Which CMS decision outlines the conditions for which a servi…

Which CMS decision outlines the conditions for which a service is considered to be covered (or not covered), limited to clinically proven items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury, and are usually issued as a program instruction?

A patient presents with shortness of breath, is treated for…

A patient presents with shortness of breath, is treated for several days, and is discharged with a principal diagnosis of pneumonia. The claim is denied, and upon review, the coder finds that the claim contained a code from the previous year’s ICD-10-CM codes. What type of denial is this?