The Centers for Medicare & Medicaid Services (CMS) under the CMS Innovation Center released a new Provider and Supplier Operational Guide to accompany the Wasteful and Inappropriate Services Reduction (WISeR) Model. The guide outlines how prior authorization will be applied items and services delivered in the traditional Medicare program. According to the agency, the model is designed to reduce unnecessary or inappropriate services while maintaining beneficiary access to needed care.

Beginning January 1, 2026, the model will launch in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Urologists providing services in these states will be included in the new model. The model will be tested for six years, ending on December 31, 2031.

Urologists participating in the model have two options: submit a prior authorization request before furnishing the item or service or proceed without prior authorization and be subject to pre-payment medical review. The following urologic procedures and associated CPT codes are subject to prior authorization in the model.

• Incontinence Control Devices: CPT codes 53445, 53451, 53452, 53440, and 57288.
• Sacral Nerve Stimulation for Urinary Incontinence: CPT codes 64561 and 64581.
• Diagnosis and Treatment of Impotence: CPT codes 54400, 54401, and 54405.

These procedures, along with others included in the model, have been identified for potential overuse or inconsistent adherence to Medicare coverage criteria. The model does not change coverage or payment policies. However, it does add a layer of review where one previously did not exist. The new prior authorization processes were crafted by the agency to ensure compliance with Medicare coverage criteria for these services.

It is important to note that a provider is not bound or required to submit a prior authorization for the services on the list, but if they do not submit one, payment for the service will automatically be held and subject to review BEFORE payment is made.

To prepare, urologists should confirm if they furnish any services on the WISeR list and establish internal workflows for tracking services subject to WISeR requirements. Once the model begins it is important to include all required data elements with the prior authorization submission. The Operational Guide provides the necessary information for providers to be successful participants in the model. AUA is monitoring this matter and will identify advocacy opportunities.