MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD FFY 2018 DECISION LISTING CASE PROVIDER FROM TO PROVIDER NAME STATUS NUMBER NUMBER MSA MSA 18C0001 52-0070 Mayo Clinic Health System - Eau Claire, Inc. Approved 20740 33460 18C0002 10-0022 Jackson Memorial Hospital Approved 33124 22744 18C0003 31-0032 Inspira Medical Center Vineland Approved 47220 12100 18C0004 24-0166 Mayo Clinic Health System - Fairmont Denied 24 31860 18C0005 44-0063 Johnson City Medical Center Approved 27740 11700 18C0006 26-0110 Southeast Hospital Denied 16020 16060 18C0006 26-0110 Southeast Hospital Denied 16020 41180 18C0007 46-0057 Park City Hospital Approved 46 41620 18C0008 39-0185 Lehigh Valley Hospital - Hazelton Approved 42540 10900 18C0009 31-0119 University Hospital Dismissed 18C0010 31-0031 Deborah Heart and Lung Center Denied 15804 35614 18C0011 38-0090 Bay Area Hospital Approved 38 21660 18C0012 17-0013 Hays Medical Center Approved 17 28 18C0013 37-0113 INTEGRIS Grove Hospital Approved 37 22220 18C0014 26-0186 Lake Regional Health System Approved 26 44180 18C0015 45-0465 Matagorda Regional Medical Center Approved 45 26420 18C0016 18-0043 Memorial Hospital Denied 18 30460 18C0017 34-0023 Park Ridge Health Approved 11700 24860 18C0018 52-0088 Saint Agnes Hospital Approved 22540 33340 18C0019 31-0002 Newark Beth Israel Medical Center Dismissed 18C0020 39-0133 Lehigh Valley Hospital Approved 10900 33874 18C0021 18-0005 Highlands Regional Medical Center Approved 18 26580 18C0022 39-0091 UPMC Northwest Medical Center Approved 39 38300 18C0024 34-0027 Lenoir Memorial Hospital, Inc. Approved 34 40580 18C0025 47-0001 Central Vermont Medical Center Approved 47 30 18C0026 15-0075 Bluffton Regional Medical Center Approved 23060 34620 18C0027 34-0024 Sampson Regional Medical Center Denied 34 48900 18C0028 36-0010 Union Hospital Association Approved 36 15940 18C0029 01-0005 Marshall Medical Center South Approved 01 13820 18C0030 07-0020 Middlesex Hospital Approved 25540 35300 18C0031 22-0073 Morton Hospital Approved 39300 14454 18C0032 51-0001 West Virginia University Hospitals, Inc. Approved 34060 38300 18C0033 25-0069 Rush Foundation Hospital Approved 25 46220 18C0034 25-0097 Southwest Mississippi Regional Medical Center Approved 25 12940 18C0035 39-0183 St. Luke's Miner's Memorial Hospital Approved 39 10900 18C0036 18-0048 Ephraim McDowell Regional Medical Center Approved 18 30460 18C0037 39-0048 Geisinger-Lewistown Hospital Approved 39 44300 18C0038 13-0018 Eastern Idaho Regional Medical Center Approved 26820 38540 18C0039 11-0125 Fairview Park Hospital Approved 11 31420 18C0040 15-0115 Memorial Hospital and Health Care Center Denied 15 21780 18C0041 18-0013 The Medical Center Denied 14540 34980 18C0042 44-0011 Blount Memorial Hospital Approved 28940 34 18C0043 11-0105 Colquitt Regional Medical Center Approved 11 45220 18C0044 17-0120 Labette Health Approved 17 27900 18C0045 37-0034 McAlester Regional Health Center Approved 37 46140 18C0046 18-0016 Jewish Hospital Shelbyville Denied 31140 30460 18C0047 01-0092 DCH Regional Medical Center Denied 46220 13820 18C0048 11-0150 Oconee Regional Medical Center Approved 11 12060 18C0049 11-0122 South Georgia Medical Center Approved 46660 45220 18C0050 11-0038 John D. Archbold Memorial Hospital Approved 11 45220 18C0051 01-0035 Cullman Regional Medical Center Approved 01 13820 18C0052 44-0059 Cookeville Regional Medical Center Approved 44 34980 18C0053 11-0002 Upson Regional Medical Center Approved 11 12060 18C0054 23-0030 MidMichigan Medical Center - Gratiot Approved 23 24340 18C0055 11-0001 Hamilton Medical Center Approved 19140 12060 18C0056 26-0006 Mosaic Life Care at St. Joseph Approved 41140 41140 18C0057 23-0037 Hillsdale Hospital Approved 23 11460 18C0058 05-0481 West Hills Hospital & Medical Center Approved 31084 37100 18C0059 01-0045 Fayette Medical Center Approved 01 13820 18C0060 39-0001 Geisinger - Community Medical Center Approved 42540 10900 Page 1 of 9 MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD FFY 2018 DECISION LISTING CASE PROVIDER FORM FROM TO PROVIDER NAME NUMBER NUMBER NO. MSA MSA 18C0061 26-0074 Moberly Regional Medical Center Approved 26 17860 18C0062 10-0249 Seven Rivers Regional Medical Center Approved 26140 45300 18C0063 39-0237 Regional Hospital of Scranton Approved 42540 10900 18C0064 26-0034 Bates County Memorial Hospital Denied 28140 28140 18C0065 52-0177 Froedtert Memorial Lutheran Hospital Denied 33340 29404 18C0066 37-0056 Comanche County Memorial Hospital Denied 30020 36420 18C0067 24-0047 St. Luke's Hospital Approved 20260 33460 18C0068 32-0011 Presbyterian Espanola Hospital Approved 32 42140 18C0069 10-0023 Citrus Memorial Hospital Approved 26140 36100 18C0070 23-0075 Bronson Battle Creek Hospital Approved 12980 28020 18C0071 34-0131 CarolinaEast Medical Center Approved 35100 24780 18C0072 26-0050 SSM Health St. Francis Hospital Approved 26 41140 18C0073 29-0009 St. Mary's Regional Medical Center Approved 39900 05 18C0074 51-0050 Wheeling Hospital Approved 48540 38300 18C0075 26-0137 Freeman Health System Denied 27980 27900 18C0075 26-0137 Freeman Health System Denied 27980 22220 18C0076 07-0007 Lawrence + Memorial Hospital Approved 35980 35004 18C0077 26-0009 Bothwell Regional Health Center Approved 26 28140 18C0078 10-0062 Munroe Regional Medical Center Approved 36100 23540 18C0079 03-0119 Mercy Gilbert Medical Center Approved 38060 39140 18C0080 45-0044 UT Southwestern Medical Center Approved 19124 19124 18C0081 33-0164 Highland Hospital of Rochester Approved 40380 15380 18C0082 03-0036 Chandler Regional Medical Center Approved 38060 39140 18C0083 14-0067 Saint Francis Medical Center Approved 37900 14010 18C0084 33-0285 Strong Memorial Hospital Approved 40380 15380 18C0085 34-0141 New Hanover Regional Medical Center Approved 48900 48900 18C0086 05-0084 St Joseph's Medical Center Approved 44700 36084 18C0087 05-0058 Glendale Memorial Hospital & Health Center Approved 31084 37100 18C0088 03-0024 St. Joseph's Hospital & Medical Center Approved 38060 39140 18C0089 17-0068 Southwest Medical Center Approved 17 11100 18C0090 45-0080 Titus Regional Medical Center Denied 45 30980 18C0091 01-0078 Northeast Alabama Regional Medical Center Denied 11500 13820 18C0092 34-0050 Southeastern Regional Medical Center Approved 34 22180 18C0093 26-0025 Hannibal Regional Hospital Approved 26 41180 18C0094 03-0010 St. Mary's Hospital Approved 46060 38060 18C0095 42-0010 Carolina Pines Regional Medical Center Approved 22500 16740 18C0096 19-0164 Byrd Regional Hospital Approved 19 10780 18C0097 39-0079 Robert Packer Hospital Approved 39 13780 18C0098 44-0144 Tennova Healthcare - Harton Approved 44 34980 18C0099 10-0286 Physicians Regional Medical Center - Pine Ridge Approved 34940 15980 18C0100 36-0151 Affinity Medical Center Approved 15940 17460 18C0101 22-0035 North Shore Medical Center Approved 15764 14454 18C0102 15-0133 Kosciusko Community Hospital Approved 15 23060 18C0103 03-0114 Oro Valley Hospital Approved 46060 38060 18C0104 01-0040 Gadsden Regional Medical Center Approved 23460 13820 18C0105 05-0006 St. Joseph Hospital Approved 05 39820 18C0106 26-0175 Golden Valley Memorial Hospital Approved 26 28140 18C0107 36-0084 Aultman Hospital Approved 15940 17460 18C0108 52-0096 Wheaton Franciscan Healthcare - All Saints Denied 39540 29404 18C0109 52-0051 Columbia St. Mary's Hospital Milwaukee Denied 33340 29404 18C0110 05-0149 California Hospital Medical Center Approved 31084 37100 18C0111 17-0142 Via Christi Hospital Manhattan Approved 31740 45820 18C0112 36-0159 Adena Regional Medical Center Approved 36 18140 18C0113 03-0007 Verde Valley Medical Center Denied 39140 22380 18C0114 47-0024 Northwestern Medical Center, Inc. Approved 15540 15540 18C0115 38-0051 Salem Hospital Approved 41420 38900 18C0116 01-0150 L.V. Stabler Memorial Hospital Approved 01 33860 18C0117 26-0065 Mercy Hospital Springfield Denied 44180 41180 18C0117 26-0065 Mercy Hospital Springfield Denied 44180 28140 18C0118 01-0083 South Baldwin Regional Medical Center Approved 19300 37860 Page 2 of 9 MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD FFY 2018 DECISION LISTING CASE PROVIDER FORM FROM TO PROVIDER NAME NUMBER NUMBER NO. MSA MSA 18C0119 26-0059 Mercy Hospital Lebanon Denied 26 41180 18C0119 26-0059 Mercy Hospital Lebanon Denied 26 44180 18C0120 36-0079 Kettering Medical Center Approved 19380 17140 18C0121 04-0118 NEA Baptist Memorial Hospital Denied 27860 32820 18C0122 33-0386 Catskill Regional Medical Center Approved 33 35084 18C0123 51-0024 Monongalia County General Hospital Approved 34060 38300 18C0124 39-0065 The Gettysburg Hospital Approved 23900 16540 18C0125 03-0011 St. Joseph's Hospital Approved 46060 38060 18C0126 10-0157 Lakeland Regional Medical Center Approved 29460 45300 18C0127 34-0028 Cape Fear Valley Medical Center Approved 22180 39580 18C0128 24-0071 District One Hospital Denied 24 33460 18C0129 37-0006 Alliance Health - Ponca City Approved 37 48620 18C0130 24-0088 Rice Memorial Hospital Approved 24 41060 18C0131 51-0071 Bluefield Regional Medical Center Approved 51 13980 18C0132 33-0222 Saratoga Hospital Approved 10580 47 18C0133 14-0040 Galesburg Cottage Hospital Approved 14 37900 18C0134 22-0077 Baystate Medical Center Approved 44140 49340 18C0135 39-0211 Sharon Regional Health System Denied 49660 17460 18C0136 26-0022 Northeast Regional Medical Center Approved 26 16 18C0137 16-0089 Ottumwa Regional Health Center Approved 16 26980 18C0138 32-0030 Artesia General Hospital Denied 32 36220 18C0139 04-0088 Medical Center South Arkansas Denied 04 33740 18C0140 45-0209 Northwest Texas Hospital Approved