{
  "_comment": "Wear-day rules by device type and payer. Updated 2026-07-07 (P2: plan-scoped keys wrapped with citation rule_ids). Run quarterly review per compliance checklist.",
  "_rule_registry": {
    "R001": "visit_renewal_days — visit renewal window in days (standard: 180)",
    "R002": "refill_window_days — resupply window in days before coverage end (standard: 30; legacy code key name retained)",
    "R003": "pa_required — prior authorization required for this plan type",
    "R004": "pecos_required — PECOS enrollment verification required for this plan type",
    "R100": "swo_required — SWO is a universal claim requirement per LCD L33822",
    "R101": "visit_required — qualifying visit is a universal requirement per LCD L33822",
    "R102": "diagnosis_required — diagnosis (ICD-10) is a universal requirement per LCD L33822"
  },
  "devices": {
    "dexcom_g6": {
      "display_name": "Dexcom G6",
      "sensor_wear_days": 10,
      "transmitter_wear_days": 90,
      "components": ["sensor", "transmitter"]
    },
    "dexcom_g7": {
      "display_name": "Dexcom G7",
      "sensor_wear_days": 10,
      "components": ["sensor"]
    },
    "freestyle_libre_2": {
      "display_name": "FreeStyle Libre 2",
      "sensor_wear_days": 14,
      "components": ["sensor"]
    },
    "freestyle_libre_3": {
      "display_name": "FreeStyle Libre 3",
      "sensor_wear_days": 14,
      "components": ["sensor"]
    },
    "omnipod_5": {
      "display_name": "Omnipod 5",
      "pod_wear_days": 3,
      "sensor_wear_days": 14,
      "components": ["pod", "sensor"]
    }
  },
  "payer_rules": {
    "medicare": {
      "visit_renewal_days": { "value": 180, "rule_id": "R001" },
      "refill_window_days": { "value": 30, "rule_id": "R002" },
      "pa_required": { "value": false, "rule_id": "R003" },
      "pecos_required": { "value": true, "rule_id": "R004" },
      "_note": "Medicare FFS. PA not required (CGM coverage expansion 2023). Face-to-face visit required every 6 months. CMS-1828-F: suppliers at >=90% affirmation rate may qualify for PA exemption from June 1, 2026.",
      "covered_devices": ["dexcom_g6", "dexcom_g7", "freestyle_libre_2", "freestyle_libre_3"]
    },
    "medicare_advantage": {
      "visit_renewal_days": { "value": 180, "rule_id": "R001" },
      "refill_window_days": { "value": 30, "rule_id": "R002" },
      "pa_required": { "value": true, "rule_id": "R003" },
      "pecos_required": { "value": true, "rule_id": "R004" },
      "_note": "Medicare Advantage — PA required, varies by plan. Verify plan-specific rules.",
      "covered_devices": ["dexcom_g6", "dexcom_g7", "freestyle_libre_2", "freestyle_libre_3"]
    },
    "medicaid": {
      "visit_renewal_days": { "value": 180, "rule_id": "R001" },
      "refill_window_days": { "value": 30, "rule_id": "R002" },
      "pa_required": { "value": true, "rule_id": "R003" },
      "pecos_required": { "value": false, "rule_id": "R004" },
      "_note": "PA required — Keystone First, UPMC Health Plan, Highmark BCBS require PA. NJ FamilyCare, Horizon BCBS NJ require PA.",
      "covered_devices": []
    },
    "commercial": {
      "visit_renewal_days": { "value": 180, "rule_id": "R001" },
      "refill_window_days": { "value": 30, "rule_id": "R002" },
      "pa_required": { "value": true, "rule_id": "R003" },
      "pecos_required": { "value": false, "rule_id": "R004" },
      "_note": "Commercial payer rules vary by plan. PA required by default — verify per plan.",
      "covered_devices": []
    },
    "default": {
      "visit_renewal_days": { "value": 180, "rule_id": "R001" },
      "refill_window_days": { "value": 30, "rule_id": "R002" },
      "pa_required": { "value": true, "rule_id": "R003" },
      "pecos_required": { "value": false, "rule_id": "R004" },
      "covered_devices": []
    }
  }
}