WISeR AI Program: What Happens When CMS Gives No Clear Instructions But Authorizes "AI"

 The WISeR program for AI-mediated autodenials is coming into effect now.  For a couple dozen procedures, physicians/hospitals will have to submit pre authorization paperwork to special CMS subcontractors, which will have several days to greenlight or deny the surgery. (Submit to, Zyter, Virtix, Humata, Cohere, Genzeon, Innovaccer.)  

CMS has stated that the contractors will simply be submitted existing CMS rules and instructions (LCDs, NCDs).   But this won't always work.  For example, penile implant codes are among the controlled codes under WISeR:  including 54400, 54401,  54405.

CMS  says the companies will follow CMS coverage rules under NCD 230.4.

Really?   NCD 230.4 says nothing:

• Impotence is a failure of a body part for which the diagnosis, and frequently the treatment, require medical expertise. 
• Depending on the cause of the condition, treatment may be surgical; e.g., implantation of a penile prosthesis, or nonsurgical; e.g., medical or psychotherapeutic treatment.

So I don't know what rules preauthorization will use, but it's literally impossible for surgeons, hospitals, or patients to know in advance whether a case is "in" or "out" of payment rules that will be applied behind the scenes.  Because CMS gives no concrete rules.

(Note also, the NCD is not just about surgery, but covers any kind of medical or psychological intervention).

An online article discusses the vendors.

CMS Gears Up for Auto-Denials of Nerve Stimulation Code 64568 (WISeR)

 On December 31, 2025, CMS issued Change Request 14205 (aka Transmittal 13570).  The title is,

Implementation of Wasteful and Inappropriate Service Reduction (WISeR) Model Prior Authorization and Medical Review Process and Establishment of New Quarterly Change Request (CR) Process for Possible Future Changes.

Find it here:

https://www.cms.gov/files/document/r13570demo.pdf

The 82-page document covers many implementation aspects for WISeR, the program that will allow AI-facilitated autodenials for a range of clinical interventions.

What caught my attention first was Table 7 (page 28), which applies from January 2026 to December 2031 in a number of large states, including New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington.  (The list of states can be expanded at the discretion of the Center for Innovation, CMMI).   

The instructions focus on one CPT code, 64568, which is cranial nerve stimulation.  See also table 8 (page 30), and Attachment B, Table 1, which states that edits designed around NCD 160.18 will be deployed.  This NCD covers vagal nerve stimulation for partial seizures therapy and for treatment-resistant depression under particular clinical protocols.  (The CPT code is further described in Attachment C, 64568, page 53.)   

However, as you'll see below, the same CPT codes may be used for quite different procedures that are variably inside or outside of WISeR, suggesting room for errors, at least early on.

The instructions include Attachment F, associated codes under WISeR, which links 64568 to NCD 160.18 again, but also links 64568 to L38307, L38310 and L38385, where 64568 is cited in connection to LCDs for hypoglossal nerve stimulation.   (Code 64582 is also linked to the same three LCDs).

Page 81 is a model letter showing the relevance to providers.  If the provider practices in AZ, NJ, oH, OK, TX, or WA, and will supply at least one of the nominated medical servics, the provider has two options to demonstrate medical necessity.  One is to submit a prior authorization request for every case.  Or, they can perform the service without prior authorization, and the claim will undergo pre-payment medical review at the MAC.  The MAC has 45 days to review the un-authorized claim.

The document has 16 pages of detailed step-by-step instructions, but it is unclear to me how the prior auth companies or the MACs will handle CPT codes that serve multiple purposes (some covered by WiSER, others not.)

Attachment A: WISeR Model Program Files (page 23)

Attachment B:  NCDs, LCDs, included in the WISeR Model (page 49)

Attachment C: Codes Requiring Prior Authorization (page 50)

Attachment D:  WISeR Model Participants (page 54)
(Zyter, Virtix, Humata, Cohere, Genzeon, Innovaccer.)
(An online article discusses the venders.)

Attachment E: Claims Data Elements (page 55) 

Attachment F: Associated Codes (page 56)

Attachment F is described as, "the codes associated with/related to services require PA, but which will not have prior authorization requests submitted for them directly."

64568 appears in five places, on page 28 Table 7 (under Attachment A, Program Files), page 30 Table 8, page 53 (under Attachment C, requiring prior authorization),  page 60 (associated codes), page 80 (associated codes).  

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In the current CPT, code 64568 is for cranial nerve stimulation, "e.g." vagus, and 64582 is for hypoglossal nerve stimulation (for sleep apnea, with certain code requirements).   64582 also appears on page 41, 42,  50, and 60.

Some of these codes have diverse uses.  For example, in the 2025 Billing Guide for Inspire V (hypoglossal nerve stimulation), 64568 is listed as, may be the initial implant code:

The Inspire IV billing guide gives 64582 as, may be the initial implant code.

CMS coding and pricing changes can lead to volatility (here, here).  The overlapping notation of various codes in different ways in different tables in WISeR suggests that the WISeR protocols will need to be implemented carefully.

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One might say the solution is, the WISeR process will stop any claim with an epilepsy or depression code (re the vagus NCD) but pass any claim with a sleep apnea code.  But many elderly men could have both medical conditions.  

It's crytpic why a WISeR edit that is stated as directed to vagus nerve stimulation (a particular NCD) should also include any edits at all for hypoglossal nerve stimulation (64582) which has nothing to do with the vagus nerve NCD for epilepsy and depression (64568).