IR Quarterly
In January, the Centers for Medicare and Medicaid Services (CMS) implemented the Wasteful and Inappropriate Service Reduction (WISeR) model, which will utilize artificial intelligence for prior authorizations. The model is optional, and has been put in place in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
According to CMS, the aim of the WISeR model is to focus healthcare spending on services that will improve patient well-being and reduce the use of “medically unnecessary care.”
Seventeen procedures have been selected for the model. Per CMS, these procedures were identified as “a source of fraud, waste, abuse, and inappropriate utilization, and which can present a very real threat of patient harm.” Among the procedures selected is vertebral augmentation, an established IR therapy which has rigorous evidence showcasing its value.
In September, SIR wrote a letter to Mehmet C. Oz, MD, MBA, the administrator for CMS, and Abe Sutton, JD, the deputy administrator and director of CMS, expressing concern over the nature of prior authorization, as well as the impact of WISeR on patients who need therapies like vertebral augmentation.
The importance of vertebral augmentation
Delays in treatment can have severe clinical consequences, especially for elderly patients with vertebral compression fractures (VCFs). This population depends heavily on Medicare coverage and can find relief from vertebral augmentation.
“Robust clinical evidence underscores the survival benefit of vertebral augmentation, including balloon kyphoplasty and vertebroplasty, over non-surgical management for patients with VCFs,” said Robert A. Lookstein, MD, FSIR, in the September SIR letter.
Dr. Lookstein cited a landmark study by Hirsch et al. (2019) which analyzed over 2 million Medicare beneficiaries and quantified this benefit using Number Needed to Treat metrics over 5 years. According to Dr. Lookstein, these figures demonstrated that vertebral augmentation is not merely a palliative procedure; it is a lifesaving intervention for patients who are appropriately selected.
“The data indicates that if pre-authorization prevents 1,000 eligible patients from receiving vertebral augmentation, approximately 58 additional deaths would occur in the first year and 79 additional deaths would occur by year five,” said Douglas P. Beall, MD, FSIR, an expert in musculoskeletal radiology and pain management, who practices in Oklahoma, where the model has taken effect.
The estimates cited by Dr. Beall and Dr. Lookstein also only reflect a fraction of the total Medicare population that undergoes vertebral augmentation each year. Scaling the impact across thousands of patients could result in hundreds to thousands of avoidable deaths nationwide.
Dr. Beall added that any delay whatsoever can worsen pain, disability and recovery—especially in patients with vertebral compression fractures, severe radiculopathy, discogenic back pain and chronic wound care. Delayed care is strongly associated with increased opioid use, more visits to the ER and prolonged morbidity, which makes some conditions more difficult to treat effectively over time.
“Prior authorization may appear to offer cost-containment advantages on paper, but its real-world implementation in critical procedures such as vertebral augmentation is ethically and clinically indefensible,” Dr. Lookstein wrote.
The risks of prior authorization
Dr. Lookstein and Dr. Beall emphasized that not only is vertebral augmentation crucial to quality of life for some patients, but that prior authorization in general puts these patients at risk.
“Prior authorization has consistently been shown to impose excessive and often harmful bureaucratic barriers, particularly in specialty care such as interventional radiology, where timely access to image-guided, minimally invasive procedures is essential,” Dr. Lookstein wrote.
CMS says the aim is that by using artificial intelligence, prior authorization will be completed quickly; ideally within 72 hours.
However, this 72-hour turnaround time only applies to WISeR participants. Any facility or physician who has not opted into the model will go through a post service/pre-payment medical review.
These reviews will still be handled by the contractors selected to handle the AI authorization, according to CMS. The companies contracted through each state will receive payments when they successfully reduce costs and will be penalized if they are found to be inappropriately denying coverage.
“The initiative also relies on automated review algorithms and predictive analytics that moves the interpretation of coverage rules into the hands of vendors using the algorithms,” Dr. Beall said. “This will inevitably produce denials based on incomplete documentation, as well as inconsistent review decisions, higher denial rates and reduced access for complex patients.”
Dr. Beall added that the patients at highest risk of denial are the elderly, frail, multimorbid, disabled, or cognitively impaired beneficiaries who have unique medical needs. This may be compounded in rural areas, where providers may opt out of the model.
Because these procedures have not previously required prior authorization, the WISeR initiative also has the potential to erode the physician-patient relationship by introducing confusion and administrative barriers, Dr. Beall said.
According to CMS, certain guardrails have been set up to prevent delays in access to care, such as a “gold card” program which will exempt certain providers from prior authorizations if 90% of their requests are approved. Additionally, CMS says that all denials will be reviewed by a licensed clinician.
Speaking up
Since announcing the launch of the WISeR model, CMS has since removed deep-brain stimulation from the model after feedback from the physician community.
“In the example of deep-brain stimulation (DBS), patients with movement disorders will often need DBS to adequately function. There is no other alternative,” Dr. Beall said, emphasizing that this is why experts should be consulted, and should use their expertise to advocate for their patients.
“The procedures that IRs do range from aiding comfort to saving lives,” he said. “No one knows these procedures better than they do and they can reach out to their government representatives, societies, and other advocacy groups to provide real world and reasonable information as to what happens when patients are denied various procedures.”
Additionally, Dr. Beall believes it will be crucial for the facilities where WISeR is implemented to provide feedback on how the model works, as well as data on when patients are treated or not.
“The CMS can try to limit certain procedures but there is no one better to know the impact of these limitations better than IRs,” Dr. Beall said. “When this impact can be devastating and catastrophic for the patients and their families it is our duty to speak up.”
Speaking out
Since the announcement of the WISeR model and SIR’s response, SIR has been working with members to communicate to Congress their concerns regarding both the WISeR program and the expansion of prior authorization in traditional Medicare.
In November, the U.S. House of Representatives Committee on Appropriations passed a bipartisan amendment that would halt funding for the implementation of the WISeR program; SIR joined 33 national physician specialty organizations thanking the Committee for their support of physicians and patients on this issue. While that Appropriations legislation has not yet passed the House, Congresswomen Suzan DelBene (WA-01), Greg Landsman (OH-01), Ami Bera, MD (CA-06), Kim Schrier, MD (WA-08), Mark Pocan (WI-02) and Rick Larsen (WA-02) introduced the Seniors Deserve SMARTER Care Act of 2025 (H.R. 5940) legislation to repeal the WISeR model entirely. Senators Ron Wyden (D-Ore), Patty Murray (D-Wash) and Kirsten Gillibrand (D-NY) followed with a Senate companion bill (S. 3480) in December of last year. Despite this legislative pressure, CMS proceeded to implement the WISeR model on Jan. 1.
SIR continues to advocate for the repeal of the WISeR model and legislation to prohibit CMS from implementing prior authorization in traditional Medicare, as well as similar legislative efforts to curb the use of prior authorization in Medicare Advantage plans.