ModifiedUnitedHealthcarePolicy DCP020.17

Removable Prosthodontics

Policy governing coverage indications, contraindications, and procedure coding for removable complete and partial dentures and related services for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyRemovable Prosthodontics

Policy CodePolicy DCP020.17

Change TypeCode updates and description revisions

Effective DateJan 1, 2026

Next Review Date

Key ActionVerify member-specific benefits and obtain prior authorization when required for listed removable prosthodontic CDT codes.

SourceLink

POLICY UPDATE CHANGES

Added CDT codes D5877 and D5878 to the list of applicable codes.

Revised descriptions for D5863, D5864, D5865, D5866, and D5867.

Archived previous policy version DCG020.16.

~70+CDT procedure codes listed

6CDT codes in excerpt

2026-01-01Effective date

1Policy ref index

Coverage Criteria for Removable Prosthodontics

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Medical Necessity Criteria

Covered when indications below are met

Primary Indication: Removable complete or partial dentures are indicated for definitive replacement of missing teeth lost due to disease, trauma, or injury.

Rebasing Indications: Rebasing is indicated when changes to the residual ridge result in loss of denture stability, retention, or occlusal disharmony; when replacing or rearranging teeth on a partial denture; or when the base has fractured or cracked.

Relining Indication: Relining is indicated when changes to the residual ridge result in loss of denture stability, retention, or occlusal disharmony.

Interim Prosthesis Indications: Interim prostheses are indicated while tissue is healing following extractions and to maintain a space for future permanent treatment such as an implant, bridge, or definitive fixed prosthesis.

Overdenture Indications: Overdentures are indicated to preserve the integrity of the edentulous ridge and when the teeth available as retainers have a good long-term prognosis.

Tissue Conditioning Indications: Tissue conditioning is indicated for the presence of inflammation and irritation of the mucosa or normal anatomic structures and for use subsequent to placement of immediate dentures; it is not indicated for long-term appliance stability or comfort.

Partial and complete removable dentures may be considered not indicated in specific clinical situations and therefore may be excluded from coverage. Examples include: chronic poor oral hygiene or abutment teeth in poor condition due to periodontal disease or extensive caries; extensive bone atrophy resulting in an inadequate edentulous ridge; poor neuromuscular control; and unresolved soft tissue concerns such as lack of vestibular depth, hypertrophy, hyperplasia, or stomatitis. Rebasing or relining procedures are not indicated when the prosthesis is broken or worn to the extent that replacement is warranted, when occlusion or structural integrity of denture teeth are no longer functional, or when a reline would be sufficient. Overdentures are not indicated when there has been significant deterioration of the edentulous ridge or for members with poor oral hygiene and non-compliance.

This policy is informational and must be used together with the member-specific benefit plan document. The member-specific benefit plan governs if its terms differ from this policy; providers should verify the member’s plan and any applicable federal or state mandates before submitting claims or obtaining prior authorization.

Applicable CDT Procedure Codes

Covered CDT Codes (part 1)CDT

D5110	Complete denture - maxillary.
D5120	Complete denture - mandibular.
D5130	Immediate denture - maxillary.
D5140	Immediate denture - mandibular.
D5211	Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth).
D5212	Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth).
D5213	Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rest and teeth).
D5214	Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rest and teeth).
D5221	Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth).
D5222	Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth).

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Covered CDT Codes (part 2)CDT

D5283	Removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular.
D5284	Removable unilateral partial denture - one-piece flexible base (including retentive/clasping materials, rests, and teeth - per quadrant.
D5286	Removable unilateral partial denture - one piece resin (including retentive/clasping materials, rests, and teeth) - per quadrant.
D5410	Adjust complete denture - maxillary.
D5411	Adjust complete denture - mandibular.
D5421	Adjust partial denture - maxillary.
D5422	Adjust partial denture - mandibular.
D5511	Repair broken complete denture base, mandibular.
D5512	Repair broken complete denture base, maxillary.
D5520	Replace missing or broken teeth - complete denture - per tooth.

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Covered CDT Codes (part 3)CDT

D5640	Replace missing or broken teeth - partial denture - per tooth.
D5650	Add tooth to existing partial denture - per tooth.
D5660	Add clasp to existing partial denture - per tooth.
D5670	Replace all teeth and acrylic on cast metal framework (maxillary).
D5671	Replace all teeth and acrylic on cast metal framework (mandibular).
D5710	Rebase complete maxillary denture.
D5711	Rebase complete mandibular denture.
D5720	Rebase maxillary partial denture.
D5721	Rebase mandibular partial denture.
D5725	Rebase hybrid prosthesis.

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Applicable CDT CodesCDT

D5875	precision attachment of natural tooth borne prosthesis, per attachment.
D5876	Modification of removable prosthesis following implant surgery.
D5877	Add metal substructure to acrylic full denture- per arch.
D5878	Duplication of complete denture - maxillary.
D5878	Duplication of complete denture - mandibular.
D5899	Unspecified removable prosthodontic procedure, by report

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Reference Member-Specific Benefit Plan

Providers must verify member benefits and reference the member-specific benefit plan document when determining coverage. The member-specific plan governs and may impose prior authorization or other requirements.

Verify member-specific benefit plan before rendering services
Check for prior authorization requirements per member plan and state/federal mandates

Documentation Required

Clinical Purpose and Indication Documentation

Documentation must support the clinical purpose of removable prostheses: restoration of function, comfort, appearance, or oral health. Record clinical findings that justify the procedure, including oral hygiene status, condition of abutment teeth, ridge anatomy, soft tissue health, and any alternatives considered.

Document clinical findings that justify treatment (function, comfort, appearance, health)
Include intraoral exam findings: hygiene, periodontal status, abutment tooth condition, ridge anatomy, soft tissue issues

Billing Rule

Use of Interim Prostheses

Interim prostheses are temporary devices intended for short-term use while tissues heal or to maintain space until definitive treatment is provided. Only bill interim codes when clinical documentation supports a temporary need.

Use interim denture codes (e.g., D5810, D5811, D5820, D5821) only for temporary clinical indications
Document anticipated timeline and planned definitive treatment (implant, bridge, definitive prosthesis)

Denial Risk

Contraindications for Rebasing/Relining and Overdentures

Rebasing, relining, and overdenture procedures are not indicated in certain clinical situations and may be denied if documentation does not support medical necessity.

Do not rebasing/reline when the prosthesis is broken or worn to the extent replacement is warranted
Do not rebasing/reline when occlusion or structural integrity of denture teeth are no longer functional
Do not rebasing/reline when a simple reline would suffice
Do not rebasing/reline or over-denture when unresolved soft tissue hyperplasia or stomatitis exists
Overdentures are not indicated with significant ridge deterioration or in members with poor oral hygiene/non-compliance

Prior Authorization

Prior Authorization and Code List

Prior authorization and applicable CDT codes may be required per the member-specific plan. Inclusion of codes in this policy is for reference only and does not guarantee coverage.

Check member-specific plan for prior authorization requirements for CDT codes listed in this policy
Examples of commonly referenced codes include D5110–D5899 (see Applicable Codes section)

Note

Verify Member Benefits

Providers must verify benefits and any state or federal mandates before providing services. In the event of conflict, the member-specific benefit plan document governs.

Verify member benefits and applicable mandates prior to treatment
Confirm prior authorization and documentation requirements with payer

Key Definitions

Immediate Denture

DefinitionAny fixed or removable dental prosthesis fabricated for placement immediately following the removal of a natural tooth/teeth.

SourceAcademy of Prosthodontics definition as listed in policy.

Clinical noteImmediate dentures are fabricated for placement at time of extraction to provide immediate replacement of teeth and associated structures.

Overdenture

DefinitionAny removable dental prosthesis that covers and rests on one or more remaining natural teeth, the roots of natural teeth, and/or dental implants; partially supported by these structures.

Clinical purposeUsed to preserve integrity of the edentulous ridge and provide support when retainers have good long-term prognosis.

Support typesMay be supported by retained teeth, retained roots, or implants.

Rebase

DefinitionThe laboratory process of replacing the entire denture base material on an existing prosthesis.

IndicationPerformed when base material is damaged or when residual ridge changes necessitate replacement of the base for proper fit.

SettingClassified as a laboratory procedure per Academy of Prosthodontics terminology.

Reline

DefinitionProcedures used to resurface the tissue side of a removable dental prosthesis with new base material to produce accurate adaptation to the denture foundation area.

IndicationIndicated when changes to the residual ridge result in loss of denture stability, retention, or occlusal disharmony.

DistinctionRelines resurface the tissue side; rebases replace the entire denture base material.

Interim Prostheses

DefinitionInterim prostheses are temporary removable dentures designed for use over a limited, defined period to prepare for a definitive appliance.

PurposeUsed while tissue is healing following extractions or to maintain space for future definitive treatment such as implants or fixed prostheses.

DurationIntended for a limited time period; they are temporary and not a substitute for a definitive prosthesis.

Removable Dentures

DefinitionRemovable dentures replace missing teeth and may be supported by the edentulous ridge, retained natural teeth, or intentionally retained roots.

FunctionRestore oral function, comfort, appearance, and health.

MaintenanceChanges to supporting structures or appliance damage may require relining, rebasing, or tissue conditioning.

OpenPayer

Removable Prosthodontics

Coverage Criteria for Removable Prosthodontics

Applicable CDT Procedure Codes

Provider Requirements, Prior Authorization, and Documentation

Key Definitions

Background

Policy Revision History