Understanding Dental Code D5284

When to Use D5284 dental code

The D5284 dental code is designated for a removable unilateral partial denture with a one-piece flexible base, including retentive or clasping materials, rests, and teeth, provided per quadrant. This CDT code is specifically used when a patient requires a partial denture that replaces teeth on only one side of the arch, and the appliance is fabricated from a flexible material such as nylon. Unlike traditional bilateral partial dentures, D5284 is appropriate when the restoration is limited to a single quadrant and does not cross the midline. This code should not be used for bilateral or full-arch partials, which have their own specific CDT codes.

Documentation and Clinical Scenarios

Accurate documentation is essential when submitting claims for D5284. Clinical notes should clearly indicate:

• The quadrant being restored (upper right, upper left, lower right, or lower left)
• The specific teeth being replaced
• The rationale for choosing a unilateral flexible partial over other prosthetic options
• Details about the material used (e.g., Valplast or other flexible base materials)

Common clinical scenarios include patients with missing teeth on only one side of the arch, where a bilateral partial would be excessive or not indicated. For example, a patient missing teeth #2 and #3 in the upper right quadrant may benefit from a D5284 appliance for comfort and esthetics. Always include pre-operative radiographs, intraoral photos, and a narrative explaining the clinical necessity to support your claim.

Insurance Billing Tips

Billing for D5284 requires attention to detail to avoid denials or delays in reimbursement. Here are key steps for successful insurance billing:

1. Verify coverage: Before treatment, confirm with the patient’s insurance whether D5284 is a covered benefit. Some plans may exclude flexible partials or limit coverage to specific materials.
2. Submit complete documentation: Include clinical notes, diagnostic images, and a detailed narrative. Clearly state why a unilateral flexible partial is the best treatment option.
3. Use correct CDT code: Double-check that D5284 is appropriate for the case. For bilateral or full-arch partials, consider D5213 or D5214 as applicable.
4. Review EOBs promptly: Once the claim is processed, review the Explanation of Benefits (EOB) for payment details or denial reasons. If denied, prepare a claim appeal with additional documentation as needed.
5. Track AR: Monitor accounts receivable (AR) to ensure timely follow-up on outstanding claims and minimize revenue leakage.

Example Case for D5284

Consider a 55-year-old patient missing teeth #29 and #30 in the lower right quadrant. The patient prefers a removable option that is comfortable and esthetic. After evaluating the case, the dentist recommends a one-piece flexible partial denture. The dental team documents the missing teeth, clinical justification, and material choice. They submit a pre-authorization with supporting images and narrative. Upon approval, the appliance is fabricated and delivered. The claim is submitted with D5284, and the EOB shows payment as per the patient’s plan. This case illustrates the importance of proper code selection, documentation, and insurance communication for successful reimbursement.