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Effective 07/01/26: New Prior Authorization Requirement for Mandibular Advancement Device

Date: 04/13/26

Effective July 1, 2026, Superior HealthPlan will require prior authorization for procedure code E0486, a custom-fabricated Mandibular Advancement Device (MAD) for obstructive sleep apnea, for Ambetter from Superior HealthPlan and Ambetter Health Solutions members.

Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following procedure code update is effective on July 1, 2026.

Procedure Code

Procedure Code Description

Clinical Criteria

E0486

ORAL DEVICE/APPLIANCE TO REDUCE UP/AIRWAY COLLAPSIBILITY ADJUSTABLE OR

Change Healthcare’s InterQual criteria, proprietary, but available upon request.

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.