On June 29, 2025, CMS announced the Wasteful and Inappropriate Service Reduction (WISeR) Model, a new payment model under the Center for Medicare and Medicaid Innovation targeting waste, fraud and abuse in Medicare fee-for-service. Unlike Medicare Advantage, Medicare fee-for-service has not previously implemented broad prior authorization policies.

This model could impact sleep practices by introducing prior authorization requirements for certain devices used in treating obstructive sleep apnea, making it important for AASM members to prepare for changes in documentation and billing processes.

The WISeR Model, which will be implemented Jan. 1, 2026, through Dec. 31, 2031, was developed in response to a Medicare Payment Advisory Commission report finding that $5.8 billion in 2022 was spent on services with minimal benefit. The goal is to test whether prior authorization can reduce such waste without harming patient care. The model will be tested in specific Medicare Administrative Contractor jurisdictions:

  • JL (New Jersey)
  • J15 (Ohio)
  • JH (Oklahoma and Texas)
  • JF (Arizona and Washington)

Although CMS calls the model voluntary, providers who do not submit prior authorization requests will face pre-payment medical reviews, which may delay payments and increase administrative burden.

CMS will partner with vendors to manage the process using AI technology and clinical criteria. Vendors managing the process will be financially incentivized to reduce unnecessary care, with a projected savings goal of $3 billion by 2031. CMS is also exploring implementation of gold carding, which is a process to exempt compliant providers/suppliers from the prior authorization process and expanded pre-payment review processes.

Services subject to review include but are not limited to electrical nerve stimulators, phrenic nerve stimulators, and hypoglossal nerve stimulators for obstructive sleep apnea. The complete list of impacted services is available in the official notice.

To help members navigate these upcoming changes, the AASM recommends the following action steps:

  1. Prepare for prior authorization requirements by reviewing national and local coverage determination documents for affected services in your Medicare jurisdiction.
  2. Implement workflows to submit prior authorization requests early, prior to service delivery, for patients receiving these services.
  3. Sign up to receive communications from your Medicare Administrative Contractor to monitor whether additional sleep-related services are added to the list.
  4. Ensure that your electronic health record and/or practice management system supports submission of prior authorization documents electronically.
  5. Train clinical and billing staff on documentation standards and proactively monitor your rates to potentially achieve gold card status.
  6. Develop internal tracking systems to manage unique tracking numbers assigned to each prior authorization claim to manage communications and appeals efficiently.

Additional information from the Centers for Medicare & Medicaid Services is available here.

Review the WISeR Model Overview fact sheet here.

Members may send any questions regarding this prior authorization model to coding@aasm.org.