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Myalgic Encephalomyelitis - Chronic Fatigue Syndrome (ME/CSF) (CPB 0369, reviewed 2026-05-20)
Effective date
Not stated in the notice
Identified
Aug 15, 2026
Summary
Aetna considers a set of exclusionary tests medically necessary for evaluating members suspected of having chronic fatigue syndrome (CFS), with the selection depending on the case. These include ANA, blood and serum chemistries, CBC with differential, ESR, HIV serology, liver function tests, thyroid function tests, urinalysis, and MRI of the head to rule out multiple sclerosis. Aetna considers many other laboratory tests, procedures and treatments experimental, investigational or unproven for CFS, including cytokine assays, gene expression profiling, metabolomics, ondansetron, duloxetine, rituximab and Anakinra.
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What to do
Action · 5 steps
01Before billing CFS evaluation services, confirm the member meets the selection criteria: unexplained chronic fatigue of new or definite onset that is not the result of ongoing exertion and is not substantially alleviated by rest, with a substantial reduction in previous occupational, educational, social or personal activities, plus 4 or more of the listed symptoms that persisted or recurred for 6 or more consecutive months.
02Document a thorough medical history, physical examination, mental status examination and laboratory tests, because a CFS classification cannot be made without them.
03Check the record for exclusionary conditions listed in the policy, such as alcohol or substance abuse within 2 years of onset, severe obesity (BMI of 45 or greater), and active medical conditions that may explain the fatigue.
04Billing team: bill the covered codes listed in the policy (for example 80050, 85025, 86038 and G93.32) only for members who meet these criteria.
05Stop scheduling and billing the experimental, investigational or unproven tests and treatments listed for CFS, such as cytokine assays, metabolomics, ondansetron, duloxetine and rituximab.
Codes mentioned
7055170553705547055580047800488005080051800768100081099844438447985025850278565185652860388643086580866178661895782957839580895811G93.32R53.81R53.83
Original notice
Myalgic Encephalomyelitis - Chronic Fatigue Syndrome (ME/CSF) (CPB 0369, reviewed 2026-05-20)
aetna.com · Always check the source before changing claims.
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Related policy hubs
Aetna policiesNeurologyInternal MedicineCode 70551Code 70553Code 70554Code 70555Code 80047Code 80048Code 80050Code 80051Code 80076Code 81000Code 81099Code 84443Code 84479Code 85025Code 85027Code 85651Code 85652Code 86038Code 86430Code 86580Code 86617Code 86618Code 95782Code 95783Code 95808Code 95811Code G93.32Code R53.81Code R53.83