Why it matters in orthopedics

WISeR reaches several services that orthopedic and spine practices perform for Original Medicare patients in its six states: knee arthroscopy for osteoarthritis (29877), epidural steroid injections, vertebroplasty and kyphoplasty, anterior cervical fusion (22554) and paddle-lead spinal cord stimulator placement (63655). Related claims follow the primary service, so a failed review can also stop payment for anesthesia and the surgeon’s professional claim. Our WISeR guide for orthopedic practices lists the codes and a step-by-step workflow.

How it works

• One technology company (a “WISeR participant”) reviews requests in each state, using AI tools plus clinicians. A licensed clinician must review every non-affirmation.

• Providers choose between requesting prior authorization, through the participant or their MAC, and letting the claim go to pre-payment medical review.

• Standard decisions typically arrive within 3 calendar days, and expedited decisions within 2 days. An affirmed request’s unique tracking number (UTN) is valid for 120 days and must appear on the claim.

• In ASCs and hospital outpatient departments, review applies to the facility claim; in the office, to the professional claim.

• WISeR does not change Medicare coverage criteria or payment rates, and it excludes Medicare Advantage, inpatient-only and emergency services.

Unlike the CMS Interoperability and Prior Authorization Final Rule, which governs Medicare Advantage, Medicaid and Exchange plans, WISeR applies to Original Medicare.

Orthopedic example

A 64-year-old Original Medicare patient in Ohio has early medial compartment knee osteoarthritis with locking and catching that persists despite therapy, and the surgeon plans arthroscopic chondroplasty (29877) at an ASC. The practice sends Innovaccer, Ohio’s WISeR participant, the standing x-ray and MRI reports and notes describing the mechanical symptoms. After a provisional affirmation, the ASC reports the UTN on its facility claim within 120 days.

Common denial triggers

• Knee arthroscopy notes describe pain alone, or severe (Outerbridge grade III or IV) osteoarthritis, which NCD 150.9 treats as noncovered.

• Epidural injection requests lack 4 weeks of failed conservative care, a baseline pain or function scale, or a session count.

• The UTN is missing from the claim, or the service falls outside the 120-day window.

• The practice misses the 45-day deadline to answer a pre-payment additional documentation request.

How to prevent or fix

Screen Original Medicare patients at scheduling for state and code. Build note templates from CMS’s documentation checklists, and agree with each ASC on who submits the request and carries the UTN. After a non-affirmation, add the missing records and resubmit; resubmissions are unlimited and can include peer-to-peer review. If the patient still wants a non-affirmed service, deliver an Advance Beneficiary Notice first and bill with modifier GA. Denied claims keep normal Medicare appeal rights.