17 Treatments on Medicare's New WISeR Model

The following 17 services/items will require prior authorization under the WISeR Model. Please note that the WISeR Model is a new program that is subject to change and will initially be applied only to Texas, Arizona, New Jersey, Ohio, Oklahoma, and Washington. The changes have not taken effect as of today, but the wheels are in motion for its implementation. It's slated to begin January 1, 2026 and run though December 31, 2031

According to the program, providers must submit documentation showing the service is medically necessary, consistent with Medicare’s National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and other CMS coverage rules. If criteria are not met, requests may be non-affirmed, but providers can resubmit or request peer-to-peer review.

• 1. Electrical nerve stimulators

Must meet NCD 160.7 – requires documentation of diagnosis and prior conservative therapy.

• 2. Sacral nerve stimulation for urinary incontinence

NCD 230.18 – must show type of incontinence and prior treatment attempts.

• 3. Phrenic nerve stimulator

NCD 160.19 – covered for central sleep apnea and other specific indications.

• 4. Deep brain stimulation (ET/Parkinson’s)

NCD 160.24 – requires disease severity, failed medication therapy, and imaging confirmation.

• 5. Vagus nerve stimulation

Requires diagnosis and confirmation of refractory epilepsy or depression under CMS rules.

• 6. Induced lesions of nerve tracts

Documentation of medical necessity per LCD requirements.

• 7. Hypoglossal nerve stimulation (OSA)

Requires documented diagnosis of obstructive sleep apnea, failed CPAP use.

• 8. Epidural steroid injections

LCDs (e.g., L39015) – imaging evidence of spinal pathology, failed conservative therapy.

• 9. Percutaneous vertebral augmentation

LCDs (e.g., L34106) – acute or chronic vertebral fracture confirmed by imaging.

• 10. Cervical fusion

LCDs (e.g., L39741) – neurologic compromise, instability, or failure of conservative treatment.

• 11. Arthroscopic lavage/debridement of knee OA

NCD 150.9 – generally not covered unless criteria met; conservative management must fail.

• 12. Incontinence control devices

Coverage only when criteria for incontinence diagnosis and prior therapies are documented.

• 13. Diagnosis and treatment of impotence

Documentation required for etiology and treatment indication.

• 14. Percutaneous image-guided lumbar decompression

LCDs – requires spinal stenosis diagnosis, failed conservative management.

• 15. Skin and tissue substitutes

LCDs – must demonstrate chronic, non-healing wound.

• 16. Application of bioengineered skin substitutes (LE wounds)

LCDs – wound chronicity and failure of standard therapy must be shown.

• 17. Wound application of cellular/tissue-based products

LCDs – non-healing wounds of lower extremities only.

Note: These requirements are tied to existing NCDs/LCDs. CMS reserves the right to add, remove, or substitute services during the WISeR model (2026–2031).