Original Medicare now has prior authorization in 6 states, including Texas. What WISeR means for you.

Track: Original Medicare

For years, one of the selling points of Original Medicare (also called Traditional Medicare) was simple: almost no prior authorization. You and your doctor decided, and Medicare paid if the care met its rules.

That’s no longer fully true. Since January 1, 2026, a Medicare program called WISeR has added an extra review for a short list of outpatient services in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

I live in Texas and I’m on Original Medicare, so this one is personal. Here’s what WISeR is, who it touches, what the recent reporting found, and what to do if a service you need is on the list.

1. The myth: “Original Medicare never needs prior authorization”

Prior authorization means someone must approve a service before Medicare will pay for it. It has long been standard in Medicare Advantage (MA) plans.

Original Medicare already required it for a handful of hospital outpatient services nationwide. WISeR goes further. It hands the reviews to outside technology companies — firms that already run prior authorization for private insurers — and they use artificial intelligence (AI) tools to help decide.

Bottom line: If you’re on Original Medicare in one of the six states, “no prior auth” is no longer a safe assumption for certain procedures.

2. What WISeR is

WISeR stands for the Wasteful and Inappropriate Service Reduction Model. It’s run by the CMS Innovation Center (CMS is the Centers for Medicare & Medicaid Services, the federal agency that runs Medicare).

The basics, from CMS:

When: January 1, 2026 through December 31, 2031.
Where: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — based on where the service is provided.
Who: Original Medicare only. Medicare Advantage members are not part of WISeR.
How: One private company per state reviews requests with AI-assisted tools. Your provider can ask for approval before the service. If they don’t, the claim is held for a review of your medical records before Medicare pays. CMS says every recommendation not to pay is made by an appropriately licensed clinician, not a computer.
How the companies are paid: CMS pays them a percentage of the spending on care their reviews avert, adjusted for how they score on quality and process measures. Critics, including the Medicare Rights Center, say this rewards denials.
What’s excluded: Emergency services, inpatient-only services, and services that would pose a substantial risk to patients if delayed.

Important: WISeR does not change what Original Medicare covers. It uses Medicare’s existing coverage rules. What changes is when someone checks — before the service, or before the claim is paid.

3. Which services are on the list

WISeR applies to a select group of outpatient services. Examples from CMS’s current provider guide include:

Epidural steroid injections for pain
Knee arthroscopy (a scope procedure) for knee osteoarthritis
Skin and tissue substitutes for chronic, non-healing leg and foot wounds
Nerve stimulator implants, including some for sleep apnea and bladder control
Cervical (neck) fusion
Vertebral augmentation for spinal compression fractures

CMS delayed two services before launch and has revised the details several times since. Don’t rely on this list. Check CMS’s WISeR page, or ask your doctor’s office directly.

Routine lab work and standard imaging are not on the list.

4. Who’s affected

KFF, a nonpartisan health policy research group, estimated that about 207,500 people with Original Medicare in the six WISeR states received at least one WISeR service in 2024 — the year before the model started.

So most people on Original Medicare in these states will never run into WISeR. But if you get pain injections, have a chronic wound, or are considering one of the procedures above, it may affect you.

5. What the September 2026 reporting found

In September, about 1,000 pages of records that the Electronic Frontier Foundation (EFF), a digital-rights group, obtained through a Freedom of Information Act lawsuit became public. As reported:

EFF (September 8, 2026) described long delays on some requests, technical problems at launch, and providers reporting patients in pain while waiting for approval.
STAT News (September 15, 2026) reported that the documents show a rushed, problem-filled launch, including a vendor warning CMS that its launch timeline was unrealistic.
The Medicare Rights Center (September 24, 2026), a consumer advocacy group, wrote that the records and earlier reporting show the model has led to inappropriate delays and denials of care.

These are news and advocacy reports based on the released records, not a CMS evaluation. Bills have been introduced in Congress to stop WISeR. As of this writing, the model is still running.

6. What you’ll actually see — and what to do

Here’s the catch: you usually don’t send the request. Your provider does. The reviewing company is supposed to send you a copy of its decision, but it may not reach you before your appointment. Don’t wait for the mail. Ask.

Before you schedule:

Ask your doctor’s office: “Is this service on the WISeR list?”
If yes: “Did you request prior authorization, and was it approved?” Ask for a copy of the decision.
Write down the date, who you spoke with, and what they said.

CMS’s guide for providers says the reviewing company typically decides within 3 calendar days — or 2 days for an expedited request, when a delay could seriously jeopardize your life, health, or ability to regain maximum function.

If the request was not approved:

The provider can resubmit. CMS allows unlimited resubmissions with more medical records or documentation. Ask your doctor whether they plan to resubmit.
The “no” on a request is not itself appealable. CMS’s rules say it isn’t a decision on a claim, so there’s nothing to appeal yet.
Your doctor can still provide the service and bill Medicare. If Medicare then denies the claim, that denial is appealable.

If you might get an ABN:

An Advance Beneficiary Notice of Non-coverage (ABN) is a form your provider gives you before a service, saying Medicare may not pay and asking whether you’ll pay if it doesn’t. CMS’s guide says that after a “no,” the provider should give you an ABN before going ahead. Read it before you sign. Without a valid ABN signed before the service, you generally owe nothing on a medical-necessity denial. More on your ABN rights: medterpret.com/abn-rights

If the service is done and the claim is denied:

You’ll see the denial on your Medicare Summary Notice (MSN), the statement Medicare mails every few months. From there, the normal Original Medicare appeal process applies: you have 120 days from receiving the MSN to ask for a redetermination (Level 1 appeal).

Few denials are ever appealed. In calendar year 2025, only 2% of denied Original Medicare claims were appealed to Level 1, counting appeals by patients and providers alike. Among Part B claims decided at Level 1 that year (all appellant types, including providers, excluding dismissals), 45% were fully favorable and 3% partially favorable.

Keep records: the request decision, any ABN, the MSN, and notes from every call.

What to do this week

[ ] If you’re on Original Medicare in NJ, OH, OK, TX, AZ, or WA, check CMS’s WISeR page for the current service list.
[ ] Planning a procedure? Ask your doctor’s office if it’s a WISeR service and whether it’s been approved.
[ ] Ask for copies of any decision letter. Log every call.
[ ] Don’t sign an ABN without reading it.
[ ] Watch your MSN. If a claim is denied, mark the 120-day deadline on your calendar.

Bottom line: WISeR is small, but it’s real — and it’s in Texas. Ask before you schedule, keep your paperwork, and remember that a denied claim can be appealed.

Got a denial or a confusing notice? Upload your MSN to Medterpret and see what it says, what it means, and what to do next — in plain English. Medterpret drafts the redetermination document and calculates your deadline; you decide what to send. Appeal a denial →

Founding members: $69 a year, locked in for as long as you stay a member. Open to the first 500 members or through December 31, 2026, whichever comes first. Reserve My Founding Rate (no card needed). Founding rate →

Medterpret is independent and not affiliated with or endorsed by Medicare, CMS, HHS, or any government agency. Educational information, not legal or medical advice.

More for Original Medicare: medterpret.com/original-medicare

Sources

“WISeR (Wasteful and Inappropriate Service Reduction) Model,” CMS Innovation Center, accessed Sept. 29, 2026 cms.gov
“WISeR Model Provider and Supplier Operational Guide,” Version 7.0, CMS, July 24, 2026 cms.gov
“CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare,” CMS press release, June 27, 2025 cms.gov
“Final List of Outpatient Department Services That Require Prior Authorization,” CMS, accessed Sept. 29, 2026 cms.gov
“Examining the Potential Impact of Medicare’s New WISeR Model,” KFF, Feb. 10, 2026 kff.org
“New Records Reveal Problems with Medicare’s AI Prior Authorization Experiment,” Electronic Frontier Foundation, Sept. 8, 2026 eff.org
“Medicare’s AI prior authorization pilot was rushed and full of problems, new documents reveal,” STAT News, Sept. 15, 2026 statnews.com
“New Records Show Medicare WISeR AI Prior Authorization Model Causing Inappropriate Denials of Care,” Medicare Rights Center, Sept. 24, 2026 medicarerights.org
H.R. 5940, Seniors Deserve SMARTER Care Act of 2025 (introduced Nov. 7, 2025), U.S. Congress congress.gov
“Original Medicare Claim Appeals Data – 2025” fact sheet, CMS (in the “Appeals Fact Sheets” ZIP on the page “First Level of Appeal: Redetermination by a Medicare Contractor”), accessed Sept. 29, 2026 cms.gov