These days, I often receive questions from friends of my parents' generation asking if Original Medicare requires prior authorization.

In the past, this was generally true. However, starting in 2026, this will change in Arizona for certain procedures.

The name of the model is WISeR, which stands for Wasteful and Inappropriate Service Reduction. It is a pilot program conducted by the CMS Innovation Center (CMMI).

There are six states involved: Arizona, Washington, New Jersey, Ohio, Oklahoma, and Texas.

The duration is from January 1, 2026, to December 31, 2031, making it a six-year program. This is not a short pilot project. Honestly, I was a bit surprised by the initial duration.

First, let's clarify the reassuring part. CMS has specified that this model does not apply to Medicare Advantage enrollees.

Emergency services, inpatient-only services, and services that pose significant risks to patients if delayed are also excluded. This means you won't be in a situation where you have to wait for approval after going to the emergency room.

So, what is included? Items such as implantable electrical nerve stimulators, epidural steroid injections for pain management, arthroscopic procedures for degenerative knee arthritis, and skin and tissue substitutes are included. Most of these procedures are scheduled and performed on an outpatient basis.

Procedures like percutaneous vertebroplasty for spinal compression fractures and sublingual nerve stimulators for sleep apnea are also on the list. These are items that CMS considers low-value services.

Arizona falls under the JF region managed by Noridian. The participating company responsible for the actual reviews is a tech company called Zyter.

These companies use AI and machine learning tools combined with clinical expert reviews to handle prior authorizations. However, CMS has mandated that a human clinical review must occur before any denial.

According to Noridian's guidelines, Arizona and Washington began accepting requests on January 5, 2026. The procedures subject to this model are those performed after January 15.

Interestingly, prior authorization is optional for healthcare providers. They can choose to obtain approval in advance or simply bill for the service.

However, if they bill without prior approval, the claim will be put on hold, and the participating company will request medical records for review. Ultimately, a review is unavoidable regardless of the route taken. If I were in a hospital's position, I would opt to seek prior approval.

The processing time is reported to be three business days for standard requests and two business days for urgent requests. Keep in mind that this is based on when all necessary documents are submitted.

From the patient's perspective, the application paperwork is usually submitted by the hospital. Still, it's a good idea to ask during your appointment if the procedure is subject to WISeR and whether approval has been obtained.

According to CMS, the Medicare coverage itself will not change, and existing appeal rights will remain intact. If a claim is denied, don't just give up; you should check the appeal process.

Analysis from KFF indicates that in 2024, there were 1.1 million Original Medicare beneficiaries who received services subject to WISeR nationwide. Of those, 207,500 were from the six states, accounting for 19.7%.

That's a surprisingly large number. In places like Arizona, which has a significant retirement population, the impact may be even more pronounced. You've probably heard discussions about knee or back procedures at least once around you.

There are certainly controversies. KFF pointed out that participating companies can receive a portion of the savings generated from denied services.

This has led to criticism that increasing denials creates a financial incentive. Conversely, CMS has stated that it will respond to inappropriate denials with payment reductions or contract terminations.

There has also been political contention. Democratic senators introduced a resolution to eliminate this model through the Congressional Review Act (CRA).

However, it was defeated in a Senate vote in July by a margin of 46 to 50. Realistically, WISeR is likely to continue for the time being.

Personally, I understand the rationale behind this direction. It makes financial sense to prevent taxpayer money from being wasted on procedures with weak evidence of effectiveness.

However, I believe that the transparency of AI reviews and the incentive structures for companies need to be continuously validated with data. Even if the intent is good, if the execution is poor, it ultimately harms patients.

In summary, if you are facing certain procedures under Original Medicare in Arizona, check whether prior authorization is required.

If you are a Medicare Advantage enrollee, this model does not apply to you. Instead, you should follow the prior authorization rules of your original plan. Most Medicare Advantage enrollees typically undergo prior authorization for some services.

You can find the list of applicable items and detailed conditions on the CMS WISeR page and Noridian JF guidelines. Since applicability may vary based on individual circumstances, be sure to confirm with your doctor or a Medicare counseling expert.

If I were you, I would get confirmation of the approval request via text or email before scheduling the procedure. That record can be quite reassuring if a claim is later put on hold.