12/20/2025    David Freedman, DPM

WiSeR Model for prior authorization effective 1/1/2026, who needs to participate?

I saw the WiSeR prior authorization model is
effective 1/1/2026 for Medicare, what services are
a practice required to get prior authorization? Is
it just for a handful of states or all Medicare
areas?

Codinghelpline.com Subscriber

Response from Codinghelpline.com: Only 15 services
are included in this new model (one of which is
skin substitute / CTP application to DFU's and
VLU's). It is only for Medicare Part B
beneficiaries and only for services performed in
certain sites of service. It is a model program in
6 states: New Jersey, Ohio, Oklahoma, Texas,
Arizona, and Washington.

The Model can only be in effect where there is an
active LCD / NCD for the service in the state
where the service was provided at the time the
service was provided. Therefore, the skin
substitute item will not apply to any of the six
states listed which does not have an active LCD
for the service at the time the service was
provided. The only Part B MAC LCDs that exist for
skin substitute application are limited in scope
to diabetic foot ulcers and venous leg ulcers.

1) Make sure you check you MAC if you are in one
of these 6 states on 1/1/2026 to see their
instructions.

2) Please note this process is voluntary according
to CMS. If you perform a service eligible for the
WISeR Model, and choose to not submit a prior
authorization request, the claim will be subject
to pre-payment medical review by your MAC.

3) If you submit a request for prior authorization
under this model, you will submit documentation
that should support coverage of the service. After
receipt of this documentation, CMS states a
notification of affirmation or non-affirmation
will be returned to the provider within 3 days.

David Freedman, DPM, Silver Spring, MD

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