GET/api/payer/decisions

Payer decisions event stream

Event stream of payer / coverage decisions across ICER, CMS, PBMs, Medicaid, VA, intl HTA.

Distinct from MMIT's static formulary state — this is the delta stream of decision events. Covers ICER Evidence Rating Matrix (A/B+/B/C+/C/C-/D/P-I/I), CMS NCD/LCD (with real L##### document IDs), Big-3 PBM 2026 formulary exclusions (CVS Caremark, Express Scripts, OptumRx — quarterly cycle), state Medicaid PDLs, VA National Formulary, DoD TRICARE, hospital P&T, and international HTA decisions.

Query parameters

Name	Type	Description
`product`required	string	Brand of interest. e.g. `ZENVARA`
`indication`required	string	Indication context for relevance scoring. e.g. `NSCLC`
`start`required	string (ISO date)	Window start.
`end`required	string (ISO date)	Window end.
`decision_body`	enum	Filter to a single body. allowed: `icercms_ncdcms_lcdpbm_commercialpbm_medicare_pdphealth_plan_commercialstate_medicaid_pdlva_national_formularydod_tricarehospital_pt_committeehta_intl`

Response schema

Path	Type	Description
`product / indication / period / total_decisions`	mixed	Echo + count.
`decisions[]`	array	Decision events sorted by decision_date ascending.
`decisions[].decision_id`	string	Stable id like `icer-2026-0042`.
`decisions[].decision_body`	enum	See `decision_body` param for allowed values.
`decisions[].decision_body_name`	string	Human-readable body name (e.g., 'CVS Caremark', 'Florida AHCA').
`decisions[].decision_type`	enum	added \| removed \| excluded \| tier_changed \| restriction_added \| restriction_removed \| coverage_decision \| value_assessment_draft \| value_assessment_final \| price_benchmark \| pdl_preferred_status_changed \| step_therapy_imposed.
`decisions[].decision_summary`	string	Human-readable 1-line.
`decisions[].decision_detail`	object	Body-specific. ICER: rating + value_for_money + price_benchmark_usd. tier_changed: tier_before/after. restriction_added: restrictions[].
`decisions[].decision_date / effective_date`	string	When announced vs when in force.
`decisions[].source_url`	string	Link to canonical source.
`decisions[].source_document_id`	string (LCD/NCD only)	CMS document IDs — L#### for LCDs, CAG-### for NCDs.
`decisions[].lives_impacted_estimate`	integer	Covered lives under this decision body (~65M for CMS NCD, ~9M for VA, etc.).
`decisions[].geography`	string	US-national \| US-state:XX \| MAC:JX \| EU-DE \| UK \| etc.
`decisions[].competitive_relevance`	object	{ score: 0-1, rationale, relationship: direct_competitor\|adjacent\|reference_product\|class_effect }.
`decisions[].ingested_at`	string	ISO timestamp when the event was ingested into the warehouse.

Behaviour notes

·Big-3 PBMs (CVS Caremark, Express Scripts, OptumRx) guaranteed in 3+ month windows.
·ICER ratings drawn from real Evidence Rating Matrix (A through D, plus P/I and I).
·CMS LCD IDs use 'L' + 5 digits — real format.
·Lives impacted anchored to real coverage figures per body.
·Volume calibrated to ~15-30 events/month for a mid-stage oncology asset.

Examples

All decisions

curl 'http://localhost:3000/api/payer/decisions?product=ZENVARA&indication=NSCLC&start=2026-02-01&end=2026-05-01'

ICER only

curl 'http://localhost:3000/api/payer/decisions?product=ZENVARA&indication=NSCLC&start=2026-02-01&end=2026-05-01&decision_body=icer'

Sources

ICER Evidence Rating Matrixhttps://icer.org/evidence-rating-matrix/
CMS Medicare Coverage Databasehttps://www.cms.gov/medicare-coverage-database/search.aspx
Drug Channels — Big-3 PBM 2026 Exclusionshttps://www.drugchannels.net/2026/01/the-big-three-pbms-2026-formulary.html
VA National Formularyhttps://www.pbm.va.gov/nationalformulary.asp

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