The appellant, by letter dated April 5, 2001, requested that the Medicare Appeals Council review the carrier's action in effectuating an Administrative Law Judge's (ALJ's) decision issued on August 24, 2000. The appellant has stated in the request for review that the carrier hearings administrator advised that the Medicare Appeals Council was the next level of appeal. We conclude that an appeal concerning the amount of reimbursement is properly within the jurisdiction of a carrier hearing officer and return the case to the carrier for further action.

The only issue before the ALJ was whether a Lightwriter, an augmentative communication device purchased on November 12, 1997, was covered by Medicare. The ALJ found that the Lightwriter was covered. The carrier implemented this decision in a new initial determination dated October 5, 2000, finding that the Medicare allowable amount was $3,862.24, payable at 80 percent at $3,089.79. The appellant appealed on December 18, 2000, asserting that the correct reimbursement amount was $3840, which was 80 percent of the $4,800 purchase price. The carrier responded on February 12, 2001, that the payment amount was determined by a gap-filling methodology.

The issue that the appellant now seeks to appeal is the amount of reimbursement for the Lightwriter. The Council has no jurisdiction over this issue because coverage was the only issue before the ALJ, and the ALJ did not consider the amount of reimbursement in his decision. 42 C.F.R. § 404.946.

Instead, we conclude that the Medicare carrier's response dated February 12, 2001, constitutes a review determination on the issue of the correct reimbursement amount. 42 C.F.R. §§ 405.807 and 405.811. Therefore, the next level of appeal is a Medicare carrier fair hearing. 42 C.F.R. § 405.812. Consequently, pursuant to 42 C.F.R. § 422.856, the Council dismisses the request for review.

The Council is referring this case to the Medicare carrier for a fair hearing determination. For further information on this case, the appellant may contact the Medicare carrier at the following address:

CIGNA - DMERC Region D
Medicare Administration
Attn: Kim Cook
P.O. Box 690
Nashville, TN 37202-0690

MEDICARE APPEALS COUNCIL

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