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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