D5213 - Partial Cast Max
Maxillary partial – cast metal with resin base.
- Procedure Code
- D5213
- Clinical Category
- Prosthodontics
- Primary ICD-10 Justification
- K08.409 (Partial loss of teeth, unspecified cause, unspecified class)
- Reference Fee & Claim Types
- BOTH
Insurance Verification Benchmarks & Billing Guidelines
Payer policy benchmarks, pre-submission attachment requirements, and denial prevention rules for D5213.
- Frequency Limitation
- 1 per arch in a 60-month interval (5 years) (rolling_12_months)
Required Claim Attachments & Pre-Submission Checklist
- Standard ADA claim form with CDT procedure code and date of service
Bill When (Allowable Clinical Criteria)
- Indicated for medically and clinically necessary treatment as documented in patient's dental record.
Restrictions & Clinical Exclusions
- A posterior fixed partial denture and a removable partial denture are not benefits in the same dental arch. The benefit is limited to the allowance for the partial removable denture.
- Fixed bridges or removable cast partials are not a benefit for patients under age 16.
- For benefit purposes, anesthesia is an integral part of the procedures being performed and additional fees are not billable to the patient.
- For benefit purposes, local anesthesia is an integral part of the procedure being performed and additional charges are not billable to the patient.
- Full or partial dentures include any reline/rebase, adjustment or repair required within six months of delivery; Benefits may be denied if repair or replacement within the contractual time limitation is the patient’s fault. General policy - The fee for an immediate denture includes any adjustments, relines, or tissue conditioning within 3 months of delivery. Laboratory relines are benefited 3 months after delivery of an immediate denture to allow adequate time for healing.
- The fees for cast restorations and prosthetic procedures include all models, temporaries and other associated procedures. Any fees charged for these procedures in excess of the approved amounts for the indirectly fabricated restorations or prosthetic procedures by the same dentist/dental office are not billable to the patient on the same date of service.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10-CM Justification & Crosswalk Mappings for D5213 (6)
Click any ICD-10-CM diagnosis code below to inspect its reverse procedure mappings and differential coding guide.
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K08.409 | Partial loss of teeth, unspecified cause, unspecified class | Other disorders of teeth and supporting structures | ★ Yes (Primary) | BOTH | maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping materials, rests and teeth) indicated for Partial loss of teeth, unspecified cause, unspecified class |
| K00.00 | Anodontia | Disorders of tooth development and eruption | Secondary | BOTH | maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping materials, rests and teeth) indicated for Anodontia |
| K08.419 | Partial loss of teeth due to trauma, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping materials, rests and teeth) indicated for Partial loss of teeth due to trauma, unspecified class |
| K08.429 | Partial loss of teeth due to periodontal diseases, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping materials, rests and teeth) indicated for Partial loss of teeth due to periodontal diseases, unspecified class |
| K08.439 | Partial loss of teeth due to caries, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping materials, rests and teeth) indicated for Partial loss of teeth due to caries, unspecified class |
| K08.499 | Partial loss of teeth due to other specified cause, unspecified class | Other disorders of teeth and supporting structures | Secondary | BOTH | maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping materials, rests and teeth) indicated for Partial loss of teeth due to other specified cause, unspecified class |
Frequently Asked Questions — D5213 (Partial Cast Max)
Quick answers for dental billers and treatment coordinators submitting claims for D5213.
What ICD-10 diagnosis codes link to dental procedure D5213?▾
Common ICD-10-CM justification codes for CDT D5213 (Partial Cast Max) include: K08.409 - Partial loss of teeth, unspecified cause, unspecified class (Primary); K00.00 - Anodontia; K08.419 - Partial loss of teeth due to trauma, unspecified class; K08.429 - Partial loss of teeth due to periodontal diseases, unspecified class; K08.439 - Partial loss of teeth due to caries, unspecified class; K08.499 - Partial loss of teeth due to other specified cause, unspecified class.
Can CDT code D5213 be billed to medical insurance?▾
Billing CDT D5213 (Partial Cast Max) to medical insurance depends on the underlying clinical necessity and trauma/pathology documentation. Supported claim types across linked diagnoses: BOTH.
What attachments and documentation are required for billing CDT D5213?▾
Required claim attachments for CDT D5213 (Partial Cast Max) include: Standard ADA claim form with CDT procedure code and date of service.
What is the insurance frequency limitation for CDT D5213?▾
Standard commercial insurance frequency for D5213: 1 per arch in a 60-month interval (5 years) (rolling_12_months).
What are common insurance denial reasons and appeal tips for CDT D5213?▾
Denial Code CO-119 (Benefit maximum or frequency limitation exceeded for procedure): Overturn appeal strategy - Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria.