Original Medicare Now Says “Ask First” in Six States. Here’s the One Form That Decides Who Pays.

A pilot called WISeR has put prior authorization on a short list of procedures in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Most people won’t feel it. If you do, one form (the ABN) decides whether you or Medicare gets the bill.

About 6.4 million people on Original Medicare live in six states where, since Jan. 1, 2026, a doctor may have to ask permission before Medicare pays for an epidural steroid injection, a nerve stimulator implant, or a skin substitute for a slow-healing wound (KFF, Feb. 10, 2026). Those are the “ask first” rules many people picked Original Medicare to avoid. The pilot is called WISeR, and a Senate resolution to block it failed 46–50 on July 16, so it is staying (Medicare Rights Center, July 16, 2026).

What actually changed

WISeR (Wasteful and Inappropriate Service Reduction) is a six-year test, 2026 through 2031, run by the CMS Innovation Center in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. In each state a private technology company reviews prior-authorization requests for a short list of services, using AI and similar tools, and is paid a share of the money Medicare saves on care it turns down (CMS WISeR model page; KFF, Feb. 10, 2026).

The list is narrow: skin substitutes for chronic wounds, orthopedic pain procedures such as epidural steroid injections and cervical fusion, electrical nerve stimulator implants, incontinence-control devices, and treatments for impotence (KFF, Feb. 10, 2026). Emergency care, inpatient-only surgery, and anything risky to delay are excluded (CMS WISeR FAQ). Medicare Advantage members aren’t affected; their plans already had prior authorization (CMS WISeR model page).

CMS says the goal is to cut services with “little to no clinical, evidence-based benefit” and catch fraud earlier; skin-substitute billing, for one, went from $509.6 million in 2019 to $10.3 billion in 2024 (CMS WISeR model page; KFF, Feb. 10, 2026). Beneficiary groups counter that paying a vendor per denial is a poor incentive, and a Washington Post report in March found delayed care and portal glitches in several pilot states (Center for Medicare Advocacy, March 26, 2026). Both can be true. Our job is to tell you what to do about it.

What this means for your wallet

Outside those six states, nothing changes. Inside them, if you aren’t scheduled for a listed service, nothing changes either. KFF counted about 1.1 million Original Medicare beneficiaries nationwide who got one of these services in 2024; about 207,500 lived in the six pilot states, roughly 3 in 100 people on Original Medicare there (KFF, Feb. 10, 2026).

If you are one of them, the paperwork is your doctor’s, not yours. The office submits the request and typically hears back within three days; if a delay could seriously harm you, it can ask for an expedited review with a two-day answer (CMS WISeR FAQ).

The form that matters is the ABN. If the reviewer says no (“non-affirmed,” in the jargon), your doctor must hand you an Advance Beneficiary Notice of Non-Coverage before doing the procedure (CMS WISeR FAQ). Sign it and go ahead, and you’ve agreed to pay if Medicare won’t. These aren’t small bills: KFF puts the average Medicare payment per encounter at about $17,200 for nerve stimulator services and $21,200 for skin substitutes in 2024 (KFF, Feb. 10, 2026).

So before you sign, ask three questions: Was this denied, or just not submitted yet? Can you resubmit with more records? What would I owe if Medicare doesn’t pay? A doctor’s office can resubmit as often as it likes, and a “no” doesn’t stop it from doing the procedure and billing Medicare anyway, which triggers the same appeal rights you’ve always had (CMS WISeR FAQ).

The catch

A denial can’t come from a computer alone: CMS requires a licensed human clinician to review every non-affirmation, and vendors lose their payment if a denial is overturned on appeal (CMS WISeR FAQ). That’s a real protection, but only if someone appeals, and denials already make up nearly a third of calls to the Medicare Rights Center helpline (Medicare Rights Center, July 16, 2026).

Also, a provider can skip the request entirely; the claim is then reviewed after the fact, before payment (CMS WISeR FAQ). If your doctor’s office in one of these states seems unsure whether it submitted anything, ask before the procedure, not after.

Free, unbiased help exists for exactly this: your State Health Insurance Assistance Program (SHIP) at 877-839-2675 or shiphelp.org, and 1-800-MEDICARE for any denial notice. Neither sells anything.

The takeaway

WISeR is a narrow pilot most people on Original Medicare will never notice. If you’re in one of the six states and a listed procedure is on your calendar, ask your doctor’s office one sentence: “Has the prior authorization come back approved?” And don’t sign an ABN until you know the number on it.

This is information, not medical or financial advice. Medicare rules and pilot terms change; figures are as of September 2026 and sourced inline. Talk to your doctor, a SHIP counselor, or 1-800-MEDICARE about your situation. Senior Savers is independent, not affiliated with Medicare or CMS, and has no financial relationship with any organization named here.

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