Medicine
Chapter 7
Section 21.1
Chronic Fatigue Syndrome
(CFS)
Issue Date: September 23, 1991
Revision:
1.0 DESCRIPTION
Chronic fatigue is defined as self-reported
persistent or relapsing fatigue of six or more consecutive months.
CFS is an illness characterized by prolonged, debilitating fatigue
and multiple non-specific symptoms such as headaches, recurrent
sore throats, muscle and joint pains and cognitive complaints. CFS
is treated as a subset of prolonged fatigue. Prolonged fatigue is
defined as self-reported, persistent fatigue of one month or longer.
The presence of prolonged or chronic fatigue requires clinical evaluation
to identify underlying or contributing conditions that require treatment. There
is no known cure for CFS. Symptoms usually disappear within three
to five years. CFS is also known in other countries as myalgic encephalomyelitis,
postviral fatigue syndrome, and chronic fatigue and immune dysfunction
syndrome.
Note: Some methodologic problems with CFS
research include inadequate sampling procedures, lack of controls,
small sample size, short duration of treatment and follow-up considering
the chronicity of the illness, poorly defined operational criteria,
and the absence of accurate and reliable diagnostic and outcome
indicators. The absence of objective response markers in the treatment
of CFS has forced researchers to reply on highly subjective measures
such as a reduction in the perception of fatigue. A great deal of
controversy and speculation of the syndrome’s heterogeneity, researchers
argue against it being a discrete disease caused by one agent. Some
researchers believe CFS represents a common set of symptoms triggered
by different combinations of various infectious and noninfectious
factors. Furthermore, little is known about the long-term treatment
efficacy of this disorder, and there is not medical consensus regarding
the treatment of CFS.
2.0 POLICY
2.1 Medically
necessary benefits for otherwise covered services and supplies required
to rule out other causes of protracted fatigue are covered.
2.2 Benefits
for CFS are limited to relieving individual symptoms, such as prescribing
analgesics for headache or muscle pains. In those cases where there
are irregular lab findings, treatment is covered for the identified
causes.
3.0 EXCLUSIONS
3.1 CFS.
Note: Separately identifying and coding all presenting
manifestations of the syndrome is not necessary since they are included
in the code assignment.
3.2 The use of tests to diagnose
CFS since such tests are unproven and do not aid in diagnosis or management
of CFS.
Note: No test can be recommended for the
specific purpose of diagnosing CFS. Tests should be directed toward
confirming or excluding other possible clinical conditions. Examples
of specific tests that do not confirm or exclude the diagnosis of
CFS include serologic tests for Epstien-Barr virus, enteroviruses,
human herpesvirus 6, and Candida albicans. Tests of immunologic
function, including cell population and function studies; and imaging
studies, including magnetic resonances imaging scans and radionuclide
scans (such as single-photon emission computed tomography and positron emission
tomography).
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