WISeR Model - Arizona and Washington Providers and Suppliers

The Wasteful and Inappropriate Service Reduction (WISeR) Model is a CMS initiative designed to reduce unnecessary and potentially harmful services in traditional Medicare. It leverages artificial intelligence (AI)-enhanced prior authorization and pre-payment medical review to ensure services meet Medicare coverage criteria.

CMS contracted directly with external WISeR Participant technology companies to conduct review and prior authorization activities. Providers should direct all questions related to a WISeR service to their state's assigned Participant.

WISeR does not change Medicare benefits or coverage rules. Instead, it introduces a streamlined review process for select services in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. WISeR model participants will be technology companies with expertise in managing prior authorization, with clinical experts available to conduct medical reviews for the service requiring prior authorization.

Key Objectives

The WISeR Model aims to:

  • Reduce fraud, waste, and abuse.
  • Ensure clinically appropriate care.
  • Maintain beneficiary access to necessary services.
  • Improve review efficiency using technology.

Who Is Affected?

Providers and suppliers are impacted if they operate in one of the six WISeR states and furnish any of the WISeR select items and services to Original Medicare beneficiaries. Medicare Advantage patients are not affected.

WISeR Participation Options

Participation is voluntary. Providers and suppliers have two pathways to receive coverage determinations:

  • Prior Authorization: Submit a voluntary WISeR participant (preferred) or Noridian. Valid for 120 days.
  • Pre-Payment Medical Review: Submit claim without prior authorization. Determination is issued within three days of receiving documentation.

Participant Technology Company

  • Arizona - Zyter Trucare
  • Washington - Virtix Health

WISeR Timeline

  • Start Date: January 1, 2026
  • Prior Authorization Requests Begin: January 5, 2026
  • Services Covered: From January 15, 2026
  • End Date: December 31, 2031

Included Services

WISeR targets services that have existing coverage criteria, are elective or pose safety risks if misused, and are high-volume or high cost. These services are furnished in hospital outpatient departments (OPDs), ambulatory surgical centers (ASCs), physician offices or in the home setting. These services include:

  • Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
  • Induced Lesions of Nerve Tracts (NCD 160.1)
  • Vagus Nerve Stimulation (NCD 160.18)
  • Phrenic Nerve Stimulator (NCD 160.19)
  • Electrical Nerve Stimulators (NCD 160.7)
  • Incontinence Control Devices (NCD 230.10)
  • Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
  • Diagnosis and Treatment of Impotence (NCD 230.4)
  • Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (LCD L34228)
  • Epidural Steroid Injections for Pain Management (LCD L39240)
  • Cervical Fusion (LCD L39758)
  • Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (LCD L38310)

A complete list of select services and corresponding codes can be found in Appendices in the WISeR Model Provider and Supplier Operational Guide, located in the resource section below.

  • Appendix A - WISeR items and services with CPT or HCPCS codes included in review
  • Appendix B - WISeR associated codes list
  • Appendix C - ICD-10 indications for relevant WISeR items and services

Providers may also use the Prior Authorization Look-Up Tool to determine if a code is included in the WISeR program.

Submitting Prior Authorization

WISeR providers and suppliers have two options for submitting a prior authorization request:

  1. Submit a prior authorization request directly to the WISeR participant, or
  2. Submit a prior authorization request to their designated MAC. The MAC forwards the request to the WISeR participant within one calendar day, or as soon as practicable. The WISeR form needed for this process can be found on the Medical Review Forms page.

Depending on which option is used above, PAR submissions can be made using either the WISeR participant or MAC portal. They can also be submitted via fax, esMD, or mail.

  • Noridian WISeR dedicated fax: 701-433-3366
  • Noridian mailing address:
    • Noridian JF Part A
      Attn: Medical Review - WISeR
      PO Box 6782
      Fargo, ND 58108-6782
    • Noridian JF Part B
      Attn: Medical Review - WISeR
      PO Box 6700
      Fargo, ND 58108-6700

In lieu of requesting prior authorization for WISeR select items and services, WISeR providers and suppliers may choose to provide the select item or service without prior authorization and submit the claim for payment. In this case, the MAC will suspend the claim and forward it to the WISeR participant for pre-payment medical review.

Regarding surgery authorization, either the provider or the facility is responsible for submitting the request. The one that obtains the UTN shares it with the other to submit the claim. The same UTN is used by both the provider and the facility.

Third parties may submit a request on behalf of the provider as long as they have written permission, and applicable patient information to support the procedure. Templated language for all patients receiving a particular service is not acceptable. Information would be unique to each patient, including past treatment options when necessary.

Completing the Request

  • Type of Service: Providers can find a complete listing under Section 10.7 of the CMS Internet Only Manual (IOM) Publication 100-04, Chapter 26. It explains the Type of Service (TOS) and indicates either a one-digit numbering (0-9) or alpha (A-W). For example, 2=Surgery and S=Surgical Dressings or Other Medical Supplies.
  • Bilateral Procedures: Request whichever code is appropriate to the service being performed. There is no need to request the same code multiple times if the documentation indicates it is bilateral. If concerned, submit the single code once and add in multiple units.
  • Unique Tracking Number (UTN): Approved requests are given a UTN, which is valid for 120 days.
  • Number of Units: The CPT entry should include the total number of units expected to be performed during the 120-day timeframe.
  • Ambulatory Surgical Center (ASC): For WISeR, when services are rendered at an ASC under Part B, the ASC must request its own prior authorization.
  • Member ID: The 11-digit member ID number is the Medicare Beneficiary Identifier (MBI) ID number found on their Medicare Card.
  • The Noridian Prior Authorization Request Coversheet is not required; however, it contains all of the necessary information. Providers may create their own coversheet as long as all of the CMS Operational Guide requirements are met.

Review Process

  • Standard Review: Decision within three days.
  • Expedited Review: Decision within two days if health is at risk.
  • Denied Requests: Request peer-to-peer review, resubmit with additional evidence, or choose not to provide the service.
    • If a code from Attachment A is denied, the associated code from Attachment B is also denied.

Status Requests

To obtain a status update, The provider/portal must have submitted the request through the Participant's portal to track updates:

Zyter Trucare - Arizona

Virtix Health - Washington

Claim Submission

  • Claims with affirmed prior authorization must include the Unique Tracking Number (UTN).
  • Claims without prior authorization will undergo pre-payment review.
  • Associated services may be denied if the primary service is denied.

Appeals

Non-affirmation decisions are not appealable. Denied claims can be appealed through standard Medicare processes.

Exemptions

Exemptions from other prior authorization programs are not recognized in the WISeR model. CMS may implement automatic exemptions for providers with consistent compliance. Details will be released in future updates.

Special Considerations

An Advance Beneficiary Notice (ABN) is required for expected denials. Claims from VA, IHS, Medicare Advantage, and emergency services are excluded.

Resources

Last Updated Feb 05 , 2026