Exhibit 4

110.4 – Exhibit 4 (Rev. 45, 05-28-04) Medicare Program - Intermediary Part A and Part B Appeals Report - Form CMS-2591, Screen 4 INTERMEDIARY APPEALS REPORT INTERMEDIARY ID REPORT PERIOD C. PART A AND B ALJ HEARINGS PART A Total (1) SNF (2) HHA/Hospice (3) Other (4) Part B (5) 52. OPENING PENDING 53. ADJUSTMENTS TO PENDING 54. ADJUSTED OPENING PENDING 55. REQUESTS RECEIVED 56. REQUESTS FRWD. TO ALJ 57. NO. OF CLAIMS INVOLVED 58. NO. IN 7 CALENDAR DAYS 59. NO. IN 14 CALENDR DAYS 60. AVG. TIME TO FORWARD 61. COMPLETED 62. AMT. IN CONTROVERSY 63. AFFIRMATIONS 64. DISMISSALS/WITHDRAWALS 65. REVERSALS (FULL/PART) 66. AMOUNT AWARDED 67. CLOSING PENDING Form CMS-2591 Screen 4