Sadder but Wiser, by Chuck Webb, MD (Article submitted to LifeLine, NaCCRA's Newsmagazine, 12/9/2025)
As we see CMS seeking to undermine Traditional Medicare, here is the 2026 foray:
On June 27, the Centers for Medicare & Medicaid Services (CMS) announced the implementation of an Innovation Center model to help ensure beneficiaries in Traditional Medicare receive safe, effective, and necessary care. WISeR (Wasteful and Inappropriate Service Reduction) will introduce prior authorization to Traditional Medicare. Using artificial intelligence (AI), seventeen procedures will be reviewed to assess their necessity. The initial phase will run from 2026 to 2031 in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington). See “CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare” https://www.cms.gov/newsroom/press-releases/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare, June 27, 2025.
“CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.” The news release continues, “Wasteful care, including services that provide little to no clinical benefit, not only increase costs, but also put patients at risk. Waste in healthcare represents up to 25% of healthcare spending in the United States. The Medicare Payment Advisory Commission (www.MedPAC.gov) estimates that up to $5.8 billion in Medicare spending in 2022 alone was spent on services with minimal benefit.
Seventeen procedures were selected for inclusion: 1) electrical nerve stimulators, 2) sacral nerve stimulators for urinary incontinence, 3) phrenic nerve stimulators, 4 and 5) deep-brain stimulators for essential tremor or for Parkinson’s disease, 6) vagus nerve stimulators, 7) induced lesions of nerve tracts, 8) hypoglossal nerve stimulation for obstructive sleep apnea, 9) epidural steroid injections for pain management, 10) percutaneous vertebral augmentation for vertebral compression fractures, 11) cervical fusions, 12 and 13) arthroscopic lavage and arthroscopic debridement for knee osteoarthritis, 14) incontinence control devices, 15) diagnosis and treatment of impotence, 16) percutaneous image-guided decompression for lumbar spinal stenosis, and 17) skin and tissue substitutes. CMS may add additional services in future years.
Reducing wasteful spending is important. Medicare is a one-trillion-dollar program. MedPAC reported that Medicare Advantage (MA) wasted $84 billion in government funds in 2022. It would make sense for CMS to reform MA. The WISeR program contradicts this logic and makes reform of MA much less likely.
WISeR will contract with private companies experienced in using these AI technologies to determine the medical necessity of these services. Many of these companies are currently working with Medicare Advantage. CMS has reassured clinicians that any AI recommendation to deny services will be reviewed by the clinical staff employed by these companies.
Companies doing these prior authorizations will receive half of any savings resulting from care denials (splitting the cost savings with the government). Any of these 17 services performed in these states without a prior authorization request from physicians will still undergo this review process when the government considers payment. Clinicians will thus choose between the risk of delayed or denied care and the risk of delayed or denied reimbursement. The system will have strong incentives to restrict access to care. It risks denying and delaying needed care and straining already overburdened clinicians. Proliferation of Prior Authorization in Traditional Medicare—None the WISeR? NEJM Oct 16, 2025;393:1457-1459