(June 23, 2026): This week, the U.S. House of Representatives' Appropriations Committee approved draft Fiscal Year (FY) 2027 appropriations language covering the Department of Health and Human Services (HHS). If ultimately enacted, this appropriations language will bar the use of federal funds to implement the Centers for Medicare & Medicaid Services’ (CMS) “Wasteful and Inappropriate Service Reduction” (WISeR) Model, or any similar model that imposes prior authorization in traditional Medicare.[1] While this development is important, until the appropriations rider is enacted into law, the WISeR prior authorization and prepayment review program will remain active. Therefore, affected health care providers in the affected states should continue to comply with program requirements while preserving their right to appeal any denials issued by CMS’s contractors. If the appropriations rider is ultimately enacted, CMS would likely be prohibited from using appropriated FY 2027 funds to continue operating the WISeR program, which, on a prospective basis, should suspend or end the WISeR-Model initiative. Even then, however, providers should not assume that prior claim denials and any related administrative actions will automatically be vacated.
I. WISeR Model Basics:
In late 2025, we published several detailed articles examining the WISeR Model. A link to the primary detailed article on this topic is noted in the footnote below. [2] As a refresher, WISeR basics are provided below:
- What is the WISeR Model? Simply put, the WISeR Model initiative is one of CMS’s latest efforts to leverage artificial intelligence (AI) and other progressive technologies to supplement human clinical medical review and payment audits. The WISeR Model is being managed by the agency’s Center for Medicare and Medicaid Innovation (CMMI). CMMI is using the WISeR Model to conduct prior authorization and prepayment reviews for a select group of traditional Medicare fee-for-service claims.
- Which States are Currently Included in the WISeR Model Initiative? Initially, the WISeR model has only been implemented in connection with traditional Medicare fee-for-service claims in six states: (1) Arizona, (2) New Jersey, (3) Ohio, (4) Oklahoma, (5) Texas, and (6) Washington. Is your state not listed? Before you get your hopes too high, if Congress does not pull funding for this initiative, we fully expect CMS to expand prior authorization mandates to other states.
- How Long is the WISeR Model Scheduled to Last? The WISeR Model is currently scheduled to run from January 1, 2026, to December 31, 2031.[3] However, if CMS finds that the WISeR Model was successful in preventing improper payments for certain high-dollar services or procedures, we have no doubt that the initiative will be extended (as CMS expanded the scope and duration of the agency’s TPE audit program[4]).
- Which Organization is Responsible for Conducting WISeR Model Reviews? CMS has contracted with private companies to conduct the WISeR Model preauthorization assessments and prepayment reviews. These private companies are referred to in the program as “Participants.” A list of the Participant companies is listed in the current version of the CMS “WISeR Provider and Supplier Operational Guide.”[5]
- Which Service Categories and Procedures are Covered Under the WISeR Model? In addition to the scope and anticipated duration of the initiative, CMS has limited the specific services and procedures covered under the WISeR Model to select high-dollar claims. The service categories subject to preauthorization and prepayment review were narrowed when the WISeR Model initiative went into effect. The remaining service categories listed below are currently subject to pre-authorization and prepayment review[6]:
| Service Categories / Procedures Impacted and Applicable Coverage and Payment Guidance |
|
|---|---|
| 1 | Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee |
| 2 | Induced Lesions of Nerve Tracts (NCD 160.1) |
| 3 | Vagus Nerve Stimulation (NCD 160.18) |
| 4 | Phrenic Nerve Stimulators (NCD 160.19) |
| 5 | Electrical Nerve Stimulators (NCD 160.7) |
| 6 | Incontinence Control Devices (NCD 230.10) |
| 7 | Sacral Nerve Stimulators for Urinary Incontinence (NCD 230.18) |
| 8 | Diagnosis and Treatment of Impotence (NCD 230.4) |
| 9 | Percutaneous Vertebral Augmentation for Vertebral Compression Fracture (L34228, L38201, L35130) |
| 10 | Epidural Steroid Injections for Pain Management (L39015, L39240, L36920) |
| 11 | Cervical Fusion (L39741, L39758, L39793) |
| 12 | Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (L38307, L38310, L38385) |
| 13 | Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041) and Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690) |
II. Industry and Patient Concerns Regarding the WISeR Model Initiative:
Since its first announcement by CMS, the WISeR Model initiative has drawn substantial criticism from health care providers, suppliers, industry associations, and patients. These groups of detractors have expressed a wide variety of reasons for opposing the program:
- Health Care Provider and Patient Concerns with Preauthorization Mandates. The implementation of the WISeR Model changes the playing field for providers and patients who have historically enjoyed the freedom of ordering medically necessary services and procedures to traditional, fee-for-service Medicare patients without having to seek preauthorization approval. The introduction of this new requirement delays care and is yet another effort by CMS contractors to substitute their judgment for that of health care providers who have actually evaluated a patient.
- The WISeR Program is Yet Another Bounty Hunter Audit Program. The WISeR Model initiative relies on CMS-engaged private contractors (known as Participants) whose compensation is tied, at least indirectly, to reductions in utilization or expenditures. In other words, it is in the Participants' business interests to deny preauthorization or payment after conducting a prepayment review of a claim.
- The WISeR Model Relies on Unproven, Non-Validated AI-Assisted Reviews. It is somewhat ironic that CMS has contracted with private companies to use AI-enhanced audit methodologies to assist in clinical decision-making and claim payment, while at the same time, the U.S. Department of Justice (DOJ) has publicly expressed its concerns that AI-enhanced business and technology systems may make determinations. uses algorithmic or AI-assisted review processes with limited transparency.
- The WISeR Model Initiative Imposes Another Layer of Possible Audit Burden. Medicare providers and suppliers are suffering from audit fatigue. As a Medicare-participating provider, you may be subject to audit and investigation by a wide range of law enforcement entities and CMS contractor organizations. The WISeR Model initiative is the proverbial “icing on the cake.”
Liles Parker attorneys have previously written about these concerns, including the structural risks created when Medicare review programs combine opaque decision-making, contractor incentives, and compressed provider response time limits. [7]
III. What Did the House Appropriations Committee Approve?
In November 2025, House Democrats first introduced legislation that would have effectively terminated the WISeR Model initiative.[8] While these initial efforts have not been successful, follow-up efforts to defund the WISeR Model may actually work. Earlier today, the House Appropriations Committee approved draft appropriations language prohibiting the use of appropriated funds for WISeR or a similar model during FY 2027.[9] As reported, the rider would bar the use of funds made available in the appropriations act to implement the WISeR model or “any such model” that imposes prior authorization in traditional Medicare. If enacted in final appropriations legislation, that language will be legally binding on CMS. If Congress ultimately enacts a funding prohibition covering the WISeR Model initiative, CMS will likely have to suspend the program for FY 2027.
IV. Conclusion -- What Should Affected Health Care Providers Do Now?
As of today, the WISeR Model is alive and ongoing. Although an effort to defund the program has been approved by the House Appropriations Committee, it is only the first of several steps required to suspend or terminate the program. To become law:
- The full House must pass the Appropriations Committee Bill.
- The Senate must approve the House Appropriations Bill. These Bills rarely pass through the Senate without changes, narrowing, or slashes to the language.
- Once the Senate marks up the proposed Appropriations Bill, it must go through and pass both the House and the Senate.
- Once both chambers of Congress have agreed on language and approved the Bill, it would have to be signed into law by the President. In light of the administration’s efforts to reduce improper billing and fraud, this might be difficult.
A more conservative prediction is that the House and Senate will continue to fund the government through the use of one or more continuing resolutions. If that occurs, the Appropriations Committee Bill is likely dead in the water. The bottom line is that health care providers and suppliers affected by the WISeR Model Initiative will continue to have targeted services subjected to preauthorization and prepayment review. It is therefore essential that providers ensure their services are medically necessary, properly documented, accurately coded, and billed. Remember, claims that are denied in connection with the WISeR Model initiative can lead to even more serious adverse administrative consequences. CMS is aggressively revoking the billing privileges of Medicare providers and suppliers found to have a pattern or practice of improperly ordering medically unnecessary Part B services. [10]
- [1] House Appropriations Committee, Fiscal Year 2027 Labor, Health and Human Services, Education, and Related Agencies Bill materials (approved June 9, 2026). https://appropriations.house.gov/
- [2] An overview of the WISeR Model is covered in our article titled “Overview of the WISeR Model: How Should Your Practice Respond?”
- [3] CMS, WISeR (Wasteful and Inappropriate Service Reduction) Model Overview. https://www.cms.gov/priorities/innovation/innovation-models/wiser
- [4] For an overview of the TPE audit initiative, please see our article titled “TPE Audits: The Process & Expected Targets in 2023.”
- [5] WISeR participants are listed on page 7 of the “CMS WISeR Model Provider and Supplier Operational Guide.”
- [6] Each of the service categories listed encompasses multiple HCPCS/CPT codes. The specific HCPCS/CPT codes subject to the WISeR Model were last updated on April 24, 2026, and are listed in Appendix A to the “CMS WISeR Model Provider and Supplier Operational Guide.” Version 6.0. See pages 32 - 36.
- [7] For discussions of the various audit programs currently facing Medicare providers and suppliers, please see our website: www.lilesparker.com
- [8] Several Democratic members of the House sponsored and introduced “The Seniors Deserve SMARTER (Streamlined Medical Approvals for Timely, Efficient Recovery) Care Act” in an effort to repeal CMS’s WISeR program.
- [9] See Healthcare Finance article titled “House Appropriations Committee Votes to End Funding for WISeR Pilot.” (June 11, 2026).
- [10] 42 CFR § 424.535(a)(21).