D5226 is the CDT code for a lower (mandibular) 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 lower teeth without a rigid cast-metal framework, using flexible, tooth- or gum-colored 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 D5226 Code
Report D5226 when a patient is missing one or more lower 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: D5226 is the mandibular flexible partial; D5225 is the maxillary (upper) flexible partial; D5214 is a mandibular partial with a cast metal framework; and D5212 is a mandibular 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 lower 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 53-year-old patient is missing several lower teeth and wants a lightweight, comfortable partial without visible metal, 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 with a 5-year frequency limit and 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 D5226 with the delivery date. Because benefits were verified, the patient portion matched the estimate.
Patients call about "getting a lower partial" or "my partial doesn't fit" — not D5226. 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 D5226 and D5214?
Framework material. D5226 is a mandibular partial with a flexible (typically nylon) base and no cast metal, while D5214 is a mandibular partial built on a cast metal framework with resin bases. Both serve the lower arch, but they're different prostheses and many plans reimburse them at different rates — so code by what was actually delivered.
Does D5226 include the clasps and replacement teeth?
Yes. The D5226 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 treated as 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 D5226 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.