guidance-generation

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:

1. Print or download the letter
2. Have your doctor review and sign if needed
3. Mail to the address on your denial notice
4. Keep a copy for your records

[View appeal letter] [Print] [Download PDF]"