How the Medicare prior authorization pilot program works

The Medicare prior authorization pilot program is the CMS WISeR Model, which adds prior authorization to traditional Medicare for 13 services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, according to the CMS operational guide for WISeR providers (version 7.0, July 24, 2026). The model runs from January 1, 2026 to December 31, 2031, according to the CMS Innovation Center’s WISeR page, updated September 30, 2026.

In those states, a provider who performs a listed service either requests prior authorization before the service or sends the claim without it. A claim sent without it goes to pre-payment medical review, under the same guide.

At a glance

• Under WISeR, Medicare still pays claims for listed services through the practice’s usual Medicare Administrative Contractor.
• Patients in Medicare Advantage and Railroad Medicare are outside the model.
• A decision typically comes back within 3 calendar days, or 2 for an expedited request.
• A clinician needs at least 10 requests in an assessment period to be considered for an exemption.
• A House spending bill would bar funds for the model, and it has not become law.

What the pilot program covers

CMS picked one technology company, called a participant, to review requests in each state. The model tests whether the participants’ enhanced technologies, such as artificial intelligence and machine learning, make medical review faster and more accurate, according to the CMS operational guide. The model is also known as Medicare AI prior authorization. Each participant receives a percentage of the spending its reviews avert on wasteful or inappropriate care. The percentage is adjusted for measures that include provider experience, and licensed clinicians make every recommendation not to pay, according to the CMS WISeR page.

The operational guide lists these services as live:

• Arthroscopic lavage and debridement for the osteoarthritic knee
• Induced lesions of nerve tracts
• Vagus nerve stimulation
• Phrenic nerve stimulators
• Electrical nerve stimulators
• Incontinence control devices
• Sacral nerve stimulation for urinary incontinence
• Diagnosis and treatment of impotence
• Percutaneous vertebral augmentation for vertebral compression fractures
• Epidural steroid injections for pain management
• Cervical fusion
• Hypoglossal nerve stimulation for obstructive sleep apnea
• Skin substitutes and cellular or tissue-based products for chronic wounds of the lower legs and feet

CMS delayed two more services, deep brain stimulation and percutaneous image-guided lumbar decompression, and will reconsider them in a later year of the model. Skin substitutes are reviewed only for diabetic foot ulcers and venous leg ulcers. They are currently not reviewed in Arizona and Washington, because the local coverage determination WISeR would have applied there was withdrawn.

The model covers these services in the office, the home, ambulatory surgery centers and hospital outpatient departments. In the last two settings the facility’s claim is reviewed. Services already in Medicare’s hospital outpatient prior authorization program, an existing CMS prior authorization program, stay in that program, and providers under review by a Unified Program Integrity Contractor are excluded from WISeR.

See how much of your prior authorization work Silna could take on

How to submit and what happens next

Each request covers one service and goes in before the service is given. A practice can send it to the participant directly or to its Medicare Administrative Contractor, which forwards it to the participant within one calendar day, according to the operational guide.

A request that is not approved can be resubmitted with more documentation as many times as needed, and a resubmission can include a peer-to-peer review with the participant’s clinician. A claim denied after pre-payment review goes through the standard Medicare appeals process, which Silna’s guide to appealing a prior authorization denial walks through.

Most of the work in a prior authorization request under WISeR is the documentation. Each request must include the records that show the service meets Medicare’s coverage criteria, and the operational guide lists them for each service. When a request is not approved, the participant names the missing or noncompliant information. AnswersNow, a virtual ABA therapy provider, uses Silna to check documents before a request is sent.

Exemptions from WISeR prior authorization

Since July 2026, participants exempt clinicians who show they follow Medicare’s coverage rules. A clinician qualifies by submitting at least 10 requests in an assessment period and meeting a minimum approval rate, under the operational guide.

The exemption is granted to the clinician’s own NPI and covers every WISeR service at every site of care. Participants add clinicians to the exemption list each quarter, and an exemption lasts at least a year. To recheck it, a participant can ask for records on up to 10 of the clinician’s services a year.

Timeline of the WISeR Model

The model runs for six years, from January 2026 to December 2031. It started on schedule, and Congress has debated it since.

As of October 2026 CMS lists the model as active, and H.R. 9260 has not been enacted. In June 2026, 31 House Democrats asked CMS how many prior authorization requests under WISeR are approved or denied and how long physicians wait for peer-to-peer review, according to an article published by Representative DelBene’s office. MGMA, which represents medical practices, says in its April 2026 regulatory burden report that the model “poses a new threat to practices providing certain services.”

KFF measured how many patients and how much spending the listed services cover.

How Silna prepares prior authorization requests

Silna handles prior authorizations under medical and behavioral health benefits. It tracks upcoming authorizations, submits each request and follows up with the payor until there is a decision. On G2 it is the #1 rated prior authorization solution, with a rating of 4.8 out of 5 across 66 verified reviews.

Predictive Document Intelligence checks each request against the payor’s requirements before it is submitted, so a missing record is found before the payor reviews the request.

Silna’s guide to Medicare prior authorization covers the rest of traditional Medicare and Medicare Advantage.

See how Silna can handle your next prior authorization request

Key terms

WISeR Model

The Wasteful and Inappropriate Service Reduction Model, a CMS Innovation Center test of prior authorization in traditional Medicare.

WISeR participant

The technology company CMS selected to review requests and records for the model in one state.

Medicare Administrative Contractor

The company that processes traditional Medicare claims for a region, known as its jurisdiction.

Pre-payment medical review

A check of a claim’s medical records before Medicare pays it.

Exemption

Release of a clinician from WISeR prior authorization and pre-payment review after a record of approved requests, also called gold carding.

Frequently Asked Questions

Does WISeR apply to Medicare Advantage patients?

No. It applies to people in traditional Medicare. A Medicare Advantage plan’s own prior authorization rules still govern its members.

Is the Medicare prior authorization pilot program still in effect?

Yes, as of October 2026. CMS lists the model as active, and the Senate voted not to take up a resolution to overturn it.

Does a patient need to do anything under WISeR?

No. The provider sends the request, and the participant sends the patient a copy of each decision.

What happens if a provider skips prior authorization?

Medicare does not deny the claim for that reason alone. The participant reviews the records first, and a denial after that review can be appealed.

Which clinicians can be exempted from WISeR?

Any clinician in the six states who meets the participant’s criteria, judged one NPI at a time. Each participant publicly posts any criteria it adds to the CMS minimum, so the criteria can differ by state.

This article is general educational information and does not give medical, legal or insurance advice. Medicare rules and the WISeR Model can change, so check the current CMS guidance or ask your Medicare Administrative Contractor about your specific situation.

About the author

Jeffrey Morelli

Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).

Last updated: October 16, 2026.