The Centers for Medicare & Medicaid Services (CMS) has announced that Original Medicare will face a series of changes. The Medicare service (United States) offers medical coverage to those beneficiaries who cannot afford it, especially people who are in a more vulnerable situation. However, with the intention of reducing cases of fraud, abuse or misuse of the services provided, the Wasteful and Inappropriate Service Reduction (WISeR) model has been created. The aim is to filter requests for certain services and medical tests, and with the help of technology and Artificial Intelligence, determine whether the person is eligible or not. There are already states that have already implemented it, such as New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington State.
Some of the medical services that will require prior authorization are Parkinson’s disease, obstructive sleep apnea, erectile dysfunction, epidural steroid injection, cervical spinal fusion, among many others. Although the model intends to rely on the use of technology and AI, it is important to emphasize that the last word will always be left to a doctor.
Centers for Medicare & Medicaid Services (CMS)
Medicare is one of the most important social assistance programs in the United States. It is a federal health insurance for people over 65 years old, people with low income, children, pregnant women and people with disabilities. It is a medical coverage that allows these people to be treated without having to face the high cost of health care. In 1965, the Centers for Medicare and Medicaid Services (CMS) was created. They are a federal agency of the U.S. Department of Health and Human Services, whose mission is to manage the operation of both health services. They are centers that provide information on eligibility and enrollment for Medicaid or Medicare and manage claims procedures.
Wasteful and Inappropriate Service Reduction (WISeR) model
If you are a beneficiary of any of these social services or you are planning to benefit from them in the future, you should be aware of the changes that are coming. There are many people who can be treated by a physician thanks to these benefits, but that number of beneficiaries could be in danger. CMS has announced that beginning January 1, 2026, preauthorization will be required for certain physician services, which will be regulated through the new Wasteful and Inappropriate Service Reduction Model (WISeR).
This new initiative aims to filter out unnecessary cases, thus ensuring that taxpayers’ money is not being wasted. How will this filtering be done? The CMS will make use of new technologies, including Artificial Intelligence. In this way they intend to streamline processes and reduce waiting lists and workloads. The use of AI is specifically intended to detect those cases where treatment is not necessary, where it is misused, vulnerable to fraud or waste of money.
States that will implement the WISeR Model
To date, 6 states will implement this new pre-authorization model as of January 1, 2026:
- New Jersey.
- Ohio.
- Oklahoma.
- Texas.
- Arizona.
- Washington.
The use of these new tools by CMS would not be possible without the partnership with specialized review technology companies. They will evaluate and process applications from geographic regions designated by CMS.
Services under pre-authorization
The list of services that will require preauthorization is extensive. It ranges from the most basic treatments to diseases such as Parkinson’s disease. It is important to emphasize that although the technology is in charge of filtering the files, the last word will always be left to a physician. Some of the services that will require this pre-authorization are:
- Electrical nerve stimulators.
- Sacral nerve stimulation for urinary incontinence.
- Phrenic nerve stimulators.
- Deep brain stimulation for essential tremor and Parkinson’s disease.
- Vagus nerve stimulation.
- Induced nerve tract lesions.
- Epidural steroid injections for pain management (excluding facet joint injections).
- Percutaneous vertebral augmentation (PVA) for vertebral compression fractures.
- Cervical spinal fusion.
- Arthroscopic lavage and debridement for osteoarthritic knees.
- Hypoglossal nerve stimulation for obstructive sleep apnea.
- Incontinence control devices.
- Diagnosis and treatment of erectile dysfunction.
- Image-guided percutaneous lumbar decompression for spinal stenosis.
- Skin and tissue substitutes.
Do you have your health insurance with BlueCross BlueShield? Then this article is for you!
