The Centers for Medicare & Medicaid Services (CMS) continues to explore strategies to reduce wasteful and inappropriate care while protecting patient outcomes and taxpayer dollars. One of the newest initiatives is the Wasteful and Inappropriate Service Reduction (WISeR) Model, an Innovation Center model that will directly affect select services commonly used in wound care - most notably skin substitutes, also known as cellular and/or tissue-based products (CTPs) or Cellular, Acellular, and Matrix-like Products (CAMPS).
This post provides an overview of what WISeR is, why it was developed, how it works, who is affected, and what wound care providers should expect, with a focused discussion on skin substitute utilization. For a deep dive on skin substitutes updates, see "Skin Substitutes - What’s New in 2026? Navigating CMS Payment Changes".
What Is the WISeR Model?
According to CMS, the WISeR model is a Center for Medicare and Medicaid Innovation (CMMI) that tests the use of enhanced technologies, such as artificial intelligence and machine learning tools, to ensure that items and services furnished to beneficiaries in Original Medicare are in line with existing Medicare coverage criteria by working with organizations skilled in these technologies to improve the efficiency and accuracy of medical reviews. By focusing on services vulnerable to fraud and waste, the model seeks to decrease clinically inappropriate care and protect beneficiaries while ensuring continued access to appropriate services.
WISeR is scheduled to run for six performance years from January 1, 2026 to December 31, 2031 in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
WISeR leverages:
- Advanced technologies, including artificial intelligence (AI) and machine learning (ML)
- Human clinical review by appropriately licensed clinicians
- Standardized, evidence-based coverage criteria
The goal is to identify and reduce low-value or inappropriate care earlier in the Medicare claims process, without changing Medicare coverage or payment policy.
Why WISeR Was Developed
Waste in U.S. health care is estimated to contribute to up to 25% of total health care spending. [1]
Low-value or medically unnecessary services may:
- Lack strong clinical evidence
- Fail to align with a patient’s condition or needs
- Increase the risk of complications
- Lead to additional, avoidable services and costs
Original Medicare’s fee-for-service structure pays based on volume, which may unintentionally incentivize overutilization. WISeR was created to address this issue by shifting focus toward evidence-supported care that improves patient outcomes.
WISeR Goals and Strategy
The WISeR Model aims to:
- Focus Medicare spending on items and services that improve patient well-being
- Reduce clinically unsupported care
- Increase transparency around existing Medicare coverage policies
- Decrease fraud, waste, and abuse
- Ease administrative burden by streamlining medical necessity reviews
The model encourages care navigation, empowering patients to partner with their health care providers on clinically appropriate care plans grounded in evidence-based best practices.
How does the WISeR Model Work?
WISeR tests the use of enhanced technology to streamline prior authorization and pre-payment medical review for a pre-selected set of services, including:
- Skin and tissue substitutes
- Electrical nerve stimulator implants
- Knee arthroscopy for knee osteoarthritis
Key design elements include:
- Reviews conducted earlier in the claims process
- Application of publicly available Medicare coverage criteria
- Determinations made by appropriately licensed clinicians
- No changes to Medicare coverage rules or payment rates
WISeR excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if delayed.
Where and When WISeR Applies
- Performance period: January 1, 2026 – December 31, 2031
- States included: Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington
- Medicare population: Original Medicare only (does not apply to Medicare Advantage)
Healthcare coverage for people with Medicare does not change, and beneficiaries retain freedom of choice in providers and suppliers.
Who Participates in WISeR
The technology firms that conduct and oversee the pre-authorization and pre-payment audits are referred to as participants.
WISeR is the first Innovation Center model in which technology companies are the only model participants. These companies apply AI-enabled tools, combined with clinician review, to make recommendations regarding medical necessity.
Participants are compensated based on averted wasteful, inappropriate care, with performance adjustments tied to process measures, including provider and supplier experience.
Provider and Supplier Participation in WISeR: Who Is Impacted?
Two questions determine whether a provider or supplier is impacted by WISeR:
- Does the provider or supplier practice in Arizona, New Jersey, Ohio, Oklahoma, Texas, or Washington?
- Will the provider or supplier deliver at least one of the WISeR-selected items or services to Original Medicare beneficiaries?
If the answer to both questions is yes, the provider or supplier is included in the WISeR model. Patients with Medicare Advantage are not impacted.
How Do Providers and Suppliers Participate in WISeR?
Options for Demonstrating Medical Necessity
Impacted providers and suppliers have two options when delivering WISeR-selected items and services:
Option One: Prior Authorization
- Submit a prior authorization request to the WISeR participant in the state or to the provider’s assigned Medicare Administrative Contractor (MAC)
- The WISeR participant applies existing National and Local Coverage Determinations (NCDs and LCDs)
Option Two: Pre-Payment Medical Review
- Provide the service without prior authorization
- Submit the claim, which will then undergo pre-payment medical review
- The WISeR participant will request supporting clinical documentation
Requests may be submitted via mail, fax, Electronic Submission of Medical Documentation, or electronic portal.
Providers with strong compliance histories may eventually qualify for a “gold card” exemption, reducing future administrative burden.
Provider and Supplier Participation in WISeR: Is It Mandatory?
According to the Provider and Supplier Operational Guide:
- Submitting prior authorization requests for WISeR select items and services is voluntary;
- However, if a claim for a WISeR select item or service is submitted without a prior authorization request decision on file, the MAC will suspend the related claim and re-route it to the WISeR participant to conduct pre-payment medical review.
- Note: requesters do not need to do anything different when submitting a claim for a WISeR select item or service without a prior authorization decision or UTN on file. They do not need to put any information in the remarks field or submit any unsolicited documentation at the time of claim submission.
Prior Authorization, Pre-Payment Review, Appeals: How Long Does It Take?
Determination Timeframes and Appeals
- Prior authorization determinations:
- Within 3 days of receipt
- Expedited requests: within 2 days
- Pre-payment medical review:
- Providers have 45 days to submit documentation
- Determination issued within 3 days of receipt of complete documentation
If a non-affirmation is issued, providers may:
- Resubmit with additional documentation (no limit on resubmissions)
- Request peer-to-peer clinical review
All Medicare appeals rights are preserved for both providers and beneficiaries.
WISeR Model Workflow [2]
Why Does WISeR Matter to Wound Care Providers?
One of WISeR’s primary areas of focus is the use of skin substitutes/ CTPs/ CAMPs for ulcers on the lower extremities:
- Diabetic foot ulcers (DFUs)
- Venous leg ulcers (VLUs)
According to CMS, these therapies are clinically valuable when used appropriately but have historically been identified as high risk for wasteful or unsupported use. Under WISeR, applications of skin substitutes will be subject to prior authorization or pre-payment medical review, with strong emphasis on documentation quality and adherence to coverage criteria.
What are the Documentation Expectations for Skin Substitutes?
The WISeR Model requires clear and complete medical necessity documentation for the application of skin substitutes and provides general documentation guidelines in the document Wasteful and Inappropriate Service Reduction (WISeR) Model Provider and Supplier Operational Guide, Version 2.0 (Current as of 12/18/25).
It’s important for physicians and healthcare providers to follow the specific LCD guidelines for the state in which they practice. For a comprehensive EMR documentation template and medical necessity documentation checklist, refer to topic "Cellular and/or Tissue Based Products".
Prior authorization and pre-payment medical review for Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (LCD L35041) and Wound Application of CTPs, Lower Extremities (L36690) will be implemented only for approved wound type ICD-10 codes.
Accurate HCPCS/CPT and ICD-10 coding aligned with Medicare criteria is essential. See topics "HCPCS/CPT Codes and Physician Fee Schedule Commonly Utilized in Wound Care and HBOT" and " Wound Care ICD-10 Codes for 2026".
What Does WISeR Mean in Practice?
For wound care teams, WISeR is meant to reinforce:
- Payment retainment: once a service such as an application of a skin substitute is approved through the pre-authorization process the decision will not be reversed.
- Stronger alignment with evidence-based practice
- More complete and consistent documentation
- Clear justification for advanced therapies
- Reduced risk of denials through proactive compliance
- While WISeR introduces additional review, its long-term intent is to reduce unnecessary administrative burden, improve care consistency, and preserve access to advanced wound therapies for patients who truly benefit.
Key Takeaways
The WISeR Model does not eliminate skin substitutes - it reinforces appropriate use, per CMS. Success under WISeR will depend on clinical rigor, documentation excellence, and adherence to Medicare coverage policy.
Understanding WISeR now allows wound care teams to prepare, adapt workflows, and continue delivering high-quality, patient-centered care in a rapidly evolving reimbursement environment.
Resources
CMS
WoundReference
