What payer algorithms
actually look for

What the algorithm scans for — in order of weight

• 1
  Named failed treatments with dates and duration

  The system requires documented evidence that lower-cost or less intensive options were tried and failed. Vague references don't satisfy the rule. Specific treatment names, start/end dates, and documented failure reasons are required.

  Write: "Patient completed 8 weeks of physical therapy (03/01–04/26/2025) with no reduction in VAS pain scores. NSAID therapy discontinued 02/2025 due to GI intolerance." — Not: "Patient has tried conservative treatment."
• 2
  Functional limitation — specific and measurable

  Algorithms score severity through functional loss, not symptoms alone. You must document what the patient cannot do, with a measurable baseline. Pain alone does not move a PA forward. Inability to perform named daily activities does.

  Write: "Patient is unable to ambulate more than 50 feet without rest. Unable to perform ADLs independently. PHQ-9 score 16 (moderately severe)." — Not: "Patient is suffering and quality of life is affected."
• 3
  ICD-10 precision matching the requested intervention

  Payer systems cross-reference the diagnosis code against the requested treatment. A code that is too broad, too general, or mismatched to the clinical level being requested triggers automatic review escalation. The code must support the severity implied by the request.

  Write: M51.16 (intervertebral disc degeneration, lumbar region) with M54.42 (lumbago with sciatica, right side) — Not: M54.5 (low back pain) for a spinal injection request.
• 4
  Severity qualifier matching the intervention tier

  Mild, moderate, and severe designations map to specific intervention tiers in clinical policy. Requesting a high-tier intervention with only mild severity documented creates a logic mismatch that denial engines flag automatically. The severity language in your notes must match the intensity of what you are requesting.

  Write: "Moderate-to-severe major depressive disorder (F33.1), unresponsive to two adequate trials of first-line pharmacotherapy." — Not: "Depression with symptoms" for a TMS request.
• 5
  Baseline measurements before the requested treatment

  Algorithms look for a documented before-state to justify the treatment request. Objective scores — pain scales, functional assessments, lab values, imaging findings — establish the baseline. Without them, the system has no reference point against which to evaluate medical necessity.

  Write: "HbA1c 9.2 as of 04/10/2025 despite adherence to current regimen. Repeat fasting glucose 248 mg/dL on 04/15/2025." — Not: "Labs are elevated and current treatment isn't working."
• 6
  "Guideline-concordant" or "evidence-based" — exact phrase required

  Many payer clinical policy documents include these terms as literal required flags. Synonyms do not satisfy the rule. Writing "consistent with current standards" or "per best practices" is not the same as writing "guideline-concordant care per [guideline source]." Use the payer's own language where possible.

  Write: "Requested treatment is guideline-concordant per ADA Standards of Medical Care 2025, Section 9." — Not: "This is the standard of care for this condition."

What gets flagged vs what gets through

This guide is for informational purposes only and does not constitute legal or medical advice. Niti Logic outputs are generated using the proprietary PRISM Logic Engine. Claude (Anthropic) formats the output. Your use of this guide does not create an attorney-client or provider-patient relationship. Coverage decisions are made by payers; outcomes may vary. © 2025 Niti Logic LLC.