D5213Maxillary Partial Denture, Cast Metal Framework with Resin Denture Bases

What This Code Covers

D5213 covers a removable partial denture for the upper jaw that uses a cast metal framework (typically cobalt-chromium alloy) with acrylic resin denture bases holding the replacement teeth. This is the most common type of removable partial denture and is considered the standard of care when a patient is missing some but not all upper teeth. Metal clasps grip onto the remaining natural teeth for retention and stability. The code includes the full fabrication process from impressions and framework try-in through final delivery, plus adjustments for six months after placement.

Billing Guide

Bill this code when:

• Patient is missing some upper teeth but still has enough natural teeth to support a partial denture
• The partial denture has a cast metal framework with acrylic resin bases and metal clasps
• The framework material is a standard cast metal alloy such as cobalt-chromium
• This is either the patient's first upper partial denture or a replacement for one that has exceeded the plan's frequency limit

Do not bill this code when:

• The partial denture is for the lower jaw. Use D5214 (mandibular partial, cast metal framework with resin bases)
• The partial is made with a flexible thermoplastic base instead of cast metal. Use D5225 (maxillary partial, flexible base)
• The patient has no remaining upper teeth. Use D5110 (complete denture, maxillary) instead
• The partial is entirely acrylic with no cast metal framework. Use D5211 (maxillary partial, resin base) if applicable

Insurance and Denial Prevention

Key Payer Rules:

• Classified as major prosthodontics, typically covered at 50% after deductible
• Most plans impose a 12-month waiting period for new enrollees before covering partial dentures
• Replacement frequency is usually once every 5 to 10 years per arch
• Some payers require that all necessary extractions and restorative work on abutment teeth be completed before approving the partial denture
• Pre-authorization is strongly recommended. Include radiographs and a list of teeth to be replaced
• Some plans apply an alternate benefit clause and downgrade D5213 to the less expensive all-resin partial (D5211). The patient pays the difference.

Common Denials and How to Respond:

• Replaced within frequency limitation -> Appeal with documentation showing the current partial denture is broken beyond repair, has poor fit due to additional tooth loss, or is causing tissue damage. Photos are helpful.
• Abutment teeth need treatment first -> Complete all necessary restorations or periodontal treatment on the abutment teeth before resubmitting. Include updated clinical notes showing the abutments are now sound.
• Downgraded to all-resin partial (D5211) -> This is typically a plan design issue. Collect the balance from the patient. If the cast metal framework is clinically necessary (e.g., for structural support with a large span), appeal with a narrative from the dentist.
• Missing teeth not documented -> Provide a clear radiograph and a tooth chart showing which teeth are present and which are being replaced. List the specific tooth numbers in the narrative.