{ "difficulty": "easy", "description": "Straightforward clinical cases with direct ICD-10/CPT mapping, single diagnoses, and clear compliance decisions.", "cases": [ { "id": "easy_001", "difficulty": "easy", "input": { "clinical_note": "Patient presents with acute pharyngitis. Throat is erythematous with no exudate. Rapid strep test negative. Diagnosed with viral pharyngitis. Advised rest, fluids, and OTC analgesics.", "symptoms": ["sore throat", "mild fever", "difficulty swallowing"], "treatments": ["rest", "fluids", "acetaminophen"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 28, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": "Rapid strep test: Negative", "medications": ["acetaminophen 500mg PRN"] }, "ground_truth": { "diagnosis_codes": ["J02.9"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_002", "difficulty": "easy", "input": { "clinical_note": "42-year-old male presents for annual wellness exam. No complaints. Vitals normal. BMI 24.3. Routine labs ordered. Patient counseled on diet and exercise.", "symptoms": [], "treatments": ["routine labs", "health counseling"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 42, "patient_sex": "M", "provider_specialty": "Internal Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": [] }, "ground_truth": { "diagnosis_codes": ["Z00.00"], "procedure_codes": ["99395"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_003", "difficulty": "easy", "input": { "clinical_note": "Patient presents with uncomplicated urinary tract infection. Dysuria and frequency for 2 days. UA positive for nitrites and leukocyte esterase. Prescribed trimethoprim-sulfamethoxazole.", "symptoms": ["dysuria", "urinary frequency", "suprapubic discomfort"], "treatments": ["trimethoprim-sulfamethoxazole"], "insurance_type": "Medicare", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 65, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": "UA: Nitrites positive, Leukocyte esterase positive, WBC >10/hpf", "medications": ["trimethoprim-sulfamethoxazole 160/800mg BID"] }, "ground_truth": { "diagnosis_codes": ["N39.0"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_004", "difficulty": "easy", "input": { "clinical_note": "Child brought in by mother for ear pain x2 days. Otoscopic exam reveals bulging, erythematous right tympanic membrane. Diagnosed with acute otitis media. Prescribed amoxicillin.", "symptoms": ["right ear pain", "fussiness", "mild fever"], "treatments": ["amoxicillin"], "insurance_type": "Medicaid", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 4, "patient_sex": "M", "provider_specialty": "Pediatrics", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["amoxicillin 250mg/5mL TID"] }, "ground_truth": { "diagnosis_codes": ["H66.91"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_005", "difficulty": "easy", "input": { "clinical_note": "Patient with known type 2 diabetes presents for routine follow-up. A1C obtained is 7.1%. Current medications reviewed. No complications. Continue metformin. Follow up in 3 months.", "symptoms": [], "treatments": ["metformin continuation", "A1C monitoring"], "insurance_type": "Medicare", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 58, "patient_sex": "M", "provider_specialty": "Internal Medicine", "visit_type": "outpatient", "comorbidities": ["type 2 diabetes"], "lab_results": "HbA1c: 7.1%", "medications": ["metformin 1000mg BID"] }, "ground_truth": { "diagnosis_codes": ["E11.65"], "procedure_codes": ["99214"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_006", "difficulty": "easy", "input": { "clinical_note": "Patient presents with acute bronchitis. Cough productive of clear sputum for 5 days. Lungs clear to auscultation. No fever. Chest x-ray not indicated. Supportive care recommended.", "symptoms": ["productive cough", "mild chest discomfort", "fatigue"], "treatments": ["rest", "fluids", "cough suppressant"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 35, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["dextromethorphan PRN"] }, "ground_truth": { "diagnosis_codes": ["J20.9"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_007", "difficulty": "easy", "input": { "clinical_note": "Patient presents for removal of a benign skin lesion on the back. Lesion is 0.8cm, non-suspicious. Shave removal performed without complications. Specimen sent to pathology.", "symptoms": ["skin lesion on back"], "treatments": ["shave removal of lesion"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 45, "patient_sex": "M", "provider_specialty": "Dermatology", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": [] }, "ground_truth": { "diagnosis_codes": ["D23.5"], "procedure_codes": ["11305"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_008", "difficulty": "easy", "input": { "clinical_note": "Patient presents with allergic rhinitis. Sneezing, nasal congestion, and watery eyes for 3 weeks. Symptoms seasonal. No fever. Started on cetirizine and fluticasone nasal spray.", "symptoms": ["sneezing", "nasal congestion", "watery eyes", "itchy nose"], "treatments": ["cetirizine", "fluticasone nasal spray"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 32, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["cetirizine 10mg daily", "fluticasone nasal spray"] }, "ground_truth": { "diagnosis_codes": ["J30.1"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_009", "difficulty": "easy", "input": { "clinical_note": "Patient twisted ankle playing basketball. X-ray negative for fracture. Mild swelling and tenderness over lateral malleolus. Diagnosed with ankle sprain. RICE protocol and ACE wrap applied.", "symptoms": ["ankle pain", "swelling", "difficulty bearing weight"], "treatments": ["RICE protocol", "ACE wrap", "ibuprofen"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 22, "patient_sex": "M", "provider_specialty": "Emergency Medicine", "visit_type": "emergency", "comorbidities": [], "lab_results": "X-ray right ankle: No fracture identified", "medications": ["ibuprofen 400mg TID PRN"] }, "ground_truth": { "diagnosis_codes": ["S93.401"], "procedure_codes": ["99283"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_010", "difficulty": "easy", "input": { "clinical_note": "Patient presents with tension headache. Reports bilateral, non-pulsating headache for 2 days. No visual changes, no nausea or vomiting. Neurological exam normal. Prescribed ibuprofen.", "symptoms": ["bilateral headache", "neck stiffness", "fatigue"], "treatments": ["ibuprofen"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 30, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["ibuprofen 400mg PRN"] }, "ground_truth": { "diagnosis_codes": ["G44.209"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_011", "difficulty": "easy", "input": { "clinical_note": "Infant presents for 6-month well-child visit. Growth and development on track. Immunizations administered per CDC schedule. Anticipatory guidance provided to parents.", "symptoms": [], "treatments": ["immunizations", "developmental screening"], "insurance_type": "Medicaid", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 0, "patient_sex": "F", "provider_specialty": "Pediatrics", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": [] }, "ground_truth": { "diagnosis_codes": ["Z00.129"], "procedure_codes": ["99391"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_012", "difficulty": "easy", "input": { "clinical_note": "Patient presents with localized contact dermatitis on both hands. Reports using new cleaning product. Erythematous, pruritic rash on dorsal hands bilaterally. Prescribed topical hydrocortisone.", "symptoms": ["itchy rash on hands", "erythema", "mild swelling"], "treatments": ["topical hydrocortisone", "avoidance of irritant"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 38, "patient_sex": "F", "provider_specialty": "Dermatology", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["hydrocortisone 1% cream BID"] }, "ground_truth": { "diagnosis_codes": ["L25.9"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_013", "difficulty": "easy", "input": { "clinical_note": "Patient presents with conjunctivitis. Red, watery left eye for 3 days. No vision changes. No discharge. Likely viral etiology. Advised warm compresses and artificial tears.", "symptoms": ["red eye", "watery discharge", "mild irritation"], "treatments": ["warm compresses", "artificial tears"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 25, "patient_sex": "M", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["artificial tears PRN"] }, "ground_truth": { "diagnosis_codes": ["H10.9"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_014", "difficulty": "easy", "input": { "clinical_note": "Patient presents with GERD symptoms. Heartburn and regurgitation for 4 weeks. No alarm symptoms. No dysphagia or weight loss. Started on omeprazole 20mg daily.", "symptoms": ["heartburn", "acid regurgitation", "epigastric discomfort"], "treatments": ["omeprazole"], "insurance_type": "Medicare", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 55, "patient_sex": "M", "provider_specialty": "Internal Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["omeprazole 20mg daily"] }, "ground_truth": { "diagnosis_codes": ["K21.0"], "procedure_codes": ["99214"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_015", "difficulty": "easy", "input": { "clinical_note": "Patient presents with insomnia. Difficulty falling asleep for 6 weeks. No daytime sleepiness while driving. Good sleep hygiene discussed. No medications prescribed; CBT-I referral placed.", "symptoms": ["difficulty falling asleep", "fatigue", "irritability"], "treatments": ["sleep hygiene counseling", "CBT-I referral"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 40, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": [] }, "ground_truth": { "diagnosis_codes": ["G47.00"], "procedure_codes": ["99214"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_016", "difficulty": "easy", "input": { "clinical_note": "Patient with known hypertension presents for medication refill. Blood pressure well controlled at 128/78. No symptoms. Continue lisinopril 10mg daily. Follow up in 6 months.", "symptoms": [], "treatments": ["lisinopril continuation"], "insurance_type": "Medicare", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 62, "patient_sex": "M", "provider_specialty": "Internal Medicine", "visit_type": "outpatient", "comorbidities": ["essential hypertension"], "lab_results": "BP: 128/78 mmHg", "medications": ["lisinopril 10mg daily"] }, "ground_truth": { "diagnosis_codes": ["I10"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_017", "difficulty": "easy", "input": { "clinical_note": "Patient presents with acute sinusitis. Facial pain, nasal congestion, and purulent discharge for 10 days. No improvement with OTC decongestants. Started amoxicillin-clavulanate.", "symptoms": ["facial pain", "nasal congestion", "purulent nasal discharge", "low-grade fever"], "treatments": ["amoxicillin-clavulanate"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 34, "patient_sex": "M", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["amoxicillin-clavulanate 875/125mg BID"] }, "ground_truth": { "diagnosis_codes": ["J01.90"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_018", "difficulty": "easy", "input": { "clinical_note": "Patient presents with impetigo on the face. Honey-colored crusted lesions around the nose and mouth. Diagnosed with non-bullous impetigo. Prescribed mupirocin ointment.", "symptoms": ["crusted lesions around nose", "mild itching"], "treatments": ["mupirocin ointment"], "insurance_type": "Medicaid", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 6, "patient_sex": "M", "provider_specialty": "Pediatrics", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["mupirocin 2% ointment TID"] }, "ground_truth": { "diagnosis_codes": ["L01.00"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_019", "difficulty": "easy", "input": { "clinical_note": "Patient presents for flu vaccination. No acute complaints. Past medical history unremarkable. Influenza vaccine (IIV4) administered intramuscularly in left deltoid.", "symptoms": [], "treatments": ["influenza vaccination"], "insurance_type": "Medicare", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 70, "patient_sex": "F", "provider_specialty": "Internal Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": [] }, "ground_truth": { "diagnosis_codes": ["Z23"], "procedure_codes": ["90688"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_020", "difficulty": "easy", "input": { "clinical_note": "Patient presents with lower back pain after lifting heavy box at work. No radiation to legs. No weakness or numbness. Lumbar strain diagnosed. NSAIDs and physical therapy recommended.", "symptoms": ["lower back pain", "stiffness", "limited range of motion"], "treatments": ["ibuprofen", "physical therapy referral"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 36, "patient_sex": "M", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["ibuprofen 600mg TID"] }, "ground_truth": { "diagnosis_codes": ["M54.5"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_021", "difficulty": "easy", "input": { "clinical_note": "Patient presents for iron deficiency anemia follow-up. Recent labs show hemoglobin 10.8 g/dL, ferritin 12 ng/mL. Iron supplementation continued. Repeat labs in 3 months.", "symptoms": ["fatigue", "pallor"], "treatments": ["iron supplementation"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 29, "patient_sex": "F", "provider_specialty": "Internal Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": "Hgb: 10.8 g/dL, Ferritin: 12 ng/mL, MCV: 72 fL", "medications": ["ferrous sulfate 325mg daily"] }, "ground_truth": { "diagnosis_codes": ["D50.9"], "procedure_codes": ["99214"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_022", "difficulty": "easy", "input": { "clinical_note": "Patient presents with acne vulgaris. Moderate papulopustular acne on face. No scarring. Started on benzoyl peroxide and topical retinoid. Follow up in 8 weeks.", "symptoms": ["facial acne", "papules", "pustules"], "treatments": ["benzoyl peroxide", "topical tretinoin"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 16, "patient_sex": "F", "provider_specialty": "Dermatology", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["benzoyl peroxide 5% gel", "tretinoin 0.025% cream"] }, "ground_truth": { "diagnosis_codes": ["L70.0"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_023", "difficulty": "easy", "input": { "clinical_note": "Patient presents with gastroenteritis. Nausea, vomiting, and watery diarrhea for 2 days. No blood in stool. Mild dehydration. Oral rehydration recommended. Symptoms improving.", "symptoms": ["nausea", "vomiting", "watery diarrhea", "abdominal cramps"], "treatments": ["oral rehydration", "bland diet"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 27, "patient_sex": "M", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["ondansetron 4mg PRN"] }, "ground_truth": { "diagnosis_codes": ["K52.9"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_024", "difficulty": "easy", "input": { "clinical_note": "Patient presents with wrist pain after fall on outstretched hand. X-ray shows distal radius fracture, non-displaced. Short arm cast applied. Orthopedic follow-up arranged.", "symptoms": ["wrist pain", "swelling", "limited wrist motion"], "treatments": ["short arm cast", "pain management"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "medium", "patient_age": 11, "patient_sex": "M", "provider_specialty": "Emergency Medicine", "visit_type": "emergency", "comorbidities": [], "lab_results": "X-ray left wrist: Non-displaced distal radius fracture", "medications": ["ibuprofen 200mg TID"] }, "ground_truth": { "diagnosis_codes": ["S52.501"], "procedure_codes": ["99283"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_025", "difficulty": "easy", "input": { "clinical_note": "Patient presents for hypothyroidism follow-up. TSH 3.2 mIU/L on levothyroxine 75mcg. Symptoms well controlled. No dose adjustment needed. Continue current therapy.", "symptoms": [], "treatments": ["levothyroxine continuation"], "insurance_type": "Medicare", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 56, "patient_sex": "F", "provider_specialty": "Endocrinology", "visit_type": "outpatient", "comorbidities": ["hypothyroidism"], "lab_results": "TSH: 3.2 mIU/L (normal range 0.4-4.0)", "medications": ["levothyroxine 75mcg daily"] }, "ground_truth": { "diagnosis_codes": ["E03.9"], "procedure_codes": ["99214"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_026", "difficulty": "easy", "input": { "clinical_note": "Patient presents with mild depression. PHQ-9 score of 8. No suicidal ideation. Started on sertraline 50mg. Counseling referral provided. Follow up in 4 weeks.", "symptoms": ["depressed mood", "decreased interest", "fatigue", "difficulty concentrating"], "treatments": ["sertraline", "counseling referral"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 33, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": "PHQ-9: 8 (mild depression)", "medications": ["sertraline 50mg daily"] }, "ground_truth": { "diagnosis_codes": ["F32.0"], "procedure_codes": ["99214"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_027", "difficulty": "easy", "input": { "clinical_note": "Patient presents with tinea pedis. Itchy, scaly rash between toes bilaterally. Classic interdigital presentation. Prescribed topical clotrimazole cream.", "symptoms": ["itchy feet", "scaly rash between toes", "mild burning"], "treatments": ["clotrimazole cream"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 44, "patient_sex": "M", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["clotrimazole 1% cream BID"] }, "ground_truth": { "diagnosis_codes": ["B35.3"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_028", "difficulty": "easy", "input": { "clinical_note": "Patient presents requesting a tetanus booster. Last Tdap was over 10 years ago. No acute injuries. Td vaccine administered in right deltoid without complications.", "symptoms": [], "treatments": ["Td vaccination"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 50, "patient_sex": "M", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": [] }, "ground_truth": { "diagnosis_codes": ["Z23"], "procedure_codes": ["90714"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_029", "difficulty": "easy", "input": { "clinical_note": "Patient presents with constipation. No bowel movement for 4 days. Abdomen soft, non-distended. No alarming features. Advised increased fiber and fluids. Prescribed polyethylene glycol.", "symptoms": ["constipation", "mild abdominal discomfort", "bloating"], "treatments": ["dietary fiber increase", "polyethylene glycol"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 48, "patient_sex": "F", "provider_specialty": "Family Medicine", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["polyethylene glycol 17g daily"] }, "ground_truth": { "diagnosis_codes": ["K59.00"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } }, { "id": "easy_030", "difficulty": "easy", "input": { "clinical_note": "Patient presents with plantar fasciitis. Heel pain worse with first steps in morning. Tenderness at medial calcaneal tubercle. Recommended stretching exercises, ice, and supportive footwear.", "symptoms": ["heel pain", "pain with first steps", "tenderness at heel"], "treatments": ["stretching exercises", "ice therapy", "supportive footwear"], "insurance_type": "Private", "prior_auth_required": false, "treatment_cost": "low", "patient_age": 42, "patient_sex": "M", "provider_specialty": "Orthopedics", "visit_type": "outpatient", "comorbidities": [], "lab_results": null, "medications": ["naproxen 500mg BID PRN"] }, "ground_truth": { "diagnosis_codes": ["M72.2"], "procedure_codes": ["99213"], "decision": "approve", "risk_flags": [] } } ] }