CMS to Add Prior Authorization for Traditional Medicare

Adding to the recent DOJ crackdowns on skin substitutes, the Centers for Medicare & Medicaid Services (CMS) recently announced a major shift in traditional Medicare: prior authorization (PA) requirements for 17 high-risk services, including skin and tissue substitutes, starting in 2026 under the Wasteful and Inappropriate Service Reduction (WISeR) model time.com+15axios.com+15ramaonhealthcare.com+15.

What It Means for Wound Care Providers:

• Pre-approval will be required for CTPs (cellular and tissue-based products) before billing. If PA isn’t obtained, claims may be denied or subjected to post-payment review.

• This affects providers across five pilot states (AZ, WA, NJ, TX, OK), but new PA processes are expected to extend nationwide by 2026 federalregister.gov.

• CMS will partner with AI-driven, tech-enabled third parties to streamline authorization, but final medical determinations must be made by licensed clinicians marketwatch.com.

What It Means	Why It Matters
Front-End Authorization	Submit PA before administering CTPs to ensure coverage and avoid claim denials.
Policy Alignment	Documentation and protocols must be airtight & aligned with LCD/NCD standards.
Tech-Enabled Workflow	Adopt compliant PA workflows to stay ahead during the WISeR pilot and future rollouts.

How Kindling Can Help

• We’ll audit your current CTP documentation and workflows, ensuring each step aligns with LCD rules and evolving PA requirements.

• We offer training modules on PA process, pre-claim documentation, and chart readiness.

• We provide workflow support to integrate PA steps seamlessly into clinic operations, so care isn’t delayed.

Resources to Know

• CMS Press Release on WISeR pilot medicareadvocacy.orgcms.gov+1investopedia.com+1federalregister.govfiercehealthcare.com+6cms.gov+6beckershospitalreview.com+6

• Becker’s Hospital Review article summarizing the pilot’s inclusion of skin substitutes en.wikipedia.org+10beckershospitalreview.com+10beckershospitalreview.com+10

• CMS Prior Authorization Resources (guide to programs and automation tools) time.com+15cms.gov+15federalregister.gov+15

Bottom Line

With both DOJ fraud enforcement and CMS’s WISeR prior authorization model targeting skin substitutes, the window for reactive compliance is closing fast. You need strong documentation, pre-claim readiness, and operational integration—before care happens.

Kindling Consulting can help you build that readiness and reduce risk. Reach out to schedule a CTP workflow and authorization review today.