MGCRB FFY 2022 Individual Decisions Case Provider's Home Requested CBSA Number Case Name Priority CBSA Code Code Request Status 22C0001 Reid Health (15-0048) Primary Request 15 34620 Approved Secondary Request 15 34620 Dismissed Tertiary Request 15 17140 Dismissed 22C0003 Beaumont Hospital Dearborn (23-0020) Primary Request 19804 47664 Approved Secondary Request 19804 11460 Dismissed Tertiary Request 19804 19804 Dismissed 22C0004 Saint Thomas DeKalb Hospital (44-0148) Primary Request 44 34980 Approved 22C0005 Saint Thomas River Park Hospital (44-0151) Primary Request 44 34980 Approved 22C0006 Lake Charles Memorial Hospital (19-0060) Primary Request 29340 13140 Approved 22C0008 Bayhealth Hospital, Sussex Campus (08-0009) Primary Request 41540 20100 Approved 22C0009 Robert Wood Johnson University Hospital (31-0038) Primary Request 35154 35614 Approved 22C0010 Texoma Medical Center (45-0324) Primary Request 43300 19124 Approved Secondary Request 43300 43300 Dismissed 22C0011 Memorial Hospital (36-0156) Primary Request 36 45780 Approved 22C0012 Northeast Alabama Regional Medical Center (01-0078) Primary Request 11500 12060 Approved Secondary Request 11500 13820 Dismissed 22C0013 Scripps Mercy Hospital (05-0077) Primary Request 41740 41740 Approved 22C0014 Scripps Green Hospital (05-0424) Primary Request 41740 41740 Approved 22C0018 Reid Health (15-0048) Primary Request 15 17140 Withdrawn (Pre-Decision) 22C0019 Onslow Memorial Hospital (34-0042) Primary Request 27340 48900 Approved Secondary Request 27340 35100 Dismissed 22C0020 Lenoir Memorial Hospital, Inc. (34-0027) Primary Request 34 24780 Approved 22C0021 OSF St. James John Albrecht Medical Center (14-0161) Primary Request 14 16984 Approved 22C0022 Cleveland Clinic Hospital (10-0289) Primary Request 22744 22744 Approved 22C0023 OSF Sacred Heart Medical Center (14-0093) Primary Request 19180 29200 Approved 22C0024 Saint Anthony Medical Center (14-0233) Primary Request 40420 20994 Approved 22C0025 Little Company of Mary Hospital (14-0179) Primary Request 16984 29404 Approved Secondary Request 16984 20994 Denied 22C0026 Northwestern Lake Forest Hospital (14-0130) Primary Request 29404 16984 Approved 22C0027 OSF Saint Mary Medical Center (14-0064) Primary Request 14 37900 Approved Secondary Request 14 19340 Dismissed Page 1 of 17 Case Provider's Home Requested CBSA Number Case Name Priority CBSA Code Code Request Status 22C0028 Hospital of Univ of Pennsylvania (39-0111) Primary Request 37964 47220 Withdrawn (Pre-Decision) Secondary Request 37964 12100 Withdrawn (Pre-Decision) Tertiary Request 37964 37964 Withdrawn (Pre-Decision) Fourth Request 37964 47220 Withdrawn (Pre-Decision) 22C0029 St. Luke's Hospital (39-0049) Primary Request 10900 35084 Approved Secondary Request 10900 33874 Dismissed 22C0030 Chester County Hospital (39-0179) Primary Request 33874 37964 Approved 22C0031 Penn Presbyterian Medical Center (39-0223) Primary Request 37964 47220 Approved Secondary Request 37964 12100 Denied Tertiary Request 37964 37964 Denied 22C0032 Pennsylvania Hospital (39-0226) Primary Request 37964 47220 Approved Secondary Request 37964 12100 Dismissed Tertiary Request 37964 37964 Dismissed 22C0033 Hospital of Univ of Pennsylvania (39-0111) Primary Request 37964 47220 Approved Secondary Request 37964 12100 Dismissed Tertiary Request 37964 37964 Dismissed 22C0034 Indian River Memorial Hospital, Inc. (10-0105) Primary Request 42680 37340 Approved 22C0035 Jackson County Memorial Hospital (37-0022) Primary Request 37 45 Approved 22C0036 Ronald Reagan UCLA Medical Center (05-0262) Primary Request 31084 37100 Approved Secondary Request 31084 31084 Dismissed 22C0037 Santa Monica UCLA Medical Center (05-0112) Primary Request 31084 37100 Approved Secondary Request 31084 31084 Dismissed 22C0038 University Health System (45-0213) Primary Request 41700 12420 Approved Secondary Request 41700 41700 Dismissed 22C0039 DCH Regional Medical Center (01-0092) Primary Request 46220 13820 Approved 22C0040 Weirton Medical Center (51-0023) Primary Request 48260 38300 Approved Secondary Request 48260 48260 Dismissed 22C0041 Eastern Idaho Regional Medical Center (13-0018) Primary Request 26820 38540 Approved Secondary Request 26820 38540 Dismissed Tertiary Request 26820 38540 Dismissed Fourth Request 26820 53 Dismissed 22C0043 Mercy Medical Center Clinton (16-0080) Primary Request 16 19340 Approved 22C0044 Mercy Medical Center North Iowa (16-0064) Primary Request 16 24 Approved 22C0045 Huntsville Hospital (01-0039) Primary Request 26620 26620 Approved 22C0046 Decatur Morgan Hospital Decatur Campus (01-0085) Primary Request 19460 26620 Approved Page 2 of 17 Case Provider's Home Requested CBSA Number Case Name Priority CBSA Code Code Request Status 22C0047 Tuscon Medical Center (03-0006) Primary Request 46060 38060 Approved 22C0048 Terrebonne General Medical Center (19-0008) Primary Request 26380 12940 Approved 22C0049 Hillsdale Hospital (23-0037) Primary Request 23 27100 Approved 22C0050 Froedtert Memorial Lutheran Hospital (52-0177) Primary Request 33340 29404 Approved Secondary Request 33340 33340 Dismissed 22C0051 Firelands Regional Medical Center (36-0025) Primary Request 36 17460 Approved Secondary Request 36 45780 Dismissed 22C0052 Main Line Hospital Paoli (39-0153) Primary Request 33874 37964 Approved 22C0053 Main Line Hospital Bryn Mawr Campus (39-0139) Primary Request 33874 37964 Approved 22C0054 Main Line Hospital Lankenau (39-0195) Primary Request 33874 37964 Approved 22C0055 McLaren Central Michigan (23-0080) Primary Request 23 13020 Approved 22C0056 Karmanos Cancer Hospital (23-0297) Primary Request 19804 47664 Approved 22C0057 MidMichigan Medical Center Gratiot (23-0030) Primary Request 23 24340 Approved 22C0058 MidMichigan Medical Center-Midland (23-0222) Primary Request 33220 33220 Approved 22C0059 Good Samaritan Regional Medical Center (38-0014) Primary Request 18700 21660 Approved 22C0060 Samaritan Albany General Hospital (38-0022) Primary Request 10540 21660 Approved 22C0061 SSM Health Saint Mary's Hospital Janesville (52-0208) Primary Request 27500 31540 Approved 22C0062 Phoenixville Hospital (39-0127) Primary Request 33874 37964 Approved Secondary Request 33874 15804 Dismissed 22C0063 UnityPoint Health Marshalltown (16-0001) Primary Request 16 19780 Approved 22C0064 Middlesex Hospital (07-0020) Primary Request 25540 14860 Approved Secondary Request 25540 25540 Dismissed 22C0066 Warren General Hospital (39-0146) Primary Request 39 33 Approved 22C0068 University of Tennessee Medical Center (44-0015) Primary Request 28940 28940 Approved 22C0069 Saint Mary's Health Care (23-0059) Primary Request 24340 24340 Approved 22C0070 Providence Holy Family Hospital (50-0077) Primary Request 44060 44060 Approved 22C0071 Providence Sacred Heart Medical Center (50-0054) Primary Request 44060 44060 Approved 22C0072 Baptist Memorial Hospital Desoto (25-0141) Primary Request 32820 32820 Approved 22C0073 Baptist Memorial Hospital Union City (44-0130) Primary Request 44 18 Approved 22C0074 Munson Healthcare Manistee Hospital (23-0303) Primary Request 23 34740 Approved 22C0075 Hollywood Presbyterian Medical Center (05-0063) Primary Request 31084 37100 Approved Secondary Request 31084 31084 Dismissed 22C0076 Memorial Satilla Health (11-0003) Primary Request 11 15260 Approved 22C0077 Tampa General Hospital (10-0128) Primary Request 45300 45300 Approved 22C0078 Baptist Medical Center Jacksonville (10-0088) Primary Request 27260 27260 Approved 22C0079 Cedars Sinai Medical Center (05-0625) Primary Request 31084 37100 Approved Page 3 of 17 Case Provider's Home Requested CBSA Number Case Name Priority CBSA Code Code Request Status 22C0080 Cayuga Medical Center at Ithaca (33-0307) Primary Request 27060 27060 Approved 22C0081 Cooper University Hospital (31-0014) Primary Request 15804 37964 Approved 22C0082 Gundersen Lutheran Medical Center (52-0087) Primary Request 29100 29100 Approved 22C0084 St. Barnabas Hospital (33-0399) Primary Request 35614 35614 Approved Secondary Request 35614 35004 Dismissed Tertiary Request 35614 35614 Dismissed 22C0085 Hillcrest Medical Center (37-0001) Primary Request 46140 36420 Approved Secondary Request 46140 46140 Dismissed 22C0086 Mercy Medical Center Sioux City (16-0153) Primary Request 43580 36540 Approved Secondary Request 43580 43580 Dismissed 22C0087 St. Mary Mercy Hospital (23-0002) Primary Request 19804 47664 Approved 22C0088 Saint Alphonsus Medical Center Nampa (13-0013) Primary Request 14260 38 Approved Secondary Request 14260 14260 Dismissed 22C0089 Saint Alphonsus Regional Medical Center (13-0007) Primary Request 14260 38 Approved Secondary Request 14260 14260 Dismissed 22C0090 Samaritan Hospital (33-0180) Primary Request 10580 47 Approved Secondary Request 10580 10580 Dismissed 22C0091 St. Joseph's Hospital Health Center (33-0140) Primary Request 45060 45060 Approved 22C0092 Reid Health (15-0048) Primary Request 15 34620 Not Considered Secondary Request 15 17140 Not Considered 22C0093 Maury Regional Hospital (44-0073) Primary Request 34980 34980 Approved 22C0094 Lovelace Medical Center Downtown (32-0009) Primary Request 10740 42140 Approved Secondary Request 10740 10740 Dismissed 22C0095 Baptist St. Anthony's Hospital (45-0231) Primary Request 11100 32 Approved Secondary Request 11100 31180 Dismissed Tertiary Request 11100 11100 Dismissed 22C0097 Montefiore Hospital Moses Campus (33-0059) Primary Request 35614 35614 Approved Secondary Request 35614 35004 Dismissed Tertiary Request 35614 35614 Dismissed 22C0098 White Plains Hospital Center (33-0304) Primary Request 35614 35614