The problem
Orthopedic practices now work several authorization programs at once. Since January 1, 2026, Original Medicare’s WISeR Model has required prior authorization, or pre-payment review, for selected services in six states, as our WISeR guide explains. Many Medicare Advantage and commercial plans also require approval for elective surgery, advanced imaging and some injections.
Approval alone doesn’t protect the claim: an approval that doesn’t match the CPT code, side, site of service or dates of the surgery can still end in a denial. And a note that misses the payer’s criteria can get the request denied; for total joints, the policies in our appeal guide generally require imaging-confirmed advanced arthritis, functional limitation and about 12 weeks of failed nonoperative care.
How it works
Check payer requirements: The free payer directory at policy.rette.ai lists payer IDs and prior authorization requirements.
Read the chart: Rette’s AI agents connect to athenahealth or eClinicalWorks and read operative and clinical notes directly, with no data migration. Using another EHR? Ask about your EHR.
Flag gaps, check rules: Rette flags documentation gaps in the note and checks claims against Medicare NCD and LCD rules before submission.
Work one queue: Prior authorization work sits in one prioritized queue with denials, appeals and workers’ compensation, so staff see what needs attention first.
What you get
One prioritized queue for prior authorization, shared with denials, appeals and workers’ comp
Operative and clinical notes read directly from the EHR your practice already uses
Documentation gaps flagged before coding and before the claim goes out
Claims checked against NCCI edits and Medicare NCD and LCD rules before submission
Built for orthopedics
Rette is built with orthopedic surgeon advisors, and orthopedic authorization work spans several rule sets:
WISeR: as of CMS’s July 24, 2026 guide, the WISeR Model covers knee arthroscopy for osteoarthritis (29877), epidural steroid injections, vertebroplasty and kyphoplasty, anterior cervical fusion (22554) and paddle-lead spinal cord stimulators, but not joint replacement.
Medicare Advantage and Medicaid: since January 1, 2026, CMS-0057-F has required most of these plans to decide standard requests within 7 calendar days and expedited ones within 72 hours.
Mismatches: an approval for 29881 (arthroscopic meniscectomy of one meniscus) doesn’t cover a billed 29880 (both menisci), a common route to CO-197.
Non-affirmed services: if a WISeR patient chooses to proceed, CMS says to deliver an Advance Beneficiary Notice first and bill with modifier GA.
Frequently asked questions
Does WISeR apply to all of our Medicare patients?
No. WISeR applies only to Original Medicare patients who receive a listed service in Arizona, New Jersey, Ohio, Oklahoma, Texas or Washington, from January 1, 2026, through December 31, 2031. Medicare Advantage patients are excluded. Requesting prior authorization is voluntary, but a listed service billed without a decision goes to pre-payment medical review.
Do payers have to explain prior authorization denials?
Many do. Under CMS-0057-F, starting in 2026, Medicare Advantage organizations, Medicaid and CHIP programs and plans, and qualified health plans on the federally facilitated Exchanges must give a specific reason for each prior authorization denial. The rule doesn’t cover Original Medicare, and other commercial plans set their own processes.
How long does it take to get started?
Go-live timing is confirmed on a call. Rette connects to the EHR your practice already uses, currently athenahealth and eClinicalWorks, so there is no rip-and-replace, no data migration and no new system for staff to learn. If you use another EHR, ask about your EHR when you request a demo.
Related guides
Read More
Prior Authorization
WISeR Model: Which Orthopedic Services Need Medicare Prior Authorization?
Oct 14, 2026
Read More
Denials & Appeals
How to Appeal a Medical-Necessity Denial for a Knee or Hip Replacement
Oct 14, 2026
Read More
Denials & Appeals
The Most Common Orthopedic Claim Denials in 2026, and How to Prevent Them
Oct 14, 2026
Key terms
Rette reads the operative note in the EHR you already use, suggests codes and checks claims against payer and NCCI rules before submission.