| name | guidance-generation |
| description | Synthesize coverage criteria into plain English actionable guidance |
| version | 1.0.0 |
| triggers | ["coverage_criteria_retrieved","user_ready_for_guidance"] |
Guidance Generation Skill
This skill transforms technical coverage requirements into plain English, actionable guidance that patients can take to their doctor appointment.
Purpose
Convert this:
LCD L35047 requires documentation of:
- ICD-10: M54.41, M54.5, M47.816
- Duration >6 weeks
- Failed conservative management
- Neurological deficit on examination
Into this:
Here's what to bring up at your mom's appointment:
□ Pain has lasted more than 6 weeks
□ She's tried physical therapy or medication first
□ The doctor should check and note any numbness or weakness
□ Ask them to document how this affects her daily life
Output Format
Standard Guidance Output
[Status summary — 1-2 sentences]
**What the doctor needs to document:**
□ [Requirement 1 in plain English]
□ [Requirement 2 in plain English]
□ [Requirement 3 in plain English]
**What to bring up at the appointment:**
- [Talking point 1]
- [Talking point 2]
[Optional: Print/download prompt]
Appeal Letter Output
[Summary of situation]
**Your appeal letter includes:**
- Medicare policy citations
- Clinical evidence supporting the service
- Documentation of your specific situation
[Letter content or preview]
**Next steps:**
1. Print this letter
2. Mail to [address] OR upload to Medicare portal
3. Keep a copy for your records
4. Deadline: [date] (120 days from denial)
Translating Requirements
Documentation Requirements
| Technical | Plain English |
|---|
| "Duration of symptoms >6 weeks" | "Pain has lasted more than 6 weeks" |
| "Failed conservative management" | "She's tried physical therapy, medication, or exercises first" |
| "Neurological deficit on examination" | "The doctor checks and notes any numbness, tingling, or weakness" |
| "Functional limitation documentation" | "How the pain affects daily activities (walking, sleeping, work)" |
| "Medical necessity established" | "Why this test is needed for her specific situation" |
| "Prior imaging reviewed" | "Any previous X-rays or scans have been looked at" |
Frequency Limits
| Technical | Plain English |
|---|
| "Once per lifetime" | "Medicare covers this once" |
| "Once per 12 months" | "Can be done once a year" |
| "Every 24 months" | "Can be done every 2 years" |
| "Per episode of care" | "Once for this particular problem" |
Exclusions
| Technical | Plain English |
|---|
| "Routine screening not covered" | "Not covered for 'just checking' — needs to be for specific symptoms" |
| "Cosmetic indications excluded" | "Not covered if it's only for appearance" |
| "Investigational/experimental" | "Medicare doesn't cover this yet because it's still being studied" |
Checklist Generation
Create actionable checklists based on requirements:
Pre-Appointment Checklist
**Before the appointment:**
□ Write down how long you've had symptoms
□ List all treatments you've tried (PT, meds, exercises)
□ Note how symptoms affect daily activities
□ Bring any previous test results or imaging
At-Appointment Talking Points
**Questions to ask the doctor:**
□ "Can you note in my chart how long I've had this?"
□ "Can you document that I've tried [treatments] without enough relief?"
□ "Can you describe how this affects my daily life in the notes?"
□ "Is there anything else Medicare needs documented?"
Documentation Checklist (for doctor)
**For the medical record:**
□ Symptom duration: [X weeks/months]
□ Prior treatments attempted: [list]
□ Current severity: [description]
□ Functional impact: [specific activities affected]
□ Physical exam findings: [relevant findings]
□ Medical necessity: [why this service is needed]
Tone Guidelines
Be Reassuring
Good: "Good news — Medicare typically covers this when..."
Avoid: "Coverage is conditional upon meeting the following criteria..."
Be Actionable
Good: "Ask the doctor to note how long you've had pain"
Avoid: "Duration documentation is required"
Be Specific
Good: "Pain lasting more than 6 weeks"
Avoid: "Extended duration of symptoms"
Acknowledge Reality
Good: "I know this is a lot to think about before an appointment"
Avoid: [Ignoring the emotional burden]
Printable Format
When generating printable guidance:
═══════════════════════════════════════════════════
MEDICARE COVERAGE CHECKLIST
Generated by denali.health
Date: [current date]
═══════════════════════════════════════════════════
PATIENT: [Name if known]
SERVICE: [Procedure in plain English]
DOCTOR: [Provider name if known]
WHAT MEDICARE NEEDS DOCUMENTED:
───────────────────────────────────────────────────
□ [Requirement 1]
□ [Requirement 2]
□ [Requirement 3]
□ [Requirement 4]
QUESTIONS TO ASK YOUR DOCTOR:
───────────────────────────────────────────────────
• [Question 1]
• [Question 2]
• [Question 3]
NOTES:
───────────────────────────────────────────────────
[Space for patient to write]
───────────────────────────────────────────────────
This guidance is based on Medicare policies as of [date].
Your doctor makes the final decisions about your care.
Questions? Visit denali.health
═══════════════════════════════════════════════════
What NOT to Do
- Never guarantee approval: Say "typically covers" not "will be approved"
- Never give medical advice: Only coverage guidance
- Never use jargon: Translate everything to plain English
- Never skip the checklist: Always provide actionable items
- Never forget the human element: Acknowledge this is stressful
Example Output
Coverage Guidance
User situation: Mom needs lumbar MRI for 3 months of back pain radiating to leg
Output:
"Good news — Medicare typically covers a lumbar spine MRI for your mom's situation. Here's what will help make sure it gets approved:
What the doctor needs to document:
□ Pain has lasted more than 6 weeks (she has 3 months ✓)
□ Pain goes into her leg (radiating symptoms ✓)
□ She's tried other treatments first (PT, medication)
□ Physical exam shows nerve involvement (numbness, weakness, reflexes)
What to mention at the appointment:
- 'I've had this pain for 3 months and it's going down my leg'
- 'I've tried [medications/PT] but it's not getting better'
- 'The pain makes it hard to [specific activities]'
- 'Can you make sure to document all of this in my chart?'
Tip: Print this checklist and bring it to the appointment. It helps make sure nothing gets missed."
[Print this checklist] [What if it's denied?]
👍 👎 Was this helpful?
Appeal Guidance
User situation: MRI was denied, appealing
Output:
"I'm sorry your MRI was denied. The good news is you have the right to appeal, and I can help you put together a strong case.
Your appeal letter is ready!
It includes:
- Medicare policy citations showing when MRI is covered
- Your specific symptoms and how long you've had them
- Evidence that you've tried other treatments
- Supporting medical literature
Important deadlines:
- You have 120 days from the denial date to appeal
- Your deadline: [calculated date]
Next steps:
- Print or download the letter
- Have your doctor review and sign if needed
- Mail to the address on your denial notice
- Keep a copy for your records
[View appeal letter] [Print] [Download PDF]"
