d24340c47a
core/rules.py format-tolerant readers + stable registry (R001-R004 plan-scoped, R100-R102 universal per LCD L33822). payer_rules.json wrapped in the same commit as both engine readers (coupling hazard closed). Every DocItem now cites the rule that decided it; NOT_EVALUATED cites nothing. Independent audit: SHIP (registry-drift test added per its L2 finding). 138 tests green. Co-Authored-By: Claude Fable 5 <noreply@anthropic.com>
82 lines
3.8 KiB
JSON
82 lines
3.8 KiB
JSON
{
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"_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.",
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"_rule_registry": {
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"R001": "visit_renewal_days — visit renewal window in days (standard: 180)",
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"R002": "refill_window_days — resupply window in days before coverage end (standard: 30; legacy code key name retained)",
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"R003": "pa_required — prior authorization required for this plan type",
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"R004": "pecos_required — PECOS enrollment verification required for this plan type",
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"R100": "swo_required — SWO is a universal claim requirement per LCD L33822",
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"R101": "visit_required — qualifying visit is a universal requirement per LCD L33822",
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"R102": "diagnosis_required — diagnosis (ICD-10) is a universal requirement per LCD L33822"
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},
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"devices": {
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"dexcom_g6": {
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"display_name": "Dexcom G6",
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"sensor_wear_days": 10,
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"transmitter_wear_days": 90,
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"components": ["sensor", "transmitter"]
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},
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"dexcom_g7": {
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"display_name": "Dexcom G7",
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"sensor_wear_days": 10,
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"components": ["sensor"]
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},
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"freestyle_libre_2": {
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"display_name": "FreeStyle Libre 2",
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"sensor_wear_days": 14,
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"components": ["sensor"]
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},
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"freestyle_libre_3": {
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"display_name": "FreeStyle Libre 3",
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"sensor_wear_days": 14,
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"components": ["sensor"]
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},
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"omnipod_5": {
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"display_name": "Omnipod 5",
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"pod_wear_days": 3,
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"sensor_wear_days": 14,
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"components": ["pod", "sensor"]
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}
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},
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"payer_rules": {
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"medicare": {
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"visit_renewal_days": { "value": 180, "rule_id": "R001" },
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"refill_window_days": { "value": 30, "rule_id": "R002" },
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"pa_required": { "value": false, "rule_id": "R003" },
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"pecos_required": { "value": true, "rule_id": "R004" },
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"_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.",
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"covered_devices": ["dexcom_g6", "dexcom_g7", "freestyle_libre_2", "freestyle_libre_3"]
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},
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"medicare_advantage": {
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"visit_renewal_days": { "value": 180, "rule_id": "R001" },
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"refill_window_days": { "value": 30, "rule_id": "R002" },
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"pa_required": { "value": true, "rule_id": "R003" },
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"pecos_required": { "value": true, "rule_id": "R004" },
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"_note": "Medicare Advantage — PA required, varies by plan. Verify plan-specific rules.",
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"covered_devices": ["dexcom_g6", "dexcom_g7", "freestyle_libre_2", "freestyle_libre_3"]
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},
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"medicaid": {
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"visit_renewal_days": { "value": 180, "rule_id": "R001" },
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"refill_window_days": { "value": 30, "rule_id": "R002" },
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"pa_required": { "value": true, "rule_id": "R003" },
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"pecos_required": { "value": false, "rule_id": "R004" },
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"_note": "PA required — Keystone First, UPMC Health Plan, Highmark BCBS require PA. NJ FamilyCare, Horizon BCBS NJ require PA.",
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"covered_devices": []
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},
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"commercial": {
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"visit_renewal_days": { "value": 180, "rule_id": "R001" },
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"refill_window_days": { "value": 30, "rule_id": "R002" },
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"pa_required": { "value": true, "rule_id": "R003" },
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"pecos_required": { "value": false, "rule_id": "R004" },
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"_note": "Commercial payer rules vary by plan. PA required by default — verify per plan.",
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"covered_devices": []
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},
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"default": {
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"visit_renewal_days": { "value": 180, "rule_id": "R001" },
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"refill_window_days": { "value": 30, "rule_id": "R002" },
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"pa_required": { "value": true, "rule_id": "R003" },
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"pecos_required": { "value": false, "rule_id": "R004" },
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"covered_devices": []
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}
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}
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}
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