Tuesday, May 16, 2023

GPT4 Solves a Model Prior Authorization Decision for a Molecular Test

This is an artificial case history, but shows that GPT4 can apply prior authorization rules to a medical record.  {The rules are fake}.


In this task, you will assess whether a patient's medical record meets Anthem’s coverage criteria for residual disease PCR testing.    Anthem requires five criteria:

1. The patient is less than 85 years old.

2. The patient has previously been treated with cyclophosphamide or vincristine.

3. The patient has B cell leukemia.

4. The patient has not had a residual disease PCR test in less than 30 days.

5. The patient is being treated by an oncologist.

Here is the medical record to analyze.  Please respond by discussing the five criteria above, for Mary Doe, in light of her medical record.  Please note that this is a mock up case, so evaluate it for the criteria above, some aspects of the record may be fictional.


Date: May 16, 2023

Doctor: Dr. Bruce Quinn

Physician Specialty: Oncology

Mary Doe is seen in clinic visit today complaining of nausea and shakiness.  She had difficulty sleeping last night.   

History.  Mary is a 70 year old woman.  She was diagnosed with hypertension at age 65 and takes hydrochlorthiazide with good control.   She had a wrist fracture after a fall at age 67 and healed well with no residual complaints.   At age 68, she developed several episodes of infection and was anemic and had lost 15 pounds.  She had intermittent fevers at night, which she had not experienced since menopause at age 51.   She was diagnosed with plasma cell leukemia.   It could be identified with PCR for a distinctive translocation t(4,14).  She was treated with four months of cyclophosphamide therapy.   Since then, evidence of leukemia has been absent on flow cytometry and molecular testing.   She had her last PCR TRANSLOCATION test on May 4, 2023, which was negative.

Physician exam:  The patient’s blood pressure is 120/90.  Her pulse is 80.  Her temperature is 37 C.   She appears comfortable.   Physical exam is otherwise normal except for mild brusing on the left upper arm.

Labs:  White count is 6000.   Hematocrit is 40%.   Urinalysis is normal.

Plan:  Patient says she feels better today.   Her mild symptoms seem to be resolving.  Order a PCR TRANSLOCATION test and run an AI prior auth analysis for it.   Ask Mary to return in 7 days, but call us if symptoms worsen.

SIG / Bruce Quinn MD     




Based on the medical record, here's how Mary Doe's case aligns with Anthem’s coverage criteria for a PCR translocation test:

Age: Mary is 70 years old, which satisfies Anthem's criterion that the patient be less than 85 years old.

Previous Treatment: Mary's record states that she was treated with cyclophosphamide therapy for four months. The criteria include cyclophosphamide as an acceptable previous treatment, so this criterion is met.

Type of Leukemia: Mary has been diagnosed with plasma cell leukemia, not B cell leukemia. Although plasma cells are a form of mature B cells, the medical and insurance communities do not always consider them as such due to their distinct characteristics and treatment approaches. Therefore, based on Anthem's specific requirement for B cell leukemia, this criterion is not met.

PCR Translocation Test Timing: Mary's last PCR translocation test was performed on May 4, 2023. As today's date is May 16, 2023, only 12 days have passed since her last test. This does not meet Anthem's criterion that a test should not be performed less than 30 days from the previous one.

Specialist Treatment: Mary is being treated by Dr. Bruce Quinn, whose specialty is Oncology. This meets Anthem's requirement that the patient is being treated by an oncologist.

In conclusion, Mary's medical record meets three out of the five criteria set by Anthem. She does not meet the criteria for the type of leukemia (B cell leukemia) and the timing since her last PCR translocation test. Therefore, based on the provided criteria, her PCR translocation test may not be covered by Anthem insurance.


OK, that was good.   I am not an oncologist, but as a physician, I would have thought that plasma cells were a form of mature B cell that makes antibodies.  Can't the terms be used this way?


Yes, you're correct. Plasma cells are indeed a type of mature B cell that produces antibodies. They are part of the B cell lineage and are formed when B cells are activated by specific immune responses. However, in a medical context, the terminology can sometimes be more precise.

When an insurance company, like Anthem, specifies "B cell leukemia" in their coverage criteria, they are likely referring to types of leukemia that specifically arise from B cells at an earlier stage of development, such as Chronic Lymphocytic Leukemia (CLL) or Acute Lymphoblastic Leukemia (ALL).

Plasma Cell Leukemia, on the other hand, arises from plasma cells, which are indeed a type of mature B cell, but this form of leukemia is typically categorized separately due to its distinct characteristics and treatment protocols.

Therefore, in a strict interpretation of the insurance criteria as stated, it may be argued that Plasma Cell Leukemia does not meet the requirement of "B cell leukemia". 

However, a case could also be made for coverage based on the fact that plasma cells are part of the B cell lineage. It might require further clarification from Anthem regarding their specific definition and criteria.

It's always a good idea in such cases to consult with the patient's oncologist and the insurance company to make sure the correct and most beneficial course of action is taken.

art / bing.com/create