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.