WISeR in New Jersey: CMS Prior Authorization for Medicare

Overview

What is WISeR?

Importantly, WISeR does not change Medicare coverage or payment policy. It supports accurate, efficient compliance with existing National and Local Coverage Determinations.

The Wasteful and Inappropriate Service Reduction (WISeR) Model is a voluntary six-year CMS Innovation Center program designed to reduce unnecessary or inappropriate services in Original Medicare (Part A & B) for selected items and services. WISeR uses enhanced technologies—like AI and machine learning—combined with human clinical review to streamline decisions and protect beneficiaries and taxpayers.

WISeR launches January 1, 2026 and runs through December 31, 2031 in six pilot states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. In New Jersey, WISeR prior authorization and pre-payment medical review activities are administered through Novitas (Jurisdiction H) with Genzeon providing the technology platform and operational support.

How the WISeR Program Works

WISeR is built to make reviews more predictable and less burdensome, while aligning with existing Medicare rules.

WISeR Request Process:

Provider submits a prior authorization (PA) request for a WISeR-included service rendered in New Jersey.
Technology-enhanced review flags completeness.
Review checks documentation against current Medicare coverage criteria.
Human clinical validation occurs when needed to confirm medical necessity.
Determination returned within CMS-defined timeframes.

If a claim is submitted without required PA, it may enter pre-payment medical review.

Webinar

Wasteful and Inappropriate Service Reduction (WISeR) Model - New Jersey Providers

Thursday, Dec. 18, 2025 – 1 – 2:30 PM EST

Join this webinar to prepare for the WISeR prior authorization process in NJ, learn more about Genzeon, and to get answers to your questions.

Audience: This presentation is intended for Part A and B Medicare providers rendering services in New Jersey only.

Services Requiring Prior Authorization

Nerve Stimulation

Electrical Nerve Stimulators
Sacral Nerve Stimulation for Urinary Incontinence
Phrenic Nerve Stimulator
Vagus Nerve Stimulation
Induced Lesions of Nerve Tracts
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Pain and Spine

Epidural Steroid Injections for Pain Management
Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
Cervical Fusion

Skin and Tissue Substitutes

Only applicable to selected WISeR MAC jurisdictions and states with an active LCD in place during the WISeR PYs starting on January 1, 2026, as of November 21, 2025

Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities

Other Services

Incontinence Control Devices
Diagnosis and Treatment of Impotence

References

Provider and Supplier Operational Guide

Wasteful and Inappropriate Service Reduction (WISeR) Model

Provider and Supplier Operational Guide, Version 2.0

Learn More

Model Details (CMS)

The Wasteful and Inappropriate Service Reduction (WISeR) Model will help protect American taxpayers by leveraging enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review, to ensure timely and appropriate Medicare payment for select items and services.

CMS WISeR Fact Sheet

Covers overview, goals, participation, coverage/payment policies, impact, and payment overview.

WISeR Model Frequently Asked Questions

Common questions including those for coverage policies, protections of patients, and scope of services.

Learn More

Federal Register Notice

CMS-5056-N. Full document details as recorded in the Federal Register, as of July 1, 2025.

Frequently Asked Questions

No. WISeR uses existing Medicare coverage policies; it’s about how reviews happen, not what is covered.

January 1, 2026, and runs through December 31, 2031.

WISeR is a voluntary model for vendors/MAC operations, but prior authorization is required for included services furnished in pilot states.

Platforms

CMS WISeR Model - NJ

What is WISeR?

How the WISeR Program Works

Wasteful and Inappropriate Service Reduction (WISeR) Model - New Jersey Providers