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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
  
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a 
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to 
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines 
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must 
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or 
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or 
other harm to the enrollee.  
 
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B 
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 
CFR Sections 422.2 and 422.136. 
 
The rules say that various Hyaluronan preparations (viscosupplementation) for intra-articular injections of the 
knee are considered reasonable and necessary when ALL of the following criteria documented in the medical 
record are met: 
 1. Symptomatic OA of the knee. Pain that interferes with functional activities (such as, ambulation and  
     prolonged standing). 
 2. The diagnosis is supported by radiographic evidence of OA of the knee, for example, joint space narrowing, 
     subchondral sclerosis, osteophytes, and subchondral cysts. 
 3. Trial and failure or contraindication of at least 3 months of conservative therapy: 
      Non-pharmacologic therapy (e.g., physical therapy, exercise, weight management, self-management 
      programs, knee brace, cane) 
    
       Pharmacologic therapy (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) (oral, 
       topical), topical capsaicin) 
 4. Failure of or contraindication to intra-articular glucocorticoid injections. 
 
For patients who have responded to a prior series, a REPEAT* series of viscosupplement therapy is considered 
reasonable and necessary when ALL of the following are met: 
  Patient continues to meet initial criteria 
  Symptoms have recurred 
  Patient has experienced improvement in pain and functional capacity following the previous series of   
   injections 
  At least 6 months have elapsed since the prior series of injections 
* A series is defined as a set of injections for each joint and each treatment as per the FDA prescribing   
   information. 
 
You can find this information in the Local Coverage Determination (LCD): Hyaluronic Acid Injections for 
Knee Osteoarthritis ( L39260). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. 
Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You 
can find this information on page 95 of the Plan's 2023 Evidence of Coverage (EOC).