Medicare WISeR · Appendix A · Guide v7.0
WISeR prior authorization code list
CMS lists 41 procedure codes in 13 service categories for WISeR prior authorization or pre-payment review in AZ, NJ, OH, OK, TX, WA, for dates of service 2026-01-15 through 2031-12-31, in every site of care. From CMS’s WISeR Model Provider and Supplier Operational Guide, version 7.0 (last updated July 24, 2026), Appendix A; checked against the document on 2026-09-17.
Codes by service category
| Table | Service category (CMS) | Codes | Policies CMS cites | Reviewed in |
|---|---|---|---|---|
| A1 | Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee | 29877 | NCD 150.9 | AZ, NJ, OH, OK, TX, WA |
| A2 | Induced Lesions of Nerve Tracts | 64605 64610 | NCD 160.1 | AZ, NJ, OH, OK, TX, WA |
| A3 | Vagus Nerve Stimulation CMS note: Only for the indications in Appendix B; 64568 with G47.33 (obstructive sleep apnea) is not WISeR. | 64568 | NCD 160.18 | AZ, NJ, OH, OK, TX, WA |
| A4 | Phrenic Nerve Stimulator | 33276 33277 | NCD 160.19 | AZ, NJ, OH, OK, TX, WA |
| A5 | Electrical Nerve Stimulators CMS note: 63650 is in the hospital-OPD prior authorization program, not WISeR. | 63655 | NCD 160.7 | AZ, NJ, OH, OK, TX, WA |
| A6 | Incontinence Control Devices | 53440 53445 53451 53452 57288 | NCD 230.10 | AZ, NJ, OH, OK, TX, WA |
| A7 | Sacral Nerve Stimulation for Urinary Incontinence CMS note: 64561 only when billed with 64590 (permanent implant); only for the indications in Appendix B. | 64561 64581 | NCD 230.18 | AZ, NJ, OH, OK, TX, WA |
| A8 | Diagnosis and Treatment of Impotence | 54400 54401 54405 | NCD 230.4 | AZ, NJ, OH, OK, TX, WA |
| A9 | Percutaneous Vertebral Augmentation for Vertebral Compression Fracture | 22510 22511 22512 22513 22514 22515 | L34228 · L38201 · L35130 | AZ, NJ, OH, OK, TX, WA |
| A10 | Epidural Steroid Injections for Pain Management CMS note: 62323 is not WISeR for indications outside the selected LCDs (e.g., intrathecal pump implantation). | 62321 62323 64479 64480 64483 64484 | L39015 · L39240 · L36920 | AZ, NJ, OH, OK, TX, WA |
| A11 | Cervical Fusion CMS note: 22551 and 22552 are in the hospital-OPD prior authorization program, not WISeR. | 22554 | L39741 · L39758 · L39793 | AZ, NJ, OH, OK, TX, WA |
| A12 | Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea C8007 from 2026-04-06; C8011 from 2026-04-06. | 64582 C8007 C8011 | L38307 · L38310 · L38385 | AZ, NJ, OH, OK, TX, WA |
| A13 | Application of Bioengineered Skin Substitutes / Wound Application of CTPs, Lower Extremities CMS note: Only for the indications in Appendix B. C5271–C5278 were removed 2026-01-01 (CY2026 OPPS). | 15271 15272 15273 15274 15275 15276 15277 15278 | L35041 · L36690 | NJ, OH, OK, TX Not reviewed in AZ or WA (Guide footnote 22: the JF contractor’s policy was withdrawn). |
Who reviews WISeR requests in each state
| State | WISeR participant (Guide Table 2) | Medicare contractor | Codes reviewed |
|---|---|---|---|
| AZ | Zyter | Noridian Healthcare Solutions, LLC (JF) | 33 of 41 |
| NJ | Genzeon | Novitas Solutions, Inc. (JL) | 41 of 41 |
| OH | Innovaccer | CGS Administrators, LLC (J15) | 41 of 41 |
| OK | Humata Health | Novitas Solutions, Inc. (JH) | 41 of 41 |
| TX | Cohere Health | Novitas Solutions, Inc. (JH) | 41 of 41 |
| WA | Virtix Health | Noridian Healthcare Solutions, LLC (JF) | 33 of 41 |
Start date, scope and what is not in WISeR
When did WISeR start?
“Starting on January 5, 2026, for dates of service on or after January 15, 2026, select items and services covered under Original Medicare are subject to prior authorization or pre-payment medical review under the WISeR Model.”
WISeR Operational Guide v7.0, Quick Reference · CMS document
Is WISeR prior authorization mandatory?
“Submitting prior authorization requests for WISeR Select Items and Services is voluntary; however, if a claim for a WISeR Select Item or Service is submitted without a prior authorization request decision on file, the MAC will suspend the related claim and re-route it to the WISeR Participant to conduct pre-payment medical review.”
WISeR Operational Guide v7.0, §7.2 · CMS document
Does WISeR apply to Medicare Advantage?
“Of note, patients with Medicare Advantage and Railroad Medicare beneficiaries are not impacted by the WISeR Model.”
WISeR Operational Guide v7.0, Quick Reference · CMS document
Is deep brain stimulation in WISeR?
“Please note that CMS is delaying the implementation of Deep Brain Stimulation (DBS) in WISeR.”
WISeR Operational Guide v7.0, §6.2 · CMS document
Is percutaneous image-guided lumbar decompression in WISeR?
“CMS is also delaying the implementation of the Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (PILD) in WISeR.”
WISeR Operational Guide v7.0, §6.2 · CMS document
Check a procedure for your state, diagnosis and setting
Which program applies, the governing coverage policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires. Free; nothing about the patient is entered.
Run the check →Source: CMS WISeR Model Provider and Supplier Operational Guide, v7.0 — Appendix A (codes and cited policies), Table 2 (participants), footnote 22 (skin substitutes in JF). Contractors per state: CMS’s A/B MAC jurisdiction pages.
These pages report what CMS publishes. They never predict whether a request will be affirmed. Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.