CMS just made Medicare prior auth mandatory for pain management.
The WISeR (Wasteful and Inappropriate Service Reduction) Model targets 17 interventional pain procedures across 8 pilot states. If you perform these procedures on traditional Medicare patients, every claim now requires prior authorization.
What is the WISeR Model?
In plain language: CMS reviewed utilization data for interventional pain procedures and decided some regions have higher-than-expected volumes. Their solution is mandatory prior authorization — before you can perform the procedure, you need approval.
This is the first time Medicare FFS has required PA at this scale. It affects an estimated 7,000+ pain management practices in the pilot states. The model runs from 2026 through 2031.
The 17 targeted procedures
Every one of these now requires PA for Medicare FFS in pilot states.
Pilot states: Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington, and additional states to be announced.
What this means for your practice
New denial category
Procedures that previously went straight through now require documentation you may not have assembled. Missing PA = automatic denial. No exceptions.
Financial exposure
A typical interventional pain practice performing 60–80 targeted procedures per month faces $150K–$250K in annual exposure from WISeR-related denials alone.
AI review requires AI prep
CMS uses AI-assisted review to evaluate PA requests. Your submissions need to be precise, evidence-complete, and formatted for algorithmic evaluation — not human judgment.
How PreClaim handles WISeR
WISeR Compliance Module
Automatically identifies which appointments require WISeR PA based on CPT code, payer, and state. Flags them in the daily queue with specific documentation requirements.
Impact Analyzer
Shows your total WISeR financial exposure — procedure by procedure. Projects denial risk based on your current documentation patterns.
Conservative Care Ladder Tracking
Maps each patient's conservative care history against WISeR requirements. Shows exactly which escalation steps are documented and which are missing.
Gold Card Pathway
Tracks your PA approval rate toward the ≥90% threshold for gold card exemption. Once qualified, WISeR PA is waived for your facility.
Get your free WISeR Impact Report
Upload your 835 data. We'll show your exact WISeR exposure — which procedures, how many patients, and the projected dollar impact.
Free WISeR Assessment