CMS Issues Updated Guidance on WISeR Model

Updated information related to implementation of the CMS Innovation Center’s Wasteful and Inappropriate Service Reduction (WISeR) Model was released Dec. 31, through Change Request 14205 and CMS Transmittal 13570. The purpose of this document is to implement the WISeR Model Prior Authorization and Medical Review Process that began Jan. 1, and establish a recurring quarterly process to allow for updates to the CPT^® code change files and documentation requirements. Additionally, the CMMI WISeR team has provided an updated Frequently Asked Questions and WISeR Provider and Supplier Guide (version 3.0) documents. ACR^® members are encouraged to review the latest documents to ensure compliance with the demonstration model. Starting on Jan. 5, for dates of service on or after Jan.15, select items and services covered under Original Medicare will be subject to prior authorization or pre-payment medical review under the WISeR Model. Claims with dates of service between 1/1/26 and 1/14/26 are exempted from the WISeR model requirements to allow for operational set up.

Of importance to ACR members, CMS decided to delay implementation of the Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (PILD) in WISeR (related coverage documents NCD 150.13 and codes 0275T “now reported with 62330 and 62331", and G0276). These services will not be subject to prior authorization or pre-payment review under the WISeR Model. CMS explains PILD has multiple clinical study approvals under its Coverage with Evidence Development program. CMS will re-evaluate implementing prior authorization or pre-payment review of PILD under WISeR in a future model performance year.

ACR staff prepared a checklist [AB1.1]to help members navigate this new program. Continue to monitor CMS and ACR for additional updates as CMS continues to refine WISeR requirements.

For more information about the Wiser Model or questions, contact Alicia Blakey, ACR Principal Economic Policy Analyst.