Prior authorization required (general)

Obtain prior authorization before providing upper limb prostheses for most Mass General Brigham Health Plan products; specific HCPCS codes L6694, L6695, L7366, and L7368 are listed as not requiring prior authorization for some plan variations.

• Prior authorization is required for Medicare Advantage, Mass General Brigham ACO, One Care/SCO, and Commercial plans.
• Exceptions noted: L6694, L6695, L7366, L7368 may be listed as not requiring prior authorization for certain products.

Obtain prior authorization per updated table

Follow the policy’s updated prior authorization table and submit prior authorization requests for the listed HCPCS codes and member product as specified; prior authorization requirements were updated and now apply per the table.

• Providers must obtain prior authorization per the policy’s updated procedures and code table (codes listed in the policy).
• Updated table and product-specific variations were added in January and March 2026 updates.

Use InterQual® for myoelectric medical necessity

Use InterQual® lookup on the plan provider website to determine medical necessity for myoelectric upper limb prostheses; the plan has customized InterQual® criteria for these devices.

• Access InterQual® Criteria Lookup via MassGeneralBrighamHealthPlan.org under the Resources menu.
• Medical necessity for myoelectric devices is determined through the plan-customized InterQual® criteria.

Follow plan-customized InterQual® subsets and hierarchy

Apply the policy’s linkage to InterQual® subsets: follow the referenced InterQual® 'Prosthetics, Myoelectric, Upper Extremity' subset and the policy’s stated criteria hierarchy and exclusions where InterQual® subsets are customized by the plan.

• InterQual® subsets (customized by the plan) contain additional literature and exclusion language referenced by the policy.
• Policy notes clarify criteria hierarchy and exclusions for customized InterQual® subsets.

Submit comprehensive, member-specific clinical documentation

Include member-specific clinical documentation with prior authorization and coordinate submission through a contracted prosthetics provider; required documentation includes medical/surgical history, co-morbid conditions, BMI, prior functional status, prior treatments/outcomes, and evidence of functional need.

• Treating physiatrist should coordinate with a contracted Mass General Brigham Health Plan prosthetics provider (prosthetist certified by ABC or BOC) to gather and submit documentation.
• Documentation must support the functional need and the member’s ability to safely use the prosthesis (weight, stability, cognitive/physical capabilities).

Follow product-specific prior authorization rules

Confirm and follow product-specific prior authorization and variation language for the member’s product (e.g., One Care, SCO, MassHealth, Medicare Advantage, Commercial) — the policy includes product-specific variations and updates that affect authorization.

• Prior authorization requirements and applicable codes may vary by product; providers must follow the rules for the member’s specific product.
• One Care/SCO and ACO sections explicitly note product variations and hierarchy where Medicare or MassHealth guidance is applied.

Avoid requests for excluded or non-improving devices

Do not request coverage for devices or features that will not improve or stabilize the member’s condition, are suboptimal versus other options, or are primarily for convenience or cosmetic purposes; such requests will be excluded or denied.

• Exclusions include devices that are primarily for convenience (e.g., swim or shower prostheses), cosmetic-only limbs/parts, recreational use, or considered experimental/investigational.
• Requests will be denied if a less intensive model adequately meets the member’s needs or if the device won’t produce the desired functional outcome.

Confirm product-specific coverage/coding to avoid denial

Verify coverage and coding requirements for the member’s specific product (Medicare Advantage, MassHealth, One Care, SCO, Commercial); failure to follow product-specific prior authorization or variation language may result in claim denial or noncoverage.

• Policy history and sections note Medicare, MassHealth, One Care/SCO, ACO, and Commercial variations that affect coverage and prior authorization.
• Providers must follow the applicable product variation language when submitting requests to avoid denials.