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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 21.1
Chronic Fatigue Syndrome (CFS)
Issue Date:  September 23, 1991
Authority:  32 CFR 199.4(g)(15)
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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