[Solved]: write an appeal for the following: From Payer: To…

write an appeal for the following: From Payer: To Payee: WeCare Insurance Best Medicine P.O. Box 78219 200 Pine St Baltimore, MD Christmas, KS (800) 111-1111 (721) 999-9999 Payment Check Number: B0000000 Payment Date: 02/12/202X Payment Amount: $0.00 Remittance Detail Claim Number: A10759-1 Patient: Smith, Steven ID Number: WEC767654 Date of Service Procedure Charge Amount Adjustment Amount Copayment Payment Remark Codes 01/19/202X 70491 $1200.00 $1200.00 $0.00 $0.00 CO96, N130 CO Contractual Obligation CO96 Non-covered charge(s). At least one Remark Code must be provided. N130 Consult plan benefit documents/guidelines for information about restrictions for this service. Submit appeals to payer address including medical record documentation, copy of claim, copy of remittance advice, claim number, patient name, identification number, and date of service. WeCare Insurance Medical Policy Manual Patients requiring CPT 70491 Computed tomography, soft tissue neck; with contrast material(s) must meet eligibility criteria for payment of service. Eligibility: • Must have documented medical necessity; and • Must be referred by a participating provider with order demonstrating medical necessity; and • Must receive course of conservative treatment; or • Must have prior surgical intervention demonstrating necessity; or • Must have prior diagnostic tests necessitating further study; or • Must have documented personal or family history for similar conditions