Prior authorization is now running inside Original Medicare in six states. The CMS Innovation Center’s WISeR model began on January 1, 2026 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, and six private companies, one per state, review the requests.
The reviews apply to services CMS says have been a source of fraud, waste and abuse, including skin and tissue substitutes, implanted electrical nerve stimulators and knee arthroscopy for knee osteoarthritis. Medicare’s usual appeal rights remain in place.
Inside the kit: The Medicare Cost & Coverage Protection Kit lays out the prior-authorization appeal steps alongside a medication and cost tracker.
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The six WISeR companies and the state each one covers
The CMS Innovation Center’s WISeR model page lists the participating companies and the Medicare Administrative Contractor (MAC) jurisdiction each one works within:
- Cohere Health, Inc.: Texas (JH, Novitas)
- Genzeon Corporation: New Jersey (JL, Novitas)
- Humata Health, Inc.: Oklahoma (JH, Novitas)
- Innovaccer Inc.: Ohio (J15, CGS)
- Virtix Health LLC: Washington (JF, Noridian)
- Zyter Inc.: Arizona (JF, Noridian)
The page, which CMS last updated on September 30, 2026, says the model will run for six performance years, from January 1, 2026 to December 31, 2031. It does not apply to Medicare Advantage enrollees, and it excludes emergency services and inpatient-only services. The provider guide for the model says requests began to be accepted on January 5, 2026 for services furnished on or after January 15, 2026, according to the WISeR Provider and Supplier Operational Guide.
When CMS announced the model on June 27, 2025, Administrator Dr. Mehmet Oz said in the agency’s press release: “CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare.” Abe Sutton, director of the CMS Innovation Center, said: “Low-value services offer patients minimal benefit and, in some cases, can result in physical harm.”
Skin substitutes, nerve stimulators and knee arthroscopy are three of 13 active services
The model page names three examples of the “select items and services” under review: skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis. The operational guide carries the longer list. It names 13 active services: knee 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 fracture; epidural steroid injections for pain management; cervical fusion; hypoglossal nerve stimulation for obstructive sleep apnea; and bioengineered skin substitutes for lower-extremity chronic non-healing wounds.
Two further services, deep brain stimulation and percutaneous image-guided lumbar decompression, have delayed implementation and did not start on January 1, 2026, the guide says. The three services named on the model page are all on the active list, so they are a subset of the reviews, not the whole of them.
How a WISeR request moves from the provider to a decision
Providers may submit prior-authorization requests to the participating company directly or through their MAC, per the model page. The guide says participants will typically issue a determination within 3 calendar days, and within 2 days for an expedited request. All recommendations for non-payment are determined by appropriately licensed clinicians, CMS says.
The WISeR Model FAQ describes what follows a non-affirmed determination. The participant notifies the requesting provider, and “the physician will be required to notify the beneficiary through an Advanced Beneficiary Notice of Non-Coverage (ABN) before furnishing the service.” Providers “have unlimited opportunities to resubmit a request.”
A provider that skips the request does not escape review. The guide says the MAC will suspend the claim and forward it to the WISeR company for pre-payment medical review, with 45 calendar days to submit documentation. If that review ends in non-affirmation, the claim faces denial.
Appealing a non-affirmed decision through the Medicare Summary Notice
The FAQ states that “all appeals rights are preserved under WISeR and the provider and beneficiary have the right to appeal any denied claims.” A non-affirmed service can still be furnished and billed, and in that case “providers, suppliers and people with Medicare will have the ability to appeal claims decisions as usual.”
The ordinary Original Medicare process is described on Medicare.gov. It has five levels: redetermination by the MAC, reconsideration by a qualified independent contractor, a hearing before an administrative law judge, review by the Medicare Appeals Council, and federal district court. The first appeal is made on the Redetermination Request form or by following the instructions on the Medicare Summary Notice (MSN), and it goes to the MAC whose address is on the last page of that notice. The page says the appeal must be filed by the date printed on the MSN, and that a late appeal can still be heard if good cause is shown, such as a disability, illness or accident that delayed it. Medicare lists 1-800-MEDICARE (1-800-633-4227) for questions about the process.
The model does not change what Medicare covers. The model page says coverage for people with Medicare does not change and that they keep the freedom to seek care from the Original Medicare provider or supplier of their choice.
A different reviewer in each state, and a notice that arrives through the provider
The difficulty CMS’s own documents describe is one of visibility. The request is filed by the provider, not the patient, so the first sign of a problem for a patient in New Jersey, Ohio, Oklahoma, Texas, Arizona or Washington can be an ABN from the physician. The company behind the decision differs by state: Genzeon in New Jersey, Innovaccer in Ohio, Humata Health in Oklahoma, Cohere Health in Texas, Zyter in Arizona and Virtix Health in Washington.
A patient who proceeds after a non-affirmed decision is in a different position from one who waits. The service can be furnished and billed, the claim can go through pre-payment review, and a denial is then handled through the appeal levels on the MSN’s schedule. The operational guide does not state what a beneficiary pays if a service is furnished after non-affirmation, so that question turns on the ABN the provider issues and the notice that follows the claim.
The official route needs nothing purchased. The provider’s request goes to the WISeR company, a denied claim is appealed directly to the MAC named on the MSN, 1-800-MEDICARE answers questions, and the State Health Insurance Assistance Programs listed on Medicare.gov offer free counseling. None of the CMS or Medicare.gov pages cited here lists a charge for filing a Medicare appeal.
The WISeR appeal path in Original Medicare
A non-affirmed WISeR decision leaves a patient choosing between waiting for a resubmission and going ahead with a claim that may be denied. The appeal that follows runs through a notice, a regional contractor and a filing date, and the reviewing company is different in each of the six states.
The Medicare Cost & Coverage Protection Kit is a 10-page kit that includes the prior-authorization appeal steps and a medication and cost tracker.
Open the prior-authorization appeal steps before a decision lands →
This article was drafted with AI assistance and checked line by line against the CMS model page, FAQ, operational guide and Medicare.gov appeal pages.
David M. Keller is a finance writer based in Columbus, Ohio, covering personal finance and consumer-focused economic topics. He earned his degree in journalism from Ohio University and began his career reporting on local business and economic trends for a regional media outlet. Since then, he has contributed to a variety of online publications, focusing on clear, practical coverage of topics such as cost of living, debt, and everyday financial decision-making.
