the case of a physician described in subparagraph (A) who submits a prior authorization request to an MA organization for an item or service with respect to which an exemption applies under this subsection, such organization shall notify such physician of such exemption as soon as possible (but in no case later than 24 hours after receiving such request). (C) Opt out Any physician eligible for an exemption under paragraph (1) may voluntarily waive such exemption by providing written notice to the applicable MA organization. (4) Requirement for coverage and payment In the case of a physician who qualifies for the exemption described in paragraph (1) with respect to an item, service, or group of similar services, an MA organization may not deny or reduce coverage and payment for such an item, service, or group based on medical necessity or appropriateness of care. (5) Protections pertaining to revocation of gold card (A) In general An MA organization may revoke an exemption described in paragraph (1) granted with respect to a physician for an item, service, or group of similar services for a plan year only if— (i) the MA organization— (I) determines that— (aa) less than 90 percent of claims submitted by such physician for such item, service, or group during the 90-day period ending on the date of such revocation would have been approved under the prior authorization process employed by such plan had such process applied with respect to such claims