WISeR Model FAQ: What Wound Care Clinics in Six States Need to Know
compliance
Answers to the most common questions about CMS's WISeR prior authorization model, affirmation rates, Gold Card status, and audit risk for wound care.
CMS's WISeR model went live in January 2026 across six states. Wound care clinics are still working out what it means day to day. Here are the questions we hear most.
What is the WISeR model?
WISeR (Wasteful and Inappropriate Service Reduction) is a CMS demonstration that inserts AI-driven prior authorization between wound clinics and Medicare payment for select procedures. It's live in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.
Which procedures require WISeR prior auth?
Only items on the CMS select-items list — currently focused on skin substitute applications and certain high-cost wound procedures. The list can expand, so check before every submission.
What happens if I skip the prior auth?
The claim isn't denied outright, but it's automatically routed to pre-payment medical review. That means a 100% audit rate on skipped submissions and long payment delays.
What is an "affirmation" and why does it matter?
An affirmation means the prior auth was approved. Sustained affirmation rates above 90% qualify your clinic for Gold Card status, which exempts you from prior auth entirely on those procedures.
Who reviews the submissions?
Each state contracts with a specific WISeR participant — Cohere Health, Genzeon, Humata Health, Innovaccer, Virtix Health, or Zyter. They apply the governing NCD or LCD to your submitted rationale.
Does WISeR change what Medicare covers?
No. Coverage criteria are unchanged. WISeR tests whether your documentation proves the patient meets those criteria.
How do I reduce denial risk?
Build patient-specific rationale mapped to the NCD/LCD, document failed conservative care, and use objective wound measurements. Templated notes are the top denial driver.
See Medicare audit readiness for wound care for the deeper compliance picture.