D5225 is the CDT code for an upper (maxillary) removable partial denture made on a flexible base — typically a nylon-type material — including the retentive/clasping materials, rests, and replacement teeth. It replaces some upper teeth without a rigid cast-metal framework, using tooth-colored or gum-colored flexible clasps.
Informational only — confirm the official CDT descriptor and your payers' rules independently. This is general guidance, not billing, coding, or clinical advice.
When to Use the D5225 Code
Report D5225 when a patient is missing one or more upper teeth and receives a removable partial with a flexible base (such as Valplast-style nylon) rather than a cast metal or rigid acrylic framework. Patients often choose flexible partials for comfort, a more natural look, or sensitivity to traditional materials.
Pick the code by arch and base type: D5225 is the maxillary flexible partial; D5226 is the mandibular (lower) flexible partial; D5213 is a maxillary partial with a cast metal framework; and D5211 is a maxillary partial with a resin base. Some plans reimburse flexible partials differently from cast or resin partials, so code by what was actually delivered.
Documentation & Clinical Scenarios
Partials are a frequently reviewed prosthetic benefit, so chart notes should justify the restoration:
- Arch and teeth being replaced — list the missing upper teeth and the teeth the flexible clasps engage.
- An evaluation confirming the remaining teeth and tissues can support a flexible partial.
- Radiographs and, where helpful, intraoral photos of the arch.
- A narrative noting initial placement vs. replacement, and why a flexible base was selected.
Adjustments at delivery are part of the partial; later adjustments (D5421/D5422), relines, and repairs are separate procedures with their own codes.
Insurance & Billing Tips
- Verify the prosthodontic benefit first. Confirm the plan covers flexible-base partials and what the patient share will be.
- Expect possible alternate-benefit down-coding. Some plans reimburse a flexible partial at the rate of a resin or cast partial; knowing this up front lets you set an accurate estimate.
- Check replacement frequency. Partials commonly carry a 5-year (sometimes 7-year) replacement limit per arch.
- Watch for missing-tooth and waiting-period clauses. Some plans won't pay for teeth lost before coverage began, and new plans may impose a waiting period on major prosthetics.
- Confirm the benefit date rule. Whether the plan pays on the impression or the delivery date affects claims that cross a benefit-year boundary.
Example Case
A 47-year-old patient is missing two upper teeth and wants a discreet, comfortable option without visible metal clasps, so the dentist plans a flexible-base partial. The office submits a pre-estimate with a radiograph and a narrative explaining the flexible base; the plan confirms coverage but notes an alternate benefit at the resin-partial rate. The patient is quoted the difference in advance. After impressions, the partial is delivered and the claim is filed as D5225 with the delivery date. Because benefits were verified, the down-coding was no surprise.
Patients call about "getting an upper partial" or "my partial doesn't fit" — not D5225. DentalReception AI answers those calls 24/7, books the consult or adjustment live into your schedule, and captures insurance details for clean intake, while coverage questions route to your team. See how it handles denture calls, or book a demo.
Frequently Asked Questions
What's the difference between D5225 and D5226?
Arch. D5225 is the maxillary (upper) flexible-base partial, while D5226 is the mandibular (lower) flexible-base partial. The material and included components are the same; only the arch differs. Reporting the correct arch code matters because some plans track partial-denture benefits separately by arch.
Does D5225 include the clasps and replacement teeth?
Yes. The D5225 descriptor includes the retentive/clasping materials, rests, and the replacement teeth, plus the adjustments performed at delivery. Later adjustments, relines, and repairs are separate procedures with their own codes and should be documented and billed on their own.
Will insurance cover a flexible partial at the full rate?
Not always. Because flexible partials are sometimes considered a premium option, a plan may apply an alternate benefit and reimburse at the rate of a resin or cast partial, leaving a larger patient portion. Verify benefits before treatment so you can give the patient an accurate estimate and avoid a billing surprise.
Do I need a pre-authorization for a D5225 partial?
Many plans recommend or require a pre-estimate for removable partials. Submitting a radiograph, a narrative noting why a flexible base was chosen, and the teeth being replaced — before the impression appointment — lets you confirm coverage, learn of any down-coding, and quote the patient an accurate out-of-pocket amount.
Confirm the current CDT descriptor and your specific payer policies before billing — browse the full dental code library or see our insurance verification feature.