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).