WoundScribe WISeR Program

CMS WISeR — Wasteful and Inappropriate Service Reduction — is a new Medicare model that confirms selected Part B services are appropriate before payment is made. Traditional Medicare paid first and audited later; WISeR moves that scrutiny up front. It runs from January 2026 through December 2031 across six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. For wound and podiatry clinics, skin substitutes are the main event — high dollar value, rapid billing growth, and detailed criteria that must be satisfied line by line. WISeR does not change coverage rules or payment rates, and AI alone cannot deny a claim: every non-affirmation must be issued by a licensed clinician. ### How the review flow works For each affected service, you choose one of two paths — submit prior authorization first, or skip it and get routed to pre-payment review. The review itself is unavoidable; your only real choice is timing. A request flows in four steps: 1. Assemble the documentation 2. Screen against coverage criteria 3. Clinician review if needed 4. Decision Standard reviews return in three business days; expedited reviews in two when a delay could jeopardize the patient's health. Outcomes are either a provisional affirmation (criteria met) or a non-affirmation (criteria not met — or not shown). Many non-affirmations are documentation gaps, not true coverage problems, and can be resolved by resubmitting with better evidence, a peer-to-peer, or standard appeal. ### What reviewers actually check WISeR is a documentation test. Reviewers evaluate two pillars: - Correct codes — defensible CPT and HCPCS - Patient-specific clinical rationale mapped to the coverage determination The most common reason good care gets non-affirmed is templated documentation. A patient-specific note names the wound, its exact measurements, weeks present, conservative care tried, and vascular status. This is exactly the work patient-specific rationale AI and AI code validation against NCDs and LCDs are built to carry. ### Gold Card and clinic readiness Clinics that sustain roughly a 90% affirmation rate across at least ten prior-authorization requests can earn a Gold Card exemption for those services. First exemption notifications begin June 2026. To get ready, identify your exposure, map each service to its coverage criteria, standardize documentation, build prior auth into scheduling, and track your affirmation rate. See WoundScribe is WISeR-Ready and the WISeR Model FAQ for wound care clinics for the full playbook.