Hypoglossal Nerve Stimulation & Medicare’s WISeR Model: A Practical Guide for Impacted ENT Practices

Why did CMMI develop the WISeR Model? 

According to CMMI, the WISeR Model was created to test the implementation of advanced analytics and AI-driven prior authorization to reduce waste, fraud, and abuse in Original, or fee-for-service, Medicare. The WISeR Model aims to “reduce unnecessary or inappropriate use of select Medicare services, while maintaining access to medically necessary care.” 

Who is impacted by the launch of WISeR Model, and how will it impact otolaryngologists and your patients? 

The WISeR Model will affect select items and services covered under Original Medicare by subjecting them to prior authorization or pre-payment medical review in designated Medicare Administrative Contractor (MAC) jurisdictions.  

In its initial program year (2026), the WISeR Model will impact all otolaryngologists who offer hypoglossal nerve stimulation (HGNS) to treat obstructive sleep apnea (OSA) for patients covered under Original Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. 

The model will operate for six performance years, from January 1, 2026, through December 31, 2031. During this period, otolaryngologists who wish to perform HGNS for OSA in impacted regions will be required to demonstrate medical necessity before Medicare payment is issued. To establish medical necessity, physicians may: 

1. Submit a prior authorization request to the WISeR participant (the contracted AI company) in your state, or to your regularly assigned MAC. 
2. Proceed with the service and submit a claim without prior authorization, understanding that the claim would then undergo pre-payment medical review. 

For physicians in impacted states, is participation mandatory? 

Although CMMI classifies participation in the WISeR model as “voluntary,” participation in the WISeR Model will be required of all physicians who wish to guarantee payment for services furnished to Medicare beneficiaries in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. If a physician opts not to submit prior authorization before performing the service, the claim would then be subject to pre-payment medical review.  

What companies have been selected to participate in the WISeR Model? 

A: CMMI selected six technology companies to participate in the initial launch of the WISeR Model—one for each of the six states impacted by the model’s launch. Each company will employ an automated process to manage WISeR’s prior authorization and pre-payment review process.  

These companies are referred to as “WISeR Model Participants,” and they will be compensated based on their ability to avert unnecessary expenditures.  

How will participating companies be held accountable?  

CMMI will evaluate model participants using several performance measures, including prior authorization request volume, response time, and response clarity. Furthermore, model participants are instructed to issue determinations within 72 hours (or 48 hours for urgent requests) and will be financially penalized for poor performance, excessive appeal rates, or delayed responses. CMMI will audit denials and track appeals to ensure accuracy and fairness. If a particular company is deemed problematic, CMMI indicates that it will remove that company from the program.  

Does WISeR apply to all items and services in Original Medicare? 

No. In its initial program year (2026), the WISeR Model includes only a narrow set of items and services that CMMI has deemed particularly vulnerable to waste, fraud, and abuse. The 15 selected items and services include skin substitutes, knee arthroscopy for knee osteoarthritis, and electrical nerve stimulation. A full list of impacted items and services is available on page 29 of the WISeR Model Provider and Supplier Guide.

What about Medicare Advantage? 

The WISeR Model applies only to procedures and services furnished to individuals covered by Original Medicare—not Medicare Advantage plans. 

What process will be used to obtain prior authorization for HGNS?  

The WISeR Model is structured so that physicians have an “option” to submit a prior authorization request, but doing so is the most practical way to ensure payment for HGNS. Physicians will be able to request prior authorization via fax, Electronic Submission of Medical Documentation (esMD), mail, or electronic portal from the WISeR participants outlined below or from their assigned MAC, which would then route the request to the WISeR participant. In its Provider and Supplier Guide, CMMI provides a flowchart to depict how the prior authorization process will work for services and procedures included in the WISeR Model. 

What are the documentation requirements for HGNS? 

CMMI has provided general documentation requirements for each service included in the WISeR Model. The requirements for HGNS for OSA are available here.  

For detailed documentation requirements, physicians should refer to the relevant National Coverage Determinations (NCDs) and/or their MAC jurisdiction’s Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs), if available, for guidance. These resources can be found on the Medicare Coverage Database website. 

Will the WISeR Model change Medicare coverage policy for HGNS? 

No, according to CMMI, “The WISeR Model will not change Medicare coverage or payment criteria. Healthcare coverage for Original Medicare beneficiaries remains the same, and beneficiaries retain the freedom to seek care from their provider or supplier of choice.” 

How will CMMI safeguard physicians and patients against inappropriate denials? 

The WISeR Model will not change existing Medicare coverage, payment criteria, or provider appeal rights. Furthermore, CMMI mandates that all denials be reviewed by a physician with relevant clinical expertise, not solely by AI.  

How can a physician, supplier, or beneficiary appeal a coverage decision? 

Physicians and beneficiaries retain all existing Medicare appeal rights. If a prior authorization request is denied, physicians may resubmit a request with additional information and documentation to support the resubmission. If a prior authorization request is denied, unlimited resubmissions are permitted. Physicians who choose to resubmit a prior authorization request will also have the opportunity to request a peer-to-peer review with a “clinician(s) with specialty expertise on the condition under review.”  

Additional information on the Medicare claim appeals process is available in Chapter 29 of the Medicare Claims Processing Manual.  

How long is a prior authorization decision valid? 

Once approved, a prior authorization decision remains valid for 120 days from the date it was issued. If a procedure is not performed before this 120-day window expires, a new prior authorization request must be submitted. 

Is there a “Gold Card Program” for physicians who consistently demonstrate adherence to the WISeR Model’s prior authorization requirements? 

Although a “gold card program” exempting physicians from the WISeR review process has not been formally announced, such a program may be available in the future. Per CMMI, “Providers and suppliers with demonstrated records of compliance may be exempt from the WISeR review process in the future. This exemption, or ‘gold card,’ would reduce administrative burden while allowing participants to focus their resources on providers and suppliers at higher risk of delivering unnecessary care.” Additional information regarding this program will be shared with Academy members in future resources. At this time, however, no such program is available. 

How is my Academy advocating against the WISeR Model?  

Soon after the WISeR Model was announced, the Academy shared a letter with CMMI opposing the expansion of prior authorization requirements in Original Medicare and objecting to the inclusion of HGNS on the Model’s list of impacted services. We have also been closely monitoring congressional activity related to the WISeR Model, as lawmakers have raised substantial concerns about its financing and implementation. Notably, the House Appropriations Committee adopted an amendment to the FY 2026 Health and Human Services appropriations bill that would prevent the Centers for Medicare & Medicaid Services from funding the WISeR Model—a move that, if passed, would pause the Model’s rollout. The Academy supported this amendment and continues to monitor legislative efforts that may delay the WISeR Mode’s implementation. Reducing administrative burden, including prior authorization, is a longstanding advocacy priority for the Academy, and we will continue to fight for policies that ensure prior authorization is minimized in Original Medicare. 

Where can I learn more about how the WISeR Model will impact my practice? 

The Academy will continue to update members as additional information surrounding the implementation of the WISeR Model is received. For more information about the WISeR Model, view these resources from the Centers for Medicaid & Medicare Services:  

• CMMI WISeR Model Frequently Asked Questions 
• CMMI WISeR Model Provider & Supplier Guide