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Understanding the new prior authorization model
ccording 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 identifi ed 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.
In January, the Centers for Medicare and Medicaid Services (CMS) implemented the Wasteful and Inappropriate Service Reduction (WISeR) model, which will utilize artifi cial intelligence for prior authorizations. The model is optional, and has been put in place in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
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 fi nd relief from vertebral augmentation.
“Robust clinical evidence underscores the survival benefi t 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 benefi ciaries and quantifi ed this benefi t 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
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