Medicare has officially launched a new compliance program that will dramatically impact Pain Management practices beginning January 2026:

WISeR — Wasteful and Inappropriate Service Reduction Model
(A CMS/CMMI Innovation Model Powered by AI + Enhanced Medical Review)

WISeR is designed to reduce inappropriate procedures and tighten access to payment for selected high-cost pain interventions. Unlike previous pilots, WISeR extends strict prior authorization oversight directly into the clinic setting — even POS 11 (Office).
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This is a fundamental shift in how Pain Management will get paid.

📌 Which Pain Practices Are Impacted?

If your practice:
✅ Treats Original Medicare patients (not MA)
✅ Performs interventional pain procedures
✅ Is located in any of the following WISeR jurisdictions:
✅ Arizona
✅ New Jersey
✅ Ohio
✅ Oklahoma
✅ Texas
✅ Washington

🏥 Included Sites of ServiceWISeR applies across multiple care settings:

• Office (POS 11)
• Home (POS 12)
• Hospital Outpatient (POS 19 & 22)
• Ambulatory Surgery Center (POS 24)

✅ Yes — in-office interventional pain procedures are included.
This is a key operational shift.

⏱ When the Model Begins

• Prior authorization submissions begin: January 5, 2026
• Payment enforcement date: January 15, 2026
• Planned performance period: Through December 31, 2031

🩺 Pain Management Procedures Included in WISeR
This reflects only the Pain Management–relevant procedures included in WISeR.


1️⃣ Epidural Steroid Injections (ESIs)
CPT Codes (from Appendix A):
62321, 62323, 64479, 64480, 64483, 64484
Documentation indicators:

• Radiculopathy or neurogenic claudication
• Pain ≥ 4 weeks + failed conservative therapy
• Functional scoring required at baseline and follow-up
• Maximum 4 ESI sessions per spinal region per 12 months
• At least 50% sustained improvement for additional sessions

Documentation Requirements (Source: Wiser Model Section 6.2.11 - (https://www.cms.gov/files/document/wiser-provider-supplier-guide.pdf)

6.2.11. Epidural Steroid Injections for Pain Management (L39015, L39240, L36920):
General documentation requirements for epidural steroid injection (ESI) are as follows:
❑ Documentation of history, physical examination, and radiological testing demonstrating one of the following: a) Lumbar, cervical, or thoracic radiculopathy; radicular pain and/or neurogenic claudication due to disc herniation; osteophyte or osteophyte complexes; severe degenerative disc disease, producing foraminal or central spinal stenosis;
OR b) Post-laminectomy syndrome (persistent or recurrent spinal pain after a prior spine surgery); OR c) Acute herpes zoster associated pain
❑ Documentation that radiculopathy, radicular pain and/or neurogenic claudication is severe enough to greatly impact quality of life or function, including documentation that an objective pain scale or functional assessment was performed at baseline (prior to interventions) and the same scale was repeated at each follow-up for assessment of response
❑ Documentation of pain duration of at least four weeks, and the inability to tolerate noninvasive conservative care OR medical documentation of failure to respond to four weeks of noninvasive conservative care OR acute herpes zoster refractory to conservative management where a four-week wait is not required 19
❑ Documentation of anticipated number of ESI sessions (four or less) per spinal region in a rolling 12-month period. For repeat sessions, documentation of at least 50% sustained improvement in pain and/or function from baseline on the same scale for at least 3 months a) Of note, if the first ESI underperforms, a repeat session after 14 days may be done with a different approach/level/medication and a clear rationale
❑ If applicable: In exceptional and unique cases, documentation establishing the patient-specific need for moderate or deep sedation, general anesthesia, or monitored anesthesia care, as these are generally not required for the procedure
❑ Documentation of the type of image guidance (fluoroscopy or CT with contrast) to be used. If the patient has a documented contrast allergy or pregnancy, ultrasound guidance without contrast may be considered ❑ Documentation of the planned approach, including targeted level(s) and region(s).
Of note, transforaminal ESIs (TFESIs) up to 2 levels in one spinal region; interlaminar ESI or caudal ESIs up to 1 level in one spinal region; and bilateral TFESI only when clinically indicated (e.g., documented bilateral foraminal stenosis or central herniation affecting both roots) are considered medically reasonable and necessary.
❑ Documentation that the ESI is performed in conjunction with conservative treatments, including but not limited to a combination of: a) Medication b) Physical Therapy c) Spinal manipulation therapy d) Cognitive behavioral therapy e) Home exercise program
❑ Documentation that the patient is part of an active rehabilitation program, home exercise program, or functional restoration program ​


2️⃣ Spinal Cord Stimulator — Permanent Implantation
✅ Spinal Cord Stimulator (SCS) Trial Requirement Under WISeR:
A successful trial is required before Medicare will consider covering a permanent SCS implant.
CMS states:
“Prior authorization is being implemented for the permanent implantation procedure.
A trial procedure should be done, and documentation should be submitted as part of the prior authorization request for permanent implantation of a stimulator device.”
Additionally, the medical documentation must show both:

• 50% reduction in pain, and
• Evidence of functional restoration
  with a temporarily implanted electrode

General documentation requirements for laminectomy for the implantation of a spinal cord stimulator for the relief of chronic intractable pain are as follows:
❑ Documentation of condition requiring procedure and applicable physical exam
❑ Documentation that stimulation is being used only as a late resort (if not a last resort) for patients with chronic intractable pain, including but not limited to at least one treatment tried and failed (or documentation that they were contraindicated):
a) Medications
b) Physical therapy
c) Injections
​d) Spine surgery
e) Cognitive behavioral therapy
❑ Documentation showing that the patient was evaluated by a multidisciplinary team (including psychological, surgical, medical and physical therapy)
❑ Documentation showing that the patient achieved demonstrated 50% reduction in pain relief and evidence of functional restoration with a temporarily implanted electrode
❑ Documentation that the patient is not a candidate for percutaneously placed leads (e.g., previous instrumentation, challenging anatomy, high BMI, other technical challenges)


🔎 What this means operationally:
For a permanent SCS implant to be approved under WISeR:

1. A trial must be performed in advance
2. The clinical documentation must demonstrate that the trial worked
3. All trial-related documentation must be included in the prior authorization submission

Without that evidence → Medicare will not approve the permanent stage.

3️⃣ Percutaneous Vertebral Augmentation(Vertebroplasty / Kyphoplasty)
CPT Codes:
22511, 22512, 22513, 22514, 22515
Documentation indicators:

• Acute or subacute vertebral compression fracture (≤12 weeks)
• Imaging confirmed
• Functional impairment documented (e.g., RDQ scoring)
• Osteoporosis evaluation + prevention/treatment plan

4️⃣ Cervical Fusion
Documentation indicators:

• Structural instability, tumor involvement, or infection
• Deformity with severe functional limitation
• Pseudarthrosis or surgical failure documentation
• Radiographic evidence supporting criteria

Note: Certain cervical fusion codes (22551/22552) not included under WISeR where already subject to Hospital OPD prior auth rules

Site of Service:

• POS 11 — Office 
• POS 12 — Home 
• POS 19 & 22 — Hospital Outpatient 
• POS 24 — Ambulatory Surgery Center 

This is a key operational change — in-office procedures are now medically reviewed.
Other specialties may be impacted as well, but these are most relevant to Pain Medicine.

📌 Core Determination StandardCoverage requires proof that the service is:

✅ Reasonable and Necessary(according to the applicable LCD/NCD)
Documentation must consistently reflect:

• Diagnosis supported by clinical findings
• Functional impairment
• Conservative therapy history
• Appropriate imaging
• Clear medical necessity rationale
• Place of service alignment

Each procedure type has its own minimum clinical documentation elements that must be included.

🔎 What Happens Without Prior Authorization?
If a covered procedure is performed without obtaining prior authorization:

1. The claim is suspended
2. The provider receives a documentation request
3. Documentation must be submitted within 45 days
4. A decision is issued within 3 days once documents are received

A payment decision is not guaranteed — all Medicare appeals rights remain available.

🧭 Why This Matters for Pain Practices:
Pain procedures under WISeR:

• Are elective
• Have specific LCD criteria
• Are often high medical review risk
• Carry significant variation in documentation quality

WISeR is designed to identify clinically inappropriate use and enforce national & local coverage rules more consistently.

📘 Educational Takeaways for Providers:
​Pain practices should:

• Review LCD/NCD requirements for each impacted service
• Ensure medical necessity is supported in every encounter note
• Track number of sessions per spinal region for ESIs
• Document conservative therapy failure thoroughly
• Capture functional improvement metrics at each follow-up
• Align scheduling to safeguard compliance before delivery
• Prepare for pre-payment review workflows when PA is not obtained

✅ CMS Regulatory-Style Citation (commonly used in compliance documentation)Centers for Medicare & Medicaid Services (CMS). Wasteful and Inappropriate Service Reduction (WISeR) Model — Provider and Supplier Operational Guide. Published October 10, 2025. Available at: https://www.cms.gov/files/document/wiser-provider-and-supplier-guide.pdf

1) Scope & Intent (What these codes are)

What:
Standardized test administration and scoring to evaluate cognitive and behavioral effects of central nervous system (CNS) impairment — diagnostic, not therapy.
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Why:
Testing must inform diagnosis, prognosis, and treatment planning in a medically necessary pain management strategy.

Current (valid) CPT® codes only:

• 96136 – QHP* administration & scoring, first 30 min (≥31 min)
• 96137 – QHP add-on, each additional 30 min
• 96138 – Technician administration & scoring, first 30 min → requires direct supervision
• 96139 – Technician add-on, each additional 30 min → requires direct supervision

* QHP = Psychologist / Physician / NP / PA acting within Medicare scope
These services must produce actionable findings that change the pain plan.​

2) Medical Necessity (WHEN you may test)

Covered only when results directly change pain management decisions such as:

• Neuromodulation (SCS/PNS/pump) candidacy & safety
  
• Opioid-related cognitive impairment affecting risk/compliance
  
• CRPS / chronic pain with psychological overlay
  
• Post-TBI or neurological disease affecting rehab performance
  
• Cognitive impact of CNS-acting medications requiring plan modification

CMS standard: If testing does not change care → NOT covered

Not medically necessary (do not bill):

• Screening tools alone: MMSE / MoCA / PHQ-9
  
• Educational/vocational evaluations
  
• Routine Alzheimer’s follow-up with no plan change
  
• Patient cannot validly participate (incl. intoxication)
  
• Repeat testing without new clinical justification
  ​

3) Time & Billing Rules (HOW to code)
31-minute rule: Minimum 31 minutes required per unit of service
Multi-day testing: Total all minutes → bill on final DOS
Add-on codes:

• 96137 requires 96136
• 96139 requires 96138
  → Only after full additional 30 min is met
  
  

Technician codes require:

• Direct supervision
• QHP on-site & immediately available

Only administration & scoring included
→ Interpretation/report writing = separate code family
Standard test batteries are NOT automatically covered
→ Each test must be individually justified

4) Documentation Requirements (WHAT the chart must show)
Your documentation MUST include:

• Clear clinical findings supporting suspected CNS impairment
• Medical necessity: why testing is needed now
• Named standardized tests administered (not generic references)
• Exact time per CPT and per date
• Patient behavior & test validity observations
• Functional implications (adherence, decision-making, safety)
• Specific treatment changes based on results
• Prior testing reviewed — duplication avoided
• Report sent to ordering/referring provider

If >8 hours → add written justification

Audit Pro-Tip:
Include management change:
“Findings support proceed with SCS trial”
“Adjust opioid plan due to cognitive risk”
“Defer high-risk procedures pending cognitive improvement”

5) Compliance Guardrails (avoid denials)

• Must be diagnostic — NOT psychotherapy
• Do NOT bill screening inventories alone
• Must document direct supervision for 96138/96139
• Remove deleted legacy codes:
  96101–96120, 96111
• Results must be tied to medical decision-making
• Only licensed, Medicare-enrolled QHPs can bill

If medical necessity or supervision is unclear → denial likely

6) EMR Smart-Phrases:
Medical Necessity (MDM)
Neuropsychological test administration and scoring were medically necessary to evaluate cognitive and behavioral factors materially impacting neuromodulation suitability and/or opioid medication safety. Results will directly inform treatment selection, adherence strategies, and clinical risk mitigation in the pain plan.
Time & Tests Block
Standardized tests administered and scored: [LIST TESTS]. Total face-to-face administration/scoring time: [MINUTES]. Time from multiple days combined and billed on the final date of service. Final report provided to referring provider.

✅ ADDITIONAL SECTIONS (as promised)

7) Utilization Safeguards

• Repeat testing only with new clinical indication
• Extended testing (>8 hrs) requires rationale
• Medical records must reflect integration of prior tests

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8) Ordering & Supervision

9) Denial Prevention Checklist

✅Before billing → Confirm ALL:
✔ 31+ minutes documented per code
✔ Named standardized tests
✔ Treatment plan change explicitly stated
✔ Direct supervision (if Tech)
✔ Report sent to ordering provider

✅ CMS References and Sources:

1️⃣ Local Coverage Determination
LCD L34646 – Psychological and Neuropsychological Testing
Centers for Medicare & Medicaid Services (CMS)
🔗 https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34646
2️⃣ Billing & Coding Article
Billing and Coding: Psychological and Neuropsychological Testing (A57481)
Centers for Medicare & Medicaid Services (CMS)
🔗 https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57481

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