D5213 - Partial Cast Max
Maxillary partial – cast metal with resin base.
- Procedure Code
- D5213
- Category
- Prosthodontics
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- 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 Justification & Crosswalk Mappings
| 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 |