How to Submit a WISeR Prior Authorization for Skin Substitutes: Step-by-Step

The primary WISeR overview explains the demonstration. This guide shows exactly how to file a prior authorization request once you're in it. The steps are the same in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.

Step 1: Confirm the service is in scope

Only certain Part B services are reviewed. For wound care, that means skin and tissue substitutes for chronic wounds. Confirm the CPT/HCPCS code is on the current WISeR list before submitting. If it isn't listed, no prior auth is needed.

Step 2: Verify the qualifying diagnosis

Reviewers look for a covered ulcer type (typically DFU or VLU) with the correct ICD-10 laterality and site. Codes must line up with your NCD and LCD requirements — mismatches are the fastest path to non-affirmation.

Step 3: Document conservative care

Most LCDs require four or more weeks of standard care with no meaningful improvement. Capture:

• Offloading (device, adherence)
• Debridement dates and method
• Infection control
• Moisture management
• Glycemic control for DFUs
• Compression for VLUs

Step 4: Attach serial measurements

Include at least two dated measurements showing the wound has stalled. Length, width, depth, and photos with a reference marker. Vague notes like "wound not healing" won't clear review.

Step 5: Write patient-specific rationale

Explain why this patient, this wound, needs this product and these units. Templated language is the top reason clean cases fail. See patient-specific rationale for WISeR for examples.

Step 6: Submit and track

Submit through the MAC's portal. Standard decisions return within three business days, expedited within two. Log the unique tracking number on the claim when you bill.

Step 7: If non-affirmed, resubmit

Most non-affirmations are documentation gaps. Fix the gap and resubmit — you don't need to abandon the case. Sustain roughly 90% affirmation across ten requests and you may qualify for Gold Card exemption.

For a broader timeline, use the six-month readiness checklist.