decision.

• The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed. However, a provider or supplier may request an expedited review, if needed.
• To safeguard against inappropriate non-affirmations the WISeR payment methodology disincentivizes inappropriate non-affirmation through regular audits, quality metrics and by allowing unlimited resubmissions.

Recommendations & Action Items

Review the WISeR provider and supplier operational guide. Identify the impacted items and services as well as instructions within the provider and supplier operational guide on how to obtain a prior authorization and what is needed when submitting the claim.

Assess the criteria. The WISeR provider and supplier operational guide also contains the clinical criteria (NCD/LCD’s) for approval of the requested items and services included in the model. Providers should review these criteria to ensure they submit all the required information for a service or item with the prior authorization request for maximal efficiency and maximal success.

Explore additional resources. Visit the WISeR website to review pertinent information and FAQ’s. Additionally, for more information about the WISeR Model, CMS has developed the WISeR innovation model, containing a variety of resources such as program updates, FAQs, fact sheet and other operational materials.